Search

Abstract Background COVID-19 constitutes a global health emergency of unprecedented proportions. Preventive measures, however, have run up against certain difficulties in low and middle-income countries. This is the case in socially and geographically marginalized communities, which are excluded from information about preventive measures. This study contains a dual objective, i) to assess knowledge of COVID-19 and the preventive measures associated with it concerning indigents in the villages of Diebougou’s district in Burkina Faso. The aim is to understand if determinants of this understanding exist, and ii) to describe how their pathways to healthcare changed from 2019 to 2020 during the COVID-19 pandemic. Methods The study was conducted in the Diebougou healthcare district, in the south-west region of Burkina Faso. We relied on a cross-sectional design and used data from the fourth round of a panel survey conducted among a sample of ultra-poor people that had been monitored since 2015. Data were collected in August 2020 and included a total of 259 ultra-poor people. A multivariate logistic regression to determine the factors associated with the respondents' knowledge of COVID-19 was used. Results Half of indigents in the district said they had heard about COVID-19. Only 29% knew what the symptoms of the disease were. The majority claimed that they protected themselves from the virus by using preventive measures. This level of knowledge of the disease can be observed with no differences between the villages. Half of the indigents who expressed themselves agreed with government measures except for the closure of markets. An increase of over 11% can be seen in indigents without the opportunity for getting healthcare compared with before the pandemic. Conclusions This research indicates that COVID-19 is partially known and that prevention measures are not universally understood. The study contributes to reducing the fragmentation of knowledge, in particular on vulnerable and marginalized populations. Results should be useful for future interventions for the control of epidemics that aim to leave no one behind.

Bangladesh completed a primary series of COVID-19 vaccinations for about 86 individuals per 100 population as of 5 July 2023. However, ensuring higher coverage in vulnerable areas is challenging. We report on the COVID-19 vaccine uptake and associated factors among adults in two vulnerable areas in Bangladesh. We conducted a cross-sectional study between August and September 2022 in Duaripara, a slum in northeast Dhaka (in-migration site), and Tala, a disaster-prone sub-district in southwest Satkhira (out-migration site). We surveyed 1,239 adults in Duaripara and 1,263 adults in Tala from 625 and 596 randomly selected households, respectively. We reported coverage and examined associations between the uptake and demographic and socioeconomic characteristics using multilevel mixed-effects generalized linear regression models. We checked for spatial autocorrelation to assess geographical patterns in vaccine distribution. First- and second-dose coverage was about 91% and 80.4% in Duaripara and 96.6% and 92.2% in Tala, respectively. Individuals above 40 were more likely to be vaccinated (IRR: 1.12, p-value = 0.04 for Duaripara, and IRR: 1.14, p-value <0.01 for Tala). Professions requiring more outdoor interactions had a higher likelihood of receiving the vaccine. In Tala, television access (IRR: 2.09, p-value <0.01) and micro-credit membership (IRR: 1.50, p-value = 0.05) were positively associated with receiving a booster dose and negatively associated with smart-phone access (IRR: 0.58, p-value = 0.03). Moreover, temporarily migrated respondents were more likely to be unvaccinated (IRR: 0.87, p-value = 0.04). Income was not associated, indicating equitable distribution. Moreover, no geographical clustering was detected. The credit for high COVID-19 vaccine coverage in Bangladesh can be attributed to the country's longstanding success in implementing immunization programs, which relied on community mobilization and effective health education to generate demand. However, to ensure comprehensive coverage in vulnerable areas, targeted interventions can help increase uptake by addressing specific sociodemographic differences., Competing Interests: The authors have declared that no competing interests exists., (Copyright: © 2025 Islam et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: The poorest in Burkina Faso face numerous barriers to healthcare access, including financial and geographic obstacles, as well as a high burden of chronic conditions and multimorbidity. This study estimates the average cost of providing curative outpatient consultations at first-level healthcare facilities to the poorest in Burkina Faso. It also estimates the budgetary impact of scaling up free access to these services nationwide. The findings provide essential evidence on cost structures to inform decision-makers in developing policies aimed at achieving universal health coverage and ensuring that no one is left behind., Methods: We conducted a micro-costing study to estimate the economic costs of providing curative outpatient healthcare services to the poorest at first-level healthcare facilities, considering a health system perspective. We measured the consumption of capital costs (building and equipment) using survey data from 32 primary health facilities and recurrent costs (drugs and consumables) from medical records of 1380 poor patients in Diébougou district. These individuals were targeted and exempted from user fees through a community-based targeting approach. We obtained unit costs from official price lists, pharmacy registries, and expert interviews. We calculated the national budget for providing curative care services to the exempted poorest based on the average cost per first-level consultation., Results: The estimated capital and recurrent costs of providing curative care services ranged between USD 0.59 - USD 0.61 and USD 2.58 - USD 5.00, respectively. The total cost ranged between USD 3.17 - USD 5.61 per first-level consultation. Providing curative care to the bottom 20% of the population, assuming 0.25 healthcare contacts per person per year, would result in an annual expense ranging from USD 2.77 M to USD 5.38 M (0.74-1.43% of the healthcare budget in 2019). With 2 healthcare contacts per person per year, costs increase to USD 22.19 M to USD 43.05 M (5.91-11.45% of the healthcare budget)., Conclusion: The results can inform policies aimed at expanding access to curative care for the poorest in Burkina Faso, contributing to the goals of universal health coverage and leaving no one behind. Further research is needed to enhance cost estimation and budgeting for higher-level care in the country., Competing Interests: Declarations. Ethics approval and consent to participate: Ethical clearance was granted by the Comité National d’Éthique pour la Recherche en Santé in Burkina Faso (Decision No. 2019-01-004). No ethical clearance for this study was required in Germany since the study relied exclusively on secondary fully-anonymized data. Informed consent to participate was obtained from all participants in the study. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Introduction: Achieving universal health coverage (UHC) through an effective health financing system is a challenge for many low-income countries. Learning is key to success due to many uncertainties and unknowns. Using the case of translating strategic health purchasing into policy and practice in Burkina Faso, our study seeks to understand how policy learning can shape policy processes and outcomes., Methods: We used a qualitative case study design and Dunlop and Radaelli's conceptualisation of policy learning to identify which modes of learning did or did not occur, what helped or hindered them and the resulting policy outcomes. Dunlop and Radaelli frame policy learning as epistemic, reflexive, negotiative or hierarchical. We collected data through documentary review and in-depth individual interviews with 21 key informants. We analysed the data manually using pattern-matching techniques., Results: The introduction of strategic health purchasing in Burkina Faso was initially seen as an opportunity to reduce the fragmentation of the health financing system by coupling a performance-based financing scheme and a user fee exemption policy. However, this has faltered, and our findings suggest that an inability to harness all modes of learning has led to blockages. Indeed, while reflective learning was present, epistemic, hierarchical and learning through bargaining were absent, preventing national policy actors from defending their own policy or scheme from reaching compromises. But thanks to facilitating processes led by a well-resourced organisation and contextual elements that encouraged the emergence of more pluralistic modes of learning, some progress was achieved in operationalising strategic health purchasing., Conclusions: Some modes of learning seem to be overlooked in countries' efforts to achieve UHC. Facilitation techniques and initiatives that encourage the use of all modes of learning, while supporting countries to take full ownership and responsibility for consolidating their own learning health systems, should be promoted., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Burkina Faso has implemented a nationwide free healthcare policy (gratuité) for pregnant and lactating women and children under 5 years since April 2016. Studies have shown that free healthcare policies can increase healthcare service use. However, the emerging coronavirus disease 2019 pandemic, escalating insecurity and the political situation in recent years might have affected the implementation of such policies. No studies have looked at whether the gratuité maintained high service use under such changing circumstances. Our study aimed to assess the effects of gratuité on the utilization of facility-based delivery and curative care of children under 5 years in light of this changing context. We employed a controlled interrupted time series analysis using data from the Health Management Information System and annual statistical reports of 2560 primary health facilities from January 2013 to December 2021. We focused on facility-based deliveries and curative care for children under 5 years, with antenatal care and curative care for children over 5 years as non-equivalent controls. We employed segmented regression with the generalized least square model, accounting for autocorrelation and monthly seasonality. The monthly utilization rate among children under 5 years compared to those above 5 years (controls) immediately increased by 111.19 visits per 1000 children (95% CI: 91.12, 131.26) due to the gratuité. This immediate effect declined afterwards with a monthly change of 0.93 per 1000 children (95% CI: -1.57, -0.29). We found no significant effects, both immediate and long-term, on the use of maternal care services attributable to the gratuité. Our findings suggest that free healthcare policies can be instrumental in improving healthcare, yet more comprehensive strategies are needed to maintain healthcare utilization. Our findings reflect the overall situation in the country, while localized research is needed to understand the effect of insecurity and the pandemic at the local level and the effects of gratuité across geographies and socioeconomic statuses., (© The Author(s) 2024. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

While the incidence of cervical cancer has dropped in high-income countries due to organized cytology-based screening programs, it remains the leading cause of cancer death among women in Eastern Africa. Therefore, the World Health Organization (WHO) now urges providers to transition from widely prevalent but low-performance visual inspection with acetic acid (VIA) screening to primary human papillomavirus (HPV) DNA testing. Due to high HPV prevalence, effective triage tests are needed to identify those lesions likely to progress and so avoid over-treatment. To identify the optimal cost-effective strategy, we compared the VIA screen-and-treat approach to primary HPV DNA testing with p16/Ki67 dual-stain cytology or VIA as triage. We used a Markov model to calculate the budget impact of each strategy with incremental quality-adjusted life years and incremental cost-effectiveness ratios (ICER) as the main outcome. Deterministic cost-effectiveness analyses show that the screen-and-treat approach is highly cost-effective (ICER 2469 Int$), while screen, triage, and treat with dual staining is the most effective with favorable ICER than triage with VIA (ICER 9943 Int$ compared with 13,177 Int$). One-way sensitivity analyses show that the results are most sensitive to discounting, VIA performance, and test prices. In the probabilistic sensitivity analyses, the triage option using dual stain is the optimal choice above a willingness to pay threshold of 7115 Int$ being cost-effective as per WHO standards. The result of our analysis favors the use of dual staining over VIA as triage in HPV-positive women and portends future opportunities and necessary research to improve the coverage and acceptability of cervical cancer screening programs., (© 2024 The Authors. International Journal of Cancer published by John Wiley & Sons Ltd on behalf of UICC.)

Background: The sustainability of diets consumed by African populations under socio-economic transition remains to be determined. This study developed and characterized a multi-dimensional Sustainable Diet Index (SDI) reflecting healthfulness, climate-friendliness, sociocultural benefits, and financial affordability using individual-level data of adults in rural and urban Ghana and Ghanaian migrants in Europe to identify the role of living environment in dietary sustainability., Methods: We used cross-sectional data from the multi-centre Research on Obesity and Diabetes among African Migrants Study (N = 3169; age range: 25-70 years). For the SDI construct (0-16 score points), we used the Diet Quality Index-International, food-related greenhouse gas emission, the ratio of natural to processed foods, and the proportion of food expenditure from income. In linear regression analyses, we estimated the adjusted ß-coefficients and 95% confidence intervals (CIs) for the differences in mean SDI across study sites (using rural Ghana as a reference), accounting for sociodemographic and lifestyle factors., Results: The overall mean SDI was 8.0 (95% CI: 7.9, 8.1). Participants in the highest SDI-quintile compared to lower quintiles were older, more often women, non-smokers, and alcohol abstainers. The highest mean SDI was seen in London (9.1; 95% CI: 8.9, 9.3), followed by rural Ghana (8.2; 95% CI: 8.0, 8.3), Amsterdam (7.9; 95% CI: 7.7, 8.1), Berlin (7.8; 95% CI: 7.6, 8.0), and urban Ghana (7.7; 95% CI: 7.5, 7.8). Compared to rural Ghana, the differences between study sites were attenuated after accounting for age, gender and energy intake. No further changes were observed after adjustment for lifestyle factors., Conclusion: The multi-dimensional SDI describes four dimensions of dietary sustainability in this Ghanaian population. Our findings suggest that living in Europe improved dietary sustainability, but the opposite seems true for urbanization in Ghana., (© 2024. The Author(s).)

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., (© 2024. The Author(s).)

This position paper by the international IMMERSE consortium reviews the evidence of a digital mental health solution based on Experience Sampling Methodology (ESM) for advancing person-centered mental health care and outlines a research agenda for implementing innovative digital mental health tools into routine clinical practice. ESM is a structured diary technique recording real-time self-report data about the current mental state using a mobile application. We will review how ESM may contribute to (1) service user engagement and empowerment, (2) self-management and recovery, (3) goal direction in clinical assessment and management of care, and (4) shared decision-making. However, despite the evidence demonstrating the value of ESM-based approaches in enhancing person-centered mental health care, it is hardly integrated into clinical practice. Therefore, we propose a global research agenda for implementing ESM in routine mental health care addressing six key challenges: (1) the motivation and ability of service users to adhere to the ESM monitoring, reporting and feedback, (2) the motivation and competence of clinicians in routine healthcare delivery settings to integrate ESM in the workflow, (3) the technical requirements and (4) governance requirements for integrating these data in the clinical workflow, (5) the financial and competence related resources related to IT-infrastructure and clinician time, and (6) implementation studies that build the evidence-base. While focused on ESM, the research agenda holds broader implications for implementing digital innovations in mental health. This paper calls for a shift in focus from developing new digital interventions to overcoming implementation barriers, essential for achieving a true transformation toward person-centered care in mental health.

Objectives: In Burkina Faso, one in every four children under 5 years is stunted. Climate change will exacerbate childhood stunting. Strengthening the health system, particularly the quality of nutrition care at primary health facilities, can minimise the adverse climate effect on stunting. Thus, we examined the quality of nutritional status assessment (QoNA) during curative childcare services in primary health facilities in rural Burkina Faso and its relationship with rainfall-induced childhood stunting., Study Design: We conducted a cross-sectional analysis using anthropometric, rainfall, and clinical observation data., Methods: Our dependent variable was the height-for-age z-score (HAZ) of children under 2 years. Our focal climatic measure was mean rainfall deviation (MRD), calculated as the mean of the difference between 30-year monthly household-level rainfall means and the corresponding months for each child from conception to data collection. QoNA was based on the weight, height, general paleness and oedema assessment. We used a mixed-effect multilevel model and analysed heterogeneity by sex and socio-economic status., Results: Among 5027 young (3-23 months) children (mean age 12 ± 6 months), 21% were stunted (HAZ ≤ -2). The mean MRD was 11 ± 4 mm, and the mean QoNA was 2.86 ± 0.99. The proportion of children in low, medium, and high QoNA areas was 10%, 54%, and 36%, respectively. HAZ showed a negative correlation with MRD. Higher QoNA lowered the negative effect of MRD on HAZ (β = 0.017, P = 0.003, confidence interval = [0.006, 0.029]). Males and children from poor households benefited less from the moderating effect of QoNA., Conclusion: Improving the quality of nutrition assessments can supplement existing efforts to reduce the adverse effects of climate change on children's nutritional well-being., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Understanding public preferences concerning vaccination is critical to inform pandemic response strategies. To investigate Chinese adults' preferences regarding COVID-19 vaccine attributes, we conducted a cross-sectional online survey in 12,000 Chinese adults in June-July, 2021. Participants were requested to answer a series of discrete choice questions related to hypothetical COVID-19 vaccines. Using mixed logit models, our analysis revealed that participants had a higher preference for COVID-19 vaccines with longer duration of protection (coefficient: 1.272, 95% confidence interval [1.016 to 1.529]) and higher efficacy (coefficient: 1.063, [0.840, 1.287]). Conversely, participants demonstrated a lower preference associated with higher risk of rare but serious side-effects (coefficient: -1.158, [-1.359, -0.958]), oral administration (coefficient: -0.211, [-0.377, -0.046]), more doses (coefficient: -0.148, [-0.296, 0.000]) and imported origin (coefficient: -0.653, [-0.864, -0.443]). Moreover, preferences were heterogeneous by individual factors: highly educated participants were more sensitive to the negative vaccine attributes including price (coefficient -0.312, [-0.370, -0.253]) and imported vaccine (coefficient -0.941, [-1.186, -0.697]); there was also substantial heterogeneity in vaccine preferences with respect to age group, marital status, work status, income, chronic diagnosis history, COVID-19 vaccination history and geographic regions. As the first study of examining the public preferences for COVID-19 vaccine in China with a large nationwide sample of 12,000 adults, our results indicate that future vaccine should pose lower risk, possess longer protection period, have higher efficacy, be domestically produced, and have lower costs to increase the COVID-19 vaccination coverage. Our current study findings from this study provide insights and recommendations for not only COVID-19 vaccine design but also vaccine attribute preferences to increase vaccine uptake in potential future pandemics., Competing Interests: The authors have declared that no competing interests exists., (Copyright: © 2024 Yu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Recent years have seen a growing interest in the use of digital tools for delivering person-centred mental health care. Experience Sampling Methodology (ESM), a structured diary technique for capturing moment-to-moment variation in experience and behaviour in service users' daily life, reflects a particularly promising avenue for implementing a person-centred approach. While there is evidence on the effectiveness of ESM-based monitoring, uptake in routine mental health care remains limited. The overarching aim of this hybrid effectiveness-implementation study is to investigate, in detail, reach, effectiveness, adoption, implementation, and maintenance as well as contextual factors, processes, and costs of implementing ESM-based monitoring, reporting, and feedback into routine mental health care in four European countries (i.e., Belgium, Germany, Scotland, Slovakia)., Methods: In this hybrid effectiveness-implementation study, a parallel-group, assessor-blind, multi-centre cluster randomized controlled trial (cRCT) will be conducted, combined with a process and economic evaluation. In the cRCT, 24 clinical units (as the cluster and unit of randomization) at eight sites in four European countries will be randomly allocated using an unbalanced 2:1 ratio to one of two conditions: (a) the experimental condition, in which participants receive a Digital Mobile Mental Health intervention (DMMH) and other implementation strategies in addition to treatment as usual (TAU) or (b) the control condition, in which service users are provided with TAU. Outcome data in service users and clinicians will be collected at four time points: at baseline (t 0 ), 2-month post-baseline (t 1 ), 6-month post-baseline (t 2 ), and 12-month post-baseline (t 3 ). The primary outcome will be patient-reported service engagement assessed with the service attachment questionnaire at 2-month post-baseline. The process and economic evaluation will provide in-depth insights into in-vivo context-mechanism-outcome configurations and economic costs of the DMMH and other implementation strategies in routine care, respectively., Discussion: If this trial provides evidence on reach, effectiveness, adoption, implementation and maintenance of implementing ESM-based monitoring, reporting, and feedback, it will form the basis for establishing its public health impact and has significant potential to bridge the research-to-practice gap and contribute to swifter ecological translation of digital innovations to real-world delivery in routine mental health care., Trial Registration: ISRCTN15109760 (ISRCTN registry, date: 03/08/2022)., (© 2024. The Author(s).)

Introduction: Universal health coverage (UHC) is a global priority, ensuring equitable access to quality healthcare services without financial hardship. Many countries face challenges in progressing towards UHC. Health financing is pivotal for advancing UHC by raising revenues, enabling risk-sharing through pooling of funds and allocating resources. Digital technologies in the healthcare sector offer promising opportunities for health systems. In low-income and middle-income countries (LMICs), digital technologies for health financing (DTHF) have gained traction, supporting these three main functions of health financing for UHC. As existing information on DTHF in LMICs is limited, our scoping review aims to provide a comprehensive overview of DTHF in LMICs. Our objectives include identifying and describing existing DTHF, exploring evaluation approaches, examining their positive and negative effects, and investigating facilitating factors and barriers to implementation at the national level., Methods and Analysis: Our scoping review follows the six stages proposed by Arksey and O'Malley, further developed by Levac et al and the Joanna Briggs Institute. The reporting adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews framework. Eligibility criteria for studies reflect the three core elements of the search: (1) health financing, (2) digital technologies and (3) LMICs. We search multiple databases, including Medline via PubMed, EMBASE via Ovid, the Web of Science Core Collection, CENTRAL via Cochrane and the Global Index Medicus by the WHO. The extracted information is synthesised from both quantitative and qualitative studies., Ethics and Dissemination: As our scoping review is based solely on information gathered from previously published studies, documents and publicly available scientific literature, ethical clearance is not required for its conduct. The findings are presented and discussed in a peer-reviewed article, as well as shared at conferences relevant to the topic., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: To address domestic shortages, high-income countries are increasingly recruiting health workers from low- and middle-income countries. This practice is much debated. Proponents underline benefits of return migration and remittances. Critics point in particular to the risk of brain drain. Empirical evidence supporting either position is yet rare. This study contributes to filling this gap in knowledge by reporting high-level stakeholders' perspectives on health system impacts of international migration in general, and active recruitment of health workers in specific, in Colombia, Indonesia, and Jordan., Method: We used a multiple case study methodology, based on qualitative methods integrated with information available in the published literature., Results: All respondents decried a lack of robust and detailed data as a serious challenge in ascertaining their perspectives on impacts of health worker migration. Stakeholders described current emigration levels as not substantially aggravating existing health workforce availability challenges. This is due to the fact that all three countries are faced with health worker unemployment grounded in unwillingness to work in rural areas and/or overproduction of certain cadres. Respondents, however, pleaded against targeting very experienced and specialised individuals. While observing little harm of health worker migration at present, stakeholders also noted few benefits such as brain gain, describing how various barriers to skill enhancement, return, and reintegration into the health system hamper in practice what may be possible in theory., Conclusion: Improved availability of data on health worker migration, including their potential return and reintegration into their country of origin's health system, is urgently necessary to understand and continuously monitor costs and benefits in dynamic national and international health labour markets. Our results imply that potential benefits of migration do not come into being automatically, but need in-country supportive policy and programming, such as favourable reintegration policies or programs targeting engagement of the diaspora., (© 2024 The Authors. The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.)

Objectives: This study aimed to evaluate the effect of introduction and subsequent withdrawal of the Results-based Financing for Maternal and Newborn Health Initiative (RBF4MNH) in Malawi on utilisation of facility-based childbirths, antenatal care (ANC) and postnatal care (PNC)., Design: A controlled interrupted time series design was used with secondary data from the Malawian Health Management Information System., Setting: Healthcare facilities at all levels identified as providing maternity services in four intervention districts and 20 non-intervention districts in Malawi., Participants: Routinely collected, secondary data of total monthly service utilisation of facility-based childbirths, ANC and PNC services., Interventions: The intervention is the RBF4MNH initiative, introduced by the Malawian government in 2013 to improve maternal and infant health outcomes and withdrawn in 2018 after ceasing of donor funding., Outcome Measures: Differences in total volume and trends of utilisation of facility-based childbirths, ANC and PNC services, compared between intervention versus non-intervention districts, for the study period of 90 consecutive months., Results: No significant effect was observed, on utilisation trends for any of the three services during the first 2.5 years of intervention. In the following 2.5 years after full implementation, we observed a small positive increase for facility-based childbirths (+0.62 childbirths/month/facility) and decrease for PNC (-0.55 consultations/month/facility) trends of utilisation respectively. After withdrawal, facility-based childbirths and ANC consultations dropped both in immediate volume after removal (-10.84 childbirths/facility and -20.66 consultations/facility, respectively), and in trends of utilisation over time (-0.27 childbirths/month/facility and -1.38 consultations/month/facility, respectively). PNC utilisation levels seemed unaffected in intervention districts against a decline in the rest of the country., Conclusions: Concurrent with wider literature, our results suggest that effects of complex health financing interventions, such as RBF4MNH, can take a long time to be seen. They might not be sustained beyond the implementation period if measures are not adopted to reform existing health financing structures., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: There is limited understanding of how universal health coverage (UHC) schemes such as publicly-funded health insurance (PFHI) benefit women as compared to men. Many of these schemes are gender-neutral in design but given the existing gender inequalities in many societies, their benefits may not be similar for women and men. We contribute to the evidence by conducting a gender analysis of the enrolment of individuals and households in India's national PFHI scheme, Rashtriya Swasthya Bima Yojana (RSBY)., Methods: We used data from a cross-sectional household survey on RSBY eligible families across eight Indian states and studied different outcome variables at both the individual and household levels to compare enrolment among women and men. We applied multivariate logistic regressions and controlled for several demographic and socio-economic characteristics., Results: At the individual level, the analysis revealed no substantial differences in enrolment between men and women. Only in one state were women more likely to be enrolled in RSBY than men (AOR: 2.66, 95% CI: 1.32-5.38), and this pattern was linked to their status in the household. At the household level, analyses revealed that female-headed households had a higher likelihood to be enrolled (AOR: 1.36, 95% CI: 1.14-1.62), but not necessarily to have all household members enrolled., Conclusion: Findings are surprising in light of India's well-documented gender bias, permeating different aspects of society, and are most likely an indication of success in designing a policy that did not favour participation by men above women, by mandating spouse enrolment and securing enrolment of up to five family members. Higher enrolment rates among female-headed households are also an indication of women's preferences for investments in health, in the context of a conducive policy environment. Further analyses are needed to examine if once enrolled, women also make use of the scheme benefits to the same extent as men do. India is called upon to capitalise on the achievements of RSBY and apply them to newer schemes such as PM-JAY., (© 2024. The Author(s).)

India launched one of the world's largest health insurance programs, the Pradhan Mantri Jan Arogya Yojana (PM-JAY), targeting more than 500 million economically and socially disadvantaged Indians. PM-JAY is publicly funded and covers hospitalization costs in public and private facilities. We examine how PM-JAY has affected hospitalizations and out-of-pocket expenditures (OOPE), and given the high use of private health care in India, we compare these outcomes across public and private facilities. We conducted a household survey to collect data on socioeconomic and demographic information, health status and hospitalizations for more than 57,000 PM-JAY eligible individuals in six Indian states. Using multivariate regression models, we estimated whether PM-JAY was associated with any changes in hospitalizations, OOPE and catastrophic health expenditures (CHE) and whether these differed across public and private facilities. We found that PM-JAY was not associated with an increase in hospitalizations, but it increased the probability of visiting a private facility by 4.6% points (p < .05). PM-JAY was associated with a relative reduction of 13% in OOPE (p < .1) and 21% in CHE (p < .01). This was entirely driven by private facilities, where relative OOPE was reduced by 17% (p < .01) and CHE by 19% (p < .01). This implied that PM-JAY has shifted use from public to private hospitalizations. Given the complex healthcare system with the presence of parallel public and private systems in India, our study concludes that for economically and socially disadvantaged groups, PM-JAY contributes to improved access to secondary and tertiary care services from private providers.

Introduction: The COVID-19 pandemic has entered its third year and continues to affect most countries worldwide. Active surveillance, i.e. testing individuals irrespective of symptoms, presents a promising strategy to accurately measure the prevalence of SARS-CoV-2. We aimed to identify the most cost-effective active surveillance strategy for COVID-19 among the four strategies tested in a randomised control trial between 18th November 2020 and 23rd December 2020 in Germany. The four strategies included: (A1) direct testing of individuals; (A2) direct testing of households; (B1) testing conditioned on upstream COVID-19 symptom pre-screening of individuals; and (B2) testing conditioned on upstream COVID-19 symptom pre-screening of households., Methods: We adopted a health system perspective and followed an activity-based approach to costing. Resource consumption data were collected prospectively from a digital individual database, daily time records, key informant interviews and direct observations. Our cost-effectiveness analysis compared each strategy with the status quo and calculated the average cost-effective ratios (ACERs) for one primary outcome (sample tested) and three secondary outcomes (responder recruited, case detected and asymptomatic case detected)., Results: Our results showed that A2, with cost per sample tested at 52,89 EURO, had the lowest ACER for the primary outcome, closely followed by A1 (63,33 EURO). This estimate was much higher for both B1 (243,84 EURO) and B2 (181,06 EURO)., Conclusion: A2 (direct testing at household level) proved to be the most cost-effective of the four evaluated strategies and should be considered as an option to strengthen the routine surveillance system in Germany and similar settings., (© 2023. The Author(s).)

Background: The government-subsidized health insurance scheme Seguro Integral de Salud ("SIS") was introduced in Peru initially to provide coverage to uninsured and poor pregnant women and children under five years old and was later extended to cover all uninsured members of the population following the Peruvian Plan Esencial de Aseguramiento Universal - "PEAS" (Essential UHC Package). Our study aimed to analyze the extent to which the introduction of SIS has increased equity in access and quality by comparing the utilization of maternal healthcare services among women with different insurance coverages., Methods: Relying on the 2021 round of the nationally-representative survey "ENDES" (Encuesta Nacional Demográfica y de Salud Familiar), we analyzed data for 19,181 women aged 15-49 with a history of pregnancy in the five years preceding the survey date. We used a series of logistic regressions to explore the association between health insurance coverage (defined as No Insurance, SIS, or Standard Insurance) and a series of outcome variables measuring access to and quality of all services along the available maternal healthcare continuum., Results: Only 46.5% of women across all insurance schemes reported having accessed effective ANC prevention. Findings from the adjusted logistic regression confirmed that insured women were more likely to have accessed ANC services compared with uninsured women. Our findings indicate that women in the "SIS" group were more likely to have accessed six ANC visits (aOR = 1.40; 95% CI 1.14-1.73) as well as effective ANC prevention (aOR = 1.32; 95% CI 1.17-1.48), ANC education (aOR = 1.59; 95% CI 1.41-1.80) and ANC screening (aOR = 1.46; 95% CI 1.27-1.69) during pregnancy, compared with women in the "Standard Insurance" group [aOR = 1.35 (95% CI 1.13-1.62), 1.22 (95% CI 1.04-1.42), 1.34 (95% CI 1.18-1.51) and 1.31(95% CI 1.15-1.49)] respectively. In addition, women in the "Standard Insurance" group were more likely to have received skilled attendance at birth (aOR = 2.17, 95% CI 1.33-3.55) compared with the women in the "SIS" insurance group (aOR = 2.12; 95% CI 1.41-3.17)., Conclusions: Our findings indicate the persistence of inequities in access to maternal healthcare services that manifest themselves not only in the reduced utilization among the uninsured, but also in the lower quality of service coverage that uninsured women received compared with women insured under "Standard Insurance" or "SIS". Further policy reforms are needed both to expand insurance coverage and to ensure that all women receive the same access to care irrespective of their specific insurance coverage., (© 2023. The Author(s).)

Background: The COVID-19 pandemic is characterized by rapid increases in infection burden owing to the emergence of new variants with higher transmissibility and immune escape. To date, monitoring the COVID-19 pandemic has mainly relied on passive surveillance, yielding biased epidemiological measures owing to the disproportionate number of undetected asymptomatic cases. Active surveillance could provide accurate estimates of the true prevalence to forecast the evolution of the pandemic, enabling evidence-based decision-making., Objective: This study compared 4 different approaches of active SARS-CoV-2 surveillance focusing on feasibility and epidemiological outcomes., Methods: A 2-factor factorial randomized controlled trial was conducted in 2020 in a German district with 700,000 inhabitants. The epidemiological outcome comprised SARS-CoV-2 prevalence and its precision. The 4 study arms combined 2 factors: individuals versus households and direct testing versus testing conditioned on symptom prescreening. Individuals aged ≥7 years were eligible. Altogether, 27,908 addresses from 51 municipalities were randomly allocated to the arms and 15 consecutive recruitment weekdays. Data collection and logistics were highly digitized, and a website in 5 languages enabled low-barrier registration and tracking of results. Gargle sample collection kits were sent by post. Participants collected a gargle sample at home and mailed it to the laboratory. Samples were analyzed with reverse transcription loop-mediated isothermal amplification (RT-LAMP); positive and weak results were confirmed with real-time reverse transcription-polymerase chain reaction (RT-PCR)., Results: Recruitment was conducted between November 18 and December 11, 2020. The response rates in the 4 arms varied between 34.31% (2340/6821) and 41.17% (2043/4962). The prescreening classified 16.61% (1207/7266) of the patients as COVID-19 symptomatic. Altogether, 4232 persons without prescreening and 7623 participating in the prescreening provided 5351 gargle samples, of which 5319 (99.4%) could be analyzed. This yielded 17 confirmed SARS-CoV-2 infections and a combined prevalence of 0.36% (95% CI 0.14%-0.59%) in the arms without prescreening and 0.05% (95% CI 0.00%-0.108%) in the arms with prescreening (initial contacts only). Specifically, we found a prevalence of 0.31% (95% CI 0.06%-0.58%) for individuals and 0.35% (95% CI 0.09%-0.61%) for households, and lower estimates with prescreening (0.07%, 95% CI 0.0%-0.15% for individuals and 0.02%, 95% CI 0.0%-0.06% for households). Asymptomatic infections occurred in 27% (3/11) of the positive cases with symptom data. The 2 arms without prescreening performed the best regarding effectiveness and accuracy., Conclusions: This study showed that postal mailing of gargle sample kits and returning home-based self-collected liquid gargle samples followed by high-sensitivity RT-LAMP analysis is a feasible way to conduct active SARS-CoV-2 population surveillance without burdening routine diagnostic testing. Efforts to improve participation rates and integration into the public health system may increase the potential to monitor the course of the pandemic., Trial Registration: Deutsches Register Klinischer Studien (DRKS) DRKS00023271; https://tinyurl.com/3xenz68a., International Registered Report Identifier (irrid): RR2-10.1186/s13063-021-05619-5., (©Andreas Deckert, Simon Anders, Ivonne Morales, Manuela De Allegri, Hoa Thi Nguyen, Aurélia Souares, Shannon McMahon, Matthias Meurer, Robin Burk, Dan Lou, Lucia Brugnara, Matthias Sand, Lisa Koeppel, Lena Maier-Hein, Tobias Ross, Tim J Adler, Stephan Brenner, Christopher Dyer, Konrad Herbst, Svetlana Ovchinnikova, Michael Marx, Paul Schnitzler, Michael Knop, Till Bärnighausen, Claudia M Denkinger. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 17.08.2023.)

Many countries are using health insurance to advance progress towards universal health coverage (UHC). India launched the Pradhan Mantri Jan Arogya Yojana (PM-JAY) health insurance scheme in 2018. We examine the political economy context around PM-JAY policy formulation, by examining the perspectives of policy stakeholders shaping decisions around the reform. More specifically, we focus on early policy design at the central (national) level. We use a framework on the politics of UHC reform proposed by Fox and Reich (The politics of universal health coverage in low- and middle-income countries: A framework for evaluation and action. J. Health Polit. Policy Law 2015;40:1023-1060), to categorize the reform into phases and examine the interactions between actors, institutions, interests, ideas and ideology which shaped reform decisions. We interviewed 15 respondents in Delhi between February and April 2019, who were either closely associated with the reform process or subject experts. The ruling centre-right government introduced PM-JAY shortly before national elections, drawing upon policy legacies from prior and state insurance schemes. Empowered policy entrepreneurs within the government focused discourse around ideas of UHC and strategic purchasing, and engaged in institution building leading to the creation of the National Health Authority and State Health Agencies through policy directives, thereby expanding state infrastructural and institutional power for insurance implementation. Indian state inputs were incorporated in scheme design features like mode of implementation, benefit package and provider network, while features like the coverage amount, portability of benefits and branding strategy were more centrally driven. These balanced negotiations opened up political space for a cohesive, central narrative of the reform and facilitated adoption. Our analysis shows that the PM-JAY reform focused on bureaucratic rather than ideological elements and that technical compromises and adjustments accommodating the interests of states enabled the political success of policy formulation. Appreciating these politics, power and structural issues shaping PM-JAY institutional design will be important to understand how PM-JAY is implemented and how it advances UHC in India., (© The Author(s) 2023. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

COVID-19 represented an unprecedented challenge for health workers around the world, resulting in strong concerns about impacts on their psychological well-being. To inform on-going support and future preparedness activities, this study documented health workers' experiences, well-being and coping throughout the first wave of the pandemic, in Burkina Faso, Senegal and The Gambia. We collected data from 68 primarily clinical staff from the COVID-19 treatment, maternity and emergency departments in 13 purposely hospitals and laboratories across the three countries. Following in-depth interviews via Zoom (mid-May to September 2020), we regularly followed up via WhatsApp until the end of 2020. We used a mixed deductive and inductive coding approach and a framework matrix to organize and analyse the material. All respondents initially assessed the situation as stressful and threatening. Major emotional reactions included fear of own infection, fear of being a risk to loved ones, guilt, compassion, and anxiety regarding the future. Many suffered from feeling left alone with the emerging crisis and feeling unvalued and unappreciated, particularly by their governments and ministries of health. Conversely, health workers drew much strength from support and valuation by direct supervisors and team members and, in part, also by patients, friends and family. We observed important heterogeneity between places of work and individual backgrounds. Respondents coped with the situation in various ways, particularly with strategies to manage adverse emotions, to minimize infection risk, to fortify health and to find meaning in the adverse circumstances. Coping strategies were primarily grounded in own resources rather than institutional support. Over time, the situation normalized and fears diminished for most respondents. With a view towards emergency preparedness, our findings underline the value of participation and transparent communication, institutional support and routine training to foster health workers' psychological preparedness, coping skill set and resilience more generally., (© The Author(s) 2023. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Combination HIV prevention aims to provide the right mix of biomedical, behavioral and structural interventions, and is considered the best approach to curb the HIV pandemic. The impact evaluation of combined HIV prevention intervention (CHPI) provides critical information for decision making. We conducted a systematic review of the literature to map the designs and methods used in these studies. We searched original articles indexed in Web of Science, Scopus and PubMed. Fifty-eight studies assessing the impact of CHPI on HIV transmission were included. Most of the studies took place in Asia or sub-Saharan Africa and were published from 2000 onward. We identified 36 (62.1%) quasi-experimental studies (posttest, pretest-posttest and nonequivalent group designs) and 22 (37.9%) experimental studies (randomized designs). The findings suggest that diverse methods are already rooted in CHPI impact evaluation practices as recommended but should be better reported. CHPI impact evaluation would benefit from more comprehensive approaches., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Malnutrition in children is a serious health problem, especially in Sub-Saharan Africa, with heavy socioeconomic burdens. The prevalence of stunting remains high in Burkina Faso. There is a need to further investigate undernutrition and identify the major factors contributing to its persistence. We aimed to assess the nutritional status of children aged under five years and the associated factors of undernutrition in Burkina Faso. We conducted a second study using a baseline household survey of the impact assessment of a performance-based financing program. The analysis focused on data of 10,032 children aged 0-59 months collected from households in 537 villages. Anthropometric indicators were assessed using the World Health Organization standards, and their association with children, mothers, and households' characteristics were assessed using logistic regression. Stunting occurred in 40.1% of children, wasting in 25.1%, and underweight in 34%. Children having both stunting, wasting, and underweight were 7.3%. Stunting and underweight was associated with the sex. Stunting was associated with ethnic groups: Fulani with AdjOR = 1.20 (95%CI: 1.01-1.42), household economic level: poorest AdjOR = 1.25 (95%CI: 1.10-1.43), two and more children aged under five years in households: AdjOR = 1.16 (95%CI: 1.05-1.27), distance more than 5km from household to health facility: with Adj OR = 1.21 (95%CI: 1.10-1.35) and household food insecurity. This study identified the modifiable factors that determine the high prevalence of undernutrition in Burkina Faso. Strategies and interventions to improve the health and economic status of the community are needed to reduce the occurrence of undernutrition., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Picbougoum et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The Pradhan Mantri Jan Arogya Yojana (PM-JAY), a publicly funded health insurance scheme, was launched in India in September 2018 to provide financial access to health services for poor Indians. PM-JAY design enables state-level program adaptations to facilitate implementation in a decentralized health implementation space. This study examines the competency, organizational, and leadership approaches affecting PM-JAY implementation in three contextually different Indian states., Methods: We used a framework on implementation drivers (competency, organizational, and leadership) to understand factors facilitating or hampering implementation experiences in three PM-JAY models: third-party administrator in Uttar Pradesh, insurance in Chhattisgarh, and hybrid in Tamil Nadu. We adopted a qualitative exploratory approach and conducted 92 interviews with national, state, district, and hospital stakeholders involved in program design and implementation in Delhi, three state capitals, and two anonymized districts in each state, between February and April 2019. We used a deductive approach to content analysis and interpreted coded material to identify linkages between organizational features, drivers, and contextual elements affecting implementation., Results and Conclusion: PM-JAY guideline flexibilities enabled implementation in very different states through state-adapted implementation models. These models utilized contextually relevant adaptations for staff and facility competencies and organizational and facilitative administration, which had considerable scope for improvement in terms of recruitment, competency development, programmatic implementation support, and rationalizing the joint needs of the program and implementers. Adaptations also created structural barriers in staff interactions and challenged implicit power asymmetries and organizational culture, indicating a need for aligning staff hierarchies and incentive structures. At the same time, specific adaptations such as decentralizing staff selection and task shifting (all models); sharing of claims processing between the insurer and state agency (insurance and hybrid model); and using stringent empanelment, accreditation, monitoring, and benchmarking criteria for performance assessment, and reserving secondary care benefit packages for public hospitals (both in the hybrid model) contributed to successful implementation. Contextual elements such as institutional memory of previous schemes and underlying state capacities influenced all aspects of implementation, including leadership styles and autonomy. These variations make comparisons across models difficult, yet highlight constraints and opportunities for cross-learning and optimizing implementation to achieve universal health coverage in decentralized contexts., (© 2023. The Author(s).)

Background: Armed conflict is on the rise in sub-Saharan Africa and affects public infrastructures, including health systems, although evidence on population health is sparse. We aimed to establish how these disruptions ultimately affect health service coverage., Methods: We geospatially matched Demographic and Health Survey data with the Uppsala Conflict Data Program Georeferenced Events Dataset, covering 35 countries for the period from 1990 to 2020. We relied on linear probability models with fixed effects to capture the effect of nearby armed conflict (within 50 km of the survey cluster) on four service coverage indicators along the continuum of maternal and child health care. We also investigated effect heterogeneity by varying conflict intensity and duration, and sociodemographic status., Findings: The estimated coefficients represent the decrease in the probability (in percentage points) of the child or their mother being covered by the respective health service following deadly conflicts within 50 km. Any nearby armed conflict was associated with reduced coverage for all examined health services, with the exception of early antenatal care: early antenatal care (-0·5 percentage points, 95% CI -1·1 to 0·1), facility-based delivery (-2·0, -2·5 to -1·4), timely childhood vaccination (-2·5, -3·1 to -1·9), and treatment of common childhood illnesses (-2·5, -3·5 to -1·4). For all four health services, the negative effects increased for high-intensity conflicts and were significant throughout. When examining conflict duration, we did not find negative effects on the treatment of common childhood illnesses in prolonged conflicts. The analysis on effect heterogeneity revealed that, except for timely childhood vaccination, the negative effects of armed conflict on health service coverage were more pronounced in urban settings., Interpretation: Our findings suggest that health service coverage is significantly affected by contemporaneous conflict, but health systems can adapt to provide routine services, such as child curative services, in situations of prolonged conflict. Our analysis underlines the importance of studying health service coverage during conflict both at the finest possible scales and across different indicators, pointing at the need for differential policy interventions., Funding: None., Translations: For the French and Portuguese translations of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests OS reports membership in the International Scientific Advisory Board of The Lancet Global Health. All other authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Rigorous evaluations of health system interventions to strengthen hypertension and cardiovascular disease (CVD) care remain scarce in sub-Saharan Africa. This study aims to evaluate the reach, effectiveness, adoption / acceptability, implementation fidelity, cost, and sustainability of the Ghana Heart Initiative (GHI), a multicomponent supply-side intervention to improve cardiovascular health in Ghana., Methods: This study adopts a mixed- and multi-methods design comparing the effects of the GHI in 42 intervention health facilities (i.e. primary, secondary and tertiary) in the Greater Accra Region versus 56 control health facilities in the Central and Western Regions. The evaluation design is guided by the RE-AIM framework underpinned by the WHO health systems building blocks framework, integrated by the Institute of Medicine's six dimensions of health care quality: safe, effective, patient-centered, timely, effi cient, equitable. The assessment tools include: (i) a health facility survey, (ii) a healthcare provider survey assessing the knowledge, attitudes, and practices on hypertension and CVD management, (iii) a patient exit survey, (iv) an outpatient and in-patient medical record review and (v) qualitative interviews with patients and various health system stakeholders to understand the barriers and facilitators around the implementation of the GHI. In addition to primary data collection, the study also relies on secondary routine health system data, i.e., the District Health Information Management System to conduct an interrupted time series analysis using monthly counts for relevant hypertension and CVD specific indicators as outcomes. The primary outcome measures are performance of health service delivery indicators, input, process and outcome of care indicators (including screening of hypertension, newly diagnosed hypertension, prescription of guideline directed medical therapy, and satisfaction with service received and acceptability) between the intervention and control facilities. Lastly, an economic evaluation and budget impact analysis is planned to inform the nationwide scale-up of the GHI., Discussion: This study will generate policy-relevant data on the reach, effectiveness, implementation fidelity, adoption / acceptability, and sustainability of the GHI, and provide insights on the costs and budget-impacts to inform nation-wide scale-up to expand the GHI to other regions across Ghana and offer lessons to other low- and middle-income countries settings as well., Ridie Registration Number: RIDIE-STUDY-ID-6375e5614fd49 (https://ridie.3ieimpact.org/index.php)., Competing Interests: Competing interests The authors have no competing interests to declare.

Background: While maternal mortality has declined globally, it remains highest in low-income countries. High-quality antenatal care (ANC) can prevent or decrease pregnancy-related complications for mothers and newborns. The implementation of performance-based financing (PBF) schemes in Sub-Saharan Africa to improve primary healthcare provision commonly includes financial indicators linked to ANC service quality indicators. In this study, we examine changes in ANC provision produced by the introduction of a PBF scheme in rural Burkina Faso., Methods: This study followed a quasi-experimental design with two data collection points comparing effects on ANC service quality between primary health facilities across intervention and control districts based on difference-in-differences estimates. Performance scores were defined using data on structural and process quality of care reflecting key clinical aspects of ANC provision related to screening and prevention pertaining to first and follow-up ANC visits., Results: We found a statistically significant increase in performance scores by 10 percent-points in facilities' readiness to provide ANC services. The clinical care provided to different ANC client groups scored generally low, especially with respect to preventive care measures, we failed to observe any substantial changes in the clinical provision of ANC care attributable to the PBF., Conclusion: The observed effect pattern reflects the incentive structure implemented by the scheme, with a stronger focus on structural elements compared with clinical aspects of care. This limited the scheme's overall potential to improve ANC provision at the client level after the observed three-year implementation period. To improve both facility readiness and health worker performance, stronger incentives are needed to increase adherence to clinical standards and patient care outcomes., (© 2023. The Author(s).)

Background: In April 2016, Burkina Faso began free healthcare for children aged from 0 to 5 years. However, its implementation faces challenges, and the goal of this study is to estimate the fees paid for this child care and to determine the causes of these direct payments., Methods: Data gathering involved 807 children aged from 0 to 5 years who had contact with the public healthcare system. The estimation of the determinants of out-of-pocket health payments involved the application of a two-part regression model., Results: About 31% of the children made out-of-pocket payments for healthcare (an average of 3407.77 CFA francs per case of illness). Of these, 96% paid for medicines and 24% paid for consultations. The first model showed that out-of-pocket payments were positively associated with hospitalization, urban area of residence, and severity of illness, were made in the East-Central and North-Central regions, and were negatively associated with the 7 to 23 month age range. The second model showed that hospitalization and severity of illness increased the amount of direct health payments., Conclusion: Children targeted by free healthcare still make out-of-pocket payments. The dysfunction of this policy needs to be studied to ensure adequate financial protection for children in Burkina Faso.

Throughout the SARS-CoV-2 pandemic, limited diagnostic capacities prevented sentinel testing, demonstrating the need for novel testing infrastructures. Here, we describe the setup of a cost-effective platform that can be employed in a high-throughput manner, which allows surveillance testing as an acute pandemic control and preparedness tool, exemplified by SARS-CoV-2 diagnostics in an academic environment. The strategy involves self-sampling based on gargling saline, pseudonymized sample handling, automated RNA extraction, and viral RNA detection using a semiquantitative multiplexed colorimetric reverse transcription loop-mediated isothermal amplification (RT-LAMP) assay with an analytical sensitivity comparable with RT-qPCR. We provide standard operating procedures and an integrated software solution for all workflows, including sample logistics, analysis by colorimetry or sequencing, and communication of results. We evaluated factors affecting the viral load and the stability of gargling samples as well as the diagnostic sensitivity of the RT-LAMP assay. In parallel, we estimated the economic costs of setting up and running the test station. We performed > 35,000 tests, with an average turnover time of < 6 h from sample arrival to result announcement. Altogether, our work provides a blueprint for fast, sensitive, scalable, cost- and labor-efficient RT-LAMP diagnostics, which is independent of potentially limiting clinical diagnostics supply chains., (© 2023 The Authors. Published under the terms of the CC BY NC ND 4.0 license.)

The literature suggests that a first barrier towards accessing benefits of health insurance in low- and middle-income countries is lack of awareness of one's benefits. Yet, across settings and emerging schemes, limited scientific evidence is available on levels of awareness and their determinants. To fill this gap, we assessed socio-demographic and economic determinants of beneficiaries' awareness of the Pradhan Mantri Jan Arogya Yojana (PM-JAY), the national health insurance scheme launched in India in 2018, and their awareness of own eligibility. We relied on cross-sectional household (HH) survey data collected in six Indian states between 2019 and 2020. Representative data of HHs eligible for PM-JAY from 11 618 respondents (an adult representative from each surveyed HH) were used. We used descriptive statistics and multivariable logistic regression models to explore the association between awareness of PM-JAY and of one's own eligibility and socio-economic and demographic characteristics. About 62% of respondents were aware of PM-JAY, and among the aware, 78% knew that they were eligible for the scheme. Regression analysis confirmed that older respondents with a higher educational level and salaried jobs were more likely to know about PM-JAY. Awareness was lower among respondents from Meghalaya and Tamil Nadu. Respondents from Other Backward Classes, of wealthier socio-economic status or from Meghalaya or Gujarat were more likely to be aware of their eligibility status. Respondents from Chhattisgarh were less likely to know about their eligibility. Our study confirms that while more than half of the eligible population was aware of PM-JAY, considerable efforts are needed to achieve universal awareness. Socio-economic gradients confirm that the more marginalized are still less aware. We recommend implementing tailored, state-specific information dissemination approaches focusing on knowledge of specific scheme features to empower beneficiaries to demand their entitled services., (© The Author(s) 2023. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Background: The American College of Surgeons Oncology Group Z0011 trial showed that complete axillary lymph node dissection (cALND) did not improve survival benefits in patients with one or two tumour-involved sentinel lymph nodes and undergoing breast conservation. Still, a considerable number of the Z0011-eligible patients continue to be treated with cALND in various countries. Given the potential economic gain from implementation of the Z0011 recommendations, we quantified population-level impacts of omitting cALND among Z0011-eligible patients in clinical practice., Methods: This 2-year economic analysis adopted both the perspective of patients under statutory insurance and the societal perspective, using data collected prospectively from 179 German breast cancer units between 2008 and 2015. The estimation of cost savings and health gain relied on a single decision tree, which considered three scenarios: clinical practice at the baseline; actual implementation in routine care; and hypothetical full implementation in all eligible patients., Results: Data for 188,909 patients with primary breast cancer were available, 13,741 (7.3%) of whom met the Z0011 inclusion criteria. The use of cALND decreased from 94.3% in 2010 to 46.9% in 2015, resulting in a gain of 335 quality-adjusted life-years and a saving of EUR50,334,756 for the society. Had cALND been omitted in all eligible patients, the total gain would have been more than double., Conclusions: The implementation of the Z0011 recommendations resulted in substantial savings and health gain in Germany. Our findings suggest that it is beneficial to introduce additional policy measures to promote further uptake of the Z0011 recommendations in clinical practice., (© 2022. The Author(s).)

Objectives: In Burkina Faso, only 2.1% of women give birth by caesarean section (CS). To improve the use of maternal health services during pregnancy and childbirth, many interventions were implemented during the 2010s including performance-based financing (PBF) and a free maternal health care policy (the gratuité). The objective of this study is to evaluate the impact of a supply-side intervention (PBF) combined with a demand-side intervention (gratuité) on institutional CS rates in Burkina Faso., Methods: We used routine health data from all the public health facilities in 21 districts (10 that implemented PBF and 11 that did not) from January 2013 to September 2017. We analysed CS rates as the proportion of CS performed out of all facility-based deliveries (FBD) that occurred in the district. We performed an interrupted time series (ITS) analysis to evaluate the impact of PBF alone and then in conjunction with the gratuité on institutional CS rates., Results: CS rates in Burkina Faso increased slightly between January 2013 and September 2017 in all districts. After the introduction of PBF, the increase of CS rates was higher in intervention than in non-intervention districts. However, after the introduction of the gratuité, CS rates decreased in all districts, independently of the PBF intervention., Conclusion: In 2017, despite high FBD rates in Burkina Faso as well as the PBF intervention and the gratuité, less than 3% of women who gave birth in a health facility did so by CS. Our study shows that the positive PBF effects were not sustained in a context of user fee exemption., (© 2022 The Authors Tropical Medicine & International Health Published by John Wiley & Sons Ltd.)

Background: Digital interventions for health financing, if implemented at scale, have the potential to improve health system performance by reducing transaction costs and improving data-driven decision-making. However, many interventions never reach sustainability, and evidence on success factors for scale is scarce. The Insurance Management Information System (IMIS) is a digital intervention for health financing, designed to manage an insurance scheme and already implemented on a national scale in Tanzania. A previous study found that the IMIS claim function was poorly adopted by health care workers (HCWs), questioning its potential to enable strategic purchasing and succeed at scale., Objective: This study aimed to understand why the adoption of the IMIS claim function by HCWs remained low in Tanzania and to assess implications for use at scale., Methods: We conducted 21 semistructured interviews with HCWs and management staff in 4 districts where IMIS was first implemented. We sampled respondents by using a maximum variation strategy. We used the framework method for data analysis, applying a combination of inductive and deductive coding to organize codes in a socioecological model. Finally, we related emerging themes to a framework for digital health interventions for scale., Results: Respondents appreciated IMIS's intrinsic software characteristics and technical factors and acknowledged IMIS as a valuable tool to simplify claim management. Human factors, extrinsic ecosystem, and health care ecosystem were considered as barriers to widespread adoption., Conclusions: Digital interventions for health financing, such as IMIS, may have the potential for scale if careful consideration is given to the environment in which they are placed. Without a sustainable health financing environment, sufficient infrastructure, and human capacity, they cannot unfold their full potential to improve health financing functions and ultimately contribute to universal health coverage., (©Leon Schuetze, Siddharth Srivastava, Abdallah Mtiba Missenye, Elizeus Josephat Rwezaula, Manfred Stoermer, Manuela De Allegri. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 06.01.2023.)

Background: Digital information management systems for health financing are implemented on the assumption thatdigitalization, among other things, enables strategic purchasing. However, little is known about the extent to which thesesystems are adopted as planned to achieve desired results. This study assesses the levels of, and the factors associated withthe adoption of the Insurance Management Information System (IMIS) by healthcare providers in Tanzania., Methods: Combining multiple data sources, we estimated IMIS adoption levels for 365 first-line health facilities in2017 by comparing IMIS claim data (verified claims) with the number of expected claims. We defined adoption as abinary outcome capturing underreporting (verified

Background: Burkina Faso has been implementing financing reforms towards universal health coverage (UHC) since 2006. Recently, the country introduced a performance-based financing (PBF) program as well as user fee removal (gratuité) policy for health services aimed at pregnant and lactating women and children under 5. We aim to assess the effect of gratuité and PBF policies on facility-based out-of-pocket expenditures (OOPEs) for outpatient services., Methods: Our study is a controlled pre- and post-test design using healthcare facility data from the PBF program's impact evaluation collected in 2014 and 2017. We compared OOPE related to primary healthcare use incurred by children under 5 and individuals above 5 to assess the effect of the gratuité policy on OOPE. We further compared OOPE incurred by individuals residing in PBF districts and non-PBF districts to estimate the effect of the PBF on OOPE. Effects were estimated using difference-in-differences models, distinguishing the estimation of the probability of incurring OOPE from the estimation of the magnitude of OOPE using a generalized linear model (GLM)., Results: The proportion of children under 5 incurring OOPE declined significantly from 90% in 2014 to 3% in 2017. Concurrently, mean OOPE also decreased. Differences in both the probability of incurring OOPE and mean OOPE between PBF and non-PBF facilities were small. Our difference in differences estimates indicated that gratuité produced an 84% (CI -86%, -81%) reduction in the probability of incurring OOPE and reduced total OOPE by 54% (CI 63%, 42%). We detected no significant effects of PBF, either in reducing the probability of incurring OOPE or in its magnitude., Conclusion: User fee removal is an effective demand-side intervention for enhancing financial accessibility. As a supply-side intervention, PBF appears to have limited effects on reducing financial burden., (© 2023 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Introduction: Gender-based discrimination (GBD) is generally defined as unequal or disadvantageous treatment based on one's gender. Emerging evidence suggests that exposure to GBD in its various forms can yield negative consequences for women's health, including delaying access to healthcare services and lowering the quality of nutrition. Although consensus exists around the theoretical definitions of GBD, current studies are limited on how to measure GBD empirically in order to assess its true impact on women's health. Our mixed-methods scoping review aims at synthesising existing evidence by answering the question How is gender-based discrimination defined and measured in the health literature, with specific reference to Low and Middle-Income Countries (LMICs )?. Our ambition is to identify commonalities across definitions and measures to generate a dialogue towards reaching consensus around the development of a single standardised tool to be applied in health studies., Methods and Analysis: Our mixed-method scoping review includes quantitative, qualitative and mixed-methods studies and unfolds according to the six stages proposed by Levac et al . Eligibility criteria for studies were defined in order to reflect the three core elements of the search, namely (1) the discrimination based on the gender, (2) the link to health outcomes and (3) the developing countries context. Four databases (PubMed, Web of Science, Cinahl and Econlit) were searched. We will extract and synthesise information from quantitative and qualitative studies following the framework proposed by Hong and use the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review tool as a guide., Ethics and Dissemination: Since our scoping review relies exclusively on information extracted from published articles, its conduct is not subjected to ethical clearance. Results will be described and discussed in a peer-reviewed article and presented at relevant workshops and conferences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Antigen-based rapid diagnostic tests (RDTs) for SARS-CoV-2 have good reliability and have been repeatedly implemented as part of pandemic response policies, especially for screening in high-risk settings (e.g., hospitals and care homes) where fast recognition of an infection is essential. However, evidence from actual implementation efforts and associated experiences is lacking. We conducted a qualitative study at a large tertiary care hospital in Germany to identify step-by-step processes when implementing RDTs for the screening of incoming patients, as well as stakeholders' implementation experiences. We relied on 30 in-depth interviews with hospital staff (members of the regulatory body, department heads, staff working on the wards, staff training providers on how to perform RDTs, and providers performing RDTs as part of the screening) and patients being screened with RDTs. Despite some initial reservations, RDTs were rapidly accepted and adopted as the best available tool for accessible and reliable screening. Decentralized implementation efforts resulted in different procedures being operationalized across departments. Procedures were continuously refined based on initial experiences (e.g., infrastructural or scheduling constraints), pandemic dynamics (growing infection rates), and changing regulations (e.g., screening of all external personnel). To reduce interdepartmental tension, stakeholders recommended high-level, consistently communicated and enforced regulations. Despite challenges, RDT-based screening for all incoming patients was observed to be feasible and acceptable among implementers and patients, and merits continued consideration in the context of high infection and stagnating vaccination rates., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: This work was supported by a grant of the Ministry of Science, Research and the Arts of Baden-Württemberg, Germany, as well as hospital-internal funds. Funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. CMD was part of the decision-making processes to implement RDT-based screening in the study setting, based on her previous work on independent validation of RDTs. Her contribution to this manuscript is independent of this role. None of the authors declare any conflicting interests, including any commercial interest related to the implementation of any diagnostic test for SARS-CoV-2. The views expressed reflect exclusively the authors’ views and not those of the institution they work for., (© 2022 The Author(s).)

Background: Low- and middle-income countries worldwide are striving to achieve universal health coverage (UHC), frequently through expansion of statutory health insurance schemes. However, oftentimes evidence is lacking on progress towards quality patient-centred care and out-of-pocket expenditure (OOPE), particularly for poor population groups. We contribute patient-centred evidence examining patient experience and OOPE under JKN, the Indonesian social health insurance., Methods: Using data from 2526 patient exit interviews conducted among JKN beneficiaries in 2015, we computed a summative patient experience measure from 14 experience items. We used descriptive statistics to assess patient experience and the probability, amount and components of OOPE. We applied a two-part model to examine the relationships between socio-demographics, facility types, and OOPE and an OLS regression on patient experience determinants., Results: The mean patient experience measure was 11.7 out of 14 maximal points. Differences were observed between single items, with highest ratings on ease of understanding providers' language (97%) and lowest on waiting time (54%). OOPE were reported by 20% of patients with a mean equivalent to US$40, the most prevalent reason being medicines (61% of all OOPE). Considerable OOPE heterogeneity occurred by province and facility type. We found differentials in OOPE by gender (females paying more likely, but less) and subsidised JKN membership (same likelihood as non-subsidised, but paying less)., Conclusion: Our findings suggest that during its early implementation, patients under JKN reported mostly positive patient experience yet a fifth incurred OOPE, mostly on medicines. Further patient-centred research is needed to ensure JKN's progress towards UHC., (© 2022 The Authors. The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.)

Background: Zambia has invested in several healthcare financing reforms aimed at achieving universal access to health services. Several evaluations have investigated the effects of these reforms on the utilization of health services. However, only one study has assessed the distributional incidence of health spending across different socioeconomic groups, but without differentiating between public and overall health spending and between curative and maternal health services. Our study aims to fill this gap by undertaking a quasi-longitudinal benefit incidence analysis of public and overall health spending between 2006 and 2014., Methods: We conducted a Benefit Incidence Analysis (BIA) to measure the socioeconomic inequality of public and overall health spending on curative services and institutional delivery across different health facility typologies at three time points. We combined data from household surveys and National Health Accounts., Results: Results showed that public (concentration index of - 0.003; SE 0.027 in 2006 and - 0.207; SE 0.011 in 2014) and overall (0.050; SE 0.033 in 2006 and - 0.169; SE 0.011 in 2014) health spending on curative services tended to benefit the poorer segments of the population while public (0.241; SE 0.018 in 2007 and 0.120; SE 0.007 in 2014) and overall health spending (0.051; SE 0.022 in 2007 and 0.116; SE 0.007 in 2014) on institutional delivery tended to benefit the least-poor. Higher inequalities were observed at higher care levels for both curative and institutional delivery services., Conclusion: Our findings suggest that the implementation of UHC policies in Zambia led to a reduction in socioeconomic inequality in health spending, particularly at health centres and for curative care. Further action is needed to address existing barriers for the poor to benefit from health spending on curative services and at higher levels of care., (© 2022. The Author(s).)