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Summary: Background: The Pacific Island country of Vanuatu is at the early stages of demographic ageing. The government is yet to develop a strategic approach to optimize the health and wellbeing of older indigenous Vanuatu residents (ni-Vanuatu). Methods: Using policy mapping and semi-structured interviews with 42 ni-Vanuatu, this research aimed to explore the current policy context surrounding ageing in Vanuatu and the priorities of older adults to inform preliminary steps to develop a national response to healthy ageing. Analyses were grounded in the World Health Organization's Regional Action Plan on Healthy Ageing in the Western Pacific. Findings: While the national policy context exhibited an indirect commitment to creating an environment conducive to healthy ageing, explicit policy commitments and monitoring indicators were lacking. Older persons reported numerous obstacles to healthy ageing, including financial insecurity, physical and psychological barriers to participation, and lack of community support. Interpretation: Findings highlighted the need for policymakers and stakeholders to focus preliminary strategic efforts on select components of the Regional Action Plan: evidence generation, advocacy/awareness, financing, community engagement and coordination, and family-centred empowerment. To ensure acceptability and sustainability, it is vital that these leverage existing strengths of traditional community values and the prevailing role of faith and religion in the lives of older ni-Vanuatu. Funding: This project was funded and supported by the World Health Organization (WHO) Regional Office for the Western Pacific (WPRO). Outcomes reflect the deliberations of authors and research partners.

Objectives: To investigate publicly funded healthcare costs according to faller status and the periods pre- and post-cataract surgeries, and identify factors associated with higher monthly costs in older people with bilateral cataract. Methods: This prospective cohort study included community-dwelling older people aged 65 and over (between 2012 and 2019); at baseline participants had bilateral cataract and were waiting for cataract surgery in New South Wales (NSW) public hospitals. Participants were followed for 24 months. The study used self-reported and linked data (Medicare Benefits Schedule, Pharmaceutical Benefits Scheme, NSW Admitted Patient and Emergency Department Data Collections) to identify falls, cataract surgeries and healthcare costs incurred by the Australian and NSW Governments, all costs were inflated to 2018–19 Australian dollars (AUD). Median monthly healthcare costs were calculated for faller status (non-faller, non-medically treated faller, medically treated faller) and surgery periods (pre-surgery, post-first surgery, post-second surgery). Costs in the 30 days following a medically treated fall were estimated. A generalised linear model was used to investigate predictors of healthcare costs. Results: During the median follow-up period of 24 months, 274 participants suffered 448 falls, with 95 falls requiring medical treatment. For medically treated falls, the mean cost in the 30 days after treatment was A$3779 (95% confidence interval $2485, $5074). Higher monthly healthcare costs were associated with a higher number of medications, being of the male sex, having one or more medically treated falls and having bilateral cataract surgery. After excluding the cost of cataract surgery, there were no significant differences in healthcare costs between the pre-cataract surgery, post-first eye cataract surgery and post-second eye cataract surgery periods. Conclusions: To our knowledge, this is the first study investigating publicly funded costs related to falls and cataract surgery in older people with bilateral cataract. This information enhances our understanding of healthcare costs in this group. The patterns in costs associated with falls can guide future government healthcare expenditure on falls treatment and prevention, including timely cataract surgery.

Abstract Background In Indonesia, the world's fourth most populous country, cardiovascular diseases (CVDs) are a leading cause of death and disability. Government efforts to reduce the burden of CVD include a community-based prevention and early detection programme, and the provision of medicines to prevent cardiovascular events. Disruptions to medicine supply chains, service provision, and movement during the COVID-19 pandemic potentially threatened the continuity of these efforts. We investigated the distribution and dispensing of common CVD medicines in Malang district, East Java, before the pandemic and early in its course. Methods From January to October 2020, we collected monthly data on stock levels, sales or dispensing volumes, and price for five common CVD medicines (amlodipine, captopril, furosemide, glibenclamide and simvastatin), from a public and a private distributor, and from public health facilities (n = 4) and private pharmacies (n = 2). We further complied monthly data on patient numbers in two primary health centres. We tracked changes in stocks held and volumes dispensed by medicine type and sector, comparing the three months before the local COVID-19 response was mobilised with the subsequent seven months. We conducted interviews with pharmacists (n = 12), community health workers (n = 2) and a supply chain logistics manager to investigate the reasons for observed changes, and to learn details of any impacts or mitigation measures. Results The pandemic affected demand more than supply, causing medicine stocks to rise. Restricted service provision, lock-down measures and fear of infection contributed to a sharp drop in patient numbers and dispensing volumes in the public sector. Meanwhile private sector sales, especially of lower-priced CVD medicines, rose. Community health workers attributed some poor health outcomes to interruption in regular patient check-ups; this interruption was aggravated by formal mitigation policies. Conclusions Fears that COVID-19 would interrupt medicine availability were unfounded in East Java. Public sector patients may have compensated for reduced service access by switching to private pharmacies. Mitigation policies that ignored administrative procedures were not effective.

Objective To review the evidence on the impact on measurable outcomes of performance-based incentives for community health workers (CHWs) in low- and middle-income countries. Methods We conducted a systematic review of intervention studies published before November 2020 that evaluated the impact of financial and non-financial performance-based incentives for CHWs. Outcomes included patient health indicators; quality, utilization or delivery of health-care services; and CHW motivation or satisfaction. We assessed risk of bias for all included studies using the Cochrane tool. We based our narrative synthesis on a framework for measuring the performance of CHW programmes, comprising inputs, processes, performance outputs and health outcomes. Findings Two reviewers screened 2811 records; we included 12 studies, 11 of which were randomized controlled trials and one a nonrandomized trial. We found that non-financial, publicly displayed recognition of CHWs' efforts was effective in improved service delivery outcomes. While large financial incentives were more effective than small ones in bringing about improved performance, they often resulted in the reallocation of effort away from other, non-incentivized tasks. We found no studies that tested a combined package of financial and non-financial incentives. The rationale for the design of performance-based incentives or explanation of how incentives interacted with contextual factors were rarely reported. Conclusion Financial performance-based incentives alone can improve CHW service delivery outcomes, but at the risk of unincentivized tasks being neglected. As calls to professionalize CHW programmes gain momentum, research that explores the interactions among different forms of incentives, context and sustainability is needed. Objectif Examiner les preuves attestant de l'impact des incitants lies aux performances sur les resultats mesurables des agents de sante communautaires (ASC) dans les pays a faible et moyen revenu. Methodes Nous avons effectue une revue systematique des etudes d'intervention publiees avant novembre 2020 et evaluant l'impact, sur les ASC, des incitants financiers et non financiers lies aux performances. Les resultats observes concernaient notamment les indicateurs de sante des patients; la qualite, l'utilisation ou la fourniture de soins de sante; et le degre de motivation ou de satisfaction des ASC. Nous avons employe l'outil Cochrane afin de calculer le risque de biais pour toutes les etudes selectionnees. Notre synthese narrative repose sur un cadre mesurant les performances des programmes d'ASC, en ce compris les moyens disponibles, les processus et les resultats en termes de performances et de sante. Resultats Deux reviseurs ont passe au crible 2811 documents; nous avons retenu 12 etudes, dont 11 essais randomises controles et un essai non randomise. Nous avons constate que le fait d'afficher ouvertement une reconnaissance non financiere des efforts consentis par les ASC entrainait une amelioration des prestations de service. En outre, bien que l'efficacite des incitants financiers soit proportionnelle au montant octroye lorsqu'il s'agissait d'obtenir de meilleures performances, cette evolution se faisait souvent aux depens des taches ne donnant pas droit a des mesures incitatives. Nous n'avons trouve aucune etude ayant teste un ensemble d'incitants financiers et non financiers. La logique derriere la conception des incitants lies aux performances ou l'explication des interactions entre incitants et facteurs contextuels n'etaient que rarement communiques. Conclusion Les incitants financiers lies aux performances suffisent a ameliorer les prestations des ASC, mais risquent de detourner l'attention des taches ne faisant pas l'objet d'incitants. De plus en plus de voix s'elevent pour reclamer une professionnalisation des programmes d'ASC; il devient donc essentiel de mener des recherches afin d'explorer les interactions entre les differentes formes d'incitants, le contexte et la perennisation. Objetivo Revisar la evidencia sobre el impacto en los resultados medibles de los incentivos basados en el rendimiento para el personal sanitario comunitario (PSC) en paises de ingresos bajos y medios. Metodos Se realizo una revision sistematica de los estudios de intervention, publicados antes de noviembre de 2020, que evaluaban el impacto de los incentivos financieros y no financieros basados en el rendimiento para el PSC. Los resultados incluyeron indicadores de salud de los pacientes; calidad, utilization o prestacion de servicios de atencion sanitaria; y motivation o satisfaction del PSC. Se evaluo el riesgo de sesgo para todos los estudios incluidos mediante Cochrane. La sintesis narrativa se baso en un marco para medir el rendimiento de los programas de PSC, que comprende aportaciones, procesos, resultados de rendimiento y resultados de salud. Resultados Dos revisores examinaron 2811 informes; se incluyeron 12 estudios, 11 de los cuales eran ensayos controlados aleatorios y uno no aleatorio. Se encontro que el reconocimiento no financiero, mostrado publicamente, de los esfuerzos del PSC fue efectivo para mejorar los resultados de la prestacion de servicios. Si bien los incentivos financieros grandes fueron mas eficaces que los pequenos para lograr un mejor rendimiento, a menudo dieron lugar a la reasignacion de esfuerzos de otras tareas no incentivadas. No encontramos ningun estudio que probara un paquete combinado de incentivos financieros y no financieros. Rara vez se informo de la justification del diseno de los incentivos basados en el rendimiento o de la explication de como los incentivos interactuaban con los factores contextuales. Conclusion Los incentivos financieros basados en el rendimiento por si solos pueden mejorar los resultados de la prestacion de servicios del PSC, pero con el riesgo de que se descuiden las tareas no incentivadas. A medida que los llamamientos a la profesionalizacion de los programas de PSC cobran impulso, es necesario realizar investigaciones que exploren las interacciones entre las diferentes formas de incentivos, el contexto y la sostenibilidad., Introduction Community health workers (CHWs) play an important role in fulfilling global commitments to strengthen primary health-care systems and achieve universal health coverage. A CHW is a member of the [...]

Abstract Background Women are disadvantaged by ageing: older women are more likely than older men to suffer from ill-health, have less access to health care and suffer discrimination within the health care system. Globally, there is a dearth of health research on gender and ageing with substantial knowledge gaps in low and middle-income country contexts. Part of a wider investigation on health and ageing in Fiji, our objective was to identify and describe gendered differences in healthy ageing in this Pacific Island context. We believe this to be the first such study in the Pacific region. Methods Applying a health systems lens, we used a mixed-methods approach, encompassing analysis of cause of death data; focus group discussion to gather community and family attitudes to health services; and policy analysis, and then used data triangulation techniques to draw out key themes and insights. Results We found that gender affects health outcomes among older persons, attitudes towards and experience of healthy ageing, and an older person’s access to and use of health services. We also found that while Fiji’s policy response to ageing has recognised the importance of gender, to-date there has been limited action to address gender differences. Gender (as oppose to sex differences) has direct and indirect implications for the health of older Fijians, while gendered inequalities and patriarchal norms appear to affect both men and women’s experience of ageing and the health system response. Further, gender and age discrimination may be intersecting, intensifying their separate effects. Conclusion This study demonstrates the feasibility and importance of applying a gender lens to the study of healthy ageing. Our findings from Fiji may be relevant to other island nations in the south Pacific which share similar challenges of population ageing, a constrained health budget and geographically-dispersed populations. The data triangulation methodology may be considered an efficient and insightful way to examine gendered responses to healthy ageing elsewhere.

Background The WHO has warned that substandard and falsified medicines threaten health, especially in low and middle-income countries (LMICs). However, the magnitude of that threat for many medicines in different regions is not well described, and high-quality studies remain rare. Recent reviews of studies of cardiovascular and diabetes medicine quality recorded that 15.4% of cardiovascular and 6.8% of diabetes samples failed at least one quality test. Review authors warn that study quality was mixed. Because they did not record medicine volume, no study reflected the risk posed to patients.Methods and findings We investigated the quality of five medicines for cardiovascular disease and diabetes in Malang district, East Java, Indonesia. Our sample frame, based on dispensing volumes by outlet and price category, included sampling from public and private providers and pharmacies and reflected the potential risk posed to patients. The content of active ingredient was determined by high-performance liquid chromatography and compared with the labelled content. Dissolution testing was also performed.We collected a total of 204 samples: amlodipine (88); captopril (22); furosemide (21); glibenclamide (21) and simvastatin (52), comprising 83 different brands/products. All were manufactured in Indonesia, and all samples met specifications for both assay and dissolution. None was suspected of being falsified.Conclusions While we cannot conclude that the prevalence of poor-quality medicines in Malang district is zero, our sampling method, which reflects likely exposure to specific brands and outlets, suggests that the risk to patients is very low; certainly nothing like the rates found in recent reviews of surveys in LMICs. Our study demonstrates the feasibility of sampling medicines based on likely exposure to specific products and underlines the dangers of extrapolating results across countries.

Cataract surgery is a safe, effective and common elective procedure in Australia but access is inequitable. True waiting times for cataract care are undisclosed or inconsistently reported by governments. Estimates of true waiting times range from 4 to 30 months and have been extended during the coronavirus disease 2019 (COVID-19) pandemic. Comparative analysis revealed that reducing waiting periods from 12 to 3 months would result in estimated public health system cost savings of $6.6 million by preventing 50 679 falls. Investment in public cataract services to address current unmet needs would prevent avoidable vision impairment and associated negative consequences.

Community health workers (CHWs) are the first point of contact with the primary health care system in many low- and middle-income countries and are situated to play a critical role in the public health response to the COVID-19 pandemic. The knowledge, attitude and practices of CHWs regarding COVID-19 may be influenced by their level of trust and participation in the community, collectively defined as their level of social capital. To assess whether social capital influences CHWs’ knowledge, attitude and practices related to COVID-19, we conducted a web-based survey of CHWs (n = 478) in Malang district, Indonesia between October 2020 and January 2021. CHW social capital was measured using the Shortened Adapted Social Capital Assessment Tool. Multiple logistic regression results show that cognitive social capital was associated with higher self-reported knowledge of COVID-19, more confidence in answering COVID-related questions from the community and feeling safe from COVID-19 when working. Membership of community organisations was associated with a higher number of COVID-related tasks conducted. Thus, CHWs in Malang district with higher levels of cognitive social capital were more likely to be confident in their knowledge and ability to respond to COVID-19, and CHWs embedded in their community were more likely to be engaged in pandemic response duties. Our findings suggest that policies aimed at promoting CHW embeddedness, targeted recruitment and addressing training needs hold promise in strengthening the positive contribution of the community health workforce to the COVID-19 response.

Abstract Background The World Health Organization recommends that community health workers (CHWs) receive a mix of financial and non-financial incentives, yet notes that there is limited evidence to support the use of one type of incentive (i.e. financial or non-financial) over another. In preparation for a larger scale trial, we investigated the acceptability and feasibility of two different forms of incentives for CHWs in Malang District, Indonesia. Methods CHWs working on a cardiovascular disease (CVD) risk screening and management programme in two villages were assigned to receive either a financial or non-financial incentive for 6 months. In the financial incentives village, CHWs (n = 20) received 16,000 IDR (USD 1.1) per patient followed up or 500,000 IDR (USD 34.1) if they followed up 100% of their assigned high-risk CVD patients each month. In the non-financial incentive village, CHWs (n = 20) were eligible to receive a Quality Care Certificate for following up the highest number of high-risk CVD patients each month, awarded in a public ceremony. At the end of the 6-month intervention period, focus group discussions were conducted with CHWs and semi-structured interviews with programme administrators to investigate acceptability, facilitators and barriers to implementation and feasibility of the incentive models. Data on monthly CHW follow-up activity were analysed using descriptive statistics to assess the preliminary impact of each incentive on service delivery outcomes, and CHW motivation levels were assessed pre- and post-implementation. Results Factors beyond the control of the study significantly interrupted the implementation of the financial incentive, particularly the threat of violence towards CHWs due to village government elections. Despite CHWs reporting that both the financial and non-financial incentives were acceptable, programme administrators questioned the sustainability of the non-financial incentive and reported CHWs were ambivalent towards them. CHW service delivery outcomes increased 17% for CHWs eligible for the non-financial incentive and 21% for CHWs eligible for the financial incentive. There was a statistically significant increase (p < 0.0001) in motivation scores for the performance domain in both villages. Conclusion It was feasible to deliver both a performance-based financial and non-financial incentive to CHWs in Malang District, Indonesia, and both incentive types were acceptable to CHWs and programme administrators. Evidence of preliminary effectiveness also suggests that both the financial and non-financial incentives were associated with improved motivation and service delivery outcomes. These findings will inform the next phase of incentive design, in which incentive feasibility and preliminary effectiveness will need to be considered alongside their longer-term sustainability within the health system.

Background Community health workers (CHWs) play a critical role in supporting health systems, and in improving accessibility to primary healthcare. In many settings CHW programmes do not have formalised employment models and face issues of high attrition and poor performance. This study aims to determine the employment preferences of CHWs in Malang district, Indonesia, to inform policy interventions.Methods A discrete choice experiment was conducted with 471 CHWs across 28 villages. Attributes relevant to CHW employment were identified through a multistage process including literature review, focus group discussions and expert consultation. Respondents’ choices were analysed with a mixed multinomial logit model and latent class analyses.Results Five attributes were identified: (1) supervision; (2) training; (3) monthly financial benefit; (4) recognition; and (5) employment structure. The most important influence on choice of job was a low monthly financial benefit (US$~2) (β=0.53, 95% CI=0.43 to 0.63), followed by recognition in the form of a performance feedback report (β=0.13, 95% CI=0.07 to 0.20). A large monthly financial benefit (US$~20) was most unappealing to respondents (β=−0.13, 95% CI=−0.23 to −0.03). Latent class analysis identified two groups of CHWs who differed in their willingness to accept either job presented and preferences over specific attributes. Preferences diverged based on respondent characteristics including experience, hours’ worked per week and income.Conclusion CHWs in Malang district, Indonesia, favour a small monthly financial benefit which likely reflects the unique cultural values underpinning the programme and a desire for remuneration that is commensurate with the limited number of hours worked. CHWs also desire enhanced methods of performance feedback and greater structure around training and their rights and responsibilities. Fulfilling these conditions may become increasingly important should CHWs work longer hours.

Background The UN Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW) represents an international commitment to equality in the enjoyment of human rights. International human rights scholars posit that, in facilitating constructive dialogues between states and human rights experts, the near-universally ratified Convention is a powerful tool for achieving global health goals, such as the Sustainable Development Goals (SDGs). Yet, the performance of such rights-based approaches in achieving gender equality, and empowering all women, has not been systematically measured and evaluated on a global scale. This study seeks to address the urgent need to support data-driven analyses to hold governments to account through the development of a global dataset measuring state action on women’s health and human rights. Methods Standard systematic review methods will be used to review CEDAW periodic review reports produced by United Nations (UN) Member States, civil society organisations and the CEDAW Committee. Global participation with the review mechanism, the scope of health inequities covered by Committee recommendations, the nature of reported government action and the extent of implementation of each program will be extracted from each report. Only data from the two most recent reporting cycles will be analysed. Descriptive statistics will be used to analyse quantitative data, and all qualitative data will be analysed using policy mapping techniques. Discussion Using these data, the study will navigate the nature and the extent of state action to address these issues including by increasing women’s leadership and participation, data collection, strengthening health systems, governance and coordination and establishing new human rights infrastructure. It will use the diversity of health and human rights issues affecting women to reframe traditional conceptualisations of global women’s health which have largely focussed on sexual and reproductive health, to the exclusion of other aspects of women’s lives through the life course. In addition, the study will aid the development of authoritative guidance on how each of these areas of state action and inaction contribute to health inequities, and a framework for designing interventions to address discrimination against women as it relates to health.

Objectives: To investigate publicly funded healthcare costs according to faller status and the periods pre- and post-cataract surgeries, and identify factors associated with higher monthly costs in older people with bilateral cataract. Methods: This prospective cohort study included community-dwelling older people aged 65 and over (between 2012 and 2019); at baseline participants had bilateral cataract and were waiting for cataract surgery in New South Wales (NSW) public hospitals. Participants were followed for 24 months. The study used self-reported and linked data (Medicare Benefits Schedule, Pharmaceutical Benefits Scheme, NSW Admitted Patient and Emergency Department Data Collections) to identify falls, cataract surgeries and healthcare costs incurred by the Australian and NSW Governments, all costs were inflated to 2018-19 Australian dollars (AUD). Median monthly healthcare costs were calculated for faller status (non-faller, non-medically treated faller, medically treated faller) and surgery periods (pre-surgery, post-first surgery, post-second surgery). Costs in the 30 days following a medically treated fall were estimated. A generalised linear model was used to investigate predictors of healthcare costs. Results: During the median follow-up period of 24 months, 274 participants suffered 448 falls, with 95 falls requiring medical treatment. For medically treated falls, the mean cost in the 30 days after treatment was A$3779 (95% confidence interval $2485, $5074). Higher monthly healthcare costs were associated with a higher number of medications, being of the male sex, having one or more medically treated falls and having bilateral cataract surgery. After excluding the cost of cataract surgery, there were no significant differences in healthcare costs between the pre-cataract surgery, post-first eye cataract surgery and post-second eye cataract surgery periods. Conclusions: To our knowledge, this is the first study investigating publicly funded costs related to falls and cataract surgery in older people with bilateral cataract. This information enhances our understanding of healthcare costs in this group. The patterns in costs associated with falls can guide future government healthcare expenditure on falls treatment and prevention, including timely cataract surgery. [ABSTRACT FROM AUTHOR]