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Background: Population ageing will accelerate rapidly in Mongolia in the coming decades. We explore whether this is likely to have deleterious effects on economic growth and health spending trends and whether any adverse consequences might be moderated by ensuring better health among the older population. Methods: Fixed-effects models are used to estimate the relationship between the size of the older working-age population (55–69 years) and economic growth from 2020 to 2100 and to simulate how growth is modified by better health among the older working-age population, as measured by a 5% improvement in years lived with disability. We next use 2017 data on per capita health spending by age from the National Health Insurance Fund to project how population ageing will influence public health spending from 2020 to 2060 and how this relationship may change if the older population (≥ 60 years) ages in better or worse health than currently. Results: The projected increase in the share of the population aged 55–69 years is associated with a 4.1% slowdown in per-person gross domestic product (GDP) growth between 2020 and 2050 and a 5.2% slowdown from 2020 to 2100. However, a 5% reduction in disability rates among the older population offsets these effects and adds around 0.2% to annual per-person GDP growth in 2020, rising to nearly 0.4% per year by 2080. Baseline projections indicate that population ageing will increase public health spending as a share of GDP by 1.35 percentage points from 2020 to 2060; this will occur slowly, adding approximately 0.03 percentage points to the share of GDP annually. Poorer health among the older population (aged ≥ 60 years) would see population ageing add an additional 0.17 percentage points above baseline estimates, but healthy ageing would lower baseline projections by 0.18 percentage points, corresponding to potential savings of just over US$ 46 million per year by 2060. Conclusions: Good health at older ages could moderate the potentially negative effects of population ageing on economic growth and health spending trends in Mongolia. Continued investment in the health of older people will improve quality of life, while also enhancing the sustainability of public budgets.

Globally, countries have agreed to pursue the progressive realization of universal health coverage (UHC) and there is now a high level of political commitment to providing universal coverage of essential health services while ensuring that individuals are financially protected against high health spending. The aim of this paper is to help policy-makers think through the progressive realization of UHC. First, the pitfalls of applying global normative expenditure targets in estimating the national revenue required for UHC are discussed. Then, several recommendations on estimating national revenue are made by moving beyond the question of how much UHC will cost and focusing instead on the national health-care reforms and policy choices needed to progress towards UHC. In particular, costing exercises are recommended as a tool for comparing different service delivery options and investment in data infrastructure is recommended for improving the information needed to identify the best policies. These recommendations are intended to assist health policy-makers and international and national agencies who are developing country plans for the progressive realization of UHC.À l'échelle mondiale, les pays sont convenus de poursuivre la réalisation progressive de la couverture sanitaire universelle, et l'on observe désormais un fort niveau d'engagement politique en faveur de la couverture universelle des services de santé essentiels en veillant à ce que les individus soient financièrement à l'abri de toute dépense de santé élevée. L'objectif de cet article est d'aider les responsables politiques à effectuer un examen minutieux en vue de la réalisation progressive de la couverture sanitaire universelle. Pour commencer, nous examinons les écueils liés à l'application d'objectifs de dépenses normatifs mondiaux au moment d'estimer le revenu national requis pour la couverture sanitaire universelle. Nous formulons ensuite plusieurs recommandations concernant l'estimation du revenu national, en dépassant la question du coût de la couverture sanitaire universelle pour nous concentrer sur les réformes nationales en matière de soins de santé et sur les choix politiques nécessaires pour faire progresser la couverture sanitaire universelle. Nous recommandons notamment de procéder à des exercices d'établissement des coûts pour comparer différentes options de prestation de services et d'investir dans des infrastructures de données pour améliorer les informations nécessaires à l'identification des meilleures politiques. Ces recommandations visent à aider les responsables des politiques de santé et les organismes internationaux et nationaux qui élaborent des plans nationaux pour la réalisation progressive de la couverture sanitaire universelle.A nivel mundial, los países han acordado procurar la realización progresiva de la cobertura sanitaria universal (universal health coverage, UHC) y ahora existe un alto nivel de compromiso político para proporcionar una cobertura universal de los servicios sanitarios esenciales, al tiempo que se garantiza la protección financiera de las personas frente a los elevados gastos sanitarios. El objetivo de este documento es ayudar a los responsables de formular políticas a pensar en la realización progresiva de la UHC. Primero, se discuten las trampas en la aplicación de las metas globales de gastos normativos al estimar los ingresos nacionales requeridos para la UHC. Luego, se hacen varias recomendaciones sobre la estimación de los ingresos nacionales al ir más allá de la cuestión de cuánto costará la UHC y enfocarse en cambio en las reformas nacionales de salud y en las opciones de políticas necesarias para progresar hacia la UHC. En particular, se recomiendan ejercicios de cálculo de costos como herramienta para comparar diferentes opciones de prestación de servicios y se recomienda invertir en infraestructura de datos para mejorar la información necesaria con el fin de identificar las mejores políticas. Estas recomendaciones tienen por objeto ayudar a los responsables de formular políticas de salud y a los organismos internacionales y nacionales que están elaborando planes nacionales para la realización progresiva de la UHC.وافقت البلدان على مستوى العالم على السعي نحو التنفيذ التدريجي للتغطية الصحية الشاملة (UHC)، وهناك الآن مستوى عالٍ من الالتزام السياسي نحو توفير تغطية شاملة للخدمات الصحية الأساسية، مع ضمان الحماية المالية للأفراد ضد ارتفاع الإنفاق على الصحة. الهدف من هذه الورقة هو مساعدة صناع السياسة على التفكير من خلال التنفيذ التدريجي للتغطية الصحية الشاملة. أولاً، تمت مناقشة مخاطر تطبيق أهداف الإنفاق المعياري العالمي في تقدير الدخل الوطني المطلوب للحصول على التغطية الصحية الشاملة. بعد ذلك، يتم تقديم العديد من التوصيات الخاصة بتقدير الدخل الوطني، وذلك عن طريق التحرك لما بعد موضوع تكلفة الرعاية الصحية الشاملة، والتركيز بدلاً من ذلك على إصلاحات الرعاية الصحية الوطنية وخيارات السياسة المطلوبة للتقدم نحو التغطية الصحية الشاملة. ويوُصى على وجه الخصوص بتدريبات التكاليف كأداة لمقارنة الخيارات المختلفة لتقديم الخدمات، كما يوصى بالاستثمار في البيانات بهدف تحسين المعلومات المطلوبة لتحديد أفضل السياسات. الهدف من هذه التوصيات هو مساعدة واضعي السياسات الصحية، والهيئات الدولية والوطنية، الذين يقومون بوضع خطط الدولة للتنفيذ التدريجي للتغطية الصحية الشاملة.在全球范围内，各国已同意逐步实现全民健康覆盖 (UHC)，目前，各国在政治上高度致力于提供基本健康服务的全民覆盖范围，同时确保个人免受高额医疗支出的经济负担。本文旨在帮助政策制定者思考如何逐步实现全民健康覆盖 (UHC)。首先，讨论采用全球规范性支出目标来估算实现全民健康覆盖 (UHC) 所需的国家税收的困难。然后，对估算国家税收提出若干建议，这些建议不仅围绕全民健康覆盖 (UHC) 的成本问题，而且把重点放在推进全民健康覆盖 (UHC) 所需的国家医疗改革和政策选择上。特别是，建议将成本计算工作作为比较不同服务交付选择的工具，并建议对数据基础架构进行投资，以改进确定最佳政策所需的信息。这些建议旨在协助健康政策制定者以及正在制定逐步实现全民健康覆盖计划的国内外机构。.Страны мира пришли к соглашению о продолжении последовательной реализации программы всеобщего охвата услугами здравоохранения (ВОУЗ). В настоящее время обеспечение всеобщего охвата основными услугами здравоохранения с одновременным созданием финансовой защиты отдельных категорий лиц от высоких расходов на медицинское обслуживание получает значительную политическую поддержку. Цель данного документа — помочь лицам, формирующим политику, продумать процесс последовательной реализации программы ВОУЗ. В нем обсуждаются возможные скрытые проблемы внедрения глобальных нормативов целевых расходов при оценке национального дохода, необходимого для обеспечения всеобщего охвата услугами здравоохранения. Документ также содержит несколько рекомендаций по оценке национального дохода посредством не только рассмотрения вопроса о том, сколько будет стоить обеспечение ВОУЗ, но и заострения внимания на национальных реформах в сфере здравоохранения и изменениях в политике, необходимых для достижения прогресса в обеспечении всеобщего охвата услугами здравоохранения. В частности, рекомендуется использовать расчет стоимости в качестве инструмента сравнения различных вариантов предоставления услуг, а также инвестиции в инфраструктуру анализа данных для повышения качества информации, необходимой для разработки наиболее эффективных политик. Такие рекомендации предназначены для оказания содействия лицам, формирующим политику в сфере здравоохранения, а также международным и национальным ведомствам, разрабатывающим планы последовательной реализации программы ВОУЗ на уровне стран.

The World Health Organization (WHO) Prequalification sets a benchmark of generic medicines quality standards for both local utilization and international procurement. So far in China, there are onl...

Background Public or patient versions of guidelines (PVGs) are derivative documents that “translate” recommendations and their rationale from clinical guidelines for health professionals into a more easily understandable and usable format for patients and the public. PVGs from different groups and organizations vary considerably in terms of quality of their reporting. In order to address this issue, we aimed to develop a reporting checklist for developers of PVGs and other potential users. Methods First, we collected a list of potential items through reviewing a sample of PVGs, existing guidance for developing and reporting PVGs or other similar evidence-based patient tools, as well as qualitative studies on original studies of patients’ needs about the content and/or reporting of information in PVGs or similar evidence-based patient tools. Second, we conducted a two-round Delphi consultation to determine the level of consensus on the items to be included in the final reporting checklist. Third, we invited two external reviewers to provide comments on the checklist. Results We generated the initial list of 45 reporting items based on a review of a sample of 30 PVGs, four PVG guidance documents, and 46 relevant studies. After the two-round Delphi consultation, we formed a checklist of 17 items grouped under 12 topics for reporting PVGs. Conclusion The RIGHT-PVG reporting checklist provides an international consensus on the important criteria for reporting PVGs.

Governments frequently draw upon the private health care sector to promote sustainability, optimal use of resources, and increased choice. In doing so, policy-makers face the challenge of harnessing resources while grappling with the market failures and equity concerns associated with private financing of health care. The growth of the private health sector in South Africa has fundamentally changed the structure of health care delivery. A mutually reinforcing ecosystem of private health insurers, private hospitals and specialists has grown to account for almost half of the country's spending on health care, despite only serving 16% of the population with the capacity to pay. Following years of consolidation among private hospital groups and insurance schemes, and after successive failures at establishing credible price benchmarks, South Africa's private hospitals charge prices comparable with countries that are considerably richer. This compromises the affordability of a broad-based expansion in health care for the population. The South African example demonstrates that prices can be part of a structure that perpetuates inequalities in access to health care resources. The lesson for other countries is the importance of norms and institutions that uphold price schedules in high-income countries. Efforts to compromise or liberalize price setting should be undertaken with a healthy degree of caution.

Global population aging is the result of successes in public health, enabling longer life expectancy in many countries. The Asia Pacific region is aging more rapidly than many other parts of the world. The implications will be profound for every sector of society, requiring policy makers to reframe their thinking about the design of health and social systems to enable older populations to thrive. With increasing demand for more and different kinds of services, an imperative is shifting resources toward primary care for the prevention and comprehensive care of people with chronic conditions, and establishing linkages with community support. Major innovations are underway that accelerate progress in attaining universal health coverage for older populations. The renewed commitments under the Sustainable Development Goals to achieve universal health coverage offer a unique opportunity to invest in the foundations of the health system of the future.

Summary Background Price setting and regulation serve as instruments to control volumes of services, while providing incentives for quality, coverage, and efficiency. In recognition of its complexity, many countries have established specific entities to carry out price setting and regulation. Methods The aim of the study is to investigate institutions established for health care price setting and regulation and determine how countries have implemented pricing strategies. Eight settings were selected for case studies: Australia, England, France, Germany, Japan, Republic of Korea, Thailand, and Maryland in the United States. Each identified the agency responsible, their role and function, and resources for implementation. Results In England, Japan, Korea, and Thailand, government entities conduct price setting and regulation. In Australia, France, Germany, and Maryland, independent entities were established. Their responsibilities include costing health services, establishing prices, negotiating with stakeholders, and publishing price and quality data for consumers. Conclusions Dedicated institutions have been established to carry out costing, price setting, and negotiation, and providing consumer information. Characteristics of successful systems include formal systems of communication with stakeholders, freedom from conflicts of interest, and the mandate to provide public information. Substantial investments in price regulatory systems have been made to attain coverage, quality, and efficiency.

The WHO Thematic Platform for Health Emergency and Disaster Risk Management Research Network (TPRN) was established in 2016 in response to the Sendai Framework for Disaster Risk Reduction 2015–2030. The TPRN facilitates global collaborative action for improving the scientific evidence base in health emergency and disaster risk management (Health EDRM). In 2018, the WHO convened a meeting to identify key research questions, bringing together leading experts from WHO, TPRN, World Association for Disaster and Emergency Medicine (WADEM), and the Japan International Cooperation Agency, and delegates to the Asia Pacific Conference on Disaster Medicine (APCDM). The meeting identified research questions in five major areas for Health EDRM: health data management, psychosocial management, community risk management, health workforce development, and research methods and ethics. Funding these key research questions is essential to accelerate evidence-based actions during emergencies and disasters.

Hospitals compose a large share of total health spending in most countries, and thus have been the target of reforms to improve efficiency and reduce costs. In China, the government implemented national health care reform to improve access to essential services and reduce high out-of-pocket medical spending. A key component is the comprehensive reform of public hospitals on a pilot basis, although it remains one of the least understood aspects of health care reform in China. This article outlines the main goals of the reform of public hospitals in China, progress to date and the direction of reform between now and 2015. Then, we review experiences from industrialized countries and discuss the applicability to the Chinese reform process. Based on the policy directions focusing on efficiency and quality, and reflecting on how hospital systems in other countries have responded, the article concludes that the hospital of the future in China operates at county level. Barriers to realizing this are discussed.

The study aims to determine the type and extent of technical gaps faced by Chinese generic medicine manufacturers to achieve the standards of WHO Medicines Prequalification. The study was undertaken with four manufacturers producing anti-tuberculosis Fixed Dose Combinations (FDCs) in China from March 2010 to June 2011 and with 47 manufacturers producing anti-HIV/AIDS, anti-tuberculosis, and anti-malaria medicines in China in August 2011. The study assessed key elements required to comply with WHO Good Manufacturing Practices and completion of regulatory dossiers. For Good Manufacturing Practices, the study found technical gaps in quality management, validation and qualification, and calibration and maintenance. More technical gaps were identified in risk management and correction action and prevention action. For dossiers, the study found three technical gaps: bioequivalence testing, incomplete information from active pharmaceutical ingredients suppliers, and stability testing. The study indicates the need for technical assistance to Chinese generic medicine manufacturers, particularly for dossier preparation but also that technical gaps are attributed to differences between the standards of Chinese drug regulations and of WHO Medicines Prequalification Program.

Background The clinical specialty of obstetrics is under particular scrutiny with increasing litigation costs and unnecessary tests and procedures done in attempts to prevent litigation. We aimed to identify reports evaluating or comparing the effectiveness of medical liability reforms and quality improvement strategies in improving litigation-related outcomes in obstetrics. Methods We conducted a rapid scoping review with a 6-week timeline. MEDLINE, EMBASE, LexisNexis Academic, the Legal Scholarship Network, Justis, LegalTrac, QuickLaw, and HeinOnline were searched for publications in English from 2004 until June 2015. The selection criteria for screening were established a priori and pilot-tested. We included reports comparing or evaluating the impact of obstetrics-related medical liability reforms and quality improvement strategies on cost containment and litigation settlement across all countries. All levels of screening were done by two reviewers independently, and discrepancies were resolved by a third reviewer. In addition, two reviewers independently extracted relevant data using a pre-tested form, and discrepancies were resolved by a third reviewer. The results were summarized descriptively. Results The search resulted in 2729 citations, of which 14 reports met our eligibility criteria. Several initiatives for improving the medical malpractice litigation system were found, including no-fault approaches, patient safety policy initiatives, communication and resolution, caps on compensation and attorney fees, alternative payment system and liabilities, and limitations on litigation. Conclusions Only a few litigation policies in obstetrics were evaluated or compared. Included documents showed that initiatives to reduce medical malpractice litigation could be associated with a decrease in adverse and malpractice events. However, due to heterogeneous settings (e.g., economic structure, healthcare system) and variation in the outcomes reported, the advantages and disadvantages of initiatives may vary. Electronic supplementary material The online version of this article (10.1186/s13643-017-0569-5) contains supplementary material, which is available to authorized users.

In the past decade, the Government of China initiated health-care reforms to achieve universal access to health care by 2020. We assessed trends in health-care access and financial protection between 2003, and 2011, nationwide.We used data from the 2003, 2008, and 2011 National Health Services Survey (NHSS), which used multistage stratified cluster sampling to select 94 of 2859 counties from China's 31 provinces and municipalities. The 2011 survey was done with a subset of the NHSS sampling frame to monitor key indicators after the national health-care reforms were announced in 2009. Three sets of indicators were chosen to measure trends in access to coverage, health-care activities, and financial protection. Data were disaggregated by urban or rural residence and by three geographical regions: east, central, and west, and by household income. We examined change in equity across and within regions.The number of households interviewed was 57,023 in 2003, 56,456 in 2008, and 18,822 in 2011. Response rates were 98·3%, 95·0%, and 95·5%, respectively. The number of individuals interviewed was 193,689 in 2003, 177,501 in 2008, and 59,835 in 2011. Between 2003 and 2011, insurance coverage increased from 29·7% (57,526 of 193,689) to 95·7% (57,262 of 59,835, p0·0001). The average share of inpatient costs reimbursed from insurance increased from 14·4 (13·7-15·1) in 2003 to 46·9 (44·7-49·1) in 2011 (p0·0001). Hospital delivery rates averaged 95·8% (1219 of 1272) in 2011. Hospital admissions increased 2·5 times to 8·8% (5288 of 59,835, p0·0001) in 2011 from 3·6% (6981 of 193,689) in 2003. 12·9% of households (2425 of 18,800) had catastrophic health expenses in 2011. Caesarean section rates increased from 19·2% (736 of 3835) to 36·3% (443 of 1221, p0·0001) between 2003 and 2011.Remarkable increases in insurance coverage and inpatient reimbursement were accompanied by increased use and coverage of health care. Important advances have been made in achieving equal access to services and insurance coverage across and within regions. However, these increases have not been accompanied by reductions in catastrophic health expenses. With the achievement of basic health-services coverage, future challenges include stronger risk protection, and greater efficiency and quality of care.None.

Health insurance programs have changed rapidly over time in China. Among rural populations, insurance coverage shifted from nearly universal levels in the 1970s to 7% in 1999; it stands at 94% of counties in 2009. This large increase is the result of a series of health reforms that aim to achieve universal access to healthcare and better risk protection, largely through the rollout of the health insurance programs and the gradual increase in subsidies and benefits over time. In this paper, we present the development of the rural and urban health insurance programs, their modes of financing and operation and the benefits and reimbursement schemes at the end of 2009. We discuss some of the problems with the rural and urban residents' schemes including reliance on local government capacity, reimbursement ceilings and rates, and incentives for unnecessary care and waste in the design of the programs. Recommendations include increasing financial support and deepening the benefits packages. Strategies to control cost and improve quality include developing mixed provider payment mechanisms, implementing essential medicines policies and strengthening the quality of primary-care provision. Copyright © 2011 John Wiley & Sons, Ltd.

ObjectivesThis review was commissioned by WHO, South Africa-Country office because of an exponential increase in medical litigation claims related to patient safety in obstetrical care in the country. A rapid review was conducted to examine the effectiveness of quality improvement (QI) strategies on maternal and newborn patient safety outcomes, risk of litigation and burden of associated costs.DesignA rapid review of the literature was conducted to provide decision-makers with timely evidence. Medical and legal databases (eg, MEDLINE, Embase, LexisNexis Academic, etc) and reference lists of relevant studies were searched. Two reviewers independently performed study selection, abstracted data and appraised risk of bias. Results were summarised narratively.InterventionsWe included randomised clinical trials (RCTs) of QI strategies targeting health systems (eg, team changes) and healthcare providers (eg, clinician education) to improve the safety of women and their newborns. Eligible studies were limited to trials published in English between 2004 and 2015.Primary and secondary outcome measuresRCTs reporting on patient safety outcomes (eg, stillbirths, mortality and caesarean sections), litigation claims and associated costs were included.ResultsThe search yielded 4793 citations, of which 10 RCTs met our eligibility criteria and provided information on over 500 000 participants. The results are presented by QI strategy, which varied from one study to another. Studies including provider education alone (one RCT), provider education in combination with audit and feedback (two RCTs) or clinician reminders (one RCT), as well as provider education with patient education and audit and feedback (one RCT), reported some improvements to patient safety outcomes. None of the studies reported on litigation claims or the associated costs.ConclusionsOur results suggest that provider education and other QI strategy combinations targeting healthcare providers may improve the safety of women and their newborns during childbirth.

Data from a controlled randomised trial are used to estimate the effect of Mexico's conditional cash transfer programme, Oportunidades, on birth outcomes, and to examine the pathways by which it works. Birth weights average 127.3 grams higher, and low birth weight incidence is 44.5 per cent lower among beneficiary mothers. Better birth outcomes are explained entirely by better quality prenatal care. Oportunidades affected quality through empowering women with information about adequate healthcare content to expect better care, and with skills and social support to negotiate better care. Efforts to empower the less well-off are necessary for public services to fully benefit the poor.

Quality is high on the Mexican health policy agenda. In this paper we evaluate the quality of prenatal care for rural low-income women. Women who obtained care from private practitioners and non-MDs received fewer procedures on average. Poverty predicts poor quality; however, indigenous women in private settings received fewer procedures, after household wealth was controlled for. We recommend strengthening clinical skills and providing incentives to adhere to quality standards. Quality reporting could promote informed employer care-purchasing and individual care-seeking choices. The national health reforms should be monitored to determine their success in not only increasing access among the poor and indigenous but also ensuring that such care meets quality norms.

Objectives: To determine if the quality of prenatal care predicts skilled institutional delivery, a primary means of reducing maternal mortality. Methods: The probability of skilled institutional delivery is predicted among 4173 rural low-income women of reproductive age in seven Mexican states, as a function of maternal retrospective reports about prenatal care services received in 1997–2003. Results: Women who received most prenatal care procedures were more likely to have a skilled institutional delivery (OR 2.29, 95% CI 1.18, 4.44). Women who received less than the 75th percentile of prenatal care procedures were not significantly different from those who received no prenatal care. Conclusions: Policies promoting increased access to prenatal services should be linked to the promotion of practice standards to impact health and behavioral outcomes.

Using published data about consumption, economic aspects, and legislation, this paper analyzes tobacco control in Indonesia, a major consumer and producer of tobacco products. Given its large population and smoking prevalence, Indonesia ranks fifth among countries with the highest tobacco consumption globally. Over 62% of Indonesian adult males smoke regularly, contributing to a growing burden of non-communicable diseases and enormous demands on the health care system. Tobacco control policies, however, have remained low on the political and public health agenda for many years. One reason was the contribution of tobacco to government revenues and employment, particularly in the industrial sector. But tobacco's importance in employment has fallen significantly since the 1970s from 38% of total manufacturing employment compared with 5.6% today. Widespread use of tobacco since the 1970s and the concomitant burden of non-communicable diseases have given rise to a more balanced view of the costs and benefits of tobacco production over the last decade. The first tobacco control regulation passed in 1999, succeeded by amendments in 2000 and 2003. Today, few restrictions exist on tobacco industry conduct, advertising, and promotion in Indonesia. We examine the relevance and prospects of advancing in Indonesia four cost-effective tobacco control strategies: price and tax measures, advertising bans, clean air legislation, and public education. We conclude with several suggestions for action for the public health community.

Generic drugs should be interchangeable with originators in terms of quality and efficacy. With relative lower prices, generic drugs are playing an important role in controlling health expenditures and ensuring access. However, the widespread understanding of “cheap price equals low quality” has a negative impact on the acceptance of generic drugs. In China, medical doctors doubt the efficacy and quality of generic drugs manufactured domestically. To address these concerns, the Chinese State Council released a policy in 2016 to ensure the interchangeability by re‐evaluating the quality and efficacy of generic drugs. It intends to make up a missed lesson in the regulation to be in line with internationally accepted practices. Generic drugs firms, depends on the availability of appropriate comparators, should conduct either comparative bioequivalence studies or full scale clinical trials. The re‐evaluation will be implemented in a stepwise approach with the essential medicines covered in the first step. The policy could achieve several benefits by increasing confidence on the Chinese produced generic drugs, upgrading regulatory standards, streamlining the Chinese generic drug industry and creating a healthy competition market. Nevertheless, enormous challenges remain in enlarging the capacity to review applications, selecting appropriate comparators, ensuring the capacity of domestic clinical research sites, and achieving the acceptance of re‐evaluated generic drugs.

In recent decades, the influence of Brazil, the Russian Federation, India, China and South Africa (BRICS) within the international arena has increased enormously.1 These countries represent around 25% of the world’s gross national income, more than 40% of the world’s population and about 30% of the world’s land area.2 Although much attention has been paid to their economic performance, less widely noted is the fact that these countries are uniquely positioned to exert a decisive influence on health at the global level. Within BRICS countries, hundreds of millions of people have been lifted out of poverty. This has resulted in marked improvements in health outcomes and in substantial progress towards achieving the Millennium Development Goals.3,4 BRICS countries are also gravitating towards universal health coverage, although not at an even pace. They are leaders in the manufacture of low-cost medicines and vaccines.5 Their experiences in reducing poverty and strengthening health systems, together with their booming economies and large populations, explain why they exert such an enormous influence on health worldwide. Besides, in only a few years they have amassed a wealth of experience and knowledge from which other low- and middle-income countries can draw valuable examples. Despite their many assets, however, BRICS countries face important health problems. India has the highest number of maternal and infant deaths of any country in the world. South Africa has the greatest number of people with human immunodeficiency virus infection. Alcohol abuse is a major public health concern in the Russian Federation. In addition, BRICS countries’ strong economic growth has created a new set of problems that need to be addressed. Over the last decade, inequities in health and in the socioeconomic sphere have become accentuated in most of these countries.6 Although life expectancy has improved substantially in Brazil, China and India, BRICS countries as a whole still account for about 40% of the global burden of disease.7 They also face a “double” disease burden resulting from the coupling of infectious diseases with the emergence of new health problems triggered by environmental factors and to an increase in road traffic injuries and noncommunicable diseases. Tackling the social determinants of health continues to be a priority for BRICS countries. Globally, BRICS countries are becoming increasingly important partners in international development cooperation.8 They are helping to reshape the landscape of aid effectiveness. According to the final declaration of the Fourth High Level Forum on Aid Effectiveness, held in 2011 in Busan, the Republic of Korea, the nature, modalities and responsibilities that apply to South–South cooperation differ from those that apply to North–South cooperation.9 Although the development cooperation coming from BRICS countries has increased substantially in recent years, estimates vary because of differences in the approaches and methods used to report development cooperation for countries not represented in the Development Assistance Committee.10,11 Through “South–South” health cooperation, BRICS countries are able to reach populations beyond their own borders. These countries can engage in cooperation of this type either individually through bilateral agreements or collectively. Inter-BRICS cooperation is gaining momentum, as highlighted in the recent meeting of ministers of health held on 10–11 January 2013 in New Delhi.12 Moreover, the establishment of the BRICS development bank, agreed upon by BRICS leaders on 27 March 2013 in Durban, South Africa, will also contribute to the advancement of health in BRICS countries and beyond. The Bulletin plans to publish a theme issue on BRICS and global health to enhance people’s understanding of the dynamics of health and development in BRICS countries and of how these countries contribute to global health, both by improving health outcomes in their own territories and by engaging in mutual cooperation. This issue will cover these countries’ key health policy achievements and their most important health challenges, as well as their rising influence on international health cooperation. We welcome papers for all sections of the Bulletin and encourage authors to consider contributions on any of the following topics as they pertain to BRICS countries: universal health coverage; universal access to medicines or vaccines; emerging and existing public health challenges, notably health inequities and the double burden of disease; South–South cooperation and inter-BRICS cooperation. The deadline for submissions is October 2013. Manuscripts should be prepared in accordance with the Bulletin’s Guidelines for contributors and authors should mention this call for papers in a covering letter. All submissions will go through the Bulletin’s peer review process. Please submit to: http://submit.bwho.org.

In OECD countries, medicines spending accounts for approximately 17% of total health spending or 1.5% of gross domestic product (GDP) [1]. New technologies and pharmaceuticals have been important contributors to rising health care costs. At the same time, patients may not have access to cost–effective medicines because of lack of health insurance coverage, limited insurance benefits, high medicines prices, physician prescribing choices, or differences between available essential medicines and consumer demand [2]. With the exception of a few countries [3], however, the approach to reform tends to be piecemeal rather than comprehensive. With the goal of universal health care coverage by 2020, the Government of China has implemented comprehensive health care reforms nationwide [4]. Between 2009 and 2011, the reforms focused on increasing access to essential medicines as well as expanding health insurance, strengthening the primary care system, financing public health, and reforming public hospitals [5]. By 2011, government investments in health reform reached Yuan 1.13 trillion (US$ 174 billion, at Yuan 6.5 per US$) [6]. Total health expenditures increased from 3.5% to 5.0% of GDP between 1995 and 2010 – amounting to an increase from US$ 21 to US$ 220 per capita [7]. The reform of the essential medicines system is a major focus of the national reform agenda. Spending on medicines accounted for 41.9% of total health expenditures in 2010, or 2.1% of GDP (Figure 1) [7]. In this paper, we review existing literature, published government documents about the essential medicines reform in China, and international literature on essential medicines and health care reform internationally. The paper first presents economic and demographic trends to explain rapid increases in medicines consumption across China. The 2009 health care reform is discussed, in terms of each component’s linkage with medicines reforms. We discuss in detail the reform of the essential medicines system, including the Essential Medicines List (EML), procurement, pricing, financing, and quality. We conclude that China’s comprehensive approach in reforming its essential medicines system could be a model for other countries that strive to ensure access to medicines while also controlling costs. Figure 1 Private and general government health expenditures, and percent of total health spending devoted to pharmaceuticals, 1995–2010. Source: ref. [7].

The quality of reporting practice guidelines is often poor, and there is no widely accepted guidance or standards for such reporting in health care. The international RIGHT (Reporting Items for practice Guidelines in HealThcare) Working Group was established to address this gap. The group followed an existing framework for developing guidelines for health research reporting and the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network approach. It developed a checklist and an explanation and elaboration statement. The RIGHT checklist includes 22 items that are considered essential for good reporting of practice guidelines: basic information (items 1 to 4), background (items 5 to 9), evidence (items 10 to 12), recommendations (items 13 to 15), review and quality assurance (items 16 and 17), funding and declaration and management of interests (items 18 and 19), and other information (items 20 to 22). The RIGHT checklist can assist developers in reporting guidelines, support journal editors and peer reviewers when considering guideline reports, and help health care practitioners understand and implement a guideline.

Health insurance programs have changed rapidly over time in China. Among rural populations, insurance coverage shifted from nearly universal levels in the 1970s to 7% in 1999; it stands at 94% of counties in 2009. This large increase is the result of a series of health reforms that aim to achieve universal access to healthcare and better risk protection, largely through the rollout of the health insurance programs and the gradual increase in subsidies and benefits over time. In this paper, we present the development of the rural and urban health insurance programs, their modes of financing and operation and the benefits and reimbursement schemes at the end of 2009. We discuss some of the problems with the rural and urban residents' schemes including reliance on local government capacity, reimbursement ceilings and rates, and incentives for unnecessary care and waste in the design of the programs. Recommendations include increasing financial support and deepening the benefits packages. Strategies to control cost and improve quality include developing mixed provider payment mechanisms, implementing essential medicines policies and strengthening the quality of primary-care provision.

Background: Caesarean section rates are increasing in Mexico and Latin America. This study evaluates the impact of a large-scale, conditional cash transfer programme in Mexico on caesarean section rates. The programme provides cash transfers to participating low income, rural households in Mexico conditional on accepting health care and nutrition supplements. Methods: The primary analyses uses retrospective reports from 979 women in poor rural communities participating in an effectiveness study and randomly assigned to incorporation into the programme in 1998 or 1999 across seven Mexican states. Using multivariate and instrumental variable analyses, we estimate the impact of the programme on caesarean sections and predict the adjusted mean rates by clinical setting. Programme participation is measured by beneficiary status, programme months and cash transfers. Results: More than two-thirds of poor rural women delivered in a health facility. Beneficiary status is associated with a 5.1 percentage point increase in caesarean rates; this impact increases to 7.5 percentage points for beneficiaries enrolled in the programme for ≥6 months before delivery. Beneficiaries had significantly higher caesarean delivery rates in social security facilities (24.0 compared with 5.6% among non-beneficiaries) and in other government facilities (19.3 compared with 9.5%). Conclusion: The Oportunidades conditional cash transfer programme is associated with higher caesarean section rates in social security and government health facilities. This effect appears to be driven by the increases in disposable income from the cash transfer. These findings are relevant to other countries implementing conditional cash transfer programmes and health care requirements.

Comprehensive tobacco control policies include high taxes. This paper describes the tobacco excise structure in Indonesia from 2007 to 2009. The design of the tobacco excise system contributes to neutralizing the effect of a tax increase on consumption. Wide gaps in tax rates allow for the availability of low-priced products, and consumers can substitute to cheaper products in response to price increases. There has been no systematic increase in the tax rates, which promotes affordable of tobacco products. Firms can reduce their prices at point of sale and absorb the tax increase instead of passing it onto consumers. Tiered tax rates by production scale allow firms to evade paying the highest tax brackets legally, thereby increasing profit margins while reducing prices at point of sale. Increases in tobacco excise rates in Indonesia may not have a large health impact under the current system of tax administration.

To evaluate the impact of Mexico's conditional cash transfer programme on the quality of health care received by poor women. Quality is measured by maternal reports of prenatal care procedures received that correspond with clinical guidelines.The data describe retrospective reports of care received from 892 women in poor rural communities in seven Mexican states. The women were participating in an effectiveness study and randomly assigned to incorporation into the programme in 1998 or 1999. Eligible women accepted cash transfers conditional on obtaining health care and nutritional supplements, and participated in health education sessions.Oportunidades beneficiaries received 12.2% more prenatal procedures compared with non-beneficiaries (adjusted mean 78.9, 95% Confidence Interval (CI): 77.5-80.3; P0.001).The Oportunidades conditional cash transfer programme is associated with better quality of prenatal care for low-income, rural women in Mexico. This result is probably a manifestation of the programme's empowerment goal, by encouraging beneficiaries to be informed and active health consumers.

OBJECTIVES To evaluate the impact of Oportunidades, a large-scale, conditional cash transfer programme in Mexico, on birthweight. The programme provides cash transfers to low-income, rural households in Mexico, conditional on accepting nutritional supplements health education, and health care. METHODS The primary analyses used retrospective reports from 840 women in poor rural communities participating in an effectiveness study and randomly assigned to incorporation into the programme in 1998 or 1999 across seven Mexican states. Pregnant women in participating households received nutrition supplements and health care, and accepted cash transfers. Using multivariate and instrumental variable analyses, we estimated the impact of the programme on birthweight in grams and low birthweight (

One in three children globally is stunted in growth. Many of the conditions that promote child stunting are amenable to quality care provided by skilled health workers.The study uses household and facility data from the Indonesian Family Life Surveys in 1993 and 1997. The first set of multivariate regression models evaluate whether the number of medical doctors (MDs), nurses, and midwives predict quality of care as measured by adherence to clinical guidelines. The second set explains the relationships between quality and length among children less than 36 months. Using the information generated from these two sets of regressions, we simulate the effect of increasing the number of MDs, nurses, and midwives on child length and stunting.Increases in the number of MDs and nurses predict increases in the quality of care. Higher quality care is associated with child length in centimeters and stunting. Simulations suggest that large health gains among children under 24 months of age result by placing MDs where none are available.Improvements in child health could be made by increasing the number of qualified health staff. The returns to investing in improvements in human resources for health are high.

In Mexico, family planning advice has been incorporated into the clinical guidelines for prenatal care. However, the relationship between women's receipt of family planning advice during prenatal care and subsequent contraceptive use has not been evaluated.Data were collected in 2003 and 2004 in 17 Mexican states from 2,238 urban low-income women postpartum. Participating women reported on prenatal services received and contraceptive use. Logistic and multinomial logistic regression models evaluated whether receiving family planning advice during prenatal care predicted current contraceptive use, after quality of care in the community, service utilization, delivery characteristics, household socioeconomic characteristics, and maternal and infant characteristics were controlled for.Overall, 47% of women used a modern contraceptive method. Women who received family planning advice during prenatal care were more likely to use a contraceptive than were those who did not receive such advice (odds ratio, 2.2). Women who received family planning advice had a higher probability of using condoms (relative risk ratio, 2.3) and IUDs (5.2), and of undergoing sterilization (1.4), than of using no method.Integrating family planning advice into prenatal care may be an important strategy for reaching women when their demand for contraception is high.

Using a representative sample of public facilities surveyed in 1993 and 1997, we took advantage of exogenous changes imposed on the Indonesian health system to evaluate the contribution of physicians, nurses, and midwives to the quality of primary care. We found that quality depends on the availability, type, and number of health workers, which, in turn, is affected by public policies about deployment. We conclude that staff deployment could be refined by analyses of the skill-mix needed to provide quality care. Professional nurses in particular could play an important role in promoting quality.

Using a representative cross-section of health care providers in Indonesia, we describe variations in prenatal, child, and adult care quality. Quality is measured as knowledge about clinical guidelines. Public health centers offer above-average-quality prenatal care, and private physicians provide high-quality curative care. Private nurses offer below-average care, as do most providers in the more remote regions of Outer Java-Bali. The poor and wealthy have access to the same levels of quality; however, the poorest women report receiving fewer prenatal procedures. Recommendations include improving the professional development of nurses in private settings, testing quality improvements in Outer Java-Bali, and investigating wealth disparities in quality received.

Quality is high on the Mexican health policy agenda. In this paper we evaluate the quality of prenatal care for rural low-income women. Women who obtained care from private practitioners and non-MDs received fewer procedures on average. Poverty predicts poor quality; however, indigenous women in private settings received fewer procedures, after household wealth was controlled for. We recommend strengthening clinical skills and providing incentives to adhere to quality standards. Quality reporting could promote informed employer care-purchasing and individual care-seeking choices. The national health reforms should be monitored to determine their success in not only increasing access among the poor and indigenous but also ensuring that such care meets quality norms.

Objective. To evaluate variations in prenatal care quality by public and private clinical settings and by household wealth. Design. The study uses 2003 data detailing retrospective reports of 12 prenatal care procedures received that correspond to clinical guidelines. The 12 procedures are summed up, and prenatal care quality is described as the average procedures received by clinical setting, provider qualifications, and household wealth. Setting. Low-income communities in 17 states in urban Mexico. Participants. A total of 1253 women of reproductive age who received prenatal care within 1 year of the survey. Main outcome measure. The mean of the 12 prenatal care procedures received, reported as unadjusted and adjusted for individual, household, and community characteristics. Results. Women received significantly more procedures in public clinical settings [80.7, 95% confidence interval (CI) = 79.3–82.1; P ≤ 0.05] compared with private (60.2, 95% CI = 57.8–62.7; P ≤ 0.05). Within private clinical settings, an increase in household wealth is associated with an increase in procedures received. Care from medical doctors is associated with significantly more procedures (78.8, 95% CI = 77.5–80.1; P ≤ 0.05) compared with non-medical doctors (50.3, 95% CI = 46.7–53.9; P ≤ 0.05). These differences are independent of individual, household, and community characteristics that affect health-seeking behavior. Conclusions. Significant differences in prenatal care quality exist across clinical settings, provider qualifications, and household wealth in urban Mexico. Strategies to improve quality include quality reporting, training, accreditation, regulation, and franchising.

Growing evidence has demonstrated that informal fees for health services comprise a large proportion of total health spending in some countries. In 1999, individual out-of-pocket payments for health in Cambodia were estimated at 27 US dollars per person, with a proportion paid as under-the-table fees at public facilities. By formalizing such payments and implementing resource management systems within a comprehensive health financing scheme, Takeo Referral Hospital controlled out-of-pocket patient expenditures, ensured patients of fixed prices, protected patients from the unpredictability of hospital fees and promoted financial sustainability. Utilization levels increased by more than 50% for inpatient and surgical services, and cost recovery from user fees averaged 33%. Furthermore, the hospital phased out external donor support gradually over 4 years and achieved financial sustainability.