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BackgroundMedical imaging is an integral part of healthcare. Globalization has resulted in increased mobilization of migrants to new host nations. The association between migration status and utilization of medical imaging is unknown.Methods and findingsA retrospective population-based matched cohort study was conducted in Ontario, Canada from April 1, 1995 to December 31, 2016. A total of 1,848,222 migrants were matched 1:1 to nonmigrants in the year of migration on age, sex, and geography. Utilization of computed tomography (CT), magnetic resonance imaging (MRI), radiography, and ultrasonography was determined. Rate differences per 1,000 person-years comparing migrants to nonmigrants were calculated. Relative rates were calculated using a recurrent event framework, adjusting for age, sex, and time-varying socioeconomic status, comorbidity score, and access to a primary care provider. Estimates were stratified by migration age: children and adolescents (≤19 years), young adults (20 to 39), adults (40 to 59), and older adults (≥60). Utilization rates of CT, MRI, and radiography were lower for migrants across all age groups compared with Ontario nonmigrants. Increasing age at migration was associated with larger differences in utilization rates. Older adult migrants had the largest gap in imaging utilization. The longer the time since migration, the larger the gap in medical imaging use. In multivariable analysis, the relative rate of imaging was approximately 20% to 30% lower for migrants: ranging from 0.77 to 0.88 for CT and 0.72 to 0.80 for MRI imaging across age groups. Radiography relative rates ranged from 0.84 to 0.90. All migrant age groups, except older adults, had higher rates of ultrasonography. The indication for imaging was not captured, thus it was not possible to determine if the imaging was necessary.ConclusionsMigrants utilized less CT, MRI, and radiography but more ultrasonography. Older adult migrants used the least amount of imaging compared with nonmigrants. Future research should evaluate whether lower utilization is due to barriers in healthcare access or health-seeking behaviors within a universal healthcare system.

ABSTRACT Objectives Methods Results Conclusions This study investigated healthcare utilisation in general practice and hospitals in the 2 years preceding a diagnosis of haematological cancer and the association with patient pathways.The nationwide register‐based cohort study included 12 994 patients diagnosed with leukaemia, multiple myeloma and lymphoma in 2014–2018 and 10 matched references. Patient pathways were analysed in unplanned routes (acute admission up to 1 month's prior diagnosis) and elective routes (other routes, e.g., cancer patient pathways).Female patients in unplanned diagnostic pathways had more contacts to general practice from 19 months before the diagnosis compared to their matched references; with IRR increasing from 1.14 (95% confidence interval (CI) 1.05–1.24) to 2.27 (95% CI 2.13–2.41) at 30–60 days before the diagnosis. Female patients had more point‐of‐care tests, hospital contacts and radiological investigations at 17, 24 and 17 months, respectively, before diagnosis compared to their references. Similar patterns were seen for male patients, although with a later onset of increase. No healthcare use variations were seen between patients diagnosed in unplanned versus elective pathways.Increased healthcare utilisation was seen in general practice and hospitals up to 24 months preceding a diagnosis, which may indicate a diagnostic window for detecting haematological cancer earlier. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to map how oral health is addressed within the universal health coverage (UHC). Methods: This scoping review followed the Joanna Briggs Institute methodology. Searches included the WHO Library and PubMed, Scopus, Embase, LILACS, and Cochrane databases. Quantitative and qualitative studies were included without publication date and language restrictions. Results: A total of 486 studies were retrieved, of which 292 were excluded in the title and abstract screening phase; 121 full-texts were assessed. After the removal of duplicates and unavailable documents, 50 studies were included in the review and categorized according to the level of scientific evidence. Conclusion: Few studies discussed oral health within the UHC, mostly because this coverage does not include oral health adequately. When offered, oral health packages are limited and include specific populations. Access and use of oral health services remain guided by economic factors, exposing the theoretical financial protectionism that perpetuates health inequalities. [ABSTRACT FROM AUTHOR]

Introduction Racial minorities have been found to have worse health care outcomes, including perioperative adverse events. We hypothesized that these racial disparities may be mitigated in a military treatment facility, where all patients have a military service connection and are universally insured. Materials and Methods This is a single institution retrospective review of American College of Surgeons National Surgical Quality Improvement Program data for all procedures collected from 2017 to 2020. The primary outcome analyzed was risk-adjusted 30-day postoperative complications compared by race. Results There were 6,941 patients included. The overall surgical complication rate was 6.9%. The complication rate was 7.3% for White patients, 6.5% for Black patients, 12.6% for Asian patients, and 3.4% for other races. However, after performing patient and procedure level risk adjustment using multivariable logistic regression, race was not independently associated with surgical complications. Conclusions Risk-adjusted surgical complication rates do not vary by race at this military treatment facility. This suggests that postoperative racial disparities may be mitigated within a universal health care system. [ABSTRACT FROM AUTHOR]

Introduction Congenital heart disease (CHD) has an incidence of 0.8% to 1.2% worldwide, making it the most common birth defect. Researchers have compared high-volume to low-volume hospitals and found significant hospital-level variation in major complications, health resource utilization, and mortality after CHD surgery. In addition, researchers found critical CHD patients at low-volume/non-teaching facilities to be associated with higher odds of inpatient mortality when compared to CHD patients at high-volume/teaching hospitals (odds ratio 1.76). We examined the effects of high-quality hospital (HQH) use on health care outcomes and health care costs in pediatric CHD care using an instrumental variable (IV) approach. Materials and Methods Using nationwide representative claim data from the United States Military Health System from 2016 to 2020, TRICARE beneficiaries with a diagnosis of CHD were tabulated based on relevant ICD-10 (International Classification of Diseases, 10th revision) codes. We examined the relationships between annual readmissions, annual emergency room (ER) use, and mortality and HQH use. We applied both the naive linear probability model (LPM), controlling for the observed patient and hospital characteristics, and the two-stage least squares (2SLS) model, accounting for the unobserved confounding factors. The differential distance between the patient and the closest HQH at the index date and the patient and nearest non-HQH was used as the IV. This protocol was approved by the Institutional Review Board at the University of Maryland, College Park (Approval Number: 1576246-2). Results The naive LPM indicated that HQH use was associated with a higher probability of annual readmissions (marginal effect, 18%; 95% CI, 0.12 to 0.23). The naive LPM indicated that HQH use was associated with a higher probability of mortality (marginal effect, 2.2%; 95% CI, 0.01 to 0.03). Using the differential distance of closest HQH and non-HQH, we identified a significant association between HQH use and annual ER use (marginal effect, −14%; 95% CI, −0.24 to −0.03). Conclusions After controlling for patient-level and facility-level covariates and adjusting for endogeneity, (1) HQH use did not increase the probability of more than one admission post 1-year CHD diagnosis, (2) HQH use lowered the probability of annual ER use post 1-year CHD diagnosis, and (3) HQH use did not increase the probability of mortality post 1-year CHD diagnosis. Patients who may have benefited from utilizing HQH for CHD care did not, alluding to potential barriers to access, such as health insurance restrictions or lack of patient awareness. Although we used hospital quality rating for congenital cardiac surgery as reported by the Society of Thoracic Surgeons, the contributing data span a 4-year period and may not reflect real-time changes in center performance. Since this study focused on inpatient care within the first-year post-initial CHD diagnosis, it may not reflect the full range of health system utilization. It is necessary for clinicians and patient advocacy groups to collaborate with policymakers to promote the development of an overarching HQH designation authority for CHD care. Such establishment will facilitate access to HQH for military beneficiary populations suffering from CHD. [ABSTRACT FROM AUTHOR]

Abstract Objective This study aimed to map how oral health is addressed within the universal health coverage (UHC). Methods This scoping review followed the Joanna Briggs Institute methodology. Searches included the WHO Library and PubMed, Scopus, Embase, LILACS, and Cochrane databases. Quantitative and qualitative studies were included without publication date and language restrictions. Results A total of 486 studies were retrieved, of which 292 were excluded in the title and abstract screening phase; 121 full-texts were assessed. After the removal of duplicates and unavailable documents, 50 studies were included in the review and categorized according to the level of scientific evidence. Conclusion Few studies discussed oral health within the UHC, mostly because this coverage does not include oral health adequately. When offered, oral health packages are limited and include specific populations. Access and use of oral health services remain guided by economic factors, exposing the theoretical financial protectionism that perpetuates health inequalities.

Despite globalization's distributional impacts, we know little about (potentially differential) tax preferences of trade winners and losers, especially within social classes. We assess tax burden preferences to sustain public good provision using a vignette experiment with randomized tax instruments in the context of a liberalizing economy. More specifically, we analyze data from an original, randomized household survey of 1008 individuals in Sao Paulo State, Brazil, in 2019. We study preferences for increases in personal income, value-added, or corporate income taxes to improve funding for the universal health care system after Brazil adopts its free trade deal with the European Union. Findings reveal that the trade-losing poor support progressive taxes, whereas the trade-winning poor favor regressive instruments. By dividing the poor, globalization may create a barrier against more progressive fiscal strategies in emerging economies. [ABSTRACT FROM AUTHOR]

This paper systematically reviewed the process of primary health care development of China over the past 45 years, and summarized the achievements of primary health care based on data related to primary health care draw from 2010-2012 China Health Statistics Year book, 2013-2017 China Health and Family Planning Statistical Yearbook and 2018-2022 China Health Statistics Year book. Data of the infant mortality rate, maternal mortality rate, and average life expectancy were from the World Bank in China and upper middle income countries in 2023. The development of primary health care of China was summarized into four phases, and the achievements included the improvement of the primary health care network, coverage expansion of basic health insurance, the increase of funding and coverage of basic public health services, the steady improvement of family doctor contracts, and the continuous improvement of women's and children's health, with major health indicators ranking among the top upper middle-income countries. The current challenges include the unbalanced development of infrastructure construction in the primary medical and health system, the decline in the proportion of medical insurance funds, the lack of vitality of the management system, the low level of remuneration and imperfect incentive system. This paper summarizes the enlightenment of international experience for China's primary health care, and puts forward the future development directions and strategies.

The article presents a study which analyzed the magniture and trends in gallbladder cancer (GBC) mortality in Chile as an indirect assessment of the potential impact of the Acceso Universal con Garantías Explécitas (AUGE) program on GBC mortality. Topics discussed include GBC mortality rates in women, age-specific mortality rates for GBC, and possible reasons for the decline in GBC mortality rate prior to initiation of the AUGE program.

Mexican President Andrés Manuel López Obrador's historic election victory in 2018 marked a sharp break from past decades of neoliberal socioeconomic policies. López Obrador campaigned on the promise of deep reform, with health care high on his agenda. The public health care sector had been decimated by decades of budget cuts, eroding workers' morale and patients' confidence, and crippling all aspects of the system. This article looks back to the creation of the nation's public health care system in the early twentieth century during the administration of President Lázaro Cárdenas (1934–1940). This "universal" system was designed to implement a central social justice goal of the Mexican Revolution of health care for all. The program rested on two pillars: providing care to the nation's vast, impoverished rural population and actively engaging communities in their own health care. Our objective is to critically assess the two presidents' health care initiatives within the distinct historical contexts of their administrations. [ABSTRACT FROM AUTHOR]

Abstract Background The policy attention to primary health care has seen a global upswing in recent years, including in India. Earlier assessments had shown that a very small proportion of Indian population used the government primary health facilities. Starting in 2018, Indian government has established more than 100,000 Health and Wellness Centres (HWCs) to increase rural population’s access to primary health care. It is crucial to know how useful people find the services of HWCs. Methods A qualitative inquiry was made to understand the perceptions, experiences and expectations of the rural communities regarding HWCs in Chhattisgarh state. Fourteen focus group discussions were conducted with community members. The study areas were chosen to include both the central and remote districts of the state. The study used accessibility, availability, acceptability and quality (AAAQ) framework to assess HWCs. Results Community members felt that the most important change brought about by HWCs was to offer a wider range of curative services than previously available. Services for noncommunicable diseases such as hypertension and diabetes were seen as a key value addition of HWCs. People felt improvements in services for acute ailments also. The services people found missing in HWCs were for injuries, dental care and mental health. In people’s experience, the availability of essential medicines and point-of-care tests at HWCs was satisfactory and the treatment was effective. People appreciated the supportive behaviour of health workers in HWCs. They did not find the referrals from HWCs as excessive but often faced difficulties in receiving necessary services at higher facilities. Conclusions The assessment based on community perceptions showed that the services of HWCs matched well with people’s needs of curative primary care. It shows that people are willing to use the government facilities for primary health care if the services are relevant, adequately functional and accessible.

The Philippine Universal Health Care (UHC) law enacted in 2019 aimed to address entrenched health system challenges to achieving equitable access to quality health care. This commentary discusses the progress in its implementation to meet its objectives. Some of these health system challenges include overlapping financing roles; weak incentives for integrating health services across local government units (LGUs), the inclusion of the private sector in networks of care, and fragmented primary health care services. The UHC law introduced reforms to transform the Philippine Health Insurance Corporation (PhilHealth) into a strategic purchaser of health services, expand population coverage, and prioritize comprehensive outpatient and primary care services. Furthermore, the law mandated bolstering subnational health financing through a Special Health Fund (SHF) intended to encourage LGUs to integrate into provincial or city health systems. Pilots of the SHF highlighted opportunities and challenges in pooling, prioritizing, and redistributing resources if local health systems are capacitated. Despite facing implementation challenges, including changing priorities, politics, and lack of resources, the Philippines' experience emphasizes the importance of adaptive leadership, sustained commitment, and effective stakeholder engagement to ensure that these health financing reforms remain objective-oriented. Maximizing the UHC law’s potential going forward requires addressing ongoing challenges: sustained resource generation, ensuring effective coverage of the poor, and capacitating local health systems. The journey of the Philippines toward UHC offers valuable insights for global health reformers, underscoring the need for adaptive approaches and active political engagement to sustain and achieve progress toward universal and equitable health care access.

INTRODUCTION: Access to medicine is a concern in India and other developing countries. In India, Pradhan Mantri Bhartiya Janaushadhi Priyojana (PMBJP) helps to a certain extent in provision of medicines to people experiencing poverty. PMBJP is India's central government scheme hosted by the Department of Pharmaceuticals, which comes under the Ministry of Chemicals and Fertilizers. The scheme was uniformly introduced in all the states of the country to benefit the people at large in 2008. The objective of the scheme is to provide high-quality medication to everyone belonging to different strata of the population, especially underprivileged and impoverished people. The state has high regional inequality where few districts are economically developed while many others are economically backward, and access to medicine remains a challenge. This paper explores the knowledge and awareness of the scheme among PMC owners, grievances, and market competition of PMCs. METHODS: This study adopted a qualitative research method to understand the concerns of pharmacists and PMCs. An interview schedule was used to assess the situation. The research revolves around subjects such as proprietorship, motivational aspects, monetary provision, faith, satisfaction, perceived benefits, and challenges of the stakeholders. Therefore, openended, in-depth interviews were best suited for the study. PMC pharmacists were the only participants in the study. The data collection took place in January and February 2023. RESULTS: The results are presented under three themes pertaining to the PMC business: awareness, grievances, and market competition. The study revealed that the ownership of the PMCs was of two types in the state of Odisha, India: one was an old PMC that started between 2008 and 2015, and the other type was a new PHC that started after 2015. In 2015, radical changes were brought into the scheme. The popularity of the scheme among private pharmacists became a phenomenon after 2015; earlier, it was under the control of the government and the District Red Cross (DRC). The scheme was made open for all independent private pharmacists in 2015. The risk of expired stocks constantly loomed over the PMC business. PMC owners discussed expired drug management mechanisms. Market competition was very much in favor of the PMC owners, as thei r products were much cheaper than the branded market products. However, they reel under small earnings due to the low price of their products. CONCLUSION: Disseminating information about the PMBJP scheme is currently limited to existing pharmacists. The scheme could be promoted to recent graduates with D. Pharma or B to expand its reach. Pharma degrees, encouraging them to become independent PMC pharmacists. Additionally, enhancing mechanisms for managing expired drugs would make the PMC business more appealing. Reforms are also needed for older PMCs (established between 2008 and 2015) to prevent conflicts with authorities and other schemes. While PMCs benefit from lower product prices, they must increase sales volume to achieve satisfactory income, which should be considered to improve the financial outcomes for PMC owners. [ABSTRACT FROM AUTHOR]

Background: The policy attention to primary health care has seen a global upswing in recent years, including in India. Earlier assessments had shown that a very small proportion of Indian population used the government primary health facilities. Starting in 2018, Indian government has established more than 100,000 Health and Wellness Centres (HWCs) to increase rural population's access to primary health care. It is crucial to know how useful people find the services of HWCs. Methods: A qualitative inquiry was made to understand the perceptions, experiences and expectations of the rural communities regarding HWCs in Chhattisgarh state. Fourteen focus group discussions were conducted with community members. The study areas were chosen to include both the central and remote districts of the state. The study used accessibility, availability, acceptability and quality (AAAQ) framework to assess HWCs. Results: Community members felt that the most important change brought about by HWCs was to offer a wider range of curative services than previously available. Services for noncommunicable diseases such as hypertension and diabetes were seen as a key value addition of HWCs. People felt improvements in services for acute ailments also. The services people found missing in HWCs were for injuries, dental care and mental health. In people's experience, the availability of essential medicines and point-of-care tests at HWCs was satisfactory and the treatment was effective. People appreciated the supportive behaviour of health workers in HWCs. They did not find the referrals from HWCs as excessive but often faced difficulties in receiving necessary services at higher facilities. Conclusions: The assessment based on community perceptions showed that the services of HWCs matched well with people's needs of curative primary care. It shows that people are willing to use the government facilities for primary health care if the services are relevant, adequately functional and accessible. [ABSTRACT FROM AUTHOR]

Background and Aims: The United States of America and Sweden both contain a public and private component to their healthcare systems. While both countries spend a similar amount per capita on public healthcare expenditures, the United States spends significantly more in the private healthcare sector. Sweden has a social democratic model of health care, and given its identity as a welfare state, private health insurance providers have a small and nuanced role. Methods: This paper was completed after searches were queried for "Sweden," "United States," and variants of the words "insurance," "public," "private," "Medicare," "Medicaid," "public," and "costs." A preliminary search in May 2022, yielded 78 articles, of which 45 were ultimately considered relevant for this review. Inclusion criteria consisted of English language articles, topic relevance, and verification of MEDLINE‐indexed journals. These searches were performed in PubMed, Google Scholar, Embase, and Cochrane. Summary findings of these searches are compiled in this review. Results: Sweden guarantees low‐cost appropriate care to all citizens with equitable access; however, drawbacks of its system include high financial burden, lack of primary care infrastructure, as well as geographical and socioeconomic inequities. On the other hand, the United States' healthcare system is built around the private sector with public health insurance reserved only for the most vulnerable patient populations. Conclusion: Our goal is to provide an overview, compare the role of private health insurance in both countries, and highlight policies that have had beneficial effects in each nation. Possible solutions to the drawbacks of each nation's health insurance policies could be addressed by additional support to Sweden's vulnerable population by developing a program similar to the US' Medicare Advantage program. Conversely, the United States may benefit from increasing access to public health insurance, especially in instances where families face unemployment. [ABSTRACT FROM AUTHOR]

ABSTRACT Introduction Chronic kidney disease is a progressive and irreversible loss of kidney function and considerably affects the lives of patients and their families. Its high incidence necessitates efficient public policies for prevention and treatment. However, policies for chronic kidney disease education and awareness are scarce. Objective To evaluate global public policies for the prevention and treatment of chronic kidney disease adopted in various regions, aiming to comprehend the differences between various models. Methods This integrative review followed PRISMA recommendations and included papers published between 2016 and 2021 across several databases. Results The 44 selected articles were categorized into three themes: structural and financial aspects of the organization of renal healthcare, access to renal healthcare or management of chronic kidney disease, and coping strategies for chronic kidney disease or kidney health. Critical analysis of the papers revealed global neglect of kidney disease in political agendas. Considerable policy variations exist between different countries and regions of the same country. Our research highlighted that free and universal health coverage, especially for the most vulnerable patients, is crucial for accessing treatment owing to the prohibitively high treatment costs. Conclusion Social, economic, and ethnic inequalities strongly correlate with disease occurrence, primarily affecting minority groups who lack health support, especially for the prevention and treatment of chronic kidney disease.

BackgroundContinuous investment and systematic evaluation of program accomplishments are required to achieve excellence in ST-segment elevation myocardial infarction (STEMI) care, especially in resource-limited settings. Therefore, this study evaluates the impact of problem-driven interventions on reperfusion use rate in a long-term operating STEMI network from a low- to middle-income country.MethodsThis is a healthcare improvement evaluation study of Salvador's public STEMI network in a quasi-experimental design, comparing data from 2009 to 2010 (pre-intervention) and 2019-2020 (post-intervention). There were evaluated all confirmed STEMI cases assisted in both periods. The interventions, implemented since 2017, included: expanding the support team, defining criteria to be a spoke, and initiating continuous education activities. The primary outcome was the rate of patients undergoing reperfusion, with secondary outcomes being time from door-to-ECG (D2E) and ECG-to-STEMI-team trigger (E2T).ResultsOver ten years, the network's coverage increased by 300,000 individuals, and expanded by 1,800 km2. A total of 885 records were analyzed, 287 in the pre-intervention group (182 men [63·4%]; mean [SD] age 62·1 [12·5] years) and 598 in the post-intervention group (356 men [59·5%]; mean [SD] age 61.9 [11·8] years). It was noticed a substantial increase in reperfusion delivery rate (90 [31%] vs. 431 [73%]; P = 001) and reductions in time from D2E (159 [83–340] vs. 29 [15–63], P = 001), and E2T (31 [21–44] vs. 16 [6–40], P = 001).ConclusionThe strategies adopted by Salvador's STEMI network were associated with significant improvements in the rate of patients undergoing reperfusion and in D2E and E2T. However, the mortality rate remains high.

BackgroundBrazil’s Unified Health System (SUS) ensures universal, equitable, and excellent quality health coverage for all. The broad right to health, supported by the Constitution, has led to excessive litigation in the public sector. This has negatively impacted the financial stability of SUS, created inequality in children and adolescents’ access to healthcare, and affected communication between the healthcare system and the judiciary. The enactment of Law Number 13.655 on 25 April 2018, proposed significant changes in judicial decisions. This study aimed to investigate decision-making changes in health litigation involving children and adolescents following the implementation of the new normative model.MethodsThe study is cross-sectional, analyzing 3753 national judgment documents from all State Courts of Brazil, available on their respective websites from 2014 to 2020. It compares regional legal decisions before and after the promulgation of Law Number 13.655/2018. Data tabulation, statistical analysis, textual analysis, coding, and counting of significant units in the collected documents were performed. The results of data cross-referencing are presented in tables and diagrams.ResultsThe majority (96.86%) of legal claims (3635 cases) received partial or total provision of what was prescribed by the physician. The Judiciary predominantly handled these cases individually. The analysis indicates that the decisions made did not adhere to the norms established in 2018.ConclusionRegional heterogeneity in health litigation was observed, and there was no significant variability in decisions during the studied period, even after the implementation of the new normative paradigm in 2018. Technical-scientific support was undervalued by the magistrates. Prioritizing litigants undermines equity in access to Universal Health Coverage for children and adolescents.

Abstract Background Rural‒urban disparity in catastrophic healthcare expenditure (CHE) is a well-documented challenge in low- and middle-income countries, including Bangladesh, limiting financial protection and hindering the achievement of the Universal Health Coverage target of the United Nations Sustainable Development Goals. However, the factors driving this divide remain poorly understood. Therefore, this study aims to identify the key determinants of the rural‒urban disparity in CHE incidence in Bangladesh and their changes over time. Methods We used nationally representative data from the latest three rounds of the Bangladesh Household Income and Expenditure Survey (2005, 2010, and 2016). CHE incidence among households seeking healthcare was measured using the normative food, housing, and utilities method. To quantify covariate contributions to the rural‒urban CHE gap, we employed the Oaxaca-Blinder multivariate decomposition approach, adapted by Powers et al. for nonlinear response models. Results CHE incidence among rural households increased persistently during the study period (2005: 24.85%, 2010: 25.74%, 2016: 27.91%) along with a significant (p-value ≤ 0.01) rural‒urban gap (2005: 9.74%-points, 2010: 13.94%-points, 2016: 12.90%-points). Despite declining over time, substantial proportions of CHE disparities (2005: 87.93%, 2010: 60.44%, 2016: 61.33%) are significantly (p-value ≤ 0.01) attributable to endowment differences between rural and urban households. The leading (three) covariate categories consistently contributing significantly (p-value ≤ 0.01) to the CHE gaps were composition disparities in the lowest consumption quintile (2005: 49.82%, 2010: 36.16%, 2016: 33.61%), highest consumption quintile (2005: 32.35%, 2010: 15.32%, 2016: 18.39%), and exclusive reliance on informal healthcare sources (2005: -36.46%, 2010: -10.17%, 2016: -12.58%). Distinctively, the presence of chronic illnesses in households emerged as a significant factor in 2016 (9.14%, p-value ≤ 0.01), superseding the contributions of composition differences in household heads with no education (4.40%, p-value ≤ 0.01) and secondary or higher education (7.44%, p-value ≤ 0.01), which were the fourth and fifth significant contributors in 2005 and 2010. Conclusions Rural‒urban differences in household economic status, educational attainment of household heads, and healthcare sources were the key contributors to the rural‒urban CHE disparity between 2005 and 2016 in Bangladesh, with chronic illness emerging as a significant factor in the latest period. Closing the rural‒urban CHE gap necessitates strategies that carefully address rural‒urban variations in the characteristics identified above.

Abstract Background Community-Based Health Insurance (CBHI) schemes are recognized as an important health financing pathway to achieving universal health coverage (UHC). Although previous studies have documented CBHIs in low-income countries, the majority of these have been provider-based. Non-provider based schemes have received comparatively less empirical attention. We sought to describe a novel non-provider based CBHI munno mubulwadde (your friend indeed) comprising informal sector members in rural central Uganda to understand the structure of the scheme, the experiences of scheme members in terms of the perceived benefits and barriers to retention in the scheme. Methods We report qualitative findings from a larger mixed-methods study. We conducted in-depth interviews with insured members (n = 18) and scheme administrators (n = 12). Four focus groups were conducted with insured members (38 participants). Data were inductively analyzed by thematic approach. Results Munno mubulwadde is a union of ten CBHI schemes coordinated by one administrative structure. Members were predominantly low-income rural informal sector households who pay annual premiums ranging from $17 and $50 annually and received medical care at 13 scheme-contracted private health facilities in Luwero District in Central Uganda. Insured members reported that scheme membership protected them from catastrophic health expenditure during episodes of sickness among household members, and especially so among households with children under-five who were reported to fall sick frequently, the scheme enabled members to receive perceived better quality health care at private providers in the study district relative to the nearest public facilities. The identified barriers to retention in the scheme include inconvenient dates for premium payment that are misaligned with harvest periods for cash crops (e.g. maize corn) on which members depended for their agrarian livelihoods, long distances to insurance-contracted private providers, falling prices of cash crops which diminished real incomes and affordability of insurance premiums in successive years after initial enrolment. Conclusion Munno mubulwadde was perceived by as a valuable financial cushion during episodes of illness by rural informal sector households. Policy interventions for promoting price stability of cash crops in central Uganda could enhance retention of members in this non-provider CBHI which is worthy of further research as an additional funding pathway for realizing UHC in Uganda and other low-income settings.

Background and purpose: A part of the expenses of every household in all societies of the world is health expenditures, which can sometimes be disastrous for families. This study was conducted to investigate the change in the share of health expenditure from the total Household costs in Mazandaran province and the possible impact of health system reforms on it in Iran during the recent two decades, especially the Health Transformation Plan. Materials and methods: This is a retrospective descriptive-analytical study, based on quantitative and secondary data. The data required for this study was taken from the Statistics Center including household income and expenditure for a period of 18 years from 2001 to 2018. Descriptive statistics indicators and trend charts were used to describe the quantitative data, and to analyze household health expenditures, the t-test was applied in SPSS software. Results: The results of the study showed that on average, the share of health expenditures in the total household expenses was 12.04% for urban households and 11.36% for rural households that is more than the stated and expected limit of 10%. The trend of changes in the percentage of health expenditures from the total household expenses at the time of the research compared to the base year has been variable and in some years it has decreased and in some years it has increased. Conclusion: The health system reforms have not ultimately led to the reduction of household health expenditure to less than the expected level and its increasing trend in Mazandaran province.This means the risk of catastrophc health expenditure among households still exist. Even with the implementation of subsequent plans, the achievement of the previous plan has been neutralized. Considering the importance of financial issues in universal health coverage and also the limited resources of the health sector, more detailed policies and plans should be designed and implemented to target vulnerable groups so that families' financial hardship is prevented as well as the possibility of universal coverage is increased to the maximum.

Background The obligation to pay for asthma medication in a country with universal healthcare might lead to increased asthma exacerbations and inequitable healthcare access for children from low-income households. Thus, the aim of this study was to examine the association between household income and childhood/preschool asthma regarding hospitalization and medication receipt. Methods In this nationwide register-based cohort study, we encompassed all 3-year-old children residing in Denmark, born between 2000 and 2014, along with their linked parents and followed them until their sixth birthday. Household income was divided into quartiles. Asthma was categorized in two mutually exclusive groups as either the redemption of two prescriptions for asthma medication or receiving a hospital diagnosis. We utilized Poisson regression to estimate the risk ratio (RR). Results The analysis included 834 422 preschool children. The prevalence of asthma dependent on medication alone was 7.3%, while 1.8% of children necessitated asthma-related hospitalization. Income inequality was evident across all income quartiles. Notably, children from the lowest income quartile had a RR of 0.95 (95% CI: 0.92–0.98) of redeeming asthma medication and conversely a RR of 1.18 (95% CI: 1.14–1.23) of asthma-related hospitalization. Conclusions Despite universal healthcare, income inequality has a dual impact on children from low-income households. They face a diminished risk of redeeming asthma medication and a higher susceptibility to asthma-related hospitalizations indicating an unequal access to healthcare. Prioritizing efforts to reduce childhood health inequalities is crucial. However, further research, particularly qualitative studies, is needed to better comprehend the underlying mechanisms to address the complexities of income inequality. [ABSTRACT FROM AUTHOR]

Introduction: The coronavirus disease 2019 (COVID-19) pandemic brought new challenges and lessons were learnt for health services. In the field of pharmaceutical care, several interventions have been proposed to optimize and expand the response capacity of services. Objective: To identify and characterize interventions performed in the management of pharmaceutical services during the COVID-19 pandemic in universal public health systems. Methods: A rapid literature review was conducted and registered in PROSPERO (CRD42022360902). Systematic searches in the MEDLINE (PubMed), Embase, and Virtual Health Library databases were conducted to identify interventions and practices adopted for the management of pharmaceutical care during the COVID-19 pandemic. Results: Thirteen articles reporting interventions developed in six countries were included. The interventions were summarized under three major themes: actions for continuous access to medicines, logistical measures for acquisition and storage, and organizational strategies. Telepharmacy services stand out as a typical action adopted in different services, which highlights the use and consolidation of digital technologies in these services. Strategies for process management were described and focused on the reorganization of the internal service of pharmacies, flow of services, and people management. Conclusions: Many interventions were developed during the pandemic, some of which have already been incorporated into routine service delivery. Although the studies did not measure the effect of each intervention, the strategies developed are a source of information for the future delivery of care. Studies should be conducted to evaluate the potential of similar interventions in other health emergency contexts. [ABSTRACT FROM AUTHOR]

Background: Community-Based Health Insurance (CBHI) schemes are recognized as an important health financing pathway to achieving universal health coverage (UHC). Although previous studies have documented CBHIs in low-income countries, the majority of these have been provider-based. Non-provider based schemes have received comparatively less empirical attention. We sought to describe a novel non-provider based CBHI munno mubulwadde (your friend indeed) comprising informal sector members in rural central Uganda to understand the structure of the scheme, the experiences of scheme members in terms of the perceived benefits and barriers to retention in the scheme. Methods: We report qualitative findings from a larger mixed-methods study. We conducted in-depth interviews with insured members (n = 18) and scheme administrators (n = 12). Four focus groups were conducted with insured members (38 participants). Data were inductively analyzed by thematic approach. Results: Munno mubulwadde is a union of ten CBHI schemes coordinated by one administrative structure. Members were predominantly low-income rural informal sector households who pay annual premiums ranging from $17 and $50 annually and received medical care at 13 scheme-contracted private health facilities in Luwero District in Central Uganda. Insured members reported that scheme membership protected them from catastrophic health expenditure during episodes of sickness among household members, and especially so among households with children under-five who were reported to fall sick frequently, the scheme enabled members to receive perceived better quality health care at private providers in the study district relative to the nearest public facilities. The identified barriers to retention in the scheme include inconvenient dates for premium payment that are misaligned with harvest periods for cash crops (e.g. maize corn) on which members depended for their agrarian livelihoods, long distances to insurance-contracted private providers, falling prices of cash crops which diminished real incomes and affordability of insurance premiums in successive years after initial enrolment. Conclusion: Munno mubulwadde was perceived by as a valuable financial cushion during episodes of illness by rural informal sector households. Policy interventions for promoting price stability of cash crops in central Uganda could enhance retention of members in this non-provider CBHI which is worthy of further research as an additional funding pathway for realizing UHC in Uganda and other low-income settings. [ABSTRACT FROM AUTHOR]

Background and purpose: A part of the expenses of every household in all societies of the world is health expenditures, which can sometimes be disastrous for families. This study was conducted to investigate the change in the share of health expenditure from the total Household costs in Mazandaran province and the possible impact of health system reforms on it in Iran during the recent two decades, especially the Health Transformation Plan. Materials and methods: This is a retrospective descriptive-analytical study, based on quantitative and secondary data. The data required for this study was taken from the Statistics Center including household income and expenditure for a period of 18 years from 2001 to 2018. Descriptive statistics indicators and trend charts were used to describe the quantitative data, and to analyze household health expenditures, the t-test was applied in SPSS software. Results: The results of the study showed that on average, the share of health expenditures in the total household expenses was 12.04% for urban households and 11.36% for rural households that is more than the stated and expected limit of 10%. The trend of changes in the percentage of health expenditures from the total household expenses at the time of the research compared to the base year has been variable and in some years it has decreased and in some years it has increased. Conclusion: The health system reforms have not ultimately led to the reduction of household health expenditure to less than the expected level and its increasing trend in Mazandaran province. This means the risk of catastrophc health expenditure among households still exist. Even with the implementation of subsequent plans, the achievement of the previous plan has been neutralized. Considering the importance of financial issues in universal health coverage and also the limited resources of the health sector, more detailed policies and plans should be designed and implemented to target vulnerable groups so that families' financial hardship is prevented as well as the possibility of universal coverage is increased to the maximum. [ABSTRACT FROM AUTHOR]

Abstract Background and Aims The United States of America and Sweden both contain a public and private component to their healthcare systems. While both countries spend a similar amount per capita on public healthcare expenditures, the United States spends significantly more in the private healthcare sector. Sweden has a social democratic model of health care, and given its identity as a welfare state, private health insurance providers have a small and nuanced role. Methods This paper was completed after searches were queried for “Sweden,” “United States,” and variants of the words “insurance,” “public,” “private,” “Medicare,” “Medicaid,” “public,” and “costs.” A preliminary search in May 2022, yielded 78 articles, of which 45 were ultimately considered relevant for this review. Inclusion criteria consisted of English language articles, topic relevance, and verification of MEDLINE‐indexed journals. These searches were performed in PubMed, Google Scholar, Embase, and Cochrane. Summary findings of these searches are compiled in this review. Results Sweden guarantees low‐cost appropriate care to all citizens with equitable access; however, drawbacks of its system include high financial burden, lack of primary care infrastructure, as well as geographical and socioeconomic inequities. On the other hand, the United States' healthcare system is built around the private sector with public health insurance reserved only for the most vulnerable patient populations. Conclusion Our goal is to provide an overview, compare the role of private health insurance in both countries, and highlight policies that have had beneficial effects in each nation. Possible solutions to the drawbacks of each nation's health insurance policies could be addressed by additional support to Sweden's vulnerable population by developing a program similar to the US' Medicare Advantage program. Conversely, the United States may benefit from increasing access to public health insurance, especially in instances where families face unemployment.

ABSTRACTEstablishing effective pharmaceutical governance is a challenge for government agencies, private enterprises, and professionals working on the ground, demanding complex ethical decisions from the actors involved, especially in a lower-middle-income country like Ghana. This letter aims to share the author’s perspectives and additional considerations on the analyses of the reports in the paper “It is very difficult in this business if you want to have a good conscience”: pharmaceutical governance and on-the-ground ethical labor in Ghana by Hampshire et al. The letter's authors discuss the need to advance universal health coverage in Ghana, the everyday ethics, and the disparities between the collective and individual moral consciousness of the participants, as well as other aspects of governance in the pharmaceutical sector.

Abstract Background Over the last two decades, many countries have moved from malaria control toward malaria elimination. However, some sub-Saharan African countries, like Malawi, have recently seen a reversal in malaria control progress with reported increases in confirmed malaria cases. This may be the result of inadequate access to effective malaria control interventions by key population groups that perpetuate transmission. This study aimed to assess the barriers to accessing malaria treatment among school-aged children (SAC) in Malawi. Methods A qualitative study was conducted between September and October 2020, where data were gathered in rural Malawi using free-listing interviews, key-informant interviews, semi-structured interviews and focus group discussions. Purposively sampled participants included SAC, parents of SAC, health workers and key stakeholders at community and district levels. Interviews were digitally recorded and transcribed verbatim. Data were organized using NVivo 12 software and analysed using the thematic method. Results The study recruited 252 participants, with 156 being SAC, equally divided between boys and girls. Health system barriers to malaria treatment included long waiting hours and queues at clinics, frequent stock-outs of medical supplies, and travel time to the facility. Provider barriers included negative attitude and limited service hours. Individual and cultural barriers included fear of malaria tests and beliefs associating witchcraft as the best treatment for malaria. In addition, COVID-19-related barriers included the inability to follow preventive measures, a shift in focus from malaria to COVID-19, and fear of contracting COVID-19 and/or being tested for COVID-19 at the facility. Conclusions This study shows most of the barriers to accessing malaria treatment among SAC are similar to those experienced by other population groups. Furthermore, COVID-19 adversely affected SAC’s access to treatment. Interventions that support SAC access to prompt diagnosis and treatment are urgently needed to improve the effective control of malaria.

Abstract Background Ovarian cancer (OC) is associated with a poor prognosis, which calls for earlier diagnosis. This study aimed to analyse the health care use in primary care and at hospitals among women with OC compared to non-cancerous women to identify a window of opportunity for earlier diagnosis. Methods This nationwide register-based observational cohort study included all Danish women aged ≥ 40 years who were diagnosed with a first-time OC or borderline ovarian tumour in 2012–2018 and with no previous cancer diagnosis (n = 4,255). For each case, ten non-cancerous women were identified (n = 42,550). We estimated monthly incidence rate ratios using a negative binomial regression model to assess the use of health care services. We calculated risk ratios of having multiple contacts to general practice before a diagnosis using a binary regression model. Results Cases had statistically significantly higher contact rates to general practice from five months prior to the diagnosis compared to references. From six to eight months prior to diagnosis, an increased use of transvaginal ultrasound and gynaecologist was seen for cases compared to references. Conclusions Increased healthcare use was seen relatively closely to the time of diagnosis for women with OC. This indicates a narrow window of opportunity for a timelier diagnosis. Still, the use of specialised assessment increased at six to eight months before the diagnosis. When women present unspecific symptoms, awareness of potential ovarian malignancies and safety-netting by the general practitioner may be pivotal. Trial registration Not relevant.

Abstract Background Universal Health Coverage (UHC) has received much attention and many countries are striving to achieve it. The Southeast Asian region, in particular, comprises many developing countries with limited resources, exacerbating challenges around attaining UHC. This paper aims to specifically explore the health financing challenges these countries face in achieving UHC via a systematic review approach and formulate recommendations that will be useful for policymakers. Methods The systematic review followed the guidelines as recommended by PRISMA. The narrative synthesis approach was used for data synthesis, followed by identifying common themes. Results The initial search returned 160 articles, and 32 articles were included after the screening process. The identified challenges in health financing towards achieving UHC in the Southeast Asian region are categorised into six main themes, namely (1) Unsustainability of revenue-raising methods, (2) Fragmented health insurance schemes, (3) Incongruity between insurance benefits and people’s needs, (4) Political and legislative indifference, (5) Intractable and rapidly rising healthcare cost, (6) Morally reprehensible behaviours. Conclusions The challenges identified are diverse and therefore require a multifaceted approach. Regional collaborative efforts between countries will play an essential role in the progress towards UHC and in narrowing the inequity gap. At the national level, individual countries must work towards sustainable health financing strategies by leveraging innovative digital technologies and constantly adapting to dynamic health trends. Registration This study is registered with PROSPERO, under registration number CRD42022336624.

Abstract Background The Government of The Gambia introduced a national health insurance scheme (NHIS) in 2021 to promote universal health coverage (UHC). Provider payment systems (PPS) are strategic purchasing arrangements that can enhance provider performance, accountability, and efficiency in the NHIS. This study assessed healthcare workers’ (HCWs’) preferences for PPS across major service areas in the NHIS. Methods A facility-based cross-sectional study was conducted using a probability proportionate to size sampling technique to select an appropriate sample size. Health care workers were presented with options for PPS to choose from across major service areas. Descriptive statistics explored HCW socio-demographic and health service characteristics. Multinomial logistic regressions were used to assess the association between these characteristics and choices of PPS. Results The majority of HCW did not have insurance coverage, but more than 60% of them were willing to join and pay for the NHIS. Gender, professional cadre, facility level, and region influenced HCW’s preference for PPS across the major service areas. The preferred PPS varied among HCW depending on the service area, with capitation being the least preferred PPS across all service areas. Conclusion The National Health Insurance Authority (NHIA) needs to consider HCW’s preference for PPS and factors that influence their preferences when choosing various payment systems. Strategic purchasing decisions should consider the incentives these payment systems may create to align incentives to guide provider behaviour towards UHC. The findings of this study can inform policy and decision-makers on the right mix of PPS to spur provider performance and value for money in The Gambia’s NHIS.

Background The reimbursement of outpatient services is an essential part of the reform of medical insurance payment methods. With the comprehensive promotion of the reform on the medical insurance payment methods for inpatient services in China, the reform on insurance payment methods for outpatient services, such as capitation-based reimbursement and ambulatory patient groups (APG) point method, will gradually be put on the agenda. Objective To explore a capitation-based reimbursement scheme for chronic diseases applicable to Beijing based on an analysis of capitation-based reimbursement implemented in different countries and regions and the current situation of chronic disease management in Beijing, to provide a reference for implementing the capitation-based reimbursement reform for chronic diseases in Beijing. Methods This study used information related to essential medical services, reimbursement by health insurance, and essential public health service funds in Beijing's C and H districts. Then through an analysis of the information, the calculation method for capitation-based reimbursement standard for four common chronic diseases (hypertension, diabetes, coronary heart disease and stroke were selected in this study) applicable in the districts was designed to calculate the capitation-based reimbursement standard for major chronic diseases in primary outpatient clinics, providing a reference for promoting the capitation reform for chronic diseases in outpatient clinics. Results By analyzing the above-mentioned information in 2017—2019, the capitation-based reimbursement standard was 4 693.11 yuan/person for hypertension, 6 597.70 yuan/person for diabetes, 5 644.46 yuan/person for coronary heart disease, and 6 437.78 yuan/person for stroke in H district calculated using the bottom-up costing, and was 4 884.18 yuan/person for hypertension, 5 960.63 yuan/person for diabetes, 3 733.93 yuan/person for coronary heart disease, and 3 886.66 yuan/person for stroke in C district calculated using the top-down estimating. Conclusion In calculating the capitation-based reimbursement standard, as different chronic disease patient groups have different outpatient costs, considering the equity of medical insurance reimbursement and the rationality of capitation-based reimbursement, it is necessary to adjust the risk of the benchmark capitation, and develop personalized service packages for different types and severity of chronic diseases. In the promotion of capitation payment for chronic disease patients, it is necessary to provide personalized essential medical service and public health service packages for patients with different chronic diseases, further improve the chronic disease management capacity of community health institutions to improve the contracting rate and establish an effective incentive and assessment mechanism for general practitioners to rationally allocate capitation balance.

Universal Health Care (UHC) in Indonesia, named the National Health Insurance (Jaminan Kesehatan Nasional - JKN), has been running since 2014. JKN was predicted to be the most extensive UHC program in the world. Under JKN, the poor get free health services through the cashless method through a sub-program called Contribution Assistance Recipients (Penerima Bantuan Iuran - PBI). Unfortunately, JKN faced several failures to cover the program's expenditures within years. Within the current dynamics, was PBI, as part of JKN still effectively helping the poor? We examined the effectiveness of the PBI program by measuring differences in out-of-pocket health expenditures for the poor with similar socio-economic characteristics who used PBI and those who did not. We incorporated secondary data from National Socio-economic Survey (SUSENAS). The dataset was executed by using Propensity Score Matching (PSM) methodology. We used health expenditures and socio-economic parameters such as income, education, and gender from the 2017 and 2018 SUSENAS data. We found that in 2017, the total health expenditures of the PBI beneficiaries were lower than the non-beneficiaries. Nevertheless, by merging all two years' data, similar to 2018, we found general pattern that PBI participants' total health out-of-pocket payments were bigger than the non-participants. Health expenditures such as medicine, traditional practitioners, and others, were expenditure classifications in which PBI beneficiaries had lower expenses than non-beneficiaries in 2017. Therefore, Therefore, the UHC subsidy program for the poor in Indonesia has not only been ineffective through the years of implementation but also has not been effectively implemented for all variations of health expenditure types.

Background As South Korea achieved universal health care (UHC) in 1989, patients’ access to low-cost health services has highly increased. However, as liability for high-cost procedures is still high, patients’ accessibility to high-cost services is has been limited. For this reason, the Korean government has implemented an initiative of the “Mid-term Health Benefits Security Plan” to expand the health benefits coverage since 2005. Nevertheless, it has been criticized as the policy has yet to show any transparent evidence of reducing patients’ out-of-pocket costs since its implementation. This study aims to identify if the benefit expansion policy affected a reduction of patients’ health care spending and utilization after policy implementation. Methods We analyze data from the Korean Health Panel Survey for years 2009-2016, a nationally representative survey of non-institutionalized Korean citizens that provide the most comprehensive information on health care utilization and costs. We utilize two-part difference-in-differences (DID) models to estimate the patients' probability of accessing any care and the intensity of care, health care spending and utilization, conditional on the initiated care Results The total out-of-pocket(OOP) payments and inpatient spending decreased by USD 175.33 (p = 0.033) and USD 358.86 (p =0.018), respectively, which were statistically significant. Outpatient spending increased by USD 57.43 (p =0.607), but it was not statistically significantly associated with the policy implementation. In utilization, there were no significant changes in either the number of visits or hospital stays. Conclusions Even though we found that the policy led to a reduction in patients' OOP spending, the effects of the policy were largely limited to inpatient services and patients with high incomes. As the limited benefits of the policy to the particular services and patients might raise some equity issues, the government needs to extend the range of coverage more broadly so that a more comprehensive population can benefit from the policy.

Resumen: En América Latina, desde los años 1990 se iniciaron reformas estructurales, con diferente grado de éxito. Uno de sus objetivos primordiales ha sido transformar los sistemas de salud, con énfasis en fortalecer la atención primaria de salud (APS), promoviendo un enfoque integral y cohesivo, reduciendo la fragmentación en la prestación de servicios, mejorando la coordinación entre los distintos niveles asistenciales y garantizando la calidad de la atención. El propósito de este artículo es realizar una breve reflexión de las iniciativas y las reformas relacionadas con la implementación de la APS en los últimos años en Brasil, Chile, Colombia, México y Perú. Estos países han tenido diferencias estructurales e históricas entre sus reformas en APS, y también algunas características comunes. A pesar de la heterogeneidad de los países analizados, existen retos comunes para lograr el acceso universal y la equidad en salud. Las reformas y los programas implementados han reconocido la importancia de la APS como eje central para mejorar el acceso y reducir las inequidades en salud. Aunque se han diseñado diferentes modelos de APS, la mayoría comparten enfoques integrales, preventivos y de promoción de la salud, con énfasis en la participación comunitaria. Sin embargo, los recientes desafíos, acentuados por la pandemia de COVID-19, han revelado las fragilidades de la APS en estos países. Para lograr un acceso universal efectivo y equitativo serán cruciales un mayor compromiso político, iniciativas intersectoriales sólidas, la formación y la retención de profesionales en la APS, así como mecanismos de financiamiento sostenibles y adaptados a las necesidades locales. Abstract: Since the 1990s, structural reforms have been initiated in Latin America, with varying degrees of success. One of their main objectives has been to transform health systems, with an emphasis on strengthening primary health care (PHC). This implies promoting a comprehensive and cohesive approach, reducing fragmentation in the provision of services, improving coordination between the different levels of care, and ensuring better quality of care. The purpose of this article is to briefly reflect on the initiatives and reforms related to the implementation of PHC in recent years in Brazil, Chile, Colombia, Mexico, and Peru. These countries have had structural and historical differences between their PHC reforms, as well as some common characteristics. Despite the heterogeneity between the countries analyzed, there are common challenges to achieve universal access and equity in health. The reforms and programs implemented have recognized the importance of PHC as a central axis to improve access and reduce health inequities. Although different models of PHC have been designed, most share comprehensive, preventive and health-promoting approaches, with an emphasis on community participation. However, recent challenges accentuated by the pandemic have revealed the fragilities of PHC in these countries. To achieve effective and equitable universal access, greater political commitment, strong intersectoral initiatives, training and retention of PHC professionals, and sustainable financing mechanisms will be crucial.

Rationale: Intravenous plasma-purified alpha-1 antitrypsin (IVAAT) has been used as therapy for alpha-1 antitrypsin deficiency (AATD) since 1987. Previous trials (RAPID and RAPID-OLE) demonstrated efficacy in preserving computed tomography of lung density but no effect on FEV1. This observational study evaluated 615 people with severe AATD from three countries with socialized health care (Ireland, Switzerland, and Austria), where access to standard medical care was equal but access to IV-AAT was not. Objectives: To assess the real-world longitudinal effects of IV-AAT. Methods: Pulmonary function and mortality data were utilized to perform longitudinal analyses on registry participants with severe AATD. Measurements and Main Results: IV-AAT confers a survival benefit in severe AATD (P<0.001). We uncovered two distinct AATD phenotypes based on an initial respiratory diagnosis: lung index and non--lung index. Lung indexes demonstrated amore rapid FEV1 decline between the ages of 20 and 50 and subsequently entered a plateau phase of minimal decline from50 onward. Consequentially, IV-AAT had no effect on FEV1 decline, except in patients with a Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 2 lung index. Conclusions: This real-world study demonstrates a survival advantage from IV-AAT. This improved survival is largely decoupled from FEV1 decline. The observation that patients with severe AATD fall into two major phenotypes has implications for clinical trial design where FEV1 is a primary endpoint. Recruits into trials are typically older lung indexes entering the plateau phase and, therefore, unlikely to show spirometric benefits. IV-AAT attenuates spirometric decline in lung indexes in GOLD stage 2, a spirometric group commonly outside current IV-AAT commencement recommendations. [ABSTRACT FROM AUTHOR]

Background: Over the last two decades, many countries have moved from malaria control toward malaria elimination. However, some sub-Saharan African countries, like Malawi, have recently seen a reversal in malaria control progress with reported increases in confirmed malaria cases. This may be the result of inadequate access to effective malaria control interventions by key population groups that perpetuate transmission. This study aimed to assess the barriers to accessing malaria treatment among school-aged children (SAC) in Malawi. Methods: A qualitative study was conducted between September and October 2020, where data were gathered in rural Malawi using free-listing interviews, key-informant interviews, semi-structured interviews and focus group discussions. Purposively sampled participants included SAC, parents of SAC, health workers and key stakeholders at community and district levels. Interviews were digitally recorded and transcribed verbatim. Data were organized using NVivo 12 software and analysed using the thematic method. Results: The study recruited 252 participants, with 156 being SAC, equally divided between boys and girls. Health system barriers to malaria treatment included long waiting hours and queues at clinics, frequent stock-outs of medical supplies, and travel time to the facility. Provider barriers included negative attitude and limited service hours. Individual and cultural barriers included fear of malaria tests and beliefs associating witchcraft as the best treatment for malaria. In addition, COVID-19-related barriers included the inability to follow preventive measures, a shift in focus from malaria to COVID-19, and fear of contracting COVID-19 and/or being tested for COVID-19 at the facility. Conclusions: This study shows most of the barriers to accessing malaria treatment among SAC are similar to those experienced by other population groups. Furthermore, COVID-19 adversely affected SAC's access to treatment. Interventions that support SAC access to prompt diagnosis and treatment are urgently needed to improve the effective control of malaria. [ABSTRACT FROM AUTHOR]

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Abstract Background The capacity to deliver essential health services has been negatively impacted by the COVID-19 pandemic, particularly due to lockdown restrictions. Telemedicine provides a safe, efficient, and effective alternative that addresses the needs of patients and the health system. However, there remain implementation challenges and barriers to patient adoption in resource-limited settings as in the Philippines. This mixed methods study aimed to describe patient perspectives and experiences with telemedicine services, and explore the factors that influence telemedicine use and satisfaction. Methods An online survey consisting of items adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician & Group Adult Visit Survey 4.0 (beta) and the Telehealth Usability Questionnaire (TUQ) was completed by 200 participants aged 18 to 65 years residing in the Philippines. A subsample of 16 participants was interviewed to provide further insights on their experiences. We used descriptive statistics to analyze survey data and thematically analyzed data from interviews guided by the principles of grounded theory. Results Participants were generally satisfied with telemedicine, and found it to be an efficient and convenient means of receiving healthcare. About 3 in 5 perceived telemedicine as affordable, with some finding telemedicine costs to be high and comparable to in-person consultations. Our results suggest that participants preferred telemedicine services, especially in cases where they feel that their condition is not urgent and does not need extensive physical examination. Safety against COVID-19, privacy, accessibility, and availability of multiple communication platforms contributed to patient satisfaction with telemedicine. Negative perceptions of patients on quality of care and service related to their telemedicine provider, inherent limitations of telemedicine in the diagnosis and management of patients, perceived high costs especially for mental health conditions, and poor connectivity and other technological issues were barriers to telemedicine use and satisfaction. Conclusion Telemedicine is viewed as a safe, efficient, and affordable alternative to receiving care. Expectations of patients on costs and outcomes need to be managed by providers to increase satisfaction. Continued adoption of telemedicine will require improvements in technology infrastructure and technical support for patients, training and performance evaluation of providers to ensure quality of care and service, better patient communication to meet patient needs, and integration of telemedicine services in remote areas that have limited access to medical services. Telemedicine, to realize its full potential, should be centered in health equity – addressing patient barriers and needs, reducing health disparities across population groups and settings, and providing quality services to all.

Establishing effective pharmaceutical governance is a challenge for government agencies, private enterprises, and professionals working on the ground, demanding complex ethical decisions from the actors involved, especially in a lower-middle-income country like Ghana. This letter aims to share the author's perspectives and additional considerations on the analyses of the reports in the paper "It is very difficult in this business if you want to have a good conscience": pharmaceutical governance and on-the-ground ethical labor in Ghana by Hampshire et al. The letter's authors discuss the need to advance universal health coverage in Ghana, the everyday ethics, and the disparities between the collective and individual moral consciousness of the participants, as well as other aspects of governance in the pharmaceutical sector. [ABSTRACT FROM AUTHOR]

Background: The high burden of out-of-pocket expenditure (OOPE) in India has led to introduction of several public-funded health insurance (PFHI) programmes. This study examined the impact of PFHI on hospitalisation-related OOPE in the Rajasthan state. Methods: Data from the National Sample Survey 75th round on Social Consumption (Health), were utilized for this study. The sample of Rajasthan state, consisting of 5045 households and 28,020 individuals, was analysed to determine factors associated to PFHI coverage, choice of healthcare provider and OOPE. Results: One third of the population was covered by PFHI. In the private facility, although PFHI reduced OOPE (INR 17000 vs 14,700), it did not reduce catastrophic health expenditure (CHE), i.e., CHE 10% (47.1% vs 47.2%), CHE 25% (19.2 vs 23.4%). In government hospitals, PFHI reduced OOPE (INR 2500 vs. 2050), CHE 10% (11.1% vs 7.8%), and CHE 25% (3.6% vs. 2.7%). PFHI did not have any significant effect on the choice of healthcare provider in hospitalised patients in Rajasthan (AOR 0.95, P = 0.538). Conclusion: The study suggests that PFHI does not have any effect on OOPE associated with hospitalisation. Government-funded healthcare is more effective in providing financial protection compared to private healthcare with PFHI. Private facilities are still chosen despite lower OOPE in government facilities due to quality and availability concerns. These limitations of PFHIs must be thoroughly examined before switching from subsidised services to purchases from private facilities. A combination of both approaches should be integrated to achieve universal health care and financial protection for all.

ABSTRACT Objectives: to analyze the occurrence of incidents in the context of mobile terrestrial pre-hospital care. Methods: a descriptive research was carried out through the observation of 239 treatments performed by 22 healthcare professionals at the Mobile Emergency Care Service, located in Baixada Fluminense, Rio de Janeiro, Brazil. Fisher’s exact test and chi-square test were used for data analysis. Results: the total time dedicated to patient care was 439.5 hours, during which 2386 security incidents were observed. The most notable ones were related to written communication (235), patient identification through bracelets (238), and safety in medication preparation (81). Conclusions: the need to promote and implement initiatives aimed at patient safety is evident, with special focus on international safety goals within the scope of mobile pre-hospital care services.

Background: Ovarian cancer (OC) is associated with a poor prognosis, which calls for earlier diagnosis. This study aimed to analyse the health care use in primary care and at hospitals among women with OC compared to non-cancerous women to identify a window of opportunity for earlier diagnosis. Methods: This nationwide register-based observational cohort study included all Danish women aged ≥ 40 years who were diagnosed with a first-time OC or borderline ovarian tumour in 2012–2018 and with no previous cancer diagnosis (n = 4,255). For each case, ten non-cancerous women were identified (n = 42,550). We estimated monthly incidence rate ratios using a negative binomial regression model to assess the use of health care services. We calculated risk ratios of having multiple contacts to general practice before a diagnosis using a binary regression model. Results: Cases had statistically significantly higher contact rates to general practice from five months prior to the diagnosis compared to references. From six to eight months prior to diagnosis, an increased use of transvaginal ultrasound and gynaecologist was seen for cases compared to references. Conclusions: Increased healthcare use was seen relatively closely to the time of diagnosis for women with OC. This indicates a narrow window of opportunity for a timelier diagnosis. Still, the use of specialised assessment increased at six to eight months before the diagnosis. When women present unspecific symptoms, awareness of potential ovarian malignancies and safety-netting by the general practitioner may be pivotal. Trial registration: Not relevant. [ABSTRACT FROM AUTHOR]

Background: Universal Health Coverage (UHC) has received much attention and many countries are striving to achieve it. The Southeast Asian region, in particular, comprises many developing countries with limited resources, exacerbating challenges around attaining UHC. This paper aims to specifically explore the health financing challenges these countries face in achieving UHC via a systematic review approach and formulate recommendations that will be useful for policymakers. Methods: The systematic review followed the guidelines as recommended by PRISMA. The narrative synthesis approach was used for data synthesis, followed by identifying common themes. Results: The initial search returned 160 articles, and 32 articles were included after the screening process. The identified challenges in health financing towards achieving UHC in the Southeast Asian region are categorised into six main themes, namely (1) Unsustainability of revenue-raising methods, (2) Fragmented health insurance schemes, (3) Incongruity between insurance benefits and people's needs, (4) Political and legislative indifference, (5) Intractable and rapidly rising healthcare cost, (6) Morally reprehensible behaviours. Conclusions: The challenges identified are diverse and therefore require a multifaceted approach. Regional collaborative efforts between countries will play an essential role in the progress towards UHC and in narrowing the inequity gap. At the national level, individual countries must work towards sustainable health financing strategies by leveraging innovative digital technologies and constantly adapting to dynamic health trends. Registration: This study is registered with PROSPERO, under registration number CRD42022336624. [ABSTRACT FROM AUTHOR]

Background: The Government of The Gambia introduced a national health insurance scheme (NHIS) in 2021 to promote universal health coverage (UHC). Provider payment systems (PPS) are strategic purchasing arrangements that can enhance provider performance, accountability, and efficiency in the NHIS. This study assessed healthcare workers' (HCWs') preferences for PPS across major service areas in the NHIS. Methods: A facility-based cross-sectional study was conducted using a probability proportionate to size sampling technique to select an appropriate sample size. Health care workers were presented with options for PPS to choose from across major service areas. Descriptive statistics explored HCW socio-demographic and health service characteristics. Multinomial logistic regressions were used to assess the association between these characteristics and choices of PPS. Results: The majority of HCW did not have insurance coverage, but more than 60% of them were willing to join and pay for the NHIS. Gender, professional cadre, facility level, and region influenced HCW's preference for PPS across the major service areas. The preferred PPS varied among HCW depending on the service area, with capitation being the least preferred PPS across all service areas. Conclusion: The National Health Insurance Authority (NHIA) needs to consider HCW's preference for PPS and factors that influence their preferences when choosing various payment systems. Strategic purchasing decisions should consider the incentives these payment systems may create to align incentives to guide provider behaviour towards UHC. The findings of this study can inform policy and decision-makers on the right mix of PPS to spur provider performance and value for money in The Gambia's NHIS. [ABSTRACT FROM AUTHOR]