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The article discusses the role of digital health solutions in strengthening health systems and improving health care services. Topics discussed include the global challenge of health inequities with billions of people facing preventable diseases and premature deaths due to the lack of health care access, the interoperability of existing health data which is needed to implement digital solutions, and the periodical's calls for papers about digital health solutions.

The authors offer observation on a theme issue on sexual health and well-being across the life course that will be publishes in "The Bulletin of the World Health Organization." Topics discussed include definition of sexual health by the World Health Organization (WHO), aim of the "Transforming our world: the 2030 Agenda for Sustainable Development," and insight on WHO's programme on sexual health.

The authors reflect on the global health inequalities in the efforts to achieve optimal health and the sustainable development goals (SDG) set by the United Nations worldwide. Other topics include the effects of the coronavirus disease 2019 (COVID-19) pandemic on programs to reduce income inequity among countries, and the authors' call for papers aimed at addressing inequalities in global health.

The authors reflect on the importance of access to rehabilitation as a basic human rights and a call for papers by the journal on the promotion of rehabilitation though health policy and systems research. Also cited are the inclusion of rehabilitation in the universal health coverage (UHC) target of the sustainable development goals, and how the coronavirus disease 2019 (COVID-19) pandemic showed the need for rehabilitation in the acute, post-acute and long-term stages of infectious diseases.

The article calls for papers addressing the health of vulnerable populations, constructs of social inclusion and exclusion, interventions for vulnerable populations in the context of sustainable development goals (SDG) at the micro- and macro-policy levels, and factors to vulnerabilities.

The article discusses principles underlying the position proposed by the World Health Organization Registry Platform Working Group on the Reporting of Findings of Clinical Trials which states that the findings of all clinical trials must be made publicly available. According to the authors, a significant proportion of health-care research remains unpublished and some researchers do not make all of their results available. They contend that the report is the start of a consultation process on how transparency can be achieved, with the intention that greater accessibility to the findings of clinical trials will lead to improvements in health care.

The authors offer observation on health impacts of climate change and geopolitics. Topics discussed include increase in global carbon dioxide emissions in 2018, direct health effects of the main drivers of climate changes like fossil fuel, and how climate change affects agriculture. It also mentions goal set by the 2015 Paris Agreement and ways geopolitics influenced the allocation of foreign assistance.

The article calls for a submission of manuscripts on how to improve universal health coverage. Topics mentioned include the importance of evidence-informed policies to expand the key dimensions of universal health coverage, the influence of public and private providers on the effectiveness of health systems, and the role that innovative technology and the design and application of health information in universal health coverage acceleration.

The authors convey their concerns on providing health care to people living in conflict-affected areas. Topics covered include accountability to affected populations as defined by the Inter-Agency Standing Committee, the need for operational guidance on the provision of trauma care in conflict settings, and the need for immediate evacuation from the location of injury to the care facility.

The World Health Organization (WHO) aims to reduce new leprosy cases by 70% by 2030, necessitating advancements in leprosy diagnostics. Here we discuss the development of two WHO's target product profiles for such diagnostics. These profiles define criteria for product use, design, performance, configuration and distribution, with a focus on accessibility and affordability. The first target product profile outlines requirements for tests to confirm diagnosis of leprosy in individuals with clinical signs and symptoms, to guide multidrug treatment initiation. The second target product profile outlines requirements for tests to detect Mycobacterium leprae or M. lepromatosis infection among asymptomatic contacts of leprosy patients, aiding prophylactic interventions and prevention. Statistical modelling was used to assess sensitivity and specificity requirements for these diagnostic tests. The paper highlights challenges in achieving high specificity, given the varying endemicity of M. leprae, and identifying target analytes with robust performance across leprosy phenotypes. We conclude that diagnostics with appropriate product design and performance characteristics are crucial for early detection and preventive intervention, advocating for the transition from leprosy management to prevention. [ABSTRACT FROM AUTHOR]

Poor control of cardiovascular disease accounts for a substantial proportion of the disease burden in developing countries, but often essential anticoagulant medicines for preventing strokes and embolisms are not widely available. In 2019, direct oral anticoagulants were added to the World Health Organization's WHO Model list of essential medicines . The aims of this paper are to summarize the benefits of direct oral anticoagulants for patients with cardiovascular disease and to discuss ways of increasing their usage internationally. Although the cost of direct oral anticoagulants has provoked debate, the affordability of introducing these drugs into clinical practice could be increased by: price negotiation; pooled procurement; competitive tendering; the use of patent pools; and expanded use of generics. In 2017, only 14 of 137 countries that had adopted national essential medicines lists included a direct oral anticoagulant on their lists. This number could increase rapidly if problems with availability and affordability can be tackled. Once the types of patient likely to benefit from direct oral anticoagulants have been clearly defined in clinical practice guidelines, coverage can be more accurately determined and associated costs can be better managed. Government action is required to ensure that direct oral anticoagulants are covered by national budgets because the absence of reimbursement remains an impediment to achieving universal coverage. Tackling cardiovascular disease with the aid of direct oral anticoagulants is an essential component of efforts to achieve the World Health Organization's target of reducing premature deaths due to noncommunicable disease by 25% by 2025., ((c) 2021 The authors; licensee World Health Organization.)

Untreated hearing loss is recognized as a growing global health priority because of its prevalence and harmful effects on health and well-being. Until recently, little progress had been made in expanding hearing care beyond traditional clinic-based models to incorporate public health approaches that increase accessibility to and affordability of hearing care. As demonstrated in numerous countries and for many health conditions, sharing health-care tasks with community health workers (CHWs) offers advantages as a complementary approach to expand health-service delivery and improve public health. This paper explores the possibilities of task shifting to provide hearing care across the life course by reviewing several ongoing projects in a variety of settings - Bangladesh, India, South Africa and the United States of America. The selected programmes train CHWs to provide a range of hearing-care services, from childhood hearing screening to management of age-related hearing loss. We discuss lessons learnt from these examples to inform best practices for task shifting within community-delivered hearing care. Preliminary evidence supports the feasibility, acceptability and effectiveness of hearing care delivered by CHWs in these varied settings. To make further progress, community-delivered hearing care must build on established models of CHWs and ensure adequate training and supervision, delineation of the scope of practice, supportive local and national legislation, incorporation of appropriate technology and analysis of programme costs and cost-effectiveness. In view of the growing evidence, community-delivered hearing care may now be a way forward to improve hearing health equity., ((c) 2019 The authors; licensee World Health Organization.)

Gender refers to the social relationships between males and females in terms of their roles, behaviours, activities, attributes and opportunities, and which are based on different levels of power. Gender interacts with, but is distinct from, the binary categories of biological sex. In this paper we consider how gender interacts with the 2030 agenda for sustainable development, including sustainable development goal (SDG) 3 and its targets for health and well-being, and the impact on health equity. We propose a conceptual framework for understanding the interactions between gender (SDG 5) and health (SDG 3) and 13 other SDGs, which influence health outcomes. We explore the empirical evidence for these interactions in relation to three domains of gender and health: gender as a social determinant of health; gender as a driver of health behaviours; and the gendered response of health systems. The paper highlights the complex relationship between health and gender, and how these domains interact with the broad 2030 agenda. Across all three domains (social determinants, health behaviours and health system), we find evidence of the links between gender, health and other SDGs. For example, education (SDG 4) has a measurable impact on health outcomes of women and children, while decent work (SDG 8) affects the rates of occupationrelated morbidity and mortality, for both men and women. We propose concerted and collaborative actions across the interlinked SDGs to deliver health equity, health and well-being for all, as well as to enhance gender equality and women's empowerment. These proposals are summarized in an agenda for action. [ABSTRACT FROM AUTHOR]

Achieving universal health coverage (UHC) involves distributing resources, especially human resources for health (HRH), to match population needs. This paper explores the policy lessons on HRH from four countries that have achieved sustained improvements in UHC: Brazil, Ghana, Mexico and Thailand. Its purpose is to inform global policy and financial commitments on HRH in support of UHC. The paper reports on country experiences using an analytical framework that examines effective coverage in relation to the availability, accessibility, acceptability and quality (AAAQ) of HRH. The AAAQ dimensions make it possible to perform tracing analysis on HRH policy actions since 1990 in the four countries of interest in relation to national trends in workforce numbers and population mortality rates. The findings inform key principles for evidence-based decision-making on HRH in support of UHC. First, HRH are critical to the expansion of health service coverage and the package of benefits; second, HRH strategies in each of the AAAQ dimensions collectively support achievements in effective coverage; and third, success is achieved through partnerships involving health and non-health actors. Facing the unprecedented health and development challenges that affect all countries and transforming HRH evidence into policy and practice must be at the heart of UHC and the post-2015 development agenda. It is a political imperative requiring national commitment and leadership to maximize the impact of available financial and human resources, and improve healthy life expectancy, with the recognition that improvements in health care are enabled by a health workforce that is fit for purpose.

The problem of how to mitigate the impact of pharmaceutical patents on the delivery of essential medicines to the world's poor is as far from being resolved as it has ever been. Extensive academic commentary and policy debate have achieved little in terms of practical outcomes. Although international instruments are now in place allowing countries to enact legislation that permits the generic manufacture of patented pharmaceuticals, many countries have not yet enacted appropriate legislation and most of those that have yet to make use of it. One major problem is that the requirements of international instruments and implementing legislation are seen as being so stringent as to be unworkable. This paper calls for fresh attempts to enact workable legislation that fits within the prescribed requirements of international law without going beyond them. It argues that high-income nations should refocus on their moral obligation to enact appropriate legislative mechanisms and provide appropriate incentives for their use. Draft legislation currently being considered in Australia is used to illustrate how workable legislative frameworks can be developed.

Problem: Birth registration remains far from complete in many developing countries. This was true of Ghana before a major registration campaign was undertaken., Approach: This study, based on survey data, assesses the results of a registration campaign initiated in 2004-2005 in Ghana. Key strategies included: extending the legal period for free registration of infants; incorporating registration in child health promotion weeks; training community health workers to register births; using community registration volunteers; registering children during celebrations, and piloting community population registers. This paper discusses the contribution of these strategies to the increase in registration rates and shows the degree of association between birth registration and various health-care access indicators and family characteristics., Local Setting: The Ghana Births and Deaths Registry worked together with international organizations, mainly Plan International and the United Nations Children's Fund, to implement the birth registration campaign., Relevant Changes: Unlike many other sub-Saharan African countries, Ghana saw a substantial rise in registration rates over the campaign period. Campaign strategies improved accessibility and shortened distance to registration centres. Survey data show that the registration rate for children younger than 5 years rose from 44% in 2003 to 71% in 2008., Lessons Learnt: Incorporation of birth registration into community health care, health campaigns and mobile registration activities can reduce the indirect costs of birth registration, especially in poorer communities, and yield substantial increases in registration rates. The link between the health sector and registration activities should be strengthened further and the use of community population registers expanded.

Twelve agencies of the United Nations, including the World Health Organization, have issued a joint statement that calls on Member States to replace the compulsory detention of people who use opioids in treatment centres with voluntary, evidence-informed and rights-based health and social services. The arguments in favour of this position fall into three broad categories: Compulsory treatment centres infringe on an individual's liberty, they put human beings at risk of harm, and evidence of their effectiveness against opioid dependence has not been generated. The United Nations statement underscores that although countries apply different criteria for sending individuals to compulsory treatment centres, detention often takes place without due process, legal safeguards or judicial review. This clearly violates internationally recognized human rights standards. Furthermore, people who are committed to these centres are often exposed to physical and sexual violence, forced labour and sub-standard living conditions. They are often denied health care, despite their heightened vulnerability to HIV infection and tuberculosis. Finally, there is no evidence, according to the statement, that these centres offer an environment that is conducive to recovery from opioid dependence or to the rehabilitation of commercial sex workers or of children who have suffered sexual exploitation, abuse or lack of care and protection. The author of this paper sets forth several arguments that counter the position taken by the United Nations and argues in favour of compulsory treatment within a broader harm reduction strategy aimed at protecting society as well as the individual concerned.

Objective: To examine the impact of maternity waiting homes on the use of facility-based birthing services for women in two remote districts of Timor-Leste., Methods: A before-and-after study design was used to compare the number of facility-based births in women who lived at different distances (0-5, 6-25, 26-50 and > 50 km) from the health centre before and after implementation of maternity waiting homes. Routine data were collected from health centre records at the end of 2007; they included 249 births in Same, Manufahi district, and 1986 births in Lospalos, Lautem district. Population data were used to estimate the percentage of women in each distance category who were accessing facility-based care., Findings: Most facility-based births in Same (80%) and Lospalos (62%) were among women who lived within 5 km of the health centre. There was no significant increase in the number of facility-based births among women in more remote areas following implementation of the maternity waiting homes. The percentage of births in the population that occurred in a health facility was low for both Manufahi district (9%) and Lautem district (17%), and use decreased markedly as distance between a woman's residence and the health facilities increased., Conclusion: The maternity waiting homes in Timor-Leste did not improve access to facility-based delivery for women in remote areas. The methods for distance analysis presented in this paper provide a framework that could be used by other countries seeking to evaluate maternity waiting homes.

Access to well trained and motivated health workers is the major rural health issue. Without local access, it is unlikely that people in rural and remote communities will be able to achieve the Millennium Development Goals. Studies in many countries have shown that the three factors most strongly associated with entering rural practice are: (i) a rural background; (ii) positive clinical and educational experiences in rural settings as part of undergraduate medical education; and (iii) targeted training for rural practice at the postgraduate level. This paper presents evidence for policy initiatives involving the training of medical students from, in and for rural and remote areas. We give examples of medical schools in different regions of the world that are using an evidence-based and context-driven educational approach to producing skilled and motivated health workers. We demonstrate how context influences the design and implementation of different rural education programmes. Successful programmes have overcome major obstacles including negative assumptions and attitudes, and limitations of human, physical, educational and financial resources. Training rural health workers in the rural setting is likely to result in greatly improved recruitment and retention of skilled health-care providers in rural underserved areas with consequent improvement in access to health care for the local communities.

Many countries have developed strategies to attract and retain qualified health workers in underserved areas, but there is only scarce and weak evidence on their successes or failures. It is difficult to compare lessons and measure results from the few evaluations that are available. Evaluation faces several challenges, including the heterogeneity of the terminology, the complexity of the interventions, the difficulty of assessing the influence of contextual factors, the lack of baseline information, and the need for multi-method and multi-disciplinary approaches for monitoring and evaluation. Moreover, the social, political and economic context in which interventions are designed and implemented is rarely considered in monitoring and evaluating interventions for human resources for health. This paper proposes a conceptual framework that offers a model for monitoring and evaluation of retention interventions taking into account such challenges. The conceptual framework is based on a systems approach and aims to guide the thinking in evaluating an intervention to increase access to health workers in underserved areas, from its design phase through to its results. It also aims to guide the monitoring of interventions through the routine collection of a set of indicators, applicable to the specific context. It suggests that a comprehensive approach needs to be used for the design, implementation, monitoring, evaluation and review of the interventions. The framework is not intended to be prescriptive and can be applied flexibly to each country context. It promotes the use of a common understanding on how attraction and retention interventions work, using a systems perspective.

Globalization of intellectual property (IP) protection for medicines has been advancing during the past decade. Countries are obliged to adapt their legislation as a requirement of their membership to the World Trade Organization or as a condition of being part of international trade agreements. There is a growing recognition that, in low-income countries, stronger IP protection is a barrier to access to medicines. At the same time, the number of low-income countries writing national legislation to protect IP for pharmaceutical products is growing worldwide, but little research has been done on the ways in which this process is happening at the national level. This paper aims to contribute to the understanding of the implementation of IP legislation at the national level by providing a comparative analysis of the countries that are part of the United States-Dominican Republic-Central America Free Trade Agreement (DR-CAFTA). The analysis shows three trends. First, countries have often implemented stronger IP protection than required by trade agreements. Second, some countries have adopted IP protection before signing the trade agreements. Third, the process of ratification of DR-CAFTA increased public debate around these issues, which in some cases led to IP legislation that considers public health needs. These trends suggest that industrialized countries and the pharmaceutical industry are using more tactics than just trade agreements to push for increased IP protection and that the process of national legislation is a valid arena for confronting public health needs to those of the industry.

In 2003, the Mexican Congress approved a reform establishing the Sistema de Protección Social en Salud [System of Social Protection in Health], whereby public funding for health is being increased by one percent of the 2003 gross domestic product over seven years to guarantee universal health insurance. Poor families that had been excluded from traditional social security can now enrol in a new public insurance scheme known as Seguro Popular [People's Insurance], which assures legislated access to a comprehensive set of health-care entitlements. This paper describes the financial innovations behind the expansion of health-care coverage in Mexico to everyone and their effects. Evidence shows improvements in mobilization of additional public resources; availability of health infrastructure and drugs; service utilization; effective coverage; and financial protection. Future challenges are discussed, among them the need for additional public funding to extend access to costly interventions for non-communicable diseases not yet covered by the new insurance scheme, and to improve the technical quality of care and the responsiveness of the health system. Eventually, the progress achieved so far will have to be reflected in health outcomes, which will continue to be evaluated so that Mexico can meet the ultimate criterion of reform success: better health through equity, quality and fair financing.

Based on articles found on the PubMed and Popline databases on the provision of first-trimester abortion by mid-level providers, this article describes policies on type of abortion provider, comparative studies of different types of abortion provider, provider perspectives, and programmatic experience in Bangladesh, Cambodia, France, Mozambique, South Africa, Sweden, the United States of America and Viet Nam. It shows that it is safe and beneficial for suitably trained mid-level health-care providers, including nurses, midwives and other non-physician clinicians, to provide first-trimester vacuum aspiration and medical abortions. Moreover, it finds that projects in Kenya, Myanmar and Uganda have successfully trained nurse-midwives to provide post-abortion care for incomplete abortion with manual vacuum aspiration, and that studies in Ethiopia and India have recommended that providers such as auxiliary nurse-midwives should be trained in abortion service delivery to ensure that they provide safe abortions for low-income women. The paper recommends the authorization of all qualified mid-level health-care providers to carry out first-trimester abortions, and it also recommends the integration of training in providing first-trimester abortion care into basic education and clinical training for all mid-level providers and medical students interested in obstetrics and gynaecology. Finally, it calls for documentation of the role of mid-level providers in managing second-trimester medical abortions to further inform policy and practice.

One central goal of the enhanced Heavily Indebted Poor Countries (HIPC) Initiative and the more recent Multilateral Debt Relief Initiative (MDRI) is to free up additional resources for public spending on poverty reduction. The health sector was expected to benefit from a considerable share of these funds. The volume of released resources is important enough in certain countries to make a difference for priority programmes that have been underfunded so far. However, the relevance of these initiatives in terms of boosting health expenditure depends essentially, at the global level, on the compliance of donors with their aid commitments and, at the domestic level, on the success of health officials in advocating for an adequate share of the additional fiscal space. Advocacy efforts are often limited by a state of asymmetric information whereby some ministries are not well aware of the economic consequences of debt relief on public finances and of the management systems in place to deal with savings from debt relief. A thorough comprehension of these issues seems essential for health advocates to increase their bargaining power and for a wider public to readjust expectations of what debt relief can realistically achieve and of what can be measured. This paper intends to narrow the information gap by classifying debt relief savings management systems observed in practice. We illustrate some of the major advantages and stated drawbacks and outline the policy implications for health officials operating in the countries concerned. There should be careful monitoring of fungibility (i.e. where untraceable funds risk substitution) and additionality (i.e. the extent to which new inputs add to existing inputs at national and international level).

The World Health Assembly of 2005 called for all health systems to move towards universal coverage, defined as " access to adequate health care for all at an affordable price" . A crucial aspect in achieving universal coverage is the extent to which there are income and risk cross-subsidies in health systems. Yet this aspect appears to be ignored in many of the policy prescriptions directed at low- and middle-income countries, often resulting in high degrees of health system fragmentation. The aim of this paper is to explore the extent of fragmentation within the health systems of three African countries (Ghana, South Africa and the United Republic of Tanzania). Using a framework for analysing health-care financing in terms of its key functions, we describe how fragmentation has developed, how each country has attempted to address the arising equity challenges and what remains to be done to promote universal coverage. The analysis suggests that South Africa has made the least progress in addressing fragmentation, while Ghana appears to be pursuing a universal coverage policy in a more coherent way. To achieve universal coverage, health systems must reduce their reliance on out-of-pocket payments, maximize the size of risk pools, and resource allocation mechanisms must be put in place to either equalize risks between individual insurance schemes or equitably allocate general tax (and donor) funds. Ultimately, there needs to be greater integration of financing mechanisms to promote universal cover with strong income and risk cross-subsidies in the overall health system.

In 2005, the Member States of WHO adopted a resolution encouraging countries to develop health financing systems capable of achieving and/or maintaining universal coverage of health services - where all people have access to needed health services without the risk of severe financial consequences. In doing this, a major challenge for many countries will be to move away from out-of-pocket payments, which are often used as an important source of fund collection. Prepayment methods will need to be developed or expanded but, in addition to questions of revenue collection, specific attention will also have to be paid to pooling funds to spread risks and to enable their efficient and equitable use. Developing prepayment mechanisms may take time, depending on countries' economic, social and political contexts. Specific rules for health financing policy will need to be developed and implementing organizations will need to be tailored to the level that countries can support and sustain. In this paper we propose a comprehensive framework focusing on health financing rules and organizations that can be used to support countries in developing their health financing systems in the search for universal coverage.

Objective: Progress towards the Millennium Development Goals for maternal health has been slow, and accelerated progress in scaling up professional delivery care is needed. This paper describes poor-rich inequalities in the use of maternity care and seeks to understand these inequalities through comparisons with other types of health care., Methods: Demographic and Health Survey (DHS) data from 45 developing countries were used to describe poor-rich inequalities by wealth quintiles in maternity care (professional delivery care and antenatal care), full childhood immunization coverage and medical treatment for diarrhoea and acute respiratory infections (ARI)., Findings: Poor-rich inequalities in maternity care in general, and professional delivery care in particular, are much greater than those in immunization coverage or treatment for childhood illnesses. Public-sector inequalities make up a major part of the poor-rich inequalities in professional delivery attendance. Even delivery care provided by nurses and midwives favours the rich in most countries. Although poor-rich inequalities within both rural and urban areas are large, most births without professional delivery care occur among the rural poor., Conclusion: Poor-rich inequalities in professional delivery care are much larger than those in the other forms of care. Reducing poor-rich inequalities in professional delivery care is essential to achieving the MDGs for maternal health. The greatest improvements in professional delivery care can be made by increasing coverage among the rural poor. Problems with availability, accessibility and affordability, as well as the nature of the services and demand factors, appear to contribute to the larger poor-rich inequalities in delivery care. A concerted effort of equity-oriented policy and research is needed to address the huge poor-rich inequalities in maternity care.

In 2006, a quadrivalent human papillomavirus (HPV) vaccine was licensed, and another vaccine may be licensed soon. Little is known about the practical considerations involved in designing and implementing cervical cancer prevention programmes that include vaccination as a primary means of prevention. Although the vaccine may ultimately be indicated for both males and females, young girls, or girls and women aged 9-25 years, will be the initial candidates for the vaccine. This paper describes avenues for service delivery of HPV vaccines and critical information gaps that must be bridged in order to inform future sexual and reproductive health programming. It proposes the role that the sexual and reproductive health community, together with immunization and cancer control programmes, could have in supporting the introduction of HPV vaccines within the context of current health systems.

Special studies and isolated initiatives over the past several decades in low-, middle- and high-income countries have consistently shown inequalities in health among socioeconomic groups and by gender, race or ethnicity, geographical area and other measures associated with social advantage. Significant health inequalities linked to social (dis)advantage rather than to inherent biological differences are generally considered unfair or inequitable. Such health inequities are the main object of health development efforts, including global targets such as the Millennium Development Goals, which require monitoring to evaluate progress. However, most national health information systems (HIS) lack key information needed to assess and address health inequities, namely, reliable, longitudinal and representative data linking measures of health with measures of social status or advantage at the individual or small-area level. Without empirical documentation and monitoring of such inequities, as well as country-level capacity to use this information for effective planning and monitoring of progress in response to interventions, movement towards equity is unlikely to occur. This paper reviews core information requirements and potential databases and proposes short-term and longer term strategies for strengthening the capabilities of HIS for the analysis of health equity and discusses HIS-related entry points for supporting a culture of equity-oriented decision-making and policy development.

Despite a growing global commitment to the provision of antiretroviral therapy (ART), its availability is still likely to be less than the need. This imbalance raises ethical dilemmas about who should be granted access to publicly-subsidized ART programmes. This paper reviews the eligibility and targeting criteria used in four case-study countries at different points in the scale-up of ART, with the aim of drawing lessons regarding ethical approaches to rationing. Mexico, Senegal, Thailand and Uganda have each made an explicit policy commitment to provide antiretrovirals to all those in need, but are achieving this goal in steps--beginning with explicit rationing of access to care. Drawing upon the case-studies and experiences elsewhere, categories of explicit rationing criteria have been identified. These include biomedical factors, adherence to treatment, prevention-driven factors, social and economic benefits, financial factors and factors driven by ethical arguments. The initial criteria for determining eligibility are typically clinical criteria and assessment of adherence prospects, followed by a number of other factors. Rationing mechanisms reflect several underlying ethical theories and the ethical underpinnings of explicit rationing criteria should reflect societal values. In order to ensure this alignment, widespread consultation with a variety of stakeholders, and not only policy-makers or physicians, is critical. Without such explicit debate, more rationing will occur implicitly and this may be more inequitable. The effects of rationing mechanisms upon equity are critically dependent upon the implementation processes. As antiretroviral programmes are implemented it is crucial to monitor who gains access to these programmes.

Objective: To examine the effects on immunization equity of the large-scale contracting of primary health-care services in rural areas of Cambodia., Methods: Data were obtained pre-intervention and post-intervention from a large-scale quasi-experiment in contracting with nongovernmental organizations to provide primary health care in nine rural districts of Cambodia between 1999 and mid-2001. Coverage targets and equity targets for all primary health-care services, including immunization of children, were explicitly included in the contracts awarded in five of nine rural districts which together have a population of over 1.25 million people. The remaining four districts used the traditional government model for providing services and were given identical targets., Findings: After the 2.5 years of the trial, bivariate and multivariate analyses of the results suggested that although there was a substantial increase in the proportion of children who were fully immunized in all districts, children in the poorest 50% of households in the districts served by contractors were more likely to be fully immunized than poor children living in similar circumstances in districts using the government's model, all other things being equal., Conclusion: The contracting approach described in this paper suggests a means of moving towards a more equitable distribution of immunization services in developing countries.

Prevention is a core value of any health system. Nonetheless, many health problems will continue to occur despite preventive services. A significant burden of diseases in developing countries is caused by time-sensitive illnesses and injuries, such as severe infections, hypoxia caused by respiratory infections, dehydration caused by diarrhoea, intentional and unintentional injuries, postpartum bleeding, and acute myocardial infarction. The provision of timely treatment during life-threatening emergencies is not a priority for many health systems in developing countries. This paper reviews evidence indicating the need to develop and/or strengthen emergency medical care systems in these countries. An argument is made for the role of emergency medical care in improving the health of populations and meeting expectations for access to emergency care. We consider emergency medical care in the community, during transportation, and at first-contact and regional referral facilities. Obstacles to developing effective emergency medical care include a lack of structural models, inappropriate training foci, concerns about cost, and sustainability in the face of a high demand for services. A basic but effective level of emergency medical care responds to perceived and actual community needs and improves the health of populations.

This paper draws lessons from a review of primary health care services in Windhoek, the capital of Namibia, undertaken by a regional health management team. The review was carried out because of perceived increases in workload and inadequate staffing levels, arising from the rapid expansion of the city associated with inward migration. A survey of the utilization of government clinics was used to develop a more equitable allocation of primary health care services between localities. The survey revealed disparities between patterns of utilization of the services and the allocation of staff: the poorer localities were relatively underprovided. Decisions made centrally on resource allocation had reinforced the inequities. On the basis of the results of the review, the regional health management team redistributed nursing and medical staff and argued for a shift in the allocation of capital expenditure towards the poorer communities. The review demonstrates the potential for regional and provincial health management teams to make effective assessments of the needs of their populations and to promote the equitable delivery of primary health care services. In order to achieve this they need not only to become effective managers, but also to develop population-based planning skills and the confidence and authority to influence the allocation of resources between and within their regions and provinces.

The potential for trade in health services has expanded rapidly in recent decades. More efficient communication systems have helped to reduce distance-related barriers to trade; rising incomes and enhanced information have increased the mobility of patients; and internal cost pressures have led various governments to consider possibilities for increased private participation. As yet, however, health services have played only a modest role in the General Agreement on Trade in Services (GATS). It is possible that Members of the World Trade Organization have been discouraged from undertaking access commitments by the novelty of the Agreement, coordination problems between relevant agencies, widespread inexperience in concepts of services trade, a traditionally strong degree of government involvement in the health sector, and concerns about basic quality and social objectives. However, more than five years have passed since GATS entered into force, allowing hesitant administrations to familiarize themselves with its main elements and its operation in practice. The present paper is intended to contribute to this process. It provides an overview of the basic structure of GATS and of the patterns of current commitments in health services and of limitations frequently used in this context. The concluding section discusses possibilities of pursuing basic policy objectives in a more open environment and indicates issues that may have to be dealt with in current negotiations on services.

Abstract In a globalizing world, public health is no longer confined to national borders. In recent years we have observed an increasing movement of patients across international borders. The full extent of this trend is yet unknown, as data are sparse and anecdotal. If this trend continues, experts are convinced that it will have major implications for public health systems around the globe. Despite the growing importance of medical travel, we still have little empirical evidence on its impact on public health, especially on health systems. This paper summarizes the most recent debates on this topic. It discusses the main forces that drive medical travel and its implications on health systems, in particular the impacts on access to health care, financing and the health workforce. This paper also offers guidance on how to define medical travel and how to improve data collection. It advocates for more scientific research that will enable countries to harness benefits and limit the potential risks to public health arising from medical travel. [ABSTRACT FROM AUTHOR]

This paper generates and analyses survey data on inequalities in mortality among infants and children aged under five years by consumption in Brazil, Côte d'Ivoire, Ghana, Nepal, Nicaragua, Pakistan, the Philippines, South Africa, and Viet Nam. The data were obtained from the Living Standards Measurement Study and the Cebu Longitudinal Health and Nutrition Survey. Mortality rates were estimated directly where complete fertility histories were available and indirectly otherwise. Mortality distributions were compared between countries by means of concentration curves and concentration indices: dominance checks were carried out for all pairwise intercountry comparisons; standard errors were calculated for the concentration indices; and tests of intercountry differences in inequality were performed.

A number of strategies have been proposed by various organizations and governments for rationalizing the use of drugs in developing countries. Such strategies include the use of essential drug lists, generic prescribing, and training in rational prescribing. None of these require doctors to become actively involved in the management of the drug supply to their health centres. In 1997, in the Kasserine region of Tunisia, the regional health authorities piloted a radically different strategy. This involved the theoretical allocation of a proportion of the regional drug budget to each district and subsequently to each health centre according to estimated demand. Medical staff were given responsibility for the management of these budgets, allowing them to control the nature and quantities of drugs supplied to the health centres in which they worked. This paper outlines the process by which this strategy was successfully implemented in the Foussana district of Kasserine region, and explores the problems encountered. It describes now the theoretical budgets were allocated to each district and how the costs of individual drugs and the consumption of drugs in the previous year were calculated. It then continues by giving an account of the training of the staff of the health centres, the preparation of a drug order form and the method of allocation of the theoretical budgets to each of the health centres. The results give an account of how the prescribing habits of doctors were changed as a result of the strategy, in order to take into account the costs of the drugs that they prescribed. They show how the health centres were able to manage their budgets, spending overall 99.8% of the budget allocated to the district. They outline some of the changes in the prescribing habits that took place, demonstrating a greater use of appropriate and essential drugs. The paper concludes that doctors and paramedical staff can successfully manage a theoretical drug budget, and that their involvement in this process leads to more rational prescribing within existing resource constraints. This has a consequence of benefiting patients, satisfying doctors and pleasing administrators.

Transforming our world: the 2030 agenda for sustainable development promotes the improvement of health equity, which entails ongoing monitoring of health inequalities. The World Health Organization has developed a multistep approach to health inequality monitoring consisting of: (i) determining the scope of monitoring; (ii) obtaining data; (iii) analysing data; (iv) reporting results; and (v) implementing changes. Technical considerations at each step have implications for the results and conclusions of monitoring and subsequent remedial actions. This paper presents some technical considerations for developing or strengthening health inequality monitoring, with the aim of encouraging more robust, systematic and transparent practices. We discuss key aspects of measuring health inequalities that are relevant to steps (i) and (iii). We highlight considerations related to the selection, measurement and categorization of dimensions of health inequality, as well as disaggregation of health data and calculation of summary measures of inequality. Inequality monitoring is linked to health and non-health aspects of the 2030 agenda for sustainable development, and strong health inequality monitoring practices can help to inform equity-oriented policy directives. [ABSTRACT FROM AUTHOR]

The World Health Assembly in 2014 adopted a resolution that recognized the importance of increasing access to biotherapeutic products, of improving their affordability and of ensuring their quality, safety and efficacy. Biosimilars are biotherapeutic products similar to already licensed reference products and are usually developed after patents on the original products have expired. Their introduction into the market is likely to reduce the costs of medicines substantially, thereby improving the availability of treatment for patients. However, there are barriers to market access for biosimilars. This article discusses the factors that give rise to these barriers and explains the importance of regulatory oversight throughout the product life-cycle of biosimilars. The paper also describes the role regulators can play in increasing confidence in biosimilars use by: (i) establishing regulatory oversight of biosimilars throughout their life-cycle, from development to postlicensing oversight, and ensuring that only high-quality, safe and efficacious biosimilars are available on the market; (ii) ensuring regulatory authorities have adequate capacity to assess and monitor the quality, safety and efficacy of biosimilars throughout their life-cycle; and (iii) monitoring the use of biosimilars in public health systems in collaboration with other stakeholders. [ABSTRACT FROM AUTHOR]

Many low- and middle-income countries facing high levels of antimicrobial resistance, and the associated morbidity from ineffective treatment, also have a high burden of tuberculosis. Over recent decades many countries have developed effective laboratory and information systems for tuberculosis control. In this paper we describe how existing tuberculosis laboratory systems can be expanded to accommodate antimicrobial resistance functions. We show how such expansion in services may benefit tuberculosis case-finding and laboratory capacity through integration of laboratory services. We further summarize the synergies between high-level strategies on tuberculosis and antimicrobial resistance control. These provide a potential platform for the integration of programmes and illustrate how integration at the health-service delivery level for diagnostic services could occur in practice in a low- and middle-income setting. Many potential mutual benefits of integration exist, in terms of accelerated scale-up of diagnostic testing towards rational use of antimicrobial drugs as well as optimal use of resources and sharing of experience. Integration of vertical disease programmes with separate funding streams is not without challenges, however, and we also discuss barriers to integration and identify opportunities and incentives to overcome these. [ABSTRACT FROM AUTHOR]

The sustainable development goals (SDGs) adopted by the United Nations in 2015 include a new target for global health: SDG 3 aims to "ensure healthy lives and promote well-being for all at all ages." Dementia care of good quality is particularly important given the projected increase in the number of people living with the condition. A range of assistive technologies have been proposed to support dementia care. However, the World Health Organization estimated in 2017 that only one in 10 of the 1 billion or more people globally who could benefit from these technologies in some way actually has access to them. For people living with dementia, there has been little analysis of whether assistive technologies will support their human rights in ways that are consistent with the United Nations Convention on the Rights of Persons with Disabilities. The aim of this paper is to examine the relevant provisions of the convention and consider their implications for the use of assistive technologies in dementia care. Assistive technologies can clearly play an important role in supporting social engagement, decision-making and advance planning by people living with dementia. However, concerns exist that some of these technologies also have the potential to restrict freedom of movement and intrude into privacy. In conclusion, an analysis of the implications of assistive technologies for human rights laws is needed to ensure that technologies are used in ways that support human rights and help meet the health-related SDG 3. [ABSTRACT FROM AUTHOR]

Rising incomes, the spread of personal insurance, lifestyle factors adding to the burden of illness, ageing populations, globalization and skills transfer within the medical community have increased worldwide demand for organ transplantation. The Global Observatory on Donation and Transplantation, which was built in response to World Health Assembly resolution WHA57.18, has conducted ongoing documentation of global transplantation activities since 2007. In this paper, we use the Global Observatory’s data to describe the current distribution of – and trends in – transplantation activities and to evaluate the role of health systems factors and macroeconomics in the diffusion of transplantation technology. We then consider the implications of our results for health policies relating to organ donation and transplantation. Of the World Health Organization’s Member States, most now engage in organ transplantation and more than a third performed deceased donor transplantation in 2011. In general, the Member States that engage in organ transplantation have greater access to physician services and greater total health spending per capita than the Member States where organ transplantation is not performed. The provision of deceased donor transplantation was closely associated with high levels of gross national income per capita. There are several ways in which governments can support the ethical development of organ donation and transplantation programmes. Specifically, they can ensure that appropriate legislation, regulation and oversight are in place, and monitor donation and transplantation activities, practices and outcomes. Moreover, they can allocate resources towards the training of specialist physicians, surgeons and transplant coordinators, and implement a professional donor-procurement network. [ABSTRACT FROM AUTHOR]

The World Health Organization has endorsed the use of outreach to promote: efficient redeployment of the health-care workforce; continuity of care at the local level; and professional support for local, rural, health-care workers. Australia is the only country that has had, since 2000, a sustained national policy on outreach for subsidizing medical specialist outreach to rural areas. This paper describes the adoption, implementation and prioritization of a national specialist outreach policy in Australia. Adoption of the national policy followed a long history of successful outreach, largely driven by the professional interest and personal commitment of the workforce. Initially the policy supported only new outreach services but concerns about the sustainability of existing services resulted in eligibility for funding being extended to all specialist services. The costs of travel, travel time, accommodation, professional support, staff relief at specialists’ primary practices and equipment hire were subsidized. Over time, a national political commitment to the equitable treatment of indigenous people resulted in more targeted support for outreach in remote areas. Current priorities are: (i) establishing team-based outreach services; (ii) improving local staff’s skills; (iii) achieving local coordination; and (iv) conducting a nationally consistent needs assessment. The absence of subsidies for specialists’ clinical work can discourage private specialists from providing services in remote areas where clinical throughput is low. To be successful, outreach policy must harmonize with the interests of the workforce and support professional autonomy. Internationally, the development of outreach policy must take account of the local pay and practice conditions of health workers. [ABSTRACT FROM AUTHOR]

Brazil, the Russian Federation, India, China and South Africa -- the countries known as BRICS -- represent some of the world’s fastest growing large economies and nearly 40% of the world’s population. Over the last two decades, BRICS have undertaken health-system reforms to make progress towards universal health coverage. This paper discusses three key aspects of these reforms: the role of government in financing health; the underlying motivation behind the reforms; and the value of the lessons learnt for non-BRICS countries. Although national governments have played a prominent role in the reforms, private financing constitutes a major share of health spending in BRICS. There is a reliance on direct expenditures in China and India and a substantial presence of private insurance in Brazil and South Africa. The Brazilian health reforms resulted from a political movement that made health a constitutional right, whereas those in China, India, the Russian Federation and South Africa were an attempt to improve the performance of the public system and reduce inequities in access. The move towards universal health coverage has been slow. In China and India, the reforms have not adequately addressed the issue of out-of-pocket payments. Negotiations between national and subnational entities have often been challenging but Brazil has been able to achieve good coordination between federal and state entities via a constitutional delineation of responsibility. In the Russian Federation, poor coordination has led to the fragmented pooling and inefficient use of resources. In mixed health systems it is essential to harness both public and private sector resources. [ABSTRACT FROM AUTHOR]

Unless the concept is clearly understood, "universal coverage" (or universal health coverage, UHC) can be used to justify practically any health financing reform or scheme. This paper unpacks the definition of health financing for universal coverage as used in the World Health Organization's World health report 2010 to show how UHC embodies specific health system goals and intermediate objectives and, broadly, how health financing reforms can influence these. All countries seek to improve equity in the use of health services, service quality and financial protection for their populations. Hence, the pursuit of UHC is relevant to every country. Health financing policy is an integral part of efforts to move towards UHC, but for health financing policy to be aligned with the pursuit of UHC, health system reforms need to be aimed explicitly at improving coverage and the intermediate objectives linked to it, namely, efficiency, equity in health resource distribution and transparency and accountability. The unit of analysis for goals and objectives must be the population and health system as a whole. What matters is not how a particular financing scheme affects its individual members, but rather, how it influences progress towards UHC at the population level. Concern only with specific schemes is incompatible with a universal coverage approach and may even undermine UHC, particularly in terms of equity. Conversely, if a scheme is fully oriented towards system-level goals and objectives, it can further progress towards UHC. Policy and policy analysis need to shift from the scheme to the system level. [ABSTRACT FROM AUTHOR]

The neglected tropical diseases (NTDs), which affect the very poor, pose a major public health problem in the South- East Asia Region of the World Health Organization (WHO). Although more than a dozen NTDs affect the region, over the past five years four of them in particular -- leprosy, lymphatic filariasis, visceral leishmaniasis (kala-azar) and yaws -- have been targeted for elimination. These four were selected for a number of reasons. First, they affect the WHO South-East Asia Region disproportionately. For example, every year around 67% of all new leprosy cases and 60% of all new cases of visceral leishmaniasis worldwide occur in countries of the region, where as many as 850 million inhabitants are at risk of contracting lymphatic filariasis. In addition, several epidemiological, technological and historical factors that are unique to the region make each of these four diseases amenable to elimination. Safe and effective tools and interventions to achieve these targets are available and concerted efforts to scale them up, singly or in an integrated manner, are likely to lead to success. The World Health Assembly and the WHO Regional Committee, through a series of resolutions, have already expressed regional and global commitments for the elimination of these diseases as public health problems. Such action is expected to have a quick and dramatic impact on poverty reduction and to contribute to the achievement of the Millennium Development Goals. This paper reviews the policy rationale for disease control in the WHO South-East Asia Region, the progress made so far, the lessons learnt along the way, and the remaining challenges and opportunities. [ABSTRACT FROM AUTHOR]

An introduction to the journal is presented that focuses on issues related to world health, including a call for papers on the subject of artificial intelligence in the health sector, proxy indicators used to estimate antibiotic consumption by people and the continued surveillance needed to control antimicrobial resistance, and updates on outbreaks and global spread of Zika virus disease.