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Thailand's health development since the 1970s has been focused on investment in the health delivery infrastructure at the district level and below and on training the health workforce. Deliberate policies increased domestic training capacities for all cadres of health personnel and distributed them to rural and underserved areas. Since 1975, targeted insurance schemes for different population groups have improved financial access to health care until universal health coverage was implemented in 2002. Despite its low gross national income per capita in Thailand, a bold decision was made to use general taxation to finance the Universal Health Coverage Scheme without relying on contributions from members. Empirical evidence shows substantial reduction in levels of out-of-pocket payments, the incidence of catastrophic health spending, and in medical impoverishment. The scheme has also greatly reduced provincial gaps in child mortality. Certain interventions such as antiretroviral therapy and renal replacement therapy have saved the lives of adults. Well designed strategic purchasing contributed to efficiency, cost containment, and equity. Remaining challenges include preparing for an ageing society, primary prevention of non-communicable diseases, law enforcement to prevent road traffic mortality, and effective coverage of diabetes and tuberculosis control.

Summary Background Japan has entered the era of super-ageing and advanced health transition, which is increasingly putting pressure on the sustainability of its health system. The level and pace of this health transition might vary across regions within Japan and concern is growing about increasing regional variations in disease burden. The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) provides a comprehensive, comparable framework. We used data from GBD 2015 with the aim to quantify the burden of disease and injuries, and to attribute risk factors in Japan at a subnational, prefecture-level. Methods We used data from GBD 2015 for 315 causes and 79 risk factors of death, disease, and injury incidence and prevalence to measure the burden of diseases and injuries in Japan and in the 47 Japanese prefectures from 1990 to 2015. We extracted data from GBD 2015 to assess mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), life expectancy, and healthy life expectancy (HALE) in Japan and its 47 prefectures. We split extracted data by prefecture and applied GBD methods to generate estimates of burden, and attributable burden due to known risk factors. We examined the prefecture-level relationships of common health system inputs (eg, health expenditure and workforces) to the GBD outputs in 2015 to address underlying determinants of regional health variations. Findings Life expectancy at birth in Japan increased by 4·2 years from 79·0 years (95% uncertainty interval [UI] 79·0 to 79·0) to 83·2 years (83·1 to 83·2) between 1990 and 2015. However, the gaps between prefectures with the lowest and highest life expectancies and HALE have widened, from 2·5 to 3·1 years and from 2·3 to 2·7 years, respectively, from 1990 to 2015. Although overall age-standardised death rates decreased by 29·0% (28·7 to 29·3) from 1990 to 2015, the rates of mortality decline in this period substantially varied across the prefectures, ranging from −32·4% (−34·8 to −30·0) to −22·0% (−20·4 to −20·1). During the same time period, the rate of age-standardised DALYs was reduced overall by 19·8% (17·9 to 22·0). The reduction in rates of age-standardised YLDs was very small by 3·5% (2·6 to 4·3). The pace of reduction in mortality and DALYs in many leading causes has largely levelled off since 2005. Known risk factors accounted for 34·5% (32·4 to 36·9) of DALYs; the two leading behavioural risk factors were unhealthy diets and tobacco smoking in 2015. The common health system inputs were not associated with age-standardised death and DALY rates in 2015. Interpretation Japan has been successful overall in reducing mortality and disability from most major diseases. However, progress has slowed down and health variations between prefectures is growing. In view of the limited association between the prefecture-level health system inputs and health outcomes, the potential sources of regional variations, including subnational health system performance, urgently need assessment. Funding Bill & Melinda Gates Foundation, Japan Ministry of Education, Science, Sports and Culture, Japan Ministry of Health, Labour and Welfare, AXA CR Fixed Income Fund and AXA Research Fund.

This interdisciplinary approach differs from previous Millennium Development Goal (MDG) studies that have either examined individual goals or made broad sociopolitical assessments of the MDGs as a development mechanism. Instead it uses the analysis of cross-cutting challenges as the basis to identify a set of principles for future goal development after 2015. It emphasizes that this is not an assessment of the MDGs and instead it focuses deliberately on challenges with the implementation of the MDGs so as to inform future goal setting.

The supervision of a domestic health system in the context of the trade environment in the 21st century needs a sophisticated understanding of how trade in health services affects, and will affect, a country's health system and policy. This notion places a premium on people engaged in the health sector understanding the importance of a comprehensive outlook on trade in health services. However, establishment of systematic comparative data for amounts of trade in health services is difficult to achieve, and most trade negotiations occur in isolation from health professionals. These difficulties compromise the ability of a health system to not just minimise the risks presented by trade in health services, but also to maximise the opportunities. We consider these issues by presenting the latest trends and developments in the worldwide delivery of health-care services, using the classification provided by the World Trade Organization for the General Agreement on Trade in Services. This classification covers four modes of service delivery: cross-border supply of services; consumption of services abroad; foreign direct investment, typically to establish a new hospital, clinic, or diagnostic facility; and the movement of health professionals. For every delivery mode we discuss the present magnitude and pattern of trade, main contributors to this trade, and key issues arising.

To promote research and develop ment for neglected diseases and access to medicines in developing countries, the World Health Assembly asked WHO to establish an Intergovernmental Working Group (IGWG) on Public Health, Innovation and Intellectual Property Rights in 2006. A draft global strategy and plan of action was completed after its fi rst meeting in December, 2006. Regional consultations provided 193 member states with opportunities to review the draft strategy. The draft strategy and plan of action were discussed but not fi nalised at its second meeting in November, 2007. To facilitate input from interested organisations, individuals, and the public, web-based public hearings were organised by the IGWG secretariat. On review of the second round of such public hearings, we were disturbed by what we found. The issue that attracted the most responses was intellectual property (IP), which was cited in 43 of 68 submissions. Although we were not surprised to see that 11 of 12 organisations directly affi liated with the pharmaceutical industry supported strong IP protection, it was surprising that 14 patient advocacy groups took a similar position, which in several cases was the only point raised in their submissions; three professional associations also took similar positions. We further investigated the sources of funding of these organisations using publicly available data (organisation websites and internet searches). For 11 of the 14 patient advocacy groups and all three professional associations, fi nancial support had been received from pharmaceutical companies, either directly to the organisation or for activities undertaken by its executive director. For example, a Canadian patient advocacy group whose submission was in favour of IP received fi nancial support from Actelion Pharma ceuticals, Amgen Canada, Bayer, Gilead Sciences Canada, INO Thera peutics, Merck Frosst Canada, Novartis Pharmaceuticals Canada, Ortho Biotech, Amicus Therapeutics, ApoPharma, BioMarin Pharmaceutical, Hoff mann-La Roche, and Sigma-Tau Pharmaceuticals. Add ition ally, we found near identical phrases or concepts in their submissions. The problem of the pharmaceutical industry compromising patient advocacy groups is not new. In this case, we have serious doubts as to the motives and the credibility of these submissions to the public hearings. We strongly suggest that contributors to public hearings must disclose any confl icts of interest, as required of authors submitting papers to peerreviewed journals.