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Background: Through medicare, residents in Canada are entitled to medically necessary physician services without paying out of pocket, but still many people struggle to access primary care. We conducted a survey to explore people's experience with and priorities for primary care. Methods: We conducted an online, bilingual survey of adults in Canada in fall 2022. We distributed an anonymous link through diverse channels and a closed link to 122 053 people via a national public opinion firm. We weighted completed responses to mirror Canada's population and adjusted for sociodemographic characteristics using regression models. Results: We analyzed 9279 completed surveys (5.9% response rate via closed link). More than one-fifth of respondents (21.8%) reported having no primary care clinician, and among those who did, 34.5% reported getting a same or next-day appointment for urgent issues. Of respondents, 89.4% expressed comfort seeing another team member if their doctor recommended it, but only 35.9%, 9.5%, and 12.4% reported that their practice had a nurse, social worker, or pharmacist, respectively. The primary care attribute that mattered most was having a clinician who 'knows me as a person and considers all the factors that affect my health.' After we adjusted for respondent characteristics, people in Quebec, the Atlantic region, and British Columbia had lower odds of reporting a primary care clinician than people in Ontario (adjusted odds ratio 0.30, 0.33, and 0.39, respectively; p < 0.001). We also observed large provincial variations in timely access, interprofessional care, and walk-in clinic use. Interpretation: More than 1 in 5 respondents did not have access to primary care, with large variation by province. Reforms should strive to expand access to relationship-based, longitudinal care in a team setting., Research over decades has shown that health systems with strong primary care have better health outcomes, better equity in outcomes, and lower costs. (1,2) Yet, worldwide, countries have struggled with [...]

Anti-Black racism produces and sustains health inequities through social and structural determinants of health such as reduced access to employment and material resources, or by increased exposure to various risk [...]

Contexte: Malgre des investissements importants dans un systeme de soins de sante public qui comprend des services preventifs, on continue d'observer des disparites evitables en matiere de sante au Canada. L'equipe avait pour objectif de formuler des recommandations pour des soins de sante preventifs qui puissent ameliorer l'equite en matiere de sante par la priorisation des interventions efficaces a l'intention des groupes defavorises. Methodes: La ligne directrice a ete elaboree par un comite compose de specialistes en soins primaires et de membres de la patientele, avec la contribution d'un groupe de patientes- et patientspartenaires ayant vecu diverses experiences. Apres avoir selectionne les sujets a prioriser, nous avons recense les revues systematiques, les essais randomises et controles recents sur les methodes de depistage et d'autres etudes pertinentes sur l'efficacite du depistage et de la prise en charge. Nous avons utilise l'approche GRADE (Grading of Recommendations, Assessment, Development and Evaluation) pour formuler les recommandations et avons suivi le guide AGREE II (Appraisal of Guidelines for Research and Evaluation) pour rediger le rapport. Il en a ete de meme avec les principes du Guidelines International Network pour la gestion des interets concurrents. Les recommandations ont ete passees en revue par un comite externe d'experts en contenu avant d'etre distribuees a des intervenants a l'echelle nationale pour approbation. Recommandations: Nous avons formule 15 recommandations concernant le depistage et d'autres soins preventifs et 1 recommandation de nature politique visant a ameliorer l'acces aux soins primaires. Ainsi, nous recommandons de prioriser une strategie de communication pour le depistage du cancer colorectal a partir de l'age de 45 ans et pour l'evaluation du risque de maladie cardiovasculaire pour lutter contre les iniquites en matiere de sante et promouvoir la sante. Les interventions particulieres qui devraient etre deployees pour lutter contre les iniquites comprennent l'autodepistage du virus du papillome humain (VPH) et du VIH, et le test de liberation de l'interferon y pour l'infection tuberculeuse. Le depistage de la depression, de la toxicomanie, de la violence conjugale et de la pauvrete devrait egalement permettre aux personnes touchees d'acceder plus facilement a des interventions eprouvees. Nous recommandons une prise de contact systematique avec des professionnels de la sante en soins primaires pour les personnes defavorisees. Interpretation: Les interventions preventives eprouvees peuvent aider a combattre les iniquites en matiere de sante si la priorite est accordee aux personnes defavorisees. Les medecins, les organisations de sante et les gouvernements devraient adopter des mesures fondees sur des donnees probantes et en faire le suivi s'ils veulent promouvoir l'equite en matiere de sante partout au Canada., Les disparites ou iniquites evitables en matiere de sante peuvent en partie etre combattues par des soins de sante primaires et preventifs (1,2). Le fait d'etre defavorise n'est pas une [...]

Background: Avoidable disparities in health outcomes persist in Canada despite substantial investments in a publicly funded health care system that includes preventive services. Our objective was to provide preventive care recommendations that promote health equity by prioritizing effective interventions for people experiencing disadvantages. Methods: The guideline was developed by a primary care provider-patient panel, with input from a patient-partner panel with diverse lived experiences. After selecting priority topics, we searched for systematic reviews and recent randomized controlled trials of screening and other relevant studies of screening accuracy and management efficacy. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to develop recommendations and followed the Appraisal of Guidelines for Research and Evaluation (AGREE II) reporting guidance. We managed competing interests using the Guideline International Network principles. The recommendations were externally reviewed by content experts and circulated for endorsement by national stakeholders. Recommendations: We developed 15 screening and other preventive care recommendations and 1 policy recommendation on improving access to primary care. We recommend prioritized outreach for colorectal cancer screening starting at age 45 years and for cardiovascular disease risk assessment, to help address inequities and promote health. Specific interventions that should be rolled out in ways that address inequities include human papillomavirus (HPV) self-testing, HIV self-testing and interferon-Y release assays for tuberculosis infection. Screening for depression, substance use, intimate partner violence and poverty should help connect people experiencing specific disadvantages with proven interventions. We recommend automatic connection to primary care for people experiencing disadvantages. Interpretation: Proven preventive care interventions can address health inequities if people experiencing disadvantages are prioritized. Clinicians, health care organizations and governments should take evidence-based actions and track progress in promoting health equity across Canada., Avoidable disparities in health outcomes, or health inequities, can be partly addressed through primary and preventive care. (1,2) People are not inherently disadvantaged--Canada has a long and continuing history of [...]

Globally, lung cancer is the leading cause of cancer death. Previous trials demonstrated that low-dose computed tomography lung cancer screening of high-risk individuals can reduce lung cancer mortality by 20% or more. Lung cancer screening has been approved by major guidelines in the United States, and over 4,000 sites offer screening. Adoption of lung screening outside the United States has, until recently, been slow. Between June 2017 and May 2019, the Ontario Lung Cancer Screening Pilot successfully recruited 7,768 individuals at high risk identified by using the PLCOm2012noRace lung cancer risk prediction model. In total, 4,451 participants were successfully screened, retained and provided with high-quality follow-up, including appropriate treatment. In the Ontario Lung Cancer Screening Pilot, the lung cancer detection rate and the proportion of early-stage cancers were 2.4% and 79.2%, respectively; serious harms were infrequent; and sensitivity to detect lung cancers was 95.3% or more. With abnormal scans defined as ones leading to diagnostic investigation, specificity was 95.5% (positive predictive value, 35.1%), and adherence to annual recall and early surveillance scans and clinical investigations were high (>85%). The Ontario Lung Cancer Screening Pilot provides insights into how a risk-based organized lung screening program can be implemented in a large, diverse, populous geographic area within a universal healthcare system.

En juin 2020, Sante publique Ontario a amorce la collecte de donnees sur la race des patients atteints de la COVID-19, apres des mois de plaidoyer de la part de [...]

La pandemie de maladie a coronavirus 2019 a fait eclater au grand jour des lacunes dans nos structures sociales, sources d'inegalites en sante. Elle a aussi revele les failles des [...]

Objective:To describe the proportion and identify predictors of community-dwelling individuals with traumatic spinal cord injury (TSCI) who were dispensed ≥1 publicly funded opioid in the year after injury using a retrospective cohort study.Setting:Ontario, Canada.Participants, Interventions, Outcome Measures:We used administrative data to identify predictors of receiving publicly funded prescription opioids during the year after injury for individuals who were injured between April 2004 and March 2015. Our outcome was modeled using robust Poisson multivariable regression and we reported adjusted relative risks (aRR) with 95% confidence intervals.Results:In our retrospective cohort of 934 individuals with TSCI who were eligible for the provincial drug program, 510 (55%) received ≥1 prescription opioid in the year after their injury. Most individuals were male (71%) and the median age was 63 years (interquartile range: 42–72). Being male (aRR 1.15, 95% confidence interval [CI] 1.01–1.31), having chronic obstructive pulmonary disease (aRR 1.25, 95% CI 1.05–1.50), and using prescription opioids before injury (aRR 1.46, 95% CI 1.29–1.66) were significantly associated with receiving opioids in the year after TSCI. Short durations of hospital stay after injury were also identified as being a significant risk factor of outpatient opioid use (aRR = 1.28, 95% CI = 1.08–1.51) when compared to longer hospital stays.Conclusion:This study presented evidence showing that most individuals eligible for Ontario’s public drug program who experienced a TSCI used opioids in the year following their injury. Due to the paucity of research on this population and their potential for elevated risks of adverse events, it is important for additional studies to be conducted on opioid use in this population to understand short-term and long-term risks and benefits.

In a study to understand acceptability and uptake of Human Papilloma Virus (HPV) self-sampling, we engaged community champions to lead recruitment and other study activities. This article describes qualitative findings relevant to the role of the community champion. We found that community champions were critical to promoting awareness about and encouraging cervical screening and HPV self-sampling. They were well-connected community members who had healthcare backgrounds, which created trust in their messages. They were highly effective at encouraging screening because of their education and cultural congruency, combined with the time for thorough and clear explanations. Women had an inherent level of comfort with the community champions that often did not exist with their physician. The community champions were seen as being able to address some of the barriers that exist within the healthcare system. We encourage health leaders to consider how this role can be sustainably and meaningfully incorporated into the healthcare system.

In June 2020, Public Health Ontario started collecting data on race of patients with COVID-19, after months of community advocacy. It soon became apparent that Black people were disproportionately infected [...]

The coronavirus disease 2019 pandemic has laid bare some of the ways in which social structures lead to inequalities in health. It has also revealed Canada's poor infrastructure for tracking [...]

IMPORTANCE: Targeted therapies have been hypothesized to prolong survival in the treatment of patients with intracranial metastatic disease (IMD) but, paradoxically, increase IMD incidence by improving systemic disease control and prolonging survival from the primary tumor. The real-world benefits of targeted therapy in treating patients with IMD are unclear, as clinical trials have excluded patients with IMD and lacked end points that report intracranial outcomes. OBJECTIVE: To assess the association of targeted therapy and IMD with patient survival. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included all patients in Ontario, Canada, who received a diagnosis of IMD from April 2005 to January 2018 with primary diagnoses of breast cancer, lung or bronchus cancer, or melanoma and control patients who were matched by primary disease without IMD. The data were analyzed between March and October 2020. EXPOSURES: EGFR-, ERBB2 (HER2-), or BRAF-targeted therapy or IMD status. MAIN OUTCOMES AND MEASURES: Kaplan-Meier and multivariable Cox regression analyses were performed to compare overall survival (OS) between patient subcohorts divided by primary disease and stratified by targeted therapy receipt or IMD status. RESULTS: In this cohort of 26 676 patients with IMD and breast cancer, lung and bronchus cancer, or melanoma, 57% of patients were women, and the median age at IMD diagnosis was 64 years (interquartile range, 56-72 years). Post-IMD targeted therapy was associated with prolonged OS in patients with ERBB2-positive breast cancer (hazard ratio [HR], 0.41; 95% CI, 0.33-0.50), EGFR-positive lung cancer (HR, 0.28; 95% CI, 0.23-0.34), and BRAF-positive melanoma (HR, 0.20; 95% CI, 0.14-0.29) compared with those who did not receive post-IMD targeted therapy. The presence of IMD was associated with shorter OS in patients with metastatic ERBB2-positive breast cancer (HR, 1.80; 95% CI, 1.56-2.08) and metastatic EGFR-positive lung cancer (HR, 1.22; 95% CI, 1.08-1.39) but not metastatic BRAF-positive melanoma (HR, 1.11; 95% CI, 0.77-1.61) compared with those without IMD. CONCLUSIONS AND RELEVANCE: The findings of this cohort study suggest an association between real-world use of targeted therapies and prolonged OS in patients with IMD in the setting of ERBB2-positive breast cancer, EGFR-positive lung cancer, and BRAF-positive melanoma. Including patients with IMD in clinical trials and using end points that interrogate IMD will be critical to determine the role of targeted therapies in treating patients with IMD.

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Study design: Cohort study. Objective: To determine the prevalence and to identify predictors of prescription opioid use among persons with nontraumatic spinal cord dysfunction within 1 year after discharge from inpatient rehabilitation. Setting: Ontario, Canada. Methods: We conducted a retrospective cohort study using administrative data to determine predictors of receiving prescription opioids during the 1 year after discharge from inpatient rehabilitation among persons with nontraumatic spinal cord dysfunction between April 1, 2004 and March 31, 2015. We modeled the outcome using a Poisson multivariable regression and reported relative risks with 95% confidence intervals. Results: We identified 3468 individuals with nontraumatic spinal cord dysfunction (50% male) with 67% who were aged ≥66. Over half of the cohort (60%) received opioids during the observation period. Older adults (≥66 years old) were significantly more likely to experience comorbidities (p&lt; 0.05) but less likely to be dispensed opioids following rehabilitation discharge. Being female, previous opioid use before rehabilitation, experiencing lower continuity of care, increasing comorbidity level, low functional status, and having a previous diagnosis of osteoarthritis or mental illness were significant risk factors for receiving opioids after discharge, as shown in a multivariable analysis. Increasing length of rehabilitation stay and higher income were protective against opioid receipt after discharge. Conclusion: Many individuals with nontraumatic spinal cord dysfunction in Ontario are prescribed opioids after discharge from inpatient rehabilitation. This may be problematic due to the number of severe complications that may arise from opioid use and their use in this population warrants future research.

Study design: Retrospective cohort study. Objectives: To examine the prevalence of polypharmacy for individuals with nontraumatic spinal cord dysfunction (NTSCD) following inpatient rehabilitation and to determine associated risk factors. Setting: Ontario, Canada. Methods: Administrative data housed at ICES, Toronto, Ontario were used. Between 2004 and 2015, we investigated prescription medications dispensed over a 1-year period for persons following an NTSCD-related inpatient rehabilitation admission. Descriptive and analytical statistics were conducted. Using a robust Poisson multivariable regression model, relative risks related to polypharmacy (ten or more drug classes) were calculated. Main independent variables were sex, age, income quintile, and continuity of care with outpatient physician visits. Results: We identified 3468 persons with NTSCD during the observation window. The mean number of drug classes taken post-inpatient rehabilitation was 11.7 (SD?=?6.0), with 4.0 different prescribers (SD?=?2.5) and 1.8 unique pharmacies (SD?=?1.0). Significant predictors for post-discharge polypharmacy were: being female, lower income, higher comorbidities prior to admission, lower Functional Independence Measure at discharge, previous number of medication classes dispensed in year prior to admission, and lower continuity of care with outpatient physician visits. The most common drugs dispensed post-inpatient rehabilitation were antihypertensives (70.0%), laxatives (61.6%), opioids (59.5%), and antibiotics (57.8%). Conclusion: Similar to previous research with traumatic spinal cord injury, our results indicate that polypharmacy is prevalent among persons with NTSCD. Additional research examining medication therapy management for NTSCD is suggested.

Cervical cancer is uniquely preventable with programs of regular screening. In many high-income nations, including Canada, the incidence of and mortality associated with cervical cancer have declined steadily and steeply [...]

Context:Pain and depression are two prevalent secondary complications associated with spinal cord injury (SCI) that negatively impact health and well-being. Self-management strategies are growing in popularity for helping people with SCI to cope with their pain and depression. However, there is still a lack of research on which approaches are best suited for this population.Objective:The aim of this scoping review was to determine what is known about the self-management of pain and depression through the use of pharmacological and non-pharmacological therapies in adults with SCI.Methods:Seven electronic databases were searched for articles published between January 1, 1990 and June 13, 2017. Grey literature was searched and additional articles were identified by manually searching the reference lists of included articles.Results:Overall, forty-two articles met the inclusion criteria; with the majority reporting on the self-management of pain, rather than on depression or on both complications. Non-pharmacological interventions were more likely to include self-management strategies than pharmacological interventions. A limited number of studies included all of the core self-management tasks and skills.Conclusions:There are significant knowledge gaps on effective self-management interventions for pain and depression post-SCI. There is a need to develop interventions that are multi-faceted, which include both pharmacological and non-pharmacological therapies to address multimorbidity.

Objective: Context/Objective:Family physicians may lack the knowledge or resources to adequately support patients with spinal cord injury (SCI). Our objectives were to determine patterns of preventive care for patients with SCI in a primary care setting (i.e. cancer screening, influenza vaccinations, general physicals, bone mineral density tests), and determine physicians’ level of comfort with providing primary care to patients with SCI.Design:i) Retrospective chart review, ii) Survey of physicians in the family practice.Setting:Six primary care practice sites in Ontario, Canada.Participants:All adult rostered patients of the family practice with SCI; All family physicians in the six sites.Outcome Measures:Proportion of patients up-to-date on cancer screening, proportion of patients with influenza vaccinations, general physicals, bone mineral density tests; physicians’ level of comfort with providing care to patients with SCI.Results:Sixty patients were included in analyses. Rates of cancer screening were generally poor. The highest uptake was seen for cervical cancer screening, where 50% of eligible women were up-to-date on Pap tests. Only 36.7% of patients were up-to-date on colorectal cancer screening. Only 14 (23.3%) patients had a documented general physical exam in their electronic record. There was a recorded flu vaccination for 55% of patients, and of those, there was a median of 19 months since last vaccination. Fifteen physicians (21.4%) responded to the survey. Ten physicians reported at least one patient with SCI, with the maximum being 20 patients. Comfort level in managing SCI-relevant conditions varied and was lowest for spasticity, respiratory issues and autonomic dysreflexia, where only 27.3% of respondents had some level of comfort.ConclusionThere are many opportunities to improve the preventive care of patients living with SCI.

Context:People with spinal cord injury and dysfunction (SCI/D) often take multiple medications (i.e. polypharmacy) to manage secondary health complications and multiple chronic conditions. Numerous healthcare providers are often involved in clinical care, increasing the risk of fragmented care, problematic polypharmacy, and conflicting health advice. These providers can play a crucial role in assisting patients with medication self-management to improve medication adherence.Design:A qualitative study involving telephone interviews, following a semi-structured guide that explored healthcare providers' conceptualization of factors impacting medication adherence for persons with SCI/D. The interviews were transcribed and analyzed descriptively and interpretively using a constant comparative process with the assistance of data display matrices. Analysis was guided by an ecological model of medication adherence.Setting and participants:Thirty-two healthcare providers from Canada, with varying clinical expertise.Intervention:Not Applicable.Outcome measures:Not Applicable.Results:Providers identified several factors that impact medication adherence for persons with SCI/D, which were grouped into micro (medication and patient-related), meso- (provider-related) and macro- (health system-related) factors. Medication-related factors included side effects, effectiveness, safety, and regimen complexity. Patient-specific factors included medication knowledge, preferences/expectations/goals, severity and type of injury, cognitive function/mental health, time since injury, and caregiver support. Provider-related factors included knowledge/confidence and trust. Health system-related factors included access to healthcare and access to medications. While providers were able to identify several factors influencing medication adherence, micro-level factors were the most frequently discussed.Conclusion:Findings from this study indicate that strategies to optimize medication adherence for persons with SCI/D should be multi-faceted.

Retrospective cohort study. The objectives for this study were to examine the prevalence of polypharmacy for people with traumatic spinal cord injury (SCI) following injury and to determine risk factors. Ontario, Canada We used provincial-level administrative health services data of publicly funded healthcare encounters housed at the Institute for Clinical Evaluative Sciences, Toronto, Ontario. We examined prescription medications dispensed over a 1 year period post injury for persons 66+ years with an index traumatic SCI between 2004 and 2014. Polypharmacy was defined as being on 10 or more drug classes. Descriptive and analytical statistics were conducted. Relative risks and 95% confidence limits for factors related to polypharmacy were calculated using a robust Poisson multivariate regression model. We identified 418 cases of persons with traumatic SCI during the observation window. A total of 233 patients (56%) were taking at least 10 drug classes in the year following discharge from care for traumatic SCI. The mean number of drug classes taken post injury was 11 (SD = 6). Continuity of care was significantly associated with polypharmacy, with a higher continuity of care (having at least 75% of visits with the same doctor) reducing the risk of polypharmacy. The most common drugs prescribed were laxatives, opioids and cardiovascular-related drugs. Findings suggest that polypharmacy is extensive among older adults with traumatic SCI. Persons with better continuity of care are less likely to have polypharmacy compared to those with less continuity. This project was funded by a Connaught New Investigator Award (University of Toronto), and the Craig H. Neilsen Foundation Psychosocial Research Pilot Grant (Grant #441259).

Multiple sclerosis (MS) is an autoimmune disease that is often treated with multiple medications. Managing multiple medications, also known as polypharmacy, can be challenging for persons with MS. Toolkits are instructional resources designed to promote behaviour change. Toolkits may support medication self-management for adults with MS, as they have been useful in other populations with chronic conditions.

Participation in lung cancer screening (LCS) is lower in populations with the highest burden of lung cancer risk (through the social patterning of smoking behavior) and lowest levels of health care utilization (through structurally inaccessible care) leading to a widening of health inequities.

To describe selected anthropometric and health status variables among immigrant and refugee children =6 years of age within an inner city clinic in Toronto, Ontario.

Federal, provincial, and municipal organizations in Canada have recently begun to promote an equity agenda for their health systems, but much of the necessary data by which to identify those with social disadvantage are not currently collected.

Women who are immigrants or socioeconomically disadvantaged have been found to have significantly lower cervical cancer screening rates than their peers in Toronto, Ontario, Canada. The objective of this study was to examine rates of appropriate cervical cancer screening among women living in Ontario, Canada, using recent registration with Ontario's universal health insurance plan as an indicator of immigrant status.

Introduction:Primary care physicians are essential to cancer care. They frequently identify signs and symptoms leading to a diagnosis of cancer, and provide ongoing support and management of non-cancer health conditions during cancer treatment. Both primary care and cancer care have been greatly affected by the COVID-19 pandemic. In the United States, cancer-related patient encounters and cancer screening decreased over 40% and 80% respectively in January to April 2020 compared to 2019 (London et al. JCO Clin Cancer Inform 2020). However, the impact of the COVID-19 pandemic on primary care access for cancer patients remain unclear.

High or increasing prostatic specific antigen (PSA) levels may be a source of anxiety in patients with metastatic prostate cancer.

Despite much media attention being given to the physician shortage in Canada in recent years, this shortage pales in comparison to that seen in many middle- and low-income countries. A major cause of the shortage in these countries is the migration of health care workers from developing to developed nations, a phenomenon known as the “brain drain”. The loss of these workers is having devastating impacts globally, particularly in Sub-Saharan Africa and the Caribbean. Causes of the “brain drain” are numerous and include poor working conditions in poorer countries and active recruitment by richer countries. Jamaica has been one of the countries in the Caribbean hardest hit by mass migration of health care workers. The multiple dimensions of Jamaica’s health worker “brain drain” illustrate both the complexity of the issues reviewed in this commentary, and the net loss for low- and middle-income countries. Creative and sustainable solutions to the problem are actively being sought globally, but will require commitment and support from all nations as well as from international funding bodies if meaningful impacts on health are to be realized. Les médias ont beaucoup parlé de la pénurie de médecins au Canada ces dernières années, mais cette pénurie n’est rien en comparaison de ce que l’on voit dans de nombreux pays à faible revenu et à revenu intermédiaire. L’une des grandes causes de la pénurie dans ces pays est la migration des travailleurs de la santé vers les pays développés, un phénomène qu’on appelle « l’exode des cerveaux ». La perte de ces travailleurs est dévastatrice à l’échelle mondiale, surtout en Afrique subsaharienne et dans les Caraïbes. Les causes de l’exode des cerveaux sont nombreuses; elles incluent les mauvaises conditions de travail dans les pays pauvres et le recrutement actif des travailleurs de la santé par les pays riches. La Jamaïque est l’un des pays des Caraïbes les plus durement touchés par la migration massive de ses travailleurs de la santé. Les multiples aspects de l’exode des travailleurs de la santé jamaïcains montrent à la fois la complexité des enjeux abordés dans ce commentaire et la perte nette subie par les pays à faible revenu et à revenu intermédiaire. On recherche activement des solutions novatrices et durables à ce problème partout dans le monde, mais il faudra l’engagement et l’appui de tous les pays ainsi que des institutions financières internationales pour que cela ait un impact concret sur la santé.