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As advocates for health, nurses are ideally situated to deliver effective health promotion in their daily interactions with people. This work evaluates the integration of healthy conversation training, making every contact count (MECC), into a health promotion module in an undergraduate nursing degree at a higher education institute (HEI). In all, 108 students completed the online questionnaire I year after receiving healthy conversation training. 67% of students reported the regular or occasional use of healthy conversation skills and identified a wide range of scenarios where they had used the skills. 65% of students used health action planning framework in their own personal self-care. Student nurses acknowledged barriers and enablers to their use of healthy conversation skills. Having knowledgeable mentors who role modelled healthy conversations skills in their consultations was the most frequently raised factor, in addition to lack of knowledge of local resources, time and confidence. All placement settings should ensure that registered nurses, especially those undertaking mentorship responsibilities have access to healthy conversation training.

Summary Background COBRA-BPS (Control of Blood Pressure and Risk Attenuation-Bangladesh, Pakistan, Sri Lanka), a multi-component hypertension management programme that is led by community health workers, has been shown to be efficacious at reducing systolic blood pressure in rural communities in Bangladesh, Pakistan, and Sri Lanka. In this study, we aimed to assess the budget required to scale up the programme and the incremental cost-effectiveness ratios. Methods In a cluster-randomised trial of COBRA-BPS, individuals aged 40 years or older with hypertension who lived in 30 rural communities in Bangladesh, Pakistan, and Sri Lanka were deemed eligible for inclusion. Costs were quantified prospectively at baseline and during 2 years of the trial. All costs, including labour, rental, materials and supplies, and contracted services were recorded, stratified by programme activity. Incremental costs of scaling up COBRA-BPS to all eligible adults in areas covered by community health workers were estimated from the health ministry (public payer) perspective. Findings Between April 1, 2016, and Feb 28, 2017, 11 510 individuals were screened and 2645 were enrolled and included in the study. Participants were examined between May 8, 2016, and March 31, 2019. The first-year per-participant costs for COBRA-BPS were US$10·65 for Bangladesh, $10·25 for Pakistan, and $6·42 for Sri Lanka. Per-capita costs were $0·63 for Bangladesh, $0·29 for Pakistan, and $1·03 for Sri Lanka. Incremental cost-effectiveness ratios were $3430 for Bangladesh, $2270 for Pakistan, and $4080 for Sri Lanka, per cardiovascular disability-adjusted life year averted, which showed COBRA-BPS to be cost-effective in all three countries relative to the WHO-CHOICE threshold of three times gross domestic product per capita in each country. Using this threshold, the cost-effectiveness acceptability curves predicted that the probability of COBRA-BPS being cost-effective is 79·3% in Bangladesh, 85·2% in Pakistan, and 99·8% in Sri Lanka. Interpretation The low cost of scale-up and the cost-effectiveness of COBRA-BPS suggest that this programme is a viable strategy for responding to the growing cardiovascular disease epidemic in rural communities in low-income and middle-income countries where community health workers are present, and that it should qualify as a priority intervention across rural settings in south Asia and in other countries with similar demographics and health systems to those examined in this study. Funding The UK Department of Health and Social Care, the UK Department for International Development, the Global Challenges Research Fund, the UK Medical Research Council, Wellcome Trust.

BackgroundCompetency frameworks are being taken up by a growing number of sectors and for a broad range of applications. However, the topic of competency frameworks is characterised by conceptual ambiguity, misunderstanding and debate. Lack of consistency in the conceptualisation and use of key terminology creates a barrier to research and development, consensus, communication and collaboration, limiting the potential that competency frameworks have to deal with real workforce challenges. This paper aims to advance the field by conducting a detailed review of the literature to understand the underlying causes of conceptual differences and divergent views and proposing a re-conceptualisation of competency framework terminology for use by the health sector.MethodsA broad scoping review of literature was conducted to identify publications relating to the conceptualisation of competency frameworks and key terms, examine how they are conceptualised and determine how this evolved. In addition, a purposive sample of health-related competency frameworks was chosen to illustrate how the terms and concepts are currently being applied in the health context.ResultsOf the 4 155 records identified, 623 underwent text searches and broad quantitative analysis, and 70 were included for qualitative analysis. Quantitative analysis identified 26 key terms, which were coded under six thematic headings. Qualitative analysis using the thematic areas revealed two distinct conceptualisations of competency frameworks and their terminology emerging concurrently in the education and employment sectors, with different underpinnings and purposes. As competency frameworks have developed, these two conceptualisations intertwined, resulting in the same terms being used to convey different concepts. Examination of health-related frameworks showed that this merging of concepts is prominent, with lack of consistency in definitions and use of key terms even within a single organisation.Discussion and conclusionsBuilding on previous efforts to address the lack of conceptual clarity surrounding competency frameworks, this paper proposes a re-conceptualisation of the terminology that encompasses two distinct competency framework interpretations, using a glossary of mutually exclusive terms to differentiate concepts. The re-conceptualisation holds relevance for multiple competency framework applications within health, enabling harmonisation, clear communication, consensus-building and effective implementation of competency frameworks.

Background In June 2021, the hospice began delivering our first ever Quality Improvement (QI) Programme. We had observed an environment that was innovative in research and could be innovative in QI. We all ‘improved quality’ but did we use QI as a framework for that improvement? Aims Our shared vision was to integrate QI into the normal working day, within a culture of continuous improvement (National Advisory Group on the Safety of Patients in England, 2013). We have now launched our QI journey with our first sequential and small steps; a QI Programme and QI Champions. Methods The programme was delivered over four days to clinical and non-clinical staff; motivated and energetic people from every department in Hospice. We delivered QI technical skills (Institute for Healthcare Improvement. How to improve [The Model for Improvement]) blending theory and practice, whilst also focusing on wider topics which support QI landing successfully in the day job. This included improvement leadership (Ovretveit, 2009), human factors (National Quality Board, 2013) and team work (Montgomery, Parkin, Chisholm, et al., 2020). These specific topics were chosen by the participants, so the programme was bespoke to their learning needs and overall the programme was designed to be a fun and interactive environment. Results We commenced evaluation with a pre-course self-assessment of QI knowledge, skills and confidence. This was repeated at the end of each facilitated day and will be concluded by a post-course self-assessment. The first cohort completes in September 2021 and we will have the programme evaluation completed the same month. Conclusions We anticipate participants will have improved QI knowledge, skills and confidence which will enable them to actively use QI in their normal working day and will also transition to become QI Champions. The QI Champion is a new role being designed to support other staff, encourage momentum and be a key part of building a network of QI Champions. We would like to share our story so far and future system plans. Sharing, learning, improving.

Background Dementia presents a major challenge for health care systems with aging populations. Over 46 million people live with dementia worldwide. This is estimated to increase to 131.5 million by 2050 (Prince, Wimo, Guerchet, et al., 2015). Much of the care for the person with dementia in the early stages takes place at home, therefore, there is a growing need for an evidence-based approach to home support for people with dementia and their carers (Chester, Clarkson, Davies, et al., 2018). Aims This study will assess the impact of a new, personalised memory games application (App), on the quality of life (QoL) of people with dementia and their carer(s). Methods This randomised controlled trial involves volunteers as participants (20 intervention group using a personalised App and 10 controls using a non-personalised App) and recruited via study promotion posters and local community organisations. Apps will present images with associated questions in the form of a quiz. The non-personalised App will use images such as flowers, fruit and geographic locations. Personalisation means the participant, carer or family members will be able to upload their own pictures which are more meaningful to the person with dementia. All study participants will be asked to use their App once a week for six months. Anticipated Results Engagement with the personalised content in the form of a game might lead to improvement in the QoL of the person with dementia and/or their carer by facilitating and improving communication. Early analysis will be presented at Hospice UK conference. Conclusions By increasing positive engagement between the person with dementia and their carer/relative via face-to-face and remote engagements, there may be a positive benefit to patients, carers or both. This study is being funded by Memory Lane Games Limited.

Commentary on : Aloufi MA, Jarden RJ, Gerdtz MF, Kapp S. Reducing stress, anxiety and depression in undergraduate nursing students: systematic review. Nurs Ed Today 2021;102:104877.1 Extensive research has identified the demands of nursing on emotional and physical well-being2 and acknowledges that mental health concerns are often reported by nurses, especially student nurses, which far exceed the stress and anxiety levels reported by other students.3 Good health and well-being within the profession is essential for the safe delivery of quality healthcare,4 and the use of effective interventions …

The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.

Financial protection is a health system goal for all countries. Assessing progress on this relies on measuring the incidence of catastrophic health expenditures (proportion of the population whose out-of-pocket (OOP) payments for health surpass a certain threshold of household resources). Standard approaches rely on selective thresholds, however this masks varying intensities of financial hardship and poses a measurement challenge as incidence is sensitive to the choice of the threshold. We address this problem by applying the dominance approach, which tests differences in catastrophic incidence curves over a continuous range of thresholds. Iran is an interesting country for empirical application of the dominance approach given its historically high reliance on OOP payments to finance its health system and its commitment to improving financial protection through several national health policies over the last two decades. Using data from annual Household Income and Expenditure Surveys from 2005 to 2017 (sample size: 26,851-39,088 households), incidence was analyzed following this novel approach. Distribution of incidence across socio-economic status was also analyzed by estimating concentration indices and across health services or products by estimating average shares of each item. Results showed that over time catastrophic health expenditures increased for thresholds lower than 25% and decreased for thresholds higher than 35%. Catastrophic health expenditures were more equally distributed across income levels at lower thresholds, becoming concentrated amongst the rich as the threshold rose. Medicines represented the largest share of catastrophic spending for the poorest; medicines, dentistry, inpatient and ancillary services for the richest. This is the first study to apply dominance methods to analyze catastrophic health expenditures in a country over time. The analysis provides a nuanced picture of who incurs catastrophic health expenditures, to what extent hardship is experienced and what were the drivers of these expenditures - thus providing a better basis for policy responses.

[Abstract] The modern hospital is at once the site of healing, the locus of medical learning and a cornerstone of the welfare state. Its technological and infrastructural costs have transformed health services into one of today's fastest growing sectors, absorbing substantial proportions of national income in both developed and emerging economies. The aim of this book is to examine this growth in different countries, with a main focus on the twentieth century, and also with a backward glance to earlier shaping forces. It will explore the hospital's economic history, the relationship between public and private forms of provision, and the political context in which health systems were constructed. The collection advances the historical world map of different hospital models, ranging across Spain, Brazil, Germany, East and Central Europe, Britain, the United States and China. Collectively, these comparative cases illuminate the complexities involved in each country and bring new historical evidence to current debates on health care organisation, financing and reform.

BackgroundRising global concern about antimicrobial resistance has drawn attention to the use of antibiotics in livestock. Understanding the current usage of antibiotics in these animals is essential for effective interventions on the optimisation of antibiotic use. However, to date few studies have been conducted in low- and middle-income countries. This study aimed to explore the use of antibiotics and estimate the total amount of antibiotics used in pig production in Thailand.MethodsThis was a mixed-methods study including a cross-sectional questionnaire-based survey of 84 pig farmers, secondary analysis of data from a survey of 31 feed mills to estimate the amount of antibiotics mixed in pig feed and interviews with five veterinarians involved in the feed mill industry to gain an understanding of medicated feed production.FindingsHalf of the farmers reported using antibiotics for disease prevention. Use was significantly associated with farmers’ experience in raising pigs, farm income, having received advice on animal health and belonging to a farm cooperative. The estimated total amount of active ingredients mixed into medicated feed for pigs for the whole country was 843 tonnes in 2017. Amoxicillin was the most commonly used antibiotic reported by both pig farms and feed mills. The use of Critically Important Antimicrobials including colistin was common, with one-third of farmers reporting their use as oral or as injectable medication, and accounting for nearly two-thirds of antibiotics contained in medicated feed.ConclusionA majority of antibiotics used in Thai pig farms belonged to the category of Critically Important Antimicrobials. Progressive restriction in the use of antibiotics in pigs is recommended through using prescriptions to control the distribution of certain antibiotics. The government should strengthen veterinary services to improve access of farmers to animal health advice and explore alternative interventions.

Background Hospice Isle of Man’s aim is to provide access to those who could benefit regardless of diagnosis. The hospice began offering services to non-cancer patients in 2016. Little is known about how many could benefit or the extent of the hospice’s involvement by disease category. The Isle of Man is not included in Hospice UK’s PopNAT. Aims To estimate the number of persons who could have potentially benefited from palliative and end-of-life care. To understand differences in hospice involvement by disease category. Methods The Isle of Man Registry maintains weekly Excel sheets with death certificate data. We extracted variables of interest for the period between 1 January 2013 to 31 December 2018. We created a variable for palliative need based on cause of death where there was any mention of cancer, Alzheimer’s/dementia, organ failure or a neurodegenerative condition. Using hospice records, we identified persons who received hospice care for the years 2016–2018. We estimated unmet need by comparing hospice involvement and presence of a condition likely to benefit from palliative care and compared hospice involvement by palliative disease category. Results There were 5,005 deaths between 2013 and 2018, representing 1% of the population per year. Prior to 2016, the hospice cared for 30% of persons who died. By 2018, 39% had hospice care representing a 21% increase from 2016. Of all deaths between 2013 and 2018, 30% had a palliative condition and hospice care. An additional 34% had a palliative condition but no hospice care. The hospice was involved in 88% of all cancer cases but only in a quarter or less of cases with organ failure (28%), neurodegenerative conditions (26%), or Alzheimer’s/dementia (16%). Conclusions Since 2016, more persons received hospice care. However, persons with non-cancer conditions who could benefit remained under-represented compared to those with cancer. Future studies are needed to understand the factors contributing to this difference.

Background Hospice UK is promoting ECHO™ (Extension of Community Healthcare Outcomes) to democratise specialist skills and increase confidence of staff in palliative and end-of-life care. Hospice Isle of Man is reaching the end of the first year of Project ECHO™ with local nursing homes. Aim To carry out a formative evaluation of project ECHO™ at the end of its first year of operation and prepare for a summative evaluation at the end of five years. Methods The logic model identifies resources and inputs, activities, outputs, short and longer-term outcomes. Inputs, activities and outputs come from routinely collected data and short-term outcomes from a mix of ad-hoc quantitative data from surveys and qualitative data from interviews. For longer-term outcomes we have 1) set up a data collection exercise to obtain feedback from all of those experiencing bereavement, 2) identified sources of data on place of care at the end-of-life with the aim of determining whether experiences change over the period of Project ECHO™’s operation. Results We are currently conducting the formative evaluation with nursing homes using the quantitative data described in the first three categories of the logic model. We are also carrying out qualitative interviews with those who participated in the first year of Project ECHO™. We trialled a validated questionnaire (Grande et al. End-of-life skills survey) on end-of life skills and confidence which will be a required part of enrolment for those who join further ECHO™s and will map to our Island skills framework. Feedback is positive and Project ECHO™ will continue in nursing homes with further ECHO™s including residential homes and other community providers. Conclusion With the formative evaluation we are learning lessons about how best to deliver Project ECHO™ in nursing homes and extend it to other sites. We have set up measures which we hope will shed light on longer-term outcomes.

Based on projected numbers, approximately only 50% of those requiring renal replacement therapy (RRT) receive it. Many patients who require RRT live in low- and middle-income countries. The objective of this study was to examine the changing pattern over time of entry into the RRT programme in Thailand following RRT’s inclusion in the Universal Coverage Scheme. This study was an ecological study using the age-period-cohort analysis to look at dialysis registration and kidney transplant trends during RRT programme implementation. Data from 2008 to 2016 of patients diagnosed with end-stage renal disease (ESRD) were obtained from the National Health Security Office. The study found that the numbers of new patients with ESRD, aged 20–69, registered with the dialysis programme increased over time. For patients aged 20–40 years, the dialysis programme took up to 400 new patients for every 1000 new ESRD diagnoses. For kidney transplant, the rates increased slowly. The kidney transplant programme could at best treat only around 50 cases for every 1000 new ESRD diagnoses in patients aged 20–30 years. Findings of this study highlighted the importance of promoting strategies to reduce the increasing number of patients with kidney disease, to consider conservative therapy for older/frail patients, and to improve access to kidney transplantation and live-donation.

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.

There is a global demand for rehabilitation services but to date little attention has been paid to rehabilitation as part of the health agenda, especially in low- and middle-income countries. The objective of the scoping review was to get an overview of the needs and unmet needs for rehabilitation services described in the literature.Electronic search was performed in PubMed and REHABDATA for studies published between 2000 and 2017.Eighty-six articles met the inclusion criteria. Results revealed a profound need for rehabilitation among different user groups with non-communicable diseases and injuries across countries. However, this need considerably outstripped the provision of services, which left many people with substantial unmet needs for rehabilitation. The main reasons for the unmet needs for rehabilitation were the absence of or unequal geographical distribution of services within a country, lack of transportation, and unaffordability of the services.There are substantial unmet needs for rehabilitation and numerous barriers to accessing services. Efforts need to focus on building the capacity for rehabilitation research predominantly in low- and middle-income countries. The comprehensive data that this review provides is useful for raising awareness for the need of rehabilitation at policy level. Implications for rehabilitation There is a profound need for rehabilitation services due to the ageing population and growing prevalence of non-communicable diseases. This scoping review shows that the need for rehabilitation considerably outstrips the provision of services. There are substantial unmet needs for rehabilitation and numerous barriers to accessing services. Concerted global action to scale up quality rehabilitation services is needed, especially in low- and middle-income countries.

The advancements in and affordability of technologies offer increasing opportunities to modernise healthcare education into packages developed to meet the expectations and requirements of the digital generation. Purposefully designed and tested Virtual Reality Learning Environments (VRLE) can offer healthcare students the means to access and revisit learning materials in ways that enhance education and meet a range of needs; including those with specific learning differences and those who have traditionally been disenfranchised. Furthermore, this will make healthcare education much more readily available to those who have been previously marginalised by distance. This paper argues that Virtual Reality (VR) has the unique potential to transform healthcare education and suggests that more providers should consider collaborating with developers and investing in the technology.

As an economist, acceptance of the need for prioritization and of the value of systematic thinking about and analysis of priorities is fundamental to my thinking about resource allocation to health...

Health Insurance Portability and Accountability Act (HIPAA) would normally be more powerful than a state law, but if a state law about health professionals communicating with the public sets a higher standard of protection for the public than HIPAA, the art therapist must follow the state law. Many forms of giving information and seeking consent occur in private practice, and many of them are enfolded within the contract. The HIPAA Omnibus Final Rule specifies that if a health care provider informs the client of the risks of sending protected health information by unsecured email, and the client wants to receive the information by email, he or she can give consent to receive normal, unsecured emails from their psychotherapist. Some clients readily accept the therapist’s late cancellation policy, volunteering the late payment fee without hesitation, while other clients persist in “forgetting” the fee even after the therapist and client have talked through one late cancellation.

This paper raises the problem of how improvements in health outcomes, a key component in many governments' strategies, can be achieved. The work highlights a novel undergraduate educational approach which offers solutions to public health challenges within nursing. Against the backdrop of one UK university institution it discusses approaches that can guide nursing students towards a deeper understanding and engagement within the principles of public health. It then proposes how nurses can use their learning to become leaders of health improvement.

Background The integrated care concept is being implemented world-wide but is often considered setting-specific. Small islands are one of these settings which face particular issues. Hospice Isle of Man is taking a measured approach, from which we hope that others might be able to benefit. Aim To develop a strategy for integrated palliative and end of life care on a small island. Methods Create connections and networks to support the planning, implementation and evaluation stages of the work Identify, via a needs assessment, what works, what gaps need filled and what matters to the population and professionals Identify particular issues facing small islands and ensure that any recommendations for change lead to solutions which are sustainable in the longer term. Results to date Hospice Isle of Man formed relationships with the International Foundation for Integrated Care (IFIC) and IFIC Scotland who facilitated two face-to-face stakeholder meetings in 2017 and 2018. Using an example of a patient journey, areas that could be improved were identified. As a result, Hospice Isle of Man, public health care providers and charities meet bi-monthly to discuss the progress of the needs assessment and consider how to work more closely together. Engagement activities for the needs assessment have included members of the public, patients and carers, schoolchildren, community groups, public and private health care providers, nursing home staff and residents with their families. Conclusions Many of the issues encountered are similar to those in other settings and proximity does not always lead to closeness although personal connections are an advantage. There is some consistency so far in the views of participants that we aim for the right care, in the right place at the right time, although the small island setting presents some unique challenges.

The United Nations Convention on the Rights of Persons with Disabilities has firmly placed disability in a human rights perspective. In the context of the Convention, disability refers to activity limitations and participation restrictions that result from the interaction of an impairment of body function or structure with environmental factors. The Convention addresses the rights of persons with disability in all aspects of life, including education and community integration and their right to equal access to services, such as schools, medical facilities and communication. Articles 25 and 26 explicitly state the right to health and access to health- related rehabilitation for persons with disabilities, 1 in all settings and situations, including during emergencies and natural disasters. Adherence to the Convention however, can be particularly challenging in a disaster response given the different economic and social vulnerabilities including poverty, as well as environmental hazards and damaged infrastructure. This can be further com- pounded by the limited time emergency medical teams are typically deployed for as part of a disaster response.

IntroductionThis paper evaluates the effectiveness of a gatekeeping pilot in shifting resources and patient visits from hospitals to primary care facilities under the Chinese New Rural Cooperative Medical Scheme.MethodsWe applied a difference-in-differences regression analysis using claims data from a pilot district in northern China. The study covered 200 685 enrollees in 17 townships in 2012 and followed-up the townships over 12 year-quarters until the end of 2014.ResultsThe gatekeeping pilot led to significantly more patients visiting primary care facilities (55.3%, p=0.001), but there was little evidence of increased ambulatory spending on primary care (1.6%, p=0.884). The pilot reduced hospital visits by 23.9% (p=0.048) and ambulatory spending at the hospitals by 22.4% (p=0.011).ConclusionsThis first impact evaluation of gatekeeping outside high-income countries found that gatekeeping policy did not seem to have expanded the care provided by primary care facilities, despite an increased volume of claimed visits. Although claimed patient visits and expenditure at hospitals reduced, we suspect this may have been because patients found it either cumbersome or difficult to obtain reimbursement for their care.

Background Many low and middle income countries are implementing reforms to support Universal Health Coverage (UHC). Perhaps one of the most ambitious examples of this is Indonesia’s national health scheme known as the JKN which is designed to make health care available to its entire population of 255 million by end of 2019. If successful, the JKN will be the biggest single payer system in the world. While Indonesia has made steady progress, around a third of its population remains without cover and out of pocket payments for health are widespread even among JKN members. To help close these gaps, especially among the poor, the Indonesian government is currently implementing a set of UHC policy reforms that include the integration of remaining government insurance schemes into the JKN, expansion of provider networks, restructuring of provider payments systems, accreditation of all contracted health facilities and a range of demand side initiatives to increase insurance uptake, especially in the informal sector. This study evaluates the equity impact of this latest set of UHC reforms. Methods Using a before and after design, we will evaluate the combined effects of the national UHC reforms at baseline (early 2018) and target of JKN full implementation (end 2019) on: progressivity of the health care financing system; pro-poorness of the health care delivery system; levels of catastrophic and impoverishing health expenditure; and self-reported health outcomes. In-depth interviews with stakeholders to document the context and the process of implementing these reforms, will also be undertaken. Discussion As countries like Indonesia focus on increasing coverage, it is critically important to ensure that the poor and vulnerable - who are often the most difficult to reach – are not excluded. The results of this study will not only help track Indonesia’s progress to universalism but also reveal what the UHC-reforms mean to the poor.

A single hospital admission can deplete household resources so considerably as to induce impoverishment, especially in the Indian context of low government healthcare expenditure. Rashtriya Swasthya Bima Yojana (RSBY) was a national health insurance scheme for below-poverty-line Indian families, to provide improved access to hospitalization and greater financial protection via a public-private-partnership employing private sector implementation capacity. Study objectives were to understand governance (including regulatory) environment and contract arrangements; evaluate expansion of services to beneficiaries; and assess compliance of providers and user satisfaction. A case study approach in two districts met the need for in-depth information on scheme functioning, and RSBY implementation was examined between 2011 and 13 in Patiala (Punjab) and Yamunanagar (Haryana). Methods included 20 key stakeholder interviews, analysis of secondary datasets on beneficiaries and claims, primary data collection in 31 public and private hospitals and in greater depth in 12 hospitals, and an exit survey of 751 patients. Enrolled and non-enrolled hospitals were mapped in each district and service availability of enrolled hospitals assessed; enrollee characteristics were analysed; for the 12 hospitals, information was obtained on structural quality and process of care, and patient satisfaction and out-of-pocket payments. The Indian states and the government of India did not specify formal regulatory and implementation procedures in detail and states largely contracted out their functions to private insurance firms. Findings show regulatory weaknesses, and contractual breaches. Enrolment rates were low in both districts and more so for Patiala and there was limited access to services. There was little difference in process of care between public and private hospitals, though the structural capacity of private hospitals was better than public hospitals. RSBY helped improve accessibility and gave some degree of financial protection to patients. It also actively engaged with existing resources in the Indian health care and insurance markets., Highlights • Contract specification and compliance were major challenges in RSBY. • Out-of-pocket payment for care was significant, especially in private hospitals. • There were few differences in care quality between public and private hospitals. • RSBY patients were slightly more satisfied than non-RSBY patients. • PPP schemes demand effective regulatory and monitoring systems.

Emergency medical teams provide urgent medical and surgical care in emergencies characterized by a surge in trauma or disease. Rehabilitation has historically not been included in the acute phase of care, as teams have either not perceived it as their responsibility or have relied on external providers, including local services and international organizations, to provide services. Low- and middle-income countries, which often have limited rehabilitation capacity within their health system, are particularly vulnerable to disaster and are usually ill-equipped to address the increased burden of rehabilitation needs that arise. The resulting unmet needs for rehabilitation culminate in unnecessary complications for patients, delayed recovery, reduced functional outcomes, and often impede return to daily activities and life roles. Recognizing the systemic neglect of rehabilitation in global emergency medical response, the World Health Organization, in collaboration with key operational partners and experts, developed technical standards and recommendations for rehabilitation which are integrated into the WHO verification process for EMTs. This protocol report presents: 1) the rationale for the development of the standards and accompanying recommendations; 2) the methodology of the development process; 3) the minimum standards and other significant content included in the document; 4) challenges encountered during development and implementation; and 5) current and next steps to continue strengthening the inclusion of rehabilitation in emergency medical response.

Background We provide a historical analysis of the evolution of the field of health policy and systems research (HPSR) since 1996. In the mid-1990s, three main challenges affected HPSR, namely (1) fragmentation and lack of a single agreed definition of the field; (2) ongoing dominance of biomedical and clinical research; and (3) lack of demand for HPSR. Cross-cutting all these challenges was the problem of relatively limited capacity to undertake high quality HPSR. Our discussion analyses how these problems were addressed so as to facilitate growth and enhanced recognition of the field. Discussion HPSR has benefitted significantly from increased recognition of the importance of strong health systems to health outcomes, particularly those linked to the Millennium Development Goals. In addition to this, some of the challenges described above have been addressed through (1) sustained advocacy for the importance of HPSR, (2) efforts to clarify the content and focus of the field, and (3) growing appreciation of and efforts to engage health practitioners and policy-makers in HPSR. While advocacy for the field of HPSR was initially fragmented, since the late 1990s there has been a consistent flow of focusing events and publications that have served to enhance the profile and understanding of the field. There have also been multiple efforts to establish greater coherence within the field, for example, interrogating the distinctions between health services research and health systems research, and how critical the “P” for policy is to HPSR. Finally, HPSR has developed at the same time as growing interest in evidence-informed policy and, more recently, implementation science, which have served to underscore the relevance and utility of HPSR to policy- and decision-makers. Conclusions During the past two decades, the field of HPSR has developed significantly, leading to enhanced clarity about its purpose, activity levels and utility. Several challenges remain that will need to be addressed in the decades ahead.

Aim Within the United Kingdom (UK) there is an increasing focus on Values Based Recruitment (VBR) of staff working in the National Health Service (NHS) in response to public inquiries criticising the lack of person-centred care. All NHS employees are recruited on the basis of a prescribed set of values. This is extended to the recruitment of student healthcare professionals, yet there is little research of how to implement this. Involving Service Users in healthcare educational practice is gaining momentum internationally, yet involvement of service users in VBR of ‘would be’ healthcare professionals remains at an embryonic phase. Adult nurses represent the largest healthcare workforce in the UK, yet involvement of service users in their recruitment has received scant attention. This paper is an evaluation of the inclusion of service users in a VBR of 640 adult student nurses. Background Design This study used a participatory mixed methods approach, with service users as co-researchers in the study. Methods The study consisted of mixed methods design. Quantitative data via an online questionnaire to ascertain candidates' perspectives ( n = 269 response rate of 42%), and academic/clinical nurses ( n = 35 response rate 34.65%). Qualitative data were gathered using focus groups and one to one interviews with service users ( n = 9). Data analysis included descriptive statistics and thematic analysis. Findings 4 overarching themes were identified; increasing sense of humanness, substantiating care values; impact of involvement; working together and making it work, a work in progress. Conclusion The findings from the study highlight that involving service users in VBR of student healthcare professionals has benefits to candidates, service users and local health services. Appreciating the perceptions of healthcare professionals is fundamental in the UK and internationally to implementing service users' engagement in service enhancement and delivery. Findings from this study identify there may be a dissonance between the policy, the nurses' thoughts and their practice.

Health systems have several key objectives; the most fundamental is to improve the health of the population. In addition, they are concerned with the distribution of health in the population—for example, with health equity—and they strive to be responsive to the needs of the population and to deliver services efficiently (WHO 2007). Notably, they also seek to provide protection against the financial risks that individuals face when accessing health services. Ideally, this financial risk protection (FRP) is accomplished through mechanisms such as risk pooling and group payment that ensure prepayment of most, if not all, health care costs (Jamison and others 2013).An effective health system is one that meets these objectives by providing equitable access to affordable, high-quality health care—including treatment and curative services as well as health promotion, prevention, and rehabilitation services—to the entire population. Unfortunately, most countries lack health systems that meet this standard. Shortfalls in access, quality, efficiency, and equity have been documented extensively, both in low- and middle-income countries (LMICs) and in some high-income countries (HICs) (WHO 2010). In addition, in many countries, households routinely face catastrophic or impoverishing health expenditure when seeking acute or chronic disease care (Xu and others 2007). These financial risks can result in further health loss and reduced economic prosperity for households and populations (Kruk and others 2009; McIntyre and others 2006).The current universal health coverage (UHC) movement emerged in response to a growing awareness of the worldwide problems of low access to health services, low quality of care, and high levels of financial risk (Ji and Chen 2016). UHC is now a core tenet of United Nations (UN) Sustainable Development Goal (SDG) 3. UHC was preceded by the aspirational notion of a minimum standard of health for all, enshrined in the Universal Declaration of Human Rights (adopted by the UN General Assembly in 1948) and the declaration of Alma-Ata in 1978, and many HICs have provided universal coverage for decades. The World Health Assembly endorsed the modern concept of UHC as an aspiration for all countries in 2005. Subsequent World Health Reports by the World Health Organization (WHO) expanded on various technical aspects of UHC, and in 2015, UHC was adopted as a subgoal (target 3.8) of SDG 3 (UN 2016; WHO 2013b).Mechanisms and approaches, summarized elsewhere (WHO 2010; WHO 2013b), have been proposed or attempted as specific means of achieving UHC, but the objectives of UHC are the same in all settings, regardless of approach: improving access to health services (particularly for disadvantaged populations), improving the health of individuals covered, and providing FRP (Giedion, Alfonso, and Diaz 2013). There are three fundamental dimensions to UHC—proportion of population covered, proportion of expenditures prepaid, and proportion of health services included in UHC—that any given health care reform strategy seeks to achieve in some prioritized order (Busse, Schreyogg, and Gericke 2007). Recent reports, including the Lancet Commission on Investing in Health and the WHO Making Fair Choices consultation, have endorsed a “progressive universalist” approach to public finance of UHC (Jamison and others 2013; WHO 2014). Progressive universalism makes the case, on the basis of efficiency and equity, for an expansion pathway through the three UHC dimensions that prioritizes full population coverage and prepayment, albeit for a narrower scope of services than could be achieved at lower coverage levels or through cost-sharing arrangements. (It has been argued that full population coverage and full prepayment are necessary conditions to ensure that UHC leaves no one behind [WHO 2014].)If progressive universalism is the preferred approach to UHC, then a critical question for health planners is which health interventions should be included. HICs are able to provide a wide array of health services, but LMICs have the resources to deliver a smaller set of services, necessitating a more explicit and systematic approach to priority setting (Glassman and others 2016). In this spirit, the Making Fair Choices report recommended that UHC focus on interventions that are the most cost-effective, improve the health of the worst off, and provide FRP (WHO 2014). The extended cost-effectiveness analysis (ECEA) approach developed for this third edition of Disease Control Priorities (DCP3) assesses policies in these dimensions and can help identify efficient, fair pathways to UHC. Chapter 8 of this volume provides an overview of ECEA methods and results of ECEAs undertaken in conjunction with DCP3 (Verguet and Jamison 2018).The set of prioritized health services publicly financed through a UHC scheme has been termed a health benefits package (Glassman and others 2016). The limited experience of LMICs with benefits packages suggests that such packages can be part of a coherent and efficient approach to health system strengthening, but many countries lack the technical capacity to review a broad range of candidate interventions and summarize the evidence for their effectiveness or cost-effectiveness. In this regard, DCP3 provides guidance on priority health interventions for UHC in LMICs in the form of a model health benefits package that is based on DCP3’s 21 essential packages (see chapter 1 of this volume, Jamison and others 2018).This chapter proposes a concrete set of priorities for UHC that is grounded in economic reality and is intended to be appropriate to the health needs and constraints of LMICs, particularly low-income countries and lower-middle-income countries. It develops a model benefits package referred to as essential UHC (EUHC) and identifies a subset of interventions termed the highest-priority package (HPP). The chapter presents a case that all countries, including low-income countries, could strive to fully implement the HPP interventions by the end of the SDG period (2030), and many middle-income countries could strive to achieve full implementation of EUHC. The chapter also presents estimates of the EUHC and HPP costs and mortality consequences. It concludes with a discussion of measures that improve the uptake and quality of health services and with some remarks on the implications of EUHC and the HPP for health systems.The chapter does not, however, prescribe one correct approach to UHC, nor does it attempt to review the wide array of delivery mechanisms, policy instruments, and financial arrangements that support the transition to UHC; these have been covered in detail elsewhere (WHO 2010; World Bank 2016). Rather, this chapter stresses that the UHC priority-setting process is contextual, depending on political economy as well as local costs, budgets, and demographic and epidemiological factors—all of which influence the value for money of specific interventions.Because the development and refinement of a benefits package is an incremental and iterative process, many ministries of health probably will not use DCP3’s recommendations as a template for their packages but rather as an aid in reviewing existing services, identifying outliers, and considering services that are not currently provided. The DCP3 model benefits package can thus serve as a starting point for deliberation on a new health benefits package or refinement of an existing package. However, as construed here, it would not be a perfect package for a particular country. To translate the DCP3 findings into an actionable UHC agenda at the national or subnational level will require context-specific technical analyses and public consultation, ideally as part of a clearly articulated political agenda and an institutionalized priority-setting process that can govern public and donor resource allocation in the health sector.

Summary Background Tracking of aid resources to reproductive, maternal, newborn, and child health (RMNCH) provides timely and crucial information to hold donors accountable. For the first time, we examine flows in official development assistance (ODA) and grants from the Bill & Melinda Gates Foundation (collectively termed ODA+) in relation to the continuum of care for RMNCH and assess progress since 2003. Methods We coded and analysed financial disbursements for maternal, newborn, and child health (MNCH) and for reproductive health (R*) to all recipient countries worldwide from all donors reporting to the creditor reporting system database for the years 2011–12. We also included grants from the Bill & Melinda Gates Foundation. We analysed trends for MNCH for the period 2003–12 and for R* for the period 2009–12. Findings ODA+ to RMNCH from all donors to all countries worldwide amounted to US$12·2 billion in 2011 (an 11·8% increase relative to 2010) and $12·8 billion in 2012 (a 5·0% increase relative to 2011). ODA+ to MNCH represents more than 60% of all aid to RMNCH. ODA+ to projects that have newborns as part of the target population has increased 34-fold since 2003. ODA to RMNCH from the 31 donors, which have reported consistently since 2003, to the 75 Countdown priority countries, saw a 3·2% increase in 2011 relative to 2010 ($8·3 billion in 2011), and an 11·8% increase in 2012 relative to 2011 ($9·3 billion in 2012). ODA to RMNCH projects has increased with time, whereas general budget support has continuously declined. Bilateral agencies are still the predominant source of ODA to RMNCH. Increased funding to family planning, nutrition, and immunisation projects were noted in 2011 and 2012. ODA+ has been targeted to RMNCH during the period 2005–12, although there is no evidence of improvements in targeting over time. Interpretation Despite a reduction in ODA+ in 2011, ODA+ to RMNCH increased in both 2011 and 2012. The increase in funding is encouraging, but continued increases are needed to accelerate progress towards achieving MDGs 4 and 5 and beyond. Funding Bill & Melinda Gates Foundation.

BackgroundMonitoring financial protection against catastrophic health expenditures is important to understand how health financing arrangements in a country protect its population against high costs associated with accessing health services. While catastrophic health expenditures are generally defined to be when household expenditures for health exceed a given threshold of household resources, there is no gold standard with several methods applied to define the threshold and household resources. These different approaches to constructing the indicator might give different pictures of a country’s progress towards financial protection. In order for monitoring to effectively provide policy insight, it is critical to understand the sensitivity of measurement to these choices.MethodsThis paper examines the impact of varying two methodological choices by analysing household expenditure data from a sample of 47 countries. We assess sensitivity of cross-country comparisons to a range of thresholds by testing for restricted dominance. We further assess sensitivity of comparisons to different methods for defining household resources (i.e. total expenditure, non-food expenditure and non-subsistence expenditure) by conducting correlation tests of country rankings.ResultsWe found country rankings are robust to the choice of threshold in a tenth to a quarter of comparisons within the 5–85% threshold range and this increases to half of comparisons if the threshold is restricted to 5–40%, following those commonly used in the literature. Furthermore, correlations of country rankings using different methods to define household resources were moderate to high; thus, this choice makes less difference from a measurement perspective than from an ethical perspective as different definitions of available household resources reflect varying concerns for equity.ConclusionsInterpreting comparisons from global monitoring based on a single threshold should be done with caution as these may not provide reliable insight into relative country progress. We therefore recommend financial protection against catastrophic health expenditures be measured across a range of thresholds using a catastrophic incidence curve as shown in this paper. We further recommend evaluating financial protection in relation to a country’s health financing system arrangements in order to better understand the extent of protection and better inform future policy changes.

Background Gatekeeping involves a generalist doctor who controls patients’ access to specialist care, and has been discussed as an important policy option to rebalance the primary care and hospital sectors in low- and middle-income countries, despite thin evidence. A gatekeeping pilot in a Chinese rural setting launched in 2013 has offered an opportunity to study the functioning of gatekeeping under such conditions. Methods In this qualitative study within a mixed-method evaluation of the gatekeeping pilot, we developed an innovative systems analysis method, combining the World Health Organisation categorisation of health system building blocks, the “Framework” approach of policy analysis and causal loop analysis. We conducted in-depth interviews with 20 stakeholders from 4 groups (patients, doctors, health facility managers and government administrators) in the pilot area over two years. Based on information extracted from the interviews, we drew a causal loop diagram which highlighted the feedback loops within the system that had self-reinforcing or self-balancing characteristics, and used the diagram to examine systematically the mechanisms of intended and actual functioning of gatekeeping and analyse the systems level challenges that affected the effectiveness of gatekeeping. Results Had the gatekeeping pilot programme worked as intended, it would incentivize both providers and patients to increase service utilization at primary care level, as well as establish and enhance two reinforcing feedback loops to shift balance towards primary care. However, a performance-based salary policy undermined the motivation for clinical primary care. Furthermore, the primary care providers suffered from three reinforcing feedback loops (related to primary care capacity, human resource sustainability, patients’ faith) that trapped primary care development in vicious cycles. At the interface between hospitals and primary care providers, there were also feedback loops exacerbating the existing hospital dominance. These feedback loops were intensified by the unintended consequences of concurrent policies (restrictions on technologies and medicines) and delayed reform in hospitals. Furthermore, the gatekeeping policy itself faced resistance to further development, due to the prevailing ineffective and ritualistic nature of gatekeeping, which formed a balancing loop. Conclusions The study shows that the intended benefits of gatekeeping were illusionary largely due to weak and worsening primary care conditions, and delay, ineffectiveness or unintended consequences of several other ongoing reforms. One particularly dangerous development of the system, which deserves urgent attention, is the harming of the professional prospects of primary care doctors. Our findings highlight the need for coordination and prioritization in designing policies related to primary care and managing changes with multiple on-going reforms. The approach used here facilitates comprehensive study of intended and actual mechanisms, and demonstrates the challenges of a complex health system intervention in a dynamic environment.

Rapeepong Suphanchaimat,1,2 Phusit Prakongsai,1 Supon Limwattananon,1,3 Anne Mills2 1International Health Policy Program (IHPP), Ministry of Public Health, Faculty of Public Health and Policy, Nonthaburi, Thailand; 2London School of Hygiene and Tropical Medicine, London, UK; 3Khon Kaen University, Khon Kaen, Thailand Objectives: This study sought to investigate the impact of the Thai “Health Insurance for People with Citizenship Problems” (HI-PCP) on access to care for stateless patients, compared to Universal Coverage Scheme patients and the uninsured, using inpatient utilization as a proxy for impact.Methods: Secondary data analysis of inpatient records of Kraburi Hospital, Ranong province, between 2009 (pre-policy) and 2012 (post-policy) was employed. Descriptive statistics and multivariate analysis by difference-in-difference model were performed.Results: The volume of inpatient service utilization by stateless patients expanded after the introduction of the HI-PCP. However, this increase did not appear to stem from the HI-PCP per se. After controlling for key covariates, including patients’ characteristics, disease condition, and domicile, there was only a weak positive association between the HI-PCP and utilization. Critical factors contributing significantly to increased utilization were older age, proximity to the hospital, and presence of catastrophic illness.Conclusion: A potential explanation for the insignificant impact of the HI-PCP on access to inpatient care of stateless patients is likely to be a lack of awareness of the existence of the scheme among the stateless population and local health staff. This problem is likely to have been accentuated by operational constraints in policy implementation, including the poor performance of local offices in registering stateless people. A key limitation of this study is a lack of data on patients who did not visit the health facility at the first opportunity. Further study of health-seeking behavior of stateless people at the household level is recommended. Keywords: people with citizenship problems, difference-in-difference, double difference, impact evaluation, health service

Migrants&rsquo, access to healthcare has attracted attention from policy makers in Thailand for many years. The most relevant policies have been (i) the Health Insurance Card Scheme (HICS) and (ii) the One Stop Service (OSS) registration measure, targeting undocumented migrants from neighbouring countries. This study sought to examine gaps and dissonance between de jure policy intention and de facto implementation through qualitative methods. In-depth interviews with policy makers and local implementers and document reviews of migrant-related laws and regulations were undertaken. Framework analysis with inductive and deductive coding was undertaken. Ranong province was chosen as the study area as it had the largest proportion of migrants. Though the government required undocumented migrants to buy the insurance card and undertake nationality verification (NV) through the OSS, in reality a large number of migrants were left uninsured and the NV made limited progress. Unclear policy messages, bureaucratic hurdles, and inadequate inter-ministerial coordination were key challenges. Some frontline implementers adapted the policies to cope with their routine problems resulting in divergence from the initial policy objectives. The study highlighted that though Thailand has been recognized for its success in expanding insurance coverage to undocumented migrants, there were still unsolved operational challenges. To tackle these, in the short term the government should resolve policy ambiguities and promote inter-ministerial coordination. In the long-term the government should explore the feasibility of facilitating lawful cross-border travel and streamlining health system functions between Thailand and its neighbours.

The Isle of Man is a small island of 83,000 residents situated in the Irish Sea. The Island is a self-governing Crown Dependency of the United Kingdom. Due to its geographic isolation, the Island provides a unique opportunity to re-design and co-create a model of care that incorporates private, public, third sector and community elements. Financially strained health services recognise that sustainability depends on integration across sectors in the community. Hospice Isle of Man, the only specialist provider of end of life care on the Island, is working with the Department of Health and Social Care and the Council of Voluntary Organisations to develop the Isle of Man’s Integrated Palliative and End of Life Care Strategy. The World Health Organization and the Worldwide Palliative Care Alliance have underscored the need for palliative care to be based on individual needs rather than on disease-specific diagnoses or prognosis Connor and Sepulveda, 2014. In order to provide the right care, at the right time, in the right place, the Island-wide strategy requires a population-based approach and methods to match patients and services based on needs. Early stakeholder engagement facilitated through a workshop held on December 7th, 2017 with members of the health services including primary care, mental health, social health, third sector and carers identified the need for earlier identification of patients at the end of life in order to provide the most appropriate services. It was recognised that patient networks and resources must be taken into account in order for gaps to be adequately identified and to meet patient needs. Patient journey case studies with different diagnoses identified needs across the spectrum of care – including the third sector and patient networks. Age-based segmentation fails to recognize the contribution and potential capacity of those who would otherwise be considered “dependent” in traditional demographic analyses. Cross-sector integration of care raises additional questions and challenges. Who leads the process? What does person-centred care look like with cross-sector involvement? Who can function as a “key worker”? How will fragmented services organise? How do charitable organisations balance mission and goals with the requirements of an integrated network? What trade-offs are stakeholders willing to make? By combining findings obtained through focus groups, patient and carer journeys and cross-sector workshops we identify the non-medical determinants of need for community end of life support and propose strategies to meet them. These findings will form the basis for initiatives that will be piloted and evaluated prior to Island-wide implementation.

Created in the wake of the September 11, 2001 terrorist attacks, Maine's Office of Public Health Emergency Preparedness within the Maine Center for Disease Control and Prevention undertook a major reorganization of epidemiology and laboratory services and began developing relationships with key partners and stakeholders, and a knowledgeable and skilled public health emergency preparedness workforce. In 2003, these newly implemented initiatives were tested extensively during a mass arsenic poisoning at the Gustav Adolph Lutheran Church in the rural northern community of New Sweden, Maine. This episode serves as a prominent marker of how increased preparedness capabilities, as demonstrated by the rapid identification and administration of antidotes and effective collaborations between key partners, can contribute to the management of broader public health emergencies in rural areas. (Disaster Med Public Health Preparedness. 2013;7:319-326)

Summary Background Information is scarce about the extent to which official development assistance (ODA) is spent on reproductive health to provide childbirth care; support family planning; address sexual health; and prevent, treat, and care for sexually transmitted infections, including HIV. We analysed flows of ODA to reproductive health for 2009 and 2010, assessed their distribution by donor type and purpose, and investigated the extent to which disbursements respond to need. We aimed to provide global estimates of aid to reproductive health, to assess the allocation of resources across reproductive health activities, and to encourage donor accountability in targeting aid flows to those most in need. Methods We applied a standard definition of reproductive health across all donors, including a portion of disease-specific activities and health systems development. We analysed disbursements to reproductive health by donor type and purpose (eg, family planning). We also reported on an indicator to monitor donor disbursements: ODA to reproductive health per woman aged 15–49 years. We analysed the extent to which funding is targeted to countries most in need, proxied by female life expectancy at birth and prevalence of HIV infection in adults. Findings Donor disbursements to reproductive health activities in all countries amounted to US$5579 million in 2009 and US$5637 million in 2010—an increase of 1·0%. ODA for such activities in the 74 Countdown priority countries increased more rapidly at 5·3%. More than half of the funding was directed towards prevention, treatment, and care of HIV infection for women of reproductive age (15–49 years of age). On average, ODA to general reproductive health activities amounted to 15·9% and ODA to family planning 7·2%. Aid to reproductive health was heavily dependent on the USA, the Global Fund, the UK, the United Nations Population Fund, and the World Bank. Interpretation Donors are prioritising reproductive health, and the slight increase in funding in 2009–10 is welcome, especially in the present economic climate. The large share of such funding for activities related to HIV infection in women of reproductive age affects the amount of ODA received by priority countries. It should thus be distinguished from resources directed to other reproductive health activities, such as family planning, which has been the focus of recent worldwide advocacy efforts. Tracking of donor aid to reproductive health should continue to allow investigation of the allocation of resources across reproductive health activities, and to encourage donor accountability in targeting aid flows to those most in need. Funding Bill & Melinda Gates Foundation, World Bank, and the Governments of Australia, Canada, Norway, Sweden, and the UK.

Measurement of health system performance increasingly includes the views of healthcare users, yet little research has focussed on general population satisfaction with health systems. This study is the first to examine public satisfaction with health systems in the former Soviet Union (fSU). Data were derived from two related studies conducted in 2001 and 2010 in nine fSU countries, using nationally representative cross-sectional surveys. The prevalence of health system satisfaction in each country was compared for 2001 and 2010. Patterns of satisfaction were further examined by comparing satisfaction with the health system and other parts of the public sector, and the views of health care users and non-users. Potential determinants of population satisfaction were explored using logistic regression. For all countries combined, the level of satisfaction with health systems increased from 19.4% in 2001 to 40.6% in 2010, but varied considerably by country. Changes in satisfaction with the health system were similar to changes with the public sector, and non-users of healthcare were slightly more likely to report satisfaction than users. Characteristics associated with higher satisfaction include younger age, lower education, higher economic status, rural residency, better health status, and higher levels of political trust. Our results suggest that satisfaction can provide useful insight into public opinion on health system performance, particularly when used in conjunction with other subjective measures of satisfaction with government performance.

Background Universal health coverage (UHC) is critical to global poverty alleviation and equity of health systems. Many low-income and middle-income countries, including small island states in the Pacific, have committed to UHC and reforming their health financing systems to better align with UHC goals. This study provides the first comprehensive evidence on equity of the health financing system in Fiji, a small Pacific island state. The health systems of such states are poorly covered in the international literature. Methods The study employs benefit and financing incidence analyses to evaluate the distribution of health financing benefits and burden across the public and private sectors. Primary data from a cross-sectional survey of 2000 households were used to assess healthcare benefits and secondary data from the 2008–2009 Fiji Household Income and Expenditure Survey to assess health financing contributions. These were analysed by socioeconomic groups to determine the relative benefit and financing incidence across these groups. Findings The distribution of healthcare benefits in Fiji slightly favours the poor—around 61% of public spending for nursing stations and 26% of spending for government hospital inpatient care were directed to services provided to the poorest 20% of the population. The financing system is significantly progressive with wealthier groups bearing a higher share of the health financing burden. Conclusions The healthcare system in Fiji achieves a degree of vertical equity in financing, with the poor receiving a higher share of benefits from government health spending and bearing a lower share of the financing burden than wealthier groups.

BACKGROUND: Timely reliable data on aid flows to maternal, newborn, and child health are essential for assessing the adequacy of current levels of funding, and to promote accountability among donors for attainment of the Millennium Development Goals (MDGs) for child and maternal health. We provide global estimates of official development assistance (ODA) to maternal, newborn, and child health in 2003 and 2004, drawing on data reported by high-income donor countries and aid agencies to the Organisation for Economic Development and Cooperation. METHODS: ODA was tracked on a project-by-project basis to 150 developing countries. We applied a standard definition of maternal, newborn, and child health across donors, and included not only funds specific to these areas, but also integrated health funds and disease-specific funds allocated on a proportional distribution basis, using appropriate factors. FINDINGS: Donor spending on activities related to maternal, newborn, and child health was estimated to be US1990 million dollars in 2004, representing just 2% of gross aid disbursements to developing countries. The 60 priority low-income countries that account for most child and newborn deaths received 1363 million dollars, or 3.1 dollars per child. Across recipient countries, there is a positive association between mortality and ODA per head, although at any given rate of mortality for children aged younger than 5 years or maternal mortality, there is significant variation in the amount of ODA per person received by developing countries. INTERPRETATION: The current level of ODA to maternal, newborn, and child health is inadequate to provide more than a small portion of the total resources needed to reach the MDGs for child and maternal health. If commitments are to be honoured, global aid flows will need to increase sharply during the next 5 years. The challenge will be to ensure a sufficient share of these new funds is channelled effectively towards the scaling up of key maternal, newborn, and child health interventions in high priority countries.

In 1985, the Rockefeller Foundation published Good health at low cost to discuss why some countries or regions achieve better health and social outcomes than do others at a similar level of income and to show the role of political will and socially progressive policies. 25 years on, the Good Health at Low Cost project revisited these places but looked anew at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which have all either achieved substantial improvements in health or access to services or implemented innovative health policies relative to their neighbours. A series of comparative case studies (2009-11) looked at how and why each region accomplished these changes. Attributes of success included good governance and political commitment, eff ective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations. Furthermore, the capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a part. Health systems are complex and no simple recipe exists for success. Yet in the countries and regions studied, progress has been assisted by institutional stability, with continuity of reforms despite political and economic turmoil, learning lessons from experience, seizing windows of opportunity, and ensuring sensitivity to context. These experiences show that improvements in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations. Copyright © 2013 Elsevier B.V.

Summary Background To track donor assistance to maternal, newborn, and child health-related activities is necessary to assess progress towards Millennium Development Goals 4 and 5 and to foster donor accountability. Our aim was to analyse aid flows to maternal, newborn, and child health for 2005 and 2006 and trends between 2003 and 2006. Methods We analysed and coded the complete aid activities database for 2005 and 2006 with methods that we developed previously to track official development assistance. For the 68 Countdown priority countries, we report two indicators for use in monitoring donor disbursements: official development assistance to child health per child and official development assistance to maternal and neonatal health per livebirth. Findings Donor disbursements increased from US$2119 million in 2003 to $3482 million in 2006; funding for child health increased by 63% and that for maternal and newborn health increased by 66%. In the 68 priority countries, child-related disbursements increased from a mean of $4 per child in 2003 to $7 per child in 2006; disbursements for maternal and neonatal health increased from $7 per livebirth in 2003 to $12 per livebirth in 2006. Nonetheless, disbursements fell in some countries. After adjustment for other determinants, countries with higher under-5 mortality received more official development assistance per child, but official development assistance to maternal and newborn health did not seem to be well targeted towards countries with the greatest maternal health needs. Interpretation Donor resource tracking should be continued to help hold donors accountable and encourage targeting of resources to countries with greatest needs. Funding Partnership for Maternal, Newborn and Child Health.

Background Malaria-endemic countries are switching antimalarial drug policy to artemisinin combination therapies (ACTs) and the global community are considering the setting up of a global subsidy mechanism in order to make them accessible and affordable. However, specific interventions may be needed to reach remote at-risk communities and to ensure that they are used appropriately. This analysis documents the coverage with ACTs versus artemisinin monotherapies, and the effectiveness of malaria outreach teams (MOTs) and Village Malaria Workers (VMWs) in increasing access to appropriate diagnosis and treatment with ACTs in Cambodia, the first country to switch national antimalarial drug policy to an ACT of artesunate and mefloquine (A+M) in 2000. Methods A cross-sectional survey was carried out in three different types of intervention area: with VMWs, MOTs and no specific interventions. Individuals with a history of fever in the last three weeks were included in the study and completed a questionnaire on their treatment seeking and drug usage behaviour. Blood was taken for a rapid diagnostic test (RDT) and data on the household socio-economic status were also obtained. Results In areas without specific interventions, only 17% (42/251) of respondents received a biological diagnosis, 8% (17/206) of respondents who received modern drug did so from a public health facility, and only 8% of them (17/210) received A+M. Worryingly, 78% (102/131) of all artemisinin use in these areas was as a monotherapy. However, both the VMW scheme and MOT scheme significantly increased the likelihood of being seen by a trained provider (Adjusted Odds Ratios (AOR) of 148 and 4 respectively) and of receiving A+M (AORs of 2.7 and 7.7 respectively). Conclusion The coverage rates of appropriate diagnosis and treatment of malaria were disappointingly low and the use of artemisinin monotherapy alarmingly high. This reflects the fragmented nature of Cambodia's health system in remote areas and the reliance placed by these communities on informal vendors from whom artemisinin monotherapies are widely available. However VMWs in particular are an effective means of improving access to malaria diagnosis and treatment. The VMW scheme and the social marketing of RDTS and blister-packaged artesunate and mefloquine have both been scaled up nationally. Case management in the public sector has also reportedly improved. Given recent concerns regarding the development of artemisinin drug resistance on the Thai-Cambodia border, the effectiveness of these measures in reducing the use of artemisinin monotherapy needs to be urgently re-evaluated.

A desire to enhance protection against health care costs and improve equity of access to health care lies at the core of many health sector financing initiatives. Until recently, international debates about financing and health equity have focused primarily on mechanisms to promote equity in relation to very specific elements of health systems. However, in recent years there has been growing interest in considering these equity challenges from a more systemic perspective. In this context, universal health coverage is becoming a rallying call, with a focus on how best universal coverage can be financed. This paper is the first in a special issue which presents a body of research whose overall aim was to critically evaluate existing inequities in health care financing and provision in Ghana, South Africa and Tanzania, and the extent to which health insurance mechanisms (broadly defined) could address financial protection and equity of access challenges. In this first paper we introduce the countries' health systems, with a special emphasis on existing mechanisms for financial protection. We also identify in broad terms the key challenges for universal coverage, setting the scene for the subsequent papers.

The importance of ill-health in perpetuating poverty is well recognized. In order to prevent the damaging downward spiral of poverty and illness, there is a need for a greater level of social protection, with greater cross-subsidization between the poor and wealthy, and the healthy and those with ill-health. The aim of this paper is to examine individual preferences for willingness to pre-pay for health care and willingness to cross-subsidize the sick and the poor in Ghana, South Africa and Tanzania. Household surveys in the three countries elicited views on cross-subsidization within health care financing. The paper examines how these preferences varied by socio-economic status, other respondent characteristics, and the extent and type of experience of health insurance in the light of country context. In South Africa and Ghana, 62% and 55% of total respondents, respectively, were in favour of a progressive financing system in which richer groups would pay a higher proportion of income than poorer groups, rather than a system where individuals pay the same proportion of income irrespective of their wealth (proportional). In Tanzania, 45% of the total sample were willing to pay for the health care of the poor. However, in all three countries, a progressive system was favoured by a smaller proportion of the most well off than of less well off groups. Solidarity has been considered to be a collective property of a specific socio-political culture, based on shared expectations and developed as part of a communal, historical learning process. The three countries had different experiences of health insurance and this may have contributed to the above differences in expressed willingness to pay between countries. Building and 'living with' institutions that provide affordable universal coverage is likely to be an essential part of the learning process which supports the development of social solidarity.

A patient diagnosed with metastatic melanoma developed the paraneoplastic syndrome of humoral hypercalcemia of malignancy and cachexia after receiving ipilumumab. The cause of the hypercalcemia was thought to be secondary to parathyroid hormone-related peptide (PTHrP) as plasma levels were found to be elevated. The patient underwent two tumor biopsies: at diagnosis (when calcium levels were normal) and upon development of hypercalcemia and cachexia. PTHrP expression was higher in melanoma cells when hypercalcemia had occurred than prior to its onset. Metabolic characterization of melanoma cells revealed that, with development of hypercalcemia, there was high expression of monocarboxylate transporter 1 (MCT1), which is the main importer of lactate and ketone bodies into cells. MCT1 is associated with high mitochondrial metabolism. Beta-galactosidase (β-GAL), a marker of senescence, had reduced expression in melanoma cells upon development of hypercalcemia compared to pre-hypercalcemia. In conclusion, PTHrP expression in melanoma is associated with cachexia, increased cancer cell lactate and ketone body import, high mitochondrial metabolism, and reduced senescence. Further studies are required to determine if PTHrP regulates cachexia, lactate and ketone body import, mitochondrial metabolism, and senescence in cancer cells.