Search

IntroductionUsing nationally representative survey data from China and India, this study examined (1) the distribution and patterns of multimorbidity in relation to socioeconomic status and (2) association between multimorbidity and out-of-pocket expenditure (OOPE) for medicines by socioeconomic groups.MethodsSecondary data analysis of adult population aged 45 years and older from WHO Study on Global Ageing and Adult Health (SAGE) India 2015 (n=7397) and China Health and Retirement Longitudinal Study (CHARLS) 2015 (n=11 570). Log-linear, two-parts, zero-inflated and quantile regression models were performed to assess the association between multimorbidity and OOPE for medicines in both countries. Quantile regression was adopted to assess the observed relationship across OOPE distributions.ResultsBased on 14 (11 self-reported) and 9 (8 self-reported) long-term conditions in the CHARLS and SAGE datasets, respectively, the prevalence of multimorbidity in the adult population aged 45 and older was found to be 63.4% in China and 42.2% in India. Of those with any long-term health condition, 38.6% in China and 20.9% in India had complex multimorbidity. Multimorbidity was significantly associated with higher OOPE for medicines in both countries (pConclusionMultimorbidity was associated with substantially higher OOPE for medicines in China and India compared with those without multimorbidity. Our findings provide supporting evidence of the need to improve financial protection for populations with an increased burden of chronic diseases in low-income and middle-income countries.

Background Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness. Methods and findings We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41–1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16–1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20–1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05–2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03–1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response. Conclusions Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of ‘ending AIDS by 2030’, while simultaneously supporting progress towards universal health coverage. Caroline Bulstra and co-workers assess evidence on the benefits of service integration in the HIV care cascade. Author summary Why was this study done? The rapid scale-up of HIV testing and antiretroviral therapy (ART) in many countries and communities over the past 2 decades has been largely achieved with stand-alone HIV programmes. Increasing life expectancy and the side effects of ART are leading to more co-morbidities among people living with HIV, suggesting that ART programmes that also offer other treatments could improve both healthcare effectiveness and the patient experience. Other reasons for integration of services include the hope that joint delivery of services will increase coverage and reduce costs. The global evidence on integration of HIV services and other health services, to our knowledge, has never been synthesised, and it is thus unclear what the empirical effects of integration are. What did the researchers do and find? We conducted a systematic review and meta-analysis to synthesise the results of integrating HIV services and other health services for HIV care cascade outcomes (testing, linkage to care, treatment initiation, treatment adherence, retention, and viral suppression), HIV health outcomes (new infections and mortality), non-HIV health outcomes, and costs and cost-effectiveness. In most of the 114 studies that our systematic review identified most outcomes were better in integrated compared to separate services. What do these findings mean? Integration of HIV services and other health services tends to improve health and health systems outcomes. The success of integration strategies is highly context-specific, and more evidence is needed on integration in specific geographical areas and for key populations in the HIV response. Despite such limitations, our systematic review and meta-analysis support the case for integration as a valuable and viable strategy to boost the sustainability of the HIV response and contribute to the goal of ‘ending AIDS by 2030’, while simultaneously supporting progress towards universal health coverage.

Background: Reducing socioeconomic inequalities in access to good quality health care is key for countries to achieve Universal Health Coverage. This study aims to assess socioeconomic inequalities in effective coverage of reproductive, maternal, newborn and child health (RMNCH) in low- and middle-income countries (LMICs). Methods: Using the most recent national health surveys from 39 LMICs (between 2014 and 2018), we calculated coverage indicators using effective coverage care cascade that consists of service contact, crude coverage, quality-adjusted coverage, and user-adherence-adjusted coverage. We quantified wealth-related and education-related inequality using the relative index of inequality, slope index of inequality, and concentration index. Findings: The quality-adjusted coverage of RMNCH services in 39 countries was substantially lower than service contact, in particular for postnatal care (64 percentage points [pp], p-value

Summary Background The tuberculosis targets for the UN Sustainable Development Goals (SDGs) call for a 90% reduction in tuberculosis deaths by 2030, compared with 2015, but meeting this target now seems highly improbable. To assess the economic impact of not meeting the target until 2045, we estimated full-income losses in 120 countries, including those due to excess deaths resulting from COVID-19-related disruptions to tuberculosis services, for the period 2020–50. Methods Annual mortality risk changes at each age in each year from 2020 to 2050 were estimated for 120 countries. This risk change was then converted to full-income risk by calculating a population-level mortality risk change and multiplying it by the value of a statistical life-year in each country and year. As a comparator, we assumed that current rates of tuberculosis continue to decline through the period of analysis. We calculated the full-income losses, and mean life expectancy losses per person, at birth and at age 35 years, under scenarios in which the SDG targets are met in 2030 and in 2045. We defined the cost of inaction as the difference in full-income losses and tuberculosis mortality between these two scenarios. Findings From 2020 to 2050, based on the current annual decrease in tuberculosis deaths of 2%, 31·8 million tuberculosis deaths (95% uncertainty interval 25·2 million–39·5 million) are estimated to occur, corresponding to an economic loss of US$17·5 trillion (14·9 trillion–20·4 trillion). If the SDG tuberculosis mortality target is met in 2030, 23·8 million tuberculosis deaths (18·9 million–29·5 million) and $13·1 trillion (11·2 trillion–15·3 trillion) in economic losses can be avoided. If the target is met in 2045, 18·1 million tuberculosis deaths (14·3 million–22·4 million) and $10·2 trillion (8·7 trillion–11·8 trillion) can be avoided. The cost of inaction of not meeting the SDG tuberculosis mortality target until 2045 (vs 2030) is, therefore, 5·7 million tuberculosis deaths (5·1 million–8·1 million) and $3·0 trillion (2·5 trillion–3·5 trillion) in economic losses. COVID-19-related disruptions add $290·3 billion (260·2 billion–570·1 billion) to this cost. Interpretation Failure to achieve the SDG tuberculosis mortality target by 2030 will lead to profound economic and health losses. The effects of delay will be greatest in sub-Saharan Africa. Affected countries, donor nations, and the private sector should redouble efforts to finance tuberculosis programmes and research because the economic dividend of such strategies is likely to be substantial. Funding None.

BackgroundIn 2019, there are more than 290 million people who have ever migrated from rural to urban areas in China. These rural-to-urban internal migrants account for more than one-fifth of China’s population and is the largest internal migrant group globally. We present the first systematic review that examines whether internal migrants are more likely to exhibit non-communicable diseases (NCDs) risk factors and have worse NCD management outcomes than non-migrant counterparts in China.MethodsA systematic review was conducted via medical, public health, and economic databases including Scopus, MEDLINE, JSTOR, WHO Library Database and World Bank e-Library from 2000 to 2020. Study quality was assessed using the National Institute of Health Quality Assessment tool. We conducted a narrative review and synthesised differences for all studies included, stratified by different types of outcomes. We also conducted random-effects meta-analysis where we had a minimum of two studies with 95% CIs reported. The study protocol has been registered with PROSPERO: CRD42019139407.ResultsFor most NCD risk factors and care cascade management, comparisons between internal migrants and other populations were either statistically insignificant or inconclusive. While most studies found migrants have a higher prevalence of tobacco use than urban residents, these differences were not statistically significant in the meta-analysis. Although three out four studies suggested that migrants may have worse access to NCD treatment and both studies suggested migrants have lower blood pressure control rates than non-migrants, these findings were not statistically significant.ConclusionFindings from this systematic review demonstrate that there is currently insufficient evidence on migrant and non-migrant differences in NCD risk factors and management in China. Further research is expected to investigate access to healthcare among internal and its effect on both their NCD outcomes and long-term healthcare costs in China.

Climate change poses an unprecedented challenge to population health and health systems' resilience, with increasing fluctuations in extreme temperatures through pressures on hospital capacity. While earlier studies have estimated morbidity attributable to hot or cold weather across cities, we provide the first large-scale, population-wide assessment of extreme temperatures on inequalities in excess emergency hospital admissions in England. We used the universe of emergency hospital admissions between 2001 and 2012 combined with meteorological data to exploit daily variation in temperature experienced by hospitals (N = 29,371,084). We used a distributed lag model with multiple fixed-effects, controlling for seasonal factors, to examine hospitalisation effects across temperature-sensitive diseases, and further heterogeneous impacts across age and deprivation. We identified larger hospitalisation impacts associated with extreme cold temperatures than with extreme hot temperatures. The less extreme temperatures produce admission patterns like their extreme counterparts, but at lower magnitudes. Results also showed an increase in admissions with extreme temperatures that were more prominent among older and socioeconomically-deprived populations - particularly across admissions for metabolic diseases and injuries.

BACKGROUND Health professions education has undergone major changes with the advent and adoption of digital technologies worldwide. OBJECTIVE This study aims to map the existing evidence and identify gaps and research priorities to enable robust and relevant research in digital health professions education. METHODS We searched for systematic reviews on the digital education of practicing and student health care professionals. We searched MEDLINE, Embase, Cochrane Library, Educational Research Information Center, CINAHL, and gray literature sources from January 2014 to July 2020. A total of 2 authors independently screened the studies, extracted the data, and synthesized the findings. We outlined the key characteristics of the included reviews, the quality of the evidence they synthesized, and recommendations for future research. We mapped the empirical findings and research recommendations against the newly developed conceptual framework. RESULTS We identified 77 eligible systematic reviews. All of them included experimental studies and evaluated the effectiveness of digital education interventions in different health care disciplines or different digital education modalities. Most reviews included studies on various digital education modalities (22/77, 29%), virtual reality (19/77, 25%), and online education (10/77, 13%). Most reviews focused on health professions education in general (36/77, 47%), surgery (13/77, 17%), and nursing (11/77, 14%). The reviews mainly assessed participants’ skills (51/77, 66%) and knowledge (49/77, 64%) and included data from high-income countries (53/77, 69%). Our novel conceptual framework of digital health professions education comprises 6 key domains (context, infrastructure, education, learners, research, and quality improvement) and 16 subdomains. Finally, we identified 61 unique questions for future research in these reviews; these mapped to framework domains of education (29/61, 47% recommendations), context (17/61, 28% recommendations), infrastructure (9/61, 15% recommendations), learners (3/61, 5% recommendations), and research (3/61, 5% recommendations). CONCLUSIONS We identified a large number of research questions regarding digital education, which collectively reflect a diverse and comprehensive research agenda. Our conceptual framework will help educators and researchers plan, develop, and study digital education. More evidence from low- and middle-income countries is needed.

Additional material: Online Supplementary Document available at http://jogh.org/documents/2021/jogh-11-05011-s001.pdf . Copyright © 2021 The Author(s). Background: Variation in the approaches taken to contain the SARS-CoV-2 (COVID-19) pandemic at country level has been shaped by economic and political considerations, technical capacity, and assumptions about public behaviours. To address the limited application of learning from previous pandemics, this study aimed to analyse perceived facilitators and inhibitors during the pandemic and to inform the development of an assessment tool for pandemic response planning. Methods A cross-sectional electronic survey of health and non-health care professionals (5 May - 5 June 2020) in six languages, with respondents recruited via email, social media and website posting. Participants were asked to score inhibitors (−10 to 0) or facilitators (0 to +10) impacting country response to COVID-19 from the following domains - Political, Economic, Sociological, Technological, Ecological, Legislative, and wider Industry (the PESTELI framework). Participants were then asked to explain their responses using free text. Descriptive and thematic analysis was followed by triangulation with the literature and expert validation to develop the assessment tool, which was then compared with four existing pandemic planning frameworks. Results 928 respondents from 66 countries (57% health care professionals) participated. Political and economic influences were consistently perceived as powerful negative forces and technology as a facilitator across high- and low-income countries. The 103-item tool developed for guiding rapid situational assessment for pandemic planning is comprehensive when compared to existing tools and highlights the interconnectedness of the 7 domains. Conclusions The tool developed and proposed addresses the problems associated with decision making in disciplinary silos and offers a means to refine future use of epidemic modelling. This study did not receive any external funding.

Chapter 3 traces the development of health systems in middle- and high-income countries since the Second World War and notes the trends that have led to the development of contemporary health systems. The authors summarize the major trends in healthcare—the benefits, costs, public attitudes and beliefs, and consumer responses to medical care. Health has improved, more citizens are able to access healthcare, standards of care have risen, and the advance of scientific medicine is stunning. The authors reflect on the forces that have led to the current successes and raise upcoming challenges in improving health and healthcare. Foremost among these are concerns about rising costs and value-for-money of health systems, which pose sustainability challenges to health systems in all countries.

In Chapter 9, the closing chapter, the authors raise four “So what?” issues that our fellow learners and aspiring health system designers should address: getting good value for money while simultaneously satisfying individual consumers of care and guaranteeing that all citizens can access the health care their nation provides; understanding the system’s developmental life cycle and capitalizing on a zone of innovation available in existing health system design; comprehending what reconceptualization means and giving some examples of what it might look like; and appreciating that a high-value health system needs to be owned by all and requires each and every citizen to do their part in preserving, protecting, and sustaining it.

Chapter 7 presents three high-level insights that can be drawn from this book’s look at a health system from a systems thinking perspective. First, all health systems suffer from one of systems theory’s classic descriptive models called The Tragedy of the Commons, in which a scarce resource is consumed when a collective benefit (e.g., health insurance) is subsidized and its price to the user is less than the cost to produce it. Second, when viewed from a systems perspective of value-for-money, most health systems face competing objectives—satisfying individual’s demands for maximizing their own medical care and providing healthcare as a fundamental right of all citizens regardless of ability to pay. Third, to integrate these goals requires re-framing the way societies think about each. The authors describe double-loop learning, which is required when confronting second-order change. The latter term describes problems where it is necessary to redesign human perceptions for change to lead to improvement. Complex changes require double-loop learning, in which underlying interpretive conflicts and differing values and beliefs are surfaced and managed.

Building a High-Value Health System presents a practical, general approach to designing a health system that provides comprehensive, effective, and affordable healthcare for nations across the globe. This book systematically leads readers through the steps of designing a system around a developed country’s needs by describing what a health systems is, how to analyze a country’s health system performance, how to evaluate the needs of a population, how to assess the key capacities available, and how to develop and implement health system improvements tailored to a constituent population. A textually rich workbook drawing on case examples from across the globe, Building a High-Value Health System will provide readers with a deeper understanding of their own health system and provide the framework for the necessary actions toward building a better one.

Chapter 6 introduces the students to a proprietary framework and tools to test, refine, and prepare each student’s system improvement plan (SIP) for implementation. The students revisit their country SIP to refine its constituent process steps and to produce a process flow map of their plan. The flow map illustrates a logical chain that links the proposed inputs through sequential action steps for implementation of the plan to produce the outputs that enable the SIP to attain the projected goals. The authors introduce the proprietary D3A3 model that consists of six interlinked steps: D1—design the intervention plan; D2—determine the measures of success; D3—deliver; A1—assess; A2—analyze; and A3—act. The D3A3 model is used to guide iterative development and agile implementation of system improvement plans. The students will use the D3A3 model to conduct one or more test runs to improve their SIP and increase their confidence that it will deliver the outputs they need. In complex dynamic systems, it is hard to predict the results of change and plans should be subjected to iterative cycles of testing. For this the authors introduce a process called a model for improvement that helps designers to understand the potential impact, effort, feasibility, and risks of implementing their SIP and to progressively test and strengthen plan design and prepare it for implementation.

Chapter 1 conceptualizes a health system as a collection of interacting elements that are designed to produce outputs that lead to better population health. A system’s elements both “hang together” as a whole and continually interact and affect each other as they interoperate to produce their final result. Systems thinking is one of the most important disciplines enabling one to understand and characterize systems that display dynamic complexity. Systems thinking in health is a framework for seeing interrelationships and repeated events rather than individual activities, for discerning patterns of change, understanding responses to policies, and for deciphering human behavior within health systems and over time.

Chapter 4 presents methods to examine the performance of a health system and to assess, define, and choose the vision, specific goals, and objectives for a health system. The authors discuss approaches to understand the performance of a country’s health system and present indicators that could be used to assess the performance of health systems. They present methodology to examine the opportunities and threats faced by a country health system and the strengths and weaknesses of the health system based on the performance achieved. They show how the results of this examination are used for a strengths and weakness, opportunities and threats (SWOT) analysis. They discuss how the SWOT analysis can be used to identify gaps in system performance and consider those that need addressing. The SWOT analysis informs the beginning of the goal-setting process and the development of an improvement plan to redesign the health system to achieve set goals.

Chapter 5 presents a semi-structured plan for each work group to produce one system intervention plan (SIP) for their country. Taking the components of their health system, its underlying system problems, and their formulation of its vision and goals, the students individually and then in their small group take a stab at identifying gaps and constructing a system improvement plan. This chapter will present various techniques and exercises to help students come up with interventions that work. The process of idea-generating is designed to generate a solution to fix one or more of their chosen system performance gaps. The students’ work product is to agree on and propose one intervention to achieve the goals, objectives, and targets they have selected for their chosen country in Chapter 4.

In Chapter 8, the authors discuss in detail factors that might influence the introduction and scale-up of the system improvement plan (SIP). Successfully maneuvering an SIP in a complicated health system is a challenge. It requires considering the multiple interlinked factors that individually and collectively influence the adoption and diffusion process. They discuss the potential enablers and barriers that may facilitate or hinder the adoption and diffusion of the SIP and the change it is designed to produce. They introduce a proprietary framework, the 7Cs model, to group these factors into categories. This framework is designed to enable students to clarify the many interconnected elements that will influence the implementation of their SIP and organize the interventions that are needed to effectively manage these factors. The 7Cs model encompasses seven factors that need to be considered in relation to the implementation strategic change and of the SIP: (i) challenge, (ii) content, (iii) context, (iv) coalitions, (v) communication, (vi) capacity, and (vii) cohesiveness.

Chapter 2 describes different definitions and conceptualizations of health systems. It presents a proprietary framework that adopts a systems view of health systems. In the authors’ framework they conceptualize health systems as a collection of functions that interact to produce outputs that in turn are used to produce outcomes. Health systems functions consist of organization and governance, financing, and resource management. These functions are used to produce health system outputs, namely public health services and personal healthcare services. Policymakers use policies to ensure the health system outputs are effective, efficient, equitable, and responsive to achieve the right level and distribution of health system outcomes, namely population health, financial protection, and user satisfaction. The health system is situated in a dynamic and changing context with which it interacts and is influenced by it. The context is shaped by demographic, epidemiological, political, legal and regulatory, economic, sociocultural, ecological, and technological changes and shifts that create opportunities and threats to which the health system must respond. Policymakers need to consider how to design health systems to ensure that they are not only responsive and resilient to the opportunities and threats created by contextual changes and shifts but also that they ensure the right balance of effectiveness, efficiency, equity, and responsiveness for the system outputs to achieve desired level and distribution of outcomes.

Summary Background COVID-19 spread rapidly in Brazil despite the country's well established health and social protection systems. Understanding the relationships between health-system preparedness, responses to COVID-19, and the pattern of spread of the epidemic is particularly important in a country marked by wide inequalities in socioeconomic characteristics (eg, housing and employment status) and other health risks (age structure and burden of chronic disease). Methods From several publicly available sources in Brazil, we obtained data on health risk factors for severe COVID-19 (proportion of the population with chronic disease and proportion aged ≥60 years), socioeconomic vulnerability (proportions of the population with housing vulnerability or without formal work), health-system capacity (numbers of intensive care unit beds and physicians), coverage of health and social assistance, deaths from COVID-19, and state-level responses of government in terms of physical distancing policies. We also obtained data on the proportion of the population staying at home, based on locational data, as a measure of physical distancing adherence. We developed a socioeconomic vulnerability index (SVI) based on household characteristics and the Human Development Index. Data were analysed at the state and municipal levels. Descriptive statistics and correlations between state-level indicators were used to characterise the relationship between the availability of health-care resources and socioeconomic characteristics and the spread of the epidemic and the response of governments and populations in terms of new investments, legislation, and physical distancing. We used linear regressions on a municipality-by-month dataset from February to October, 2020, to characterise the dynamics of COVID-19 deaths and response to the epidemic across municipalities. Findings The initial spread of COVID-19 was mostly affected by patterns of socioeconomic vulnerability as measured by the SVI rather than population age structure and prevalence of health risk factors. The states with a high (greater than median) SVI were able to expand hospital capacity, to enact stringent COVID-19-related legislation, and to increase physical distancing adherence in the population, although not sufficiently to prevent higher COVID-19 mortality during the initial phase of the epidemic compared with states with a low SVI. Death rates accelerated until June, 2020, particularly in municipalities with the highest socioeconomic vulnerability. Throughout the following months, however, differences in policy response converged in municipalities with lower and higher SVIs, while physical distancing remained relatively higher and death rates became relatively lower in the municipalities with the highest SVIs compared with those with lower SVIs. Interpretation In Brazil, existing socioeconomic inequalities, rather than age, health status, and other risk factors for COVID-19, have affected the course of the epidemic, with a disproportionate adverse burden on states and municipalities with high socioeconomic vulnerability. Local government responses and population behaviour in the states and municipalities with higher socioeconomic vulnerability have helped to contain the effects of the epidemic. Targeted policies and actions are needed to protect those with the greatest socioeconomic vulnerability. This experience could be relevant in other low-income and middle-income countries where socioeconomic vulnerability varies greatly. Funding None. Translation For the Portuguese translation of the abstract see Supplementary Materials section.

Background Job satisfaction of doctors is an important factor determining quality and performance of a health system. The aim of this study was to assess job satisfaction among doctors of the public and private primary care clinics in Malaysia and evaluate factors that could influence the job satisfaction rating. Methods This study was part of the Quality and Costs of Primary Care (QUALICOPC) Malaysia, a cross-sectional survey conducted between August 2015 and June 2016 in Malaysia. Data was collected from doctors recruited from public and private primary care clinics using a standardised questionnaire. Comparisons were made between doctors working in public and private clinics, and logistic regression analysis was used to determine factors influencing the likelihood of job satisfaction outcomes. Results A total of 221 doctors from the public and 239 doctors from the private sector completed the questionnaire. Compared to private doctors, a higher proportion of public doctors felt they were being overloaded with the administrative task (59.7% vs 36.0%) and part of the work does not make sense (33.9% vs 18.4%). Only 62.9% of public doctors felt that there was a good balance between effort and reward while a significantly higher proportion (85.8%) of private doctors reported the same. Over 80% of doctors in both sectors indicated continued interest in their job and agreed that being a doctor is a well-respected job. Logistic regression analysis showed public-private sector and practice location (urban-rural) to be significantly associated with work satisfaction outcomes. Conclusion A higher proportion of public doctors experienced pressure from administrative tasks and felt that part of their work does not make sense than their colleague in the private sector. At the same time, the majority of private doctors reported positive outcome on effort-and-reward balance compared to only one third of public doctors. The finding suggests that decreasing administrative workload and enhancing work-based supports might be the most effective ways to improve job satisfaction of primary care doctors because these are some of the main aspects of the job that doctors, especially in public clinics, are most unhappy with.

There is growing evidence that political economy factors are central to whether or not proposed health financing reforms are adopted, but there is little consensus about which political and institutional factors determine the fate of reform proposals. One set of scholars see the relative strength of interest groups in favour of and opposed to reform as the determining factor. An alternative literature identifies aspects of a country’s political institutions–specifically the number and strength of formal ‘veto gates’ in the political decision-making process—as a key predictor of reform’s prospects. A third group of scholars highlight path dependence and ‘policy feedback’ effects, stressing that the sequence in which health policies are implemented determines the set of feasible reform paths, since successive policy regimes bring into existence patterns of public opinion and interest group mobilization which can lock in the status quo. We examine these theories in the context of Malaysia, a successful health system which has experienced several instances of proposed, but ultimately blocked, health financing reforms. We argue that policy feedback effects on public opinion were the most important factor inhibiting changes to Malaysia’s health financing system. Interest group opposition was a closely related factor; this opposition was particularly powerful because political leaders perceived that it had strong public support. Institutional veto gates, by contrast, played a minimal role in preventing health financing reform in Malaysia. Malaysia’s dramatic early success at achieving near-universal access to public sector healthcare at low cost created public opinion resistant to any change which could threaten the status quo. We conclude by analysing the implications of these dynamics for future attempts at health financing reform in Malaysia.

Viral hepatitis is a leading cause of morbidity and mortality worldwide, but has long been neglected by national and international policymakers. Recent modelling studies suggest that investing in the global elimination of viral hepatitis is feasible and cost‐effective. In 2016, all 194 member states of the World Health Organization endorsed the goal to eliminate viral hepatitis as a public health threat by 2030, but complex systemic and social realities hamper implementation efforts. This paper presents eight case studies from a diverse range of countries that have invested in responses to viral hepatitis and adopted innovative approaches to tackle their respective epidemics. Based on an investment framework developed to build a global investment case for the elimination of viral hepatitis by 2030, national activities and key enablers are highlighted that showcase the feasibility and impact of concerted hepatitis responses across a range of settings, with different levels of available resources and infrastructural development. These case studies demonstrate the utility of taking a multipronged, public health approach to: (a) evidence‐gathering and planning; (b) implementation; and (c) integration of viral hepatitis services into the Agenda for Sustainable Development. They provide models for planning, investment and implementation strategies for other countries facing similar challenges and resource constraints.

Summary Background Evidence from nationally representative studies in low-income and middle-income countries (LMICs) on where in the hypertension care continuum patients are lost to care is sparse. This information, however, is essential for effective targeting of interventions by health services and monitoring progress in improving hypertension care. We aimed to determine the cascade of hypertension care in 44 LMICs—and its variation between countries and population groups—by dividing the progression in the care process, from need of care to successful treatment, into discrete stages and measuring the losses at each stage. Methods In this cross-sectional study, we pooled individual-level population-based data from 44 LMICs. We first searched for nationally representative datasets from the WHO Stepwise Approach to Surveillance (STEPS) from 2005 or later. If a STEPS dataset was not available for a LMIC (or we could not gain access to it), we conducted a systematic search for survey datasets; the inclusion criteria in these searches were that the survey was done in 2005 or later, was nationally representative for at least three 10-year age groups older than 15 years, included measured blood pressure data, and contained data on at least two hypertension care cascade steps. Hypertension was defined as a systolic blood pressure of at least 140 mm Hg, diastolic blood pressure of at least 90 mm Hg, or reported use of medication for hypertension. Among those with hypertension, we calculated the proportion of individuals who had ever had their blood pressure measured; had been diagnosed with hypertension; had been treated for hypertension; and had achieved control of their hypertension. We weighted countries proportionally to their population size when determining this hypertension care cascade at the global and regional level. We disaggregated the hypertension care cascade by age, sex, education, household wealth quintile, body-mass index, smoking status, country, and region. We used linear regression to predict, separately for each cascade step, a country's performance based on gross domestic product (GDP) per capita, allowing us to identify countries whose performance fell outside of the 95% prediction interval. Findings Our pooled dataset included 1 100 507 participants, of whom 192 441 (17·5%) had hypertension. Among those with hypertension, 73·6% of participants (95% CI 72·9–74·3) had ever had their blood pressure measured, 39·2% of participants (38·2–40·3) had been diagnosed with hypertension, 29·9% of participants (28·6–31·3) received treatment, and 10·3% of participants (9·6–11·0) achieved control of their hypertension. Countries in Latin America and the Caribbean generally achieved the best performance relative to their predicted performance based on GDP per capita, whereas countries in sub-Saharan Africa performed worst. Bangladesh, Brazil, Costa Rica, Ecuador, Kyrgyzstan, and Peru performed significantly better on all care cascade steps than predicted based on GDP per capita. Being a woman, older, more educated, wealthier, and not being a current smoker were all positively associated with attaining each of the four steps of the care cascade. Interpretation Our study provides important evidence for the design and targeting of health policies and service interventions for hypertension in LMICs. We show at what steps and for whom there are gaps in the hypertension care process in each of the 44 countries in our study. We also identified countries in each world region that perform better than expected from their economic development, which can direct policy makers to important policy lessons. Given the high disease burden caused by hypertension in LMICs, nationally representative hypertension care cascades, as constructed in this study, are an important measure of progress towards achieving universal health coverage. Funding Harvard McLennan Family Fund, Alexander von Humboldt Foundation.

Summary Background Radiotherapy is standard of care for cervical cancer, but major global gaps in access exist, particularly in low-income and middle-income countries. We modelled the health and economic benefits of a 20-year radiotherapy scale-up to estimate the long-term demand for treatment in the context of human papillomavirus (HPV) vaccination. Methods We applied the Global Task Force on Radiotherapy for Cancer Control investment framework to model the health and economic benefits of scaling up external-beam radiotherapy and brachytherapy for cervical cancer in upper-middle-income, lower-middle-income, and low-income countries between 2015 and 2035. We estimated the unique costs of external-beam radiotherapy and brachytherapy and included a specific valuation of women's caregiving contributions. Model outcomes life-years gained and the human capital and full income net present value of investment. We estimated the effects of stage at diagnosis, radiotherapy delivery system, and simultaneous HPV vaccination (75% coverage) up to a time horizon set at 2072. Findings For the period from 2015 to 2035, we estimated that 9·4 million women in low-income and middle-income countries required treatment with external-beam radiotherapy, of which 7·0 million also required treatment with brachytherapy. Incremental scale-up of radiotherapy in these countries from 2015 to meet optimal radiotherapy demand by 2035 yielded 11·4 million life-years gained, $59·3 billion in human capital net present value (−$1·5 billion in low-income, $19·9 billion in lower-middle-income, and $40·9 billion in upper-middle-income countries), and $151·5 billion in full income net present value ($1·5 billion in low-income countries, $53·6 billion in lower-middle-income countries, and $96·4 billion in upper-middle-income countries). Benefits increased with advanced stage of cervical cancer and more efficient scale up of radiotherapy. Bivalent HPV vaccination of 12-year-old girls resulted in a 3·9% reduction in incident cases from 2015–2035. By 2072, when the first vaccinated cohort of girls reaches 70 years of age, vaccination yielded a 22·9% reduction in cervical cancer incidence, with 38·4 million requiring external-beam radiotherapy and 28·8 million requiring brachytherapy. Interpretation Effective cervical cancer control requires a comprehensive strategy. Even with HPV vaccination, radiotherapy treatment scale-up remains essential and produces large health benefits and a strong return on investment to countries at different levels of development. Funding None.

BACKGROUND The WHO recommends 400 g/d of fruits and vegetables (the equivalent of ∼5 servings/d) for the prevention of noncommunicable diseases (NCDs). However, there is limited evidence regarding individual-level correlates of meeting these recommendations in low- and middle-income countries (LMICs). In order to target policies and interventions aimed at improving intake, global monitoring of fruit and vegetable consumption by socio-demographic subpopulations is required. OBJECTIVES The aims of this study were to 1) assess the proportion of individuals meeting the WHO recommendation and 2) evaluate socio-demographic predictors (age, sex, and educational attainment) of meeting the WHO recommendation. METHODS Data were collected from 193,606 individuals aged ≥15 y in 28 LMICs between 2005 and 2016. The prevalence of meeting the WHO recommendation took into account the complex survey designs, and countries were weighted according to their World Bank population estimates in 2015. Poisson regression was used to estimate associations with socio-demographic characteristics. RESULTS The proportion (95% CI) of individuals aged ≥15 y who met the WHO recommendation was 18.0% (16.6-19.4%). Mean intake of fruits was 1.15 (1.10-1.20) servings per day and for vegetables, 2.46 (2.40-2.51) servings/d. The proportion of individuals meeting the recommendation increased with increasing country gross domestic product (GDP) class (P

5-year net survival of children and adolescents diagnosed with cancer is approximately 80% in many high-income countries. This estimate is encouraging as it shows the substantial progress that has been made in the diagnosis and treatment of childhood cancer. Unfortunately, scarce data are available for low-income and middle-income countries (LMICs), where nearly 90% of children with cancer reside, suggesting that global survival estimates are substantially worse in these regions. As LMICs are undergoing a rapid epidemiological transition, with a shifting burden from infectious diseases to non-communicable diseases, cancer care for all ages has become a global focus. To improve outcomes for children and adolescents diagnosed with cancer worldwide, an accurate appraisal of the global burden of childhood cancer is a necessary first step. In this Review, we analyse four studies of the global cancer burden that included data for children and adolescents. Each study used various overlapping and non-overlapping statistical approaches and outcome metrics. Moreover, to provide guidance on improving future estimates of the childhood global cancer burden, we propose several recommendations to strengthen data collection and standardise analyses. Ultimately, these data could help stakeholders to develop plans for national and institutional cancer programmes, with the overall aim of helping to reduce the global burden of cancer in children and adolescents.

ObjectivesTo determine the prevalence and frequency of using any tobacco product and each of a detailed set of tobacco products, how tobacco use and frequency of use vary across countries, world regions, and World Bank country income groups, and the socioeconomic and demographic gradients of tobacco use and frequency of use within countries.DesignSecondary analysis of nationally representative, cross-sectional, household survey data from 82 low and middle income countries collected between 1 January 2015 and 31 December 2020.SettingPopulation based survey data.Participants1 231 068 individuals aged 15 years and older.Main outcome measuresSelf-reported current smoking, current daily smoking, current smokeless tobacco use, current daily smokeless tobacco use, pack years, and current use and use frequencies of each tobacco product. Products were any type of cigarette, manufactured cigarette, hand rolled cigarette, water pipe, cigar, oral snuff, nasal snuff, chewing tobacco, and betel nut (with and without tobacco).ResultsThe smoking prevalence in the study sample was 16.5% (95% confidence interval 16.1% to 16.9%) and ranged from 1.1% (0.9% to 1.3%) in Ghana to 50.6% (45.2% to 56.1%) in Kiribati. The user prevalence of smokeless tobacco was 7.7% (7.5% to 8.0%) and prevalence was highest in Papua New Guinea (daily user prevalence of 65.4% (63.3% to 67.5%)). Although variation was wide between countries and by tobacco product, for many low and middle income countries, the highest prevalence and cigarette smoking frequency was reported in men, those with lower education, less household wealth, living in rural areas, and higher age.ConclusionsBoth smoked and smokeless tobacco use and frequency of use vary widely across tobacco products in low and middle income countries. This study can inform the design and targeting of efforts to reduce tobacco use in low and middle income countries and serve as a benchmark for monitoring progress towards national and international goals.

Background Priority setting process for the health care sector in low- and middle-income countries involves multiple agencies, each with their unique power, decision-making and funding mechanisms. Methods This paper developed and applied a new framework to analyze priority setting processes in Ethiopia, Nigeria, and Tanzania, from a scoping review of literature. Interviews were then conducted using a pre-determined interview guide developed by the research team. Transcripts were reviewed and coded based on the framework to identify what principles, players, processes, and products were considered during priority setting. Those elements were further used to identify where the potential capacity of local decision-makers could be harnessed. Results a framework was developed based on 40 articles selected from 6860 distinct search records. 21 interviews were conducted in three case countries from 12 institutions. Transcripts or meeting notes were analyzed to identify common practices and specific challenges faced by each country. We found that multiple stakeholders working around one national plan was the preferred approach used for priority setting in the countries studied. Conclusions Priority setting process can be further strengthened through better use of analytical tools, such as the one described in our study, to enhance local ownership and improve aid effectiveness.

Health and economic benefits possible with emerging tuberculosis vaccines are not fully known. We estimated gains possible with novel post-exposure vaccines, in India and Indonesia. We modeled vaccine impact on TB incidence, TB mortality, and on national income growth and the intrinsic value of living longer, known as Full-income. We considered several vaccine efficacies, initiation and scale-up scenarios. We found that if all age groups are vaccinated in 2025, then 2.3 million TB deaths in India and 695,000 TB deaths in Indonesia can be prevented, adding 0.09 years and 0.17 years to individual life expectancy at birth, on average annually. Full-income savings is US$2 trillion in India and US$680 billion in Indonesia. Even if delayed until 2030, 1.6 million deaths in India and 489,000 deaths in Indonesia can be prevented, with full-income savings of US$1.5 trillion and US$490 billion. These benefits suggest that further investment in the vaccines is prudent.Significance Statement There are no prior economic evaluations of candidate tuberculosis vaccines. Our study addresses this gap to answer two questions: (1) is there value in making the vaccine available given the efficacies demonstrated to date; and (2) is there an optimal time window for making the vaccine available. The conclusions in relation to these two questions are important because: (1) they are based on findings from two countries, which jointly account for 35% of global TB incidence and 38.8% of global TB mortality in 2019; (2) they provide guidance for future investment in the vaccine and roll-out in those countries.

Background Global cardiovascular disease (CVD) burden is high and rising, especially in low-income and middle-income countries (LMICs). Focussing on 45 LMICs, we aimed to determine (1) the adult population’s median 10-year predicted CVD risk, including its variation within countries by socio-demographic characteristics, and (2) the prevalence of self-reported blood pressure (BP) medication use among those with and without an indication for such medication as per World Health Organization (WHO) guidelines. Methods and findings We conducted a cross-sectional analysis of nationally representative household surveys from 45 LMICs carried out between 2005 and 2017, with 32 surveys being WHO Stepwise Approach to Surveillance (STEPS) surveys. Country-specific median 10-year CVD risk was calculated using the 2019 WHO CVD Risk Chart Working Group non-laboratory-based equations. BP medication indications were based on the WHO Package of Essential Noncommunicable Disease Interventions guidelines. Regression models examined associations between CVD risk, BP medication use, and socio-demographic characteristics. Our complete case analysis included 600,484 adults from 45 countries. Median 10-year CVD risk (interquartile range [IQR]) for males and females was 2.7% (2.3%–4.2%) and 1.6% (1.3%–2.1%), respectively, with estimates indicating the lowest risk in sub-Saharan Africa and highest in Europe and the Eastern Mediterranean. Higher educational attainment and current employment were associated with lower CVD risk in most countries. Of those indicated for BP medication, the median (IQR) percentage taking medication was 24.2% (15.4%–37.2%) for males and 41.6% (23.9%–53.8%) for females. Conversely, a median (IQR) 47.1% (36.1%–58.6%) of all people taking a BP medication were not indicated for such based on CVD risk status. There was no association between BP medication use and socio-demographic characteristics in most of the 45 study countries. Study limitations include variation in country survey methods, most notably the sample age range and year of data collection, insufficient data to use the laboratory-based CVD risk equations, and an inability to determine past history of a CVD diagnosis. Conclusions This study found underuse of guideline-indicated BP medication in people with elevated CVD risk and overuse by people with lower CVD risk. Country-specific targeted policies are needed to help improve the identification and management of those at highest CVD risk., Author summary Why was this study done? CVD burden in low-income and middle-income countries (LMICs) is high and rising. CVD risk estimation using validated risk prediction equations is recommended in most guidelines; however, there are few population-representative analyses of CVD risk and its association with socio-demographic characteristics. Despite guidelines recommending using CVD risk estimates as an essential first step in guiding management practices, the extent to which risk-based approaches are being implemented in LMICs is not well characterised. What did the researchers do and find? We analysed population-representative survey data from 45 LMICs to determine country-specific levels of CVD risk, associations between socio-demographic factors and levels of CVD risk, and adherence to WHO guidelines on use of blood pressure medication. We found high variation in CVD risk profiles, with higher levels of risk in the Europe and the Eastern Mediterranean region and lower levels of risk in sub-Saharan Africa, as well as an inverse association between CVD risk and higher education and employment in most countries. We found an underuse of medicines in people at elevated CVD risk across all countries (only 24.2% of males and 41.6% of females at high CVD risk are taking guideline-recommended BP medication) and an overuse of medicines in people at lower levels of CVD risk, with 47% of all BP medication being used by people at low CVD risk without a guideline indication for use. What do these findings mean? There is large variation in CVD risk across LMICs, and an inverse association between CVD risk and higher education and employment in most countries. There is an overuse of medicines in people at lower levels of CVD risk and an underuse of medicines in people at elevated CVD risk across all countries. The large heterogeneity of the findings in this study reflects varying country contexts. Country-specific targeted policies are needed to improve the identification and management of those at highest CVD risk.

Background Multimorbidity (the presence of two or more non-communicable diseases) is a major growing challenge for many low-income and middle-income countries (LMICs). Yet, its effects on health care costs and financial burden for patients have not been adequately studied. This study investigates the effect of multimorbidity across the different percentiles of healthcare utilisation and out-of-pocket expenditure (OOPE). Methods We conducted a secondary data analysis of the 2014/2015 Indonesian Family Life Survey (IFLS-5), which included 13,798 respondents aged ≥40 years. Poisson regression was used to assess the association between sociodemographic characteristics and the total number of non-communicable diseases (NCDs), while multivariate logistic regression and quantile regression analysis was used to estimate the associations between multimorbidity, health service use and OOPE. Results Overall, 20.8% of total participants had two or more NCDs in 2014/2015. The number of NCDs was associated with higher healthcare utilisation (coefficient 0.11, 95% CI 0.07–0.14 for outpatient care and coefficient 0.09 (95% CI 0.02–0.16 for inpatient care) and higher four-weekly OOPE (coefficient 27.0, 95% CI 11.4–42.7). The quantile regression results indicated that the marginal effect of having three or more NCDs on the absolute amount of four-weekly OOPE was smaller for the lower percentiles (at the 25th percentile, coefficient 1.0, 95% CI 0.5–1.5) but more pronounced for the higher percentile of out-of-pocket spending distribution (at the 90th percentile, coefficient 31.0, 95% CI 15.9–46.2). Conclusion Multimorbidity is positively correlated with health service utilisation and OOPE and has a significant effect, especially among those in the upper tail of the utilisation/costs distribution. Health financing strategies are urgently required to meet the needs of patients with multimorbidity, particularly for vulnerable groups that have a higher level of health care utilisation.

Background To evaluate the effectiveness of the Enhanced Primary Healthcare (EnPHC) interventions on process of care and intermediate clinical outcomes among type 2 diabetes patients. Research Design and Methods This was a quasi-experimental controlled study of multi-pronged interventions conducted in 20 intervention and 20 control public primary care clinics in Malaysia from November 2016 to June 2019. Malaysian patients aged 30 years and above with a diagnosis of type 2 diabetes were selected via systematic random sampling. We conducted difference-in-differences analyses of data on process of care and intermediate clinical outcomes extracted from medical records. Results We reviewed 12,017 medical records of patients with type 2 diabetes. Process of care measures improved: HbA1c tests performed within the past three months (odds ratio (OR) 3.31, 95% CI 2.13, 5.13); lipid test (OR 4.59, 95% CI 2.64, 7.97), LDL (OR 4.33, 95% CI 2.16, 8.70), and urine albumin (OR 1.99, 95% CI 1.12, 3.55) tests within the past year; BMI measured within the past six months (OR 15.80, 95% CI 4.78, 52.24); cardiovascular risk assessment (OR 174.65, 95% CI 16.84, 1810.80); and exercise counselling (OR 1.18, 95% CI 1.04, 1.33). We found no statistically significant changes in intermediate clinical outcomes. Conclusions EnPHC interventions were effective in improving process of care but not intermediate clinical outcomes for type 2 diabetes patients. The intervention package was successful in enhancing the quality of care in diabetes from the health provider perspective. Patient engagement and self-management support may be needed to bring forth changes in patient outcomes.

ObjectiveMultimorbidity is a growing challenge in low-income and middle-income countries. This study investigates the effects of multimorbidity on annual medical costs and the out-of-pocket expenditures (OOPEs) along the cost distribution.MethodsData from the nationally representative China Health and Retirement Longitudinal Study (CHARLS 2015), including 10 592 participants aged ≥45 years and 15 physical and mental chronic diseases, were used for this nationally representative cross-sectional study. Quantile multivariable regressions were employed to understand variations in the association of chronic disease multimorbidity with medical cost and OOPE.ResultsOverall, 69.5% of middle-aged and elderly Chinese had multimorbidity in 2015. Increased number of chronic diseases was significantly associated with greater health expenditures across every cost quantile groups. The effect of chronic diseases on total medical cost was found to be larger among the upper tail than those in the lower tail of the cost distributions (coefficients 12, 95% CI 6 to 17 for 10th percentile; coefficients 296, 95% CI 71 to 522 for 90th percentile). Annual OOPE also increased with chronic diseases from the 10th percentile to the 90th percentile. Multimorbidity had larger effects on OOPE and was more pronounced at the upper tail of the health expenditure distribution (regression coefficients of 8 and 84 at the 10th percentile and 75th percentile, respectively).ConclusionMultimorbidity is associated with escalating healthcare costs in China. Further research is required to understand the impact of multimorbidity across different population groups.

The diagnosis and treatment of patients with cancer requires access to imaging to ensure accurate management decisions and optimal outcomes. Our global assessment of imaging and nuclear medicine resources identified substantial shortages in equipment and workforce, particularly in low-income and middle-income countries (LMICs). A microsimulation model of 11 cancers showed that the scale-up of imaging would avert 3·2% (2·46 million) of all 76·0 million deaths caused by the modelled cancers worldwide between 2020 and 2030, saving 54·92 million life-years. A comprehensive scale-up of imaging, treatment, and care quality would avert 9·55 million (12·5%) of all cancer deaths caused by the modelled cancers worldwide, saving 232·30 million life-years. Scale-up of imaging would cost US$6·84 billion in 2020-30 but yield lifetime productivity gains of $1·23 trillion worldwide, a net return of $179·19 per $1 invested. Combining the scale-up of imaging, treatment, and quality of care would provide a net benefit of $2·66 trillion and a net return of $12·43 per $1 invested. With the use of a conservative approach regarding human capital, the scale-up of imaging alone would provide a net benefit of $209·46 billion and net return of $31·61 per $1 invested. With comprehensive scale-up, the worldwide net benefit using the human capital approach is $340·42 billion and the return per dollar invested is $2·46. These improved health and economic outcomes hold true across all geographical regions. We propose actions and investments that would enhance access to imaging equipment, workforce capacity, digital technology, radiopharmaceuticals, and research and training programmes in LMICs, to produce massive health and economic benefits and reduce the burden of cancer globally.

Importance The COVID-19 pandemic is the greatest global test of health leadership of our generation. There is an urgent need to provide guidance for leaders at all levels during the unprecedented preresolution recovery stage. Objective To create an evidence- and expertise-informed framework of leadership imperatives to serve as a resource to guide health and public health leaders during the postemergency stage of the pandemic. Evidence Review A literature search in PubMed, MEDLINE, and Embase revealed 10 910 articles published between 2000 and 2021 that included the terms leadership and variations of emergency, crisis, disaster, pandemic, COVID-19, or public health. Using the Standards for Quality Improvement Reporting Excellence reporting guideline for consensus statement development, this assessment adopted a 6-round modified Delphi approach involving 32 expert coauthors from 17 countries who participated in creating and validating a framework outlining essential leadership imperatives. Findings The 10 imperatives in the framework are: (1) acknowledge staff and celebrate successes; (2) provide support for staff well-being; (3) develop a clear understanding of the current local and global context, along with informed projections; (4) prepare for future emergencies (personnel, resources, protocols, contingency plans, coalitions, and training); (5) reassess priorities explicitly and regularly and provide purpose, meaning, and direction; (6) maximize team, organizational, and system performance and discuss enhancements; (7) manage the backlog of paused services and consider improvements while avoiding burnout and moral distress; (8) sustain learning, innovations, and collaborations, and imagine future possibilities; (9) provide regular communication and engender trust; and (10) in consultation with public health and fellow leaders, provide safety information and recommendations to government, other organizations, staff, and the community to improve equitable and integrated care and emergency preparedness systemwide. Conclusions and Relevance Leaders who most effectively implement these imperatives are ideally positioned to address urgent needs and inequalities in health systems and to cocreate with their organizations a future that best serves stakeholders and communities.

Introduction The prevalence of chronic physical and mental health conditions is rising globally. Little evidence exists on the joint effect of physical and mental health conditions on health care use, work productivity, and health-related quality of life in Australia. Methods We analyzed data from the Household, Income and Labour Dynamics in Australia (HILDA) Survey, waves 9 (2009), 13 (2013), and 17 (2017). Economic effects associated with multimorbidity were measured through health service use, work productivity loss, and health-related quality of life. We used generalized estimating equations to assess the effect of the association between physical multimorbidity and mental health conditions and economic outcomes. Results From 2009 through 2017 the prevalence of physical multimorbidity increased from 15.1% to 16.2%, and the prevalence of mental health conditions increased from 11.2% to 17.3%. The number of physical health conditions was associated with the number of health services used (general practitioner visits, incidence rate ratio = 1.41), work productivity loss (labor force participation, adjusted odds ratio = 0.71), and reduced health-related quality of life (SF-6D score: Coefficient = -0.03). These effects were exacerbated by the presence of mental health conditions and low socioeconomic status. Conclusion Having multiple physical health conditions (physical multimorbidity) creates substantial health and financial burdens on individuals, the health system, and society, including increased use of health services, loss of work productivity, and decreased health-related quality of life. The adverse effects of multimorbidity on health, quality of life, and economic well-being are exacerbated by the co-occurrence of mental health conditions and low socioeconomic status.

Demand for neonatal care in the United Kingdom (UK) has increased in recent years. This care is provided by neonatal services, which are chronically saturated due to years of budget austerity in the UK. The aim of this paper is to investigate the possible impact of increasing resources to these services to improve their operational performance and alleviate the pressure they are facing. To achieve this aim, a system dynamics (SD) simulation model was built and validated in a UK neonatal unit. The SD model was used initially to evaluate the impact of increasing resources on the unit performance and the results showed that this policy will have a limited effect on performance. The model was then extended to predict the effect of reducing the length of stay (LoS) in conjunction with increasing resources. These joint interventions will have a positive impact on the unit performance if LoS is reduced for all care categories and resources are slightly increased. Results' implications and SD's modelling usefulness to guide decision making in complex health settings are discussed.

Aim: The purpose of this paper is to describe the recruitment strategies, the response rates and the reasons for non-response of Malaysian public and private primary care doctors in an international survey on the quality, cost and equity in primary care. Background: Low research participation by primary care doctors, especially those working in the private sector, is a challenge to quality benchmarking. Methods: Primary care doctors were sampled through multi-stage sampling. The first stage-sampling unit was the primary care clinics, which were randomly sampled from five states in Malaysia to reflect their proportions in two strata – sector (public/private) and location (urban/rural). Strategies through endorsement, personalised invitation, face-to-face interview and non-monetary incentives were used to recruit public and private doctors. Data collection was carried out by fieldworkers through structured questionnaires. Findings: A total of 221 public and 239 private doctors participated in the study. Among the public doctors, 99.5% response rates were obtained. Among the private doctors, a 32.8% response rate was obtained. Totally, 30% of private clinics were uncontactable by telephone, and when these were excluded, the overall response rate is 46.8%. The response rate of the private clinics across the states ranges from 31.5% to 34.0%. A total of 167 answered the non-respondent questionnaire. Among the non-respondents, 77.4 % were male and 22.6% female (P = 0.011). There were 33.6% of doctors older than 65 years (P = 0.003) and 15.9% were from the state of Sarawak (P = 0.016) when compared to non-respondents. Reason for non-participation included being too busy (51.8%), not interested (32.9%), not having enough patients (9.1%) and did not find it beneficial (7.9%). Our study demonstrated the feasibility of obtaining favourable response rate in a survey involving doctors from public and private primary care settings

Importance The World Health Organization is developing a global strategy to eliminate cervical cancer, with goals for screening prevalence among women aged 30 through 49 years. However, evidence on prevalence levels of cervical cancer screening in low- and middle-income countries (LMICs) is sparse. Objective To determine lifetime cervical cancer screening prevalence in LMICs and its variation across and within world regions and countries. Design, setting, and participants Analysis of cross-sectional nationally representative household surveys carried out in 55 LMICs from 2005 through 2018. The median response rate across surveys was 93.8% (range, 64.0%-99.3%). The population-based sample consisted of 1 136 289 women aged 15 years or older, of whom 6885 (0.6%) had missing information for the survey question on cervical cancer screening. Exposures World region, country; countries' economic, social, and health system characteristics; and individuals' sociodemographic characteristics. Main outcomes and measures Self-report of having ever had a screening test for cervical cancer. Results Of the 1 129 404 women included in the analysis, 542 475 were aged 30 through 49 years. A country-level median of 43.6% (interquartile range [IQR], 13.9%-77.3%; range, 0.3%-97.4%) of women aged 30 through 49 years self-reported to have ever been screened, with countries in Latin America and the Caribbean having the highest prevalence (country-level median, 84.6%; IQR, 65.7%-91.1%; range, 11.7%-97.4%) and those in sub-Saharan Africa the lowest prevalence (country-level median, 16.9%; IQR, 3.7%-31.0%; range, 0.9%-50.8%). There was large variation in the self-reported lifetime prevalence of cervical cancer screening among countries within regions and among countries with similar levels of per capita gross domestic product and total health expenditure. Within countries, women who lived in rural areas, had low educational attainment, or had low household wealth were generally least likely to self-report ever having been screened. Conclusions and relevance In this cross-sectional study of data collected in 55 low- and middle-income countries from 2005 through 2018, there was wide variation between countries in the self-reported lifetime prevalence of cervical cancer screening. However, the median prevalence was only 44%, supporting the need to increase the rate of screening.

Summary Background In addition to increased availability of treatment modalities, advanced imaging modalities are increasingly recommended to improve global cancer care. However, estimates of the costs and benefits of investments to improve cancer survival are scarce, especially for low-income and middle-income countries (LMICs). In this analysis, we aimed to estimate the costs and lifetime health and economic benefits of scaling up imaging and treatment modality packages on cancer survival, both globally and by country income group. Methods Using a previously developed model of global cancer survival, we estimated stage-specific cancer survival and life-years gained (accounting for competing mortality) in 200 countries and territories for patients diagnosed with one of 11 cancers (oesophagus, stomach, colon, rectum, anus, liver, pancreas, lung, breast, cervix uteri, and prostate) representing 60% of all cancer diagnoses between 2020 and 2030 (inclusive of full years). We evaluated the costs and health and economic benefits of scaling up packages of treatment (chemotherapy, surgery, radiotherapy, and targeted therapy), imaging modalities (ultrasound, x-ray, CT, MRI, PET, single-photon emission CT), and quality of care to the mean level of high-income countries, separately and in combination, compared with no scale-up. Costs and benefits are presented in 2018 US$ and discounted at 3% annually. Findings For the 11 cancers studied, we estimated that without scale-up (ie, with current availability of treatment, imaging, and quality of care) there will be 76·0 million cancer deaths (95% UI 73·9–78·6) globally for patients diagnosed between 2020 and 2030, with more than 70% of these deaths occurring in LMICs. Comprehensive scale-up of treatment, imaging, and quality of care could avert 12·5% (95% UI 9·0–16·3) of these deaths globally, ranging from 2·8% (1·8–4·3) in high-income countries to 38·2% (32·6–44·5) in low-income countries. Globally, we estimate that comprehensive scale-up would cost an additional $232·9 billion (95% UI 85·9–422·0) between 2020 and 2030 (representing a 6·9% increase in cancer treatment costs), but produce $2·9 trillion (1·8–4·0) in lifetime economic benefits, yielding a return of $12·43 (6·47–33·23) per dollar invested. Scaling up treatment and quality of care without imaging would yield a return of $6·15 (2·66–16·71) per dollar invested and avert 7·0% (3·9–10·3) of cancer deaths worldwide. Interpretation Simultaneous investment in cancer treatment, imaging, and quality of care could yield substantial health and economic benefits, especially in LMICs. These results provide a compelling rationale for the value of investing in the global scale-up of cancer care. Funding Harvard TH Chan School of Public Health and National Cancer Institute.

Although Value-Based Health Care (VBHC) is widely debated and cited, there are few empirical studies focused on how its concepts are understood and applied in real-world contexts. This comparative case study of two prominent adopters in Brazil and Sweden, situated at either end of the spectrum in terms of contextual prerequisites, provides insights into the complex interactions involved in the adoption of value-based strategies. We found that the adoption of VBHC emphasized either health outcomes or costs – not both as suggested by the value equation. This may be linked to broader health system and societal contexts. Implementation can generate tensions with traditional business models, suggesting that providers should first analyze how these strategies align with their internal context. Adoption by a single provider organization is challenging, if not impossible. An effective VBHC transformation seems to require a systematic and systemic approach where all stakeholders need to clearly define the purpose and the scope of the transformation, and together steer their actions and decisions accordingly.

OBJECTIVE The prevalence of type 2 diabetes is rising rapidly in low-income and middle-income countries (LMICs), but the factors driving this rapid increase are not well understood. Adult height, in particular shorter height, has been suggested to contribute to the pathophysiology and epidemiology of diabetes and may inform how adverse environmental conditions in early life affect diabetes risk. We therefore systematically analyzed the association of adult height and diabetes across LMICs, where such conditions are prominent. RESEARCH DESIGN AND METHODS We pooled individual-level data from nationally representative surveys in LMICs that included anthropometric measurements and diabetes biomarkers. We calculated odds ratios (ORs) for the relationship between attained adult height and diabetes using multilevel mixed-effects logistic regression models. We estimated ORs for the pooled sample, major world regions, and individual countries, in addition to stratifying all analyses by sex. We examined heterogeneity by individual-level characteristics. RESULTS Our sample included 554,122 individuals across 25 population-based surveys. Average height was 161.7 cm (95% CI 161.2–162.3), and the crude prevalence of diabetes was 7.5% (95% CI 6.9–8.2). We found no relationship between adult height and diabetes across LMICs globally or in most world regions. When stratifying our sample by country and sex, we found an inverse association between adult height and diabetes in 5% of analyses (2 out of 50). Results were robust to alternative model specifications. CONCLUSIONS Adult height is not associated with diabetes across LMICs. Environmental factors in early life reflected in attained adult height likely differ from those predisposing individuals for diabetes.

Summary Background Accurate survival estimates are important for cancer control planning. Although observed survival estimates are unavailable for many countries, where they are available, wide variations are reported. Understanding the impact of specific treatment and imaging modalities can help decision makers to effectively allocate resources to improve cancer survival in their local context. Methods We developed a microsimulation model of stage-specific cancer survival in 200 countries and territories for 11 cancers (oesophagus, stomach, colon, rectum, anus, liver, pancreas, lung, breast, cervix uteri, and prostate) comprising 60% of global diagnosed cancer cases. The model accounts for country-specific availability of treatment (chemotherapy, surgery, radiotherapy, and targeted therapy) and imaging modalities (ultrasound, x-ray, CT, MRI, PET, single-photon emission CT), as well as quality of care. We calibrated the model to reported survival estimates from CONCORD-3 (which reports global trends in cancer survival in 2000–14). We estimated 5-year net survival for diagnosed cancers in each country or territory and estimated potential survival gains from increasing the availability of individual treatment and imaging modalities, and more comprehensive packages of scale-up of these interventions. We report the mean and 95% uncertainty intervals (UIs) for all outcomes, calculated as the 2·5 and 97·5 percentiles of the simulation results. Findings The estimated global 5-year net survival for all 11 cancers combined is 42·6% (95% uncertainty interval 40·3–44·3), with survival in high-income countries being an average of 12 times (range 4–17) higher than that in low-income countries. Expanding availability of surgery or radiotherapy or improving quality of care would yield the largest survival gains in low-income (2·5–3·4 percentage point increase in survival) and lower-middle-income countries (2·4–6·1 percentage point increase), whereas upper-middle-income and high-income countries are more likely to benefit from improved availability of targeted therapy (0·7 percentage point increase for upper-middle income and 0·4 percentage point increase for high income). Investing in medical imaging will also be necessary to achieve substantial survival gains, with traditional modalities estimated to provide the largest gains in low-income settings, while MRI and PET would yield the largest gains in higher-income countries. Simultaneous expansion of treatment, imaging, and quality of care could improve 5-year net survival by more than ten times in low-income countries (3·8% [95% UI 0·5–9·2] to 45·2% [40·2–52·1]) and could more than double 5-year net survival in lower-middle-income countries (20·1% [7·2–31·7] to 47·1% [42·8–50·8]). Interpretation Scaling up both treatment and imaging availability could yield synergistic survival gains for patients with cancer. Expanding traditional modalities in lower-income settings might be a feasible pathway to improve survival before scaling up more modern technologies. Funding Harvard T H Chan School of Public Health.