Achieving Universal Health Coverage in Low- and Middle-Income Countries: Challenges for Policy Post-Pandemic and Beyond

Analysis and comparison of trends in the burden of subarachnoid hemorrhage in china and globally, 1990-2021

BACKGROUND

Subarachnoid hemorrhage (SAH), the rarest form of hemorrhagic stroke, is associated with high mortality and disability rates. Therefore, it is a major public health concern.

METHODS

This study reviewed the epidemiological characteristics of SAH in China and worldwide, focusing on the 2021 Global Burden of Disease (GBD) database. Researchers, using the GBD database, conducted epidemiological studies that included joinpoint regression analyses covering the incidence, mortality, prevalence, and disability-adjusted life years of SAH in the years 1990-2021. This analysis revealed the trends and effects of SAH in China and globally.

RESULTS

From 1990 to 2021, the age-standardized incidence rate (ASIR) in China decreased from 17.96 to 7.81 per 100,000 people. The age-standardized mortality rate (ASMR) decreased from 27.29 to 4.72 per 100,000 people. This resulted in a 51.58 % reduction in mortality. In contrast, both the ASIR and ASMR showed a slower decline at the global level. China has reported that women aged 70 years and older are at a high risk for SAH. Furthermore, middle-aged men have high prevalence and mortality rates.

CONCLUSIONS

The current observations warrant the design of focused interventions for both the elderly and female patients with oblique stroke. They can be useful for addressing the SAH burden globally. This study provides valuable information regarding the effectiveness of existing healthcare interventions. This information can also inform future strategies for the prevention and management of SAH.

Impact of COVID-19 on healthcare programs in Zimbabwe: a mixed methods study

BACKGROUND

The COVID-19 pandemic disrupted healthcare services. Understanding similar epidemic-related disruptions on a broader scope in our local setting is critical for the effective planning of essential services. The study determined the impact of Coronavirus disease(COVID-19) on healthcare programs in Zimbabwe.

METHODS

A mixed-methods study compared healthcare service delivery trends from the Ministry of Health and Child Care before, during and post the pandemic. It employed two methods of data collection: Key informant interviews (KII) and secondary data analysis from the Zimbabwe District Health Information Systems 2 (DHIS2). Purposive sampling obtained key informants for interviews whilst 18 healthcare service indicators were identified from the national database. Statistical analysis consisted of an interrupted time series analysis of those indicators preceded by visualization to appreciate trend change. An inductive approach was used to code and identify basic themes which were then triangulated against DHIS2 findings.

RESULTS

The study revealed that COVID-19 had a negative impact on health service delivery; increasing disruptions of critical healthcare services, maternal and child health, reproductive health issues, and other specialist services were prominent. The rise in maternal and child mortality cases and caesarean sections could be directly linked to the decline in service delivery during the pandemic. Mitigation strategies that were introduced during the pandemic included the use of community-based services, outreach services, capacity building, and de-congestion of public services.

CONCLUSIONS

The pandemic disrupted healthcare delivery, causing service usage to decline due to lockdowns. Response strategies included community services, capacity building, and stakeholder engagement. Future readiness requires epidemic plans, enhanced resources, a multisectoral approach, workforce training, and public education.

Integrating Digital Health Innovations to Achieve Universal Health Coverage: Promoting Health Outcomes and Quality Through Global Public Health Equity

Digital health innovations are reshaping global healthcare systems by enhancing access, efficiency, and quality of care. Technologies such as artificial intelligence, telemedicine, mobile health applications, and big data analytics have been widely applied to support disease surveillance, enable remote care, and improve clinical decision making. This review critically identifies persistent implementation challenges that hinder the equitable adoption of digital health solutions, such as the digital divide, limited infrastructure, and weak data governance, particularly in low- and middle-income countries (LMICs). It aims to propose strategic pathways for integrating digital innovations to strengthen universal health coverage (UHC) and bridge health disparities in the region. By analyzing the best global practices and emerging innovations, this study contributes to the ongoing dialogue on leveraging digital health for inclusive, scalable, and sustainable healthcare delivery in underserved regions.

Enhancing Intersectoral Collaboration in Maternal Healthcare for the Realization of Universal Health Coverage in Kenya: The Perspectives of Health Facility Administrators in Kilifi County, Kenya

Intersectoral collaboration is an instrument that enables better productivity by filling in for possible gaps in knowledge, skills, and competencies in a given department by leveraging them from other departments. In Kenya, there is a paucity of information on intersectoral collaboration in healthcare. This article explores the possibilities of intersectoral collaboration, specifically in maternal healthcare, and what can be done to realize such collaborations to drive universal health coverage (UHC) in Kenya. Free maternity services (FMSs) are among the primary healthcare services that push Kenya towards UHC. In light of the centrality of UHC in driving current health policy, there are still several challenges which must be faced before this goal can be achieved. Moreover, competing priorities in health systems necessitate difficult choices regarding which health actions and investments to fund; these are complex, value-based, and highly political decisions. Therefore, the primary objective of this article is to explore health facility administrators' views on whether intersectoral collaboration could help with the realization of UHC in Kenya. The study area was Kilifi County, Kenya. The article is based on follow-up qualitative research conducted between March and July 2016 and from January to July 2017, and follow-up interviews conducted during COVID-19 in 2020 and 2021. The data are analyzed through a thematic analysis approach. The findings indicate that through Linda Mama, the expanded free maternity services program is one of the possible pathways to UHC. However, participants noted fair representation of stakeholders, distributed leadership, and local participation, considering bargaining power as a key issue that could enhance the realization of UHC in intersectoral collaboration through Linda Mama. These techniques require a bottom-up strategy to establish accountability, a sense of ownership, and trust, which are essential for UHC.

Contribution of health system governance in delivering primary health care services for universal health coverage: A scoping review

BACKGROUND

The implementation of the primary health care (PHC) approach requires essential health system inputs, including structures, policies, programs, organization, and governance. Effective health system governance (HSG) is crucial in PHC systems and services, as it can significantly influence health service delivery. Therefore, understanding HSG in the context of PHC is vital for designing and implementing health programs that contribute to universal health coverage (UHC). This scoping review explores how health system governance contributes to delivering PHC services aimed at achieving UHC.

METHODS

We conducted a scoping review of published evidence on HSG in the delivery of PHC services toward UHC. Our search strategy focused on three key concepts: health system governance, PHC, and UHC. We followed Arksey and O'Malley's scoping review framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist to guide our methodology. We used the World Health Organization's framework on HSG to organize the data and present the findings.

RESULTS

Seventy-four studies were included in the final review. Various functions of HSG influenced PHC systems and services, including:1) formulating health policies and strategic plans (e.g., addressing epidemiological and demographic shifts and strategic financial planning), 2) implementing policy levers and tools (such as decentralization, regulation, workforce capacity, and supply chain management), 3) generating intelligence and evidence (including priority setting, monitoring, benchmarking, and evidence-informed decision-making), 4) ensuring accountability (through commitments to transparency), and 5) fostering coordination and collaboration (via subnational coordination, civil society engagement, and multisectoral partnerships). The complex interplay of these HSG interventions operates through intricate mechanisms, and has synergistic effects on PHC service delivery.

CONCLUSION

PHC service delivery is closely linked to HSG functions, which include formulating strategic policies and plans responsive to evolving epidemiological and demographic needs, utilizing digital tools, decentralizing resources, and fostering multisectoral actions. Effective policy implementation requires robust regulation, evidence-based decision-making, and continuous monitoring. Accountability within health systems, alongside community engagement and civil society collaboration, is vital for realizing PHC principles. Local health institutions should collaborate with communities-end users of these systems-to implement formal rules and ensure PHC service delivery progresses toward UHC. Sociocultural contexts and community values should inform decision-making aligning health needs and services to achieve universal access to PHC services.

Analysis and comparison of the trends in burden of low back pain in China and worldwide from 1990 to 2021

BACKGROUND

Low back pain (LBP) substantially affects quality of life and functional capacity, ranking as a major global cause of disability. While the global burden of LBP has been extensively studied, China's unique demographic, socioeconomic, and healthcare contexts warrant focused attention. As the world's most populous nation undergoing rapid urbanization and aging, China presents a distinct landscape for LBP epidemiology. This study aims to chart the temporal shifts in the age- and sex-specific burdens of LBP in China from 1990 to 2021, encompassing incidence, prevalence, and disability-adjusted life years (DALYs). By benchmarking these trends against the worldwide disease burden, this research provides critical insights into how China's experience aligns with or diverges from global patterns, offering valuable guidance for targeted public health strategies.

METHODS

This study leveraged open-access data from the Global Burden of Disease (GBD) repository, spanning the years 1990 to 2021, to scrutinize the epidemiological profile of LBP in China and across the globe. The analysis encompassed fluctuations in LBP incidence, prevalence, and DALYs. The Joinpoint regression model was employed to determine the average annual percentage change (AAPC) and its associated 95% confidence interval (95% CI), thereby quantifying the trajectory of LBP burden. A multifaceted comparative evaluation was performed to elucidate disparities in LBP burden between China and other regions, examining various aspects such as age, gender, and temporal dynamics.

RESULTS

From 1990 to 2021, both China and the world experienced a decline in age-standardized metrics related to LBP. In China, the age-standardized incidence rate (ASIR) decreased from 2,859.383 to 2,342.459 per 100,000, while globally, it fell from 3,534.988 to 3,176.63 per 100,000. Similarly, the age-standardized prevalence rate (ASPR) in China declined from 6,635.488 to 5,342.1 per 100,000, compared to a global reduction from 8,391.582 to 7,463.13 per 100,000. The age-standardized DALYs rate (ASDR) in China also dropped from 749.026 to 603.033 per 100,000, while globally, it decreased from 937.339 to 832.179 per 100,000. Notably, according to the AAPC results, China showed a more pronounced decrease in these metrics compared to the global averages, especially before 2015. Gender differences were evident, with women consistently exhibiting higher incidence, prevalence, and DALYs for LBP across all age groups and years. Age-related disparities were also significant: in 2021, the crude incidence rate (CIR), crude prevalence rate (CPR), and crude DALY rate (CDR) peaked in the 85-89 age group, reflecting the substantial burden of LBP among older adults. However, the highest number of incidence, prevalence, and DALYs was observed in the 55-59 age group, indicating a shift toward middle-aged individuals as a key affected population. Overall, while China's LBP burden demonstrated a consistent decline, the gender and age patterns suggest a need for tailored public health interventions targeting middle-aged and elderly populations, as well as women who are disproportionately affected.

CONCLUSION

Although China's LBP burden has declined, it remains significant among middle-aged and elderly populations, with women disproportionately affected. Public health efforts should focus on ergonomic improvements, promoting physical activity, and accessible nonpharmacological treatments. Integrating LBP care into primary healthcare is vital to mitigate its impact and support the aging population.

System Models for Synchronous Strategies in Operational Healthcare Forecasting

The delivery of healthcare in Low-to-Medium-Income Countries (LMICs) has long posed challenges, with established models predominantly found in wealthier nations. These models are found to be either strategic or operational, and very rarely combine these two perspectives. Most importantly, these models lack a comprehensive, holistic and synchronous construct that accompanies a systems thinking approach. This research evaluates international best practices, fundamental global theories and existing systems and tools in healthcare through a systems approach. It collates these data to propose a customized systems-based, comprehensive framework for modeling and optimizing both the management and operational tiers of healthcare in LMICs. The approach is based on the adoption of digital tools, inclusive of AI, to analyze, assimilate, align and develop advanced, holistic and inclusive frameworks. The current gap in global healthcare delivery is characterized by an ongoing lack of ability to provide quality and cost-effective care, especially in the LMICs. Despite the fact that developmental challenges are unique and specific to respective countries, there are commonalities with regard to healthcare processes that present opportunities for optimization. The main challenge lies in the effective collation and synchronization of data and tools with the specific contexts of each country. This situation highlights the need for a cohesive systems approach to enhance healthcare delivery in LMICs, allowing for tailored solutions that can bridge existing gaps. This paper presents a strategic model, with initial data quantification guiding the development of the system model. The practical significance of this research lies in its potential to transform healthcare delivery in LMICs, leading to enhanced access and quality of care through optimized systems.

Role of private providers in the implementation of the national health insurance scheme in Zambia: a qualitative study of perceptions and experiences

INTRODUCTION

An increasing number of sub-Saharan African countries are implementing national health insurance schemes (NHISs) to support the aspiration of universal health coverage (UHC). A growing body of literature recognises the private sector role in improving NHIS equity in service access, public provider complementarity and overall member satisfaction. Zambia has implemented the NHIS since 2019 as a priority health financing strategy to support UHC. This study provides the first examination of the private sector's experiences implementing the Zambia NHIS.

METHODS

The study uses a qualitative study design and inductively synthesises data from 30 in-depth interviews with the private sector accredited to the Zambia NHIS in one rural and one urban province.

RESULTS

The private sector was motivated by profits and complementarity with public providers regarding service readiness and availability. Providers perceived the accreditation process and fees as standard and affordable. Providers reported increased service utilisation, mainly by the NHIS clients. Senior citizens and the informal sector constituted the majority of users. There were implementation challenges, including delays in preauthorisations, loss of member details and exclusion and restrictions of interventions in the benefits package. Private providers also experienced overcrowding and reduced service quality. Providers perceived the service reimbursement levels as relatively cost-reflective, but some providers shifted models to maximise profits, including inducing demand to defraud the fund. Generally, providers perceived payments as within the agreed timelines, especially for online claims.

CONCLUSION

The initial scepticism among private providers before the initiation of the NHIS has subsided. The private provider's experiences with accreditation, service utilisation, claims and reimbursements have been overall positive.

Trust in the integrity of a micro health insurance scheme and its determinants in two rural districts of Ethiopia

BACKGROUND

Mistrust in community-based health insurance schemes is a significant deterrent to enrollment and renewal decisions. Despite its significance, there is little evidence on the level of community trust in such schemes. This study examined the level of trust in the integrity of a community-based health insurance scheme and its determinants in two rural districts of northeast Ethiopia.

METHODS

A community-based cross-sectional study was carried out on 1,232 randomly selected rural households who had been registered in a community-based health insurance scheme. The data were collected through face-to-face interviews using an electronic data collection platform. Multivariable ordinal logistic regression analysis was performed using the partial proportional odds model to examine predictors of trust. The degree of association was assessed using odds ratios, and statistical significance was determined at a 95% confidence interval.

RESULTS

The mean score of the five trust dimensions was 5.86 on a scale of 0-10, ranging from 5.06 to 7.65. In the multivariable regression analysis, age (AOR = 1.58; 95% CI: 1.10, 2.29), female gender (AOR = 2.05; 95% CI: 1.29, 3.25), education (AOR = 1.36; 95% CI: 1.03, 1.80), insurance membership status (AOR = 2.68; 95% CI: 1.89, 3.80), membership duration (AOR = 1.51; 95% CI: 1.19, 1.92), value for solidarity (AOR = 1.71; 95% CI: 1.20, 2.45), perceived risk protection (AOR = 3.35; 95% CI: 2.27, 4.96), and perceived quality of care (AOR = 1.78; 95% CI: 1.34, 2.37) were positive predictors of trust in the integrity of the scheme, while wealth index (AOR = 0.33; 95% CI: 0.23, 0.47), and hospitalization history (AOR = 0.62; 95% CI: 0.48, 0.82) were negative predictors of trust.

CONCLUSIONS

Trust in the integrity of the scheme received mediocre scores, with some trust dimensions having lower ratings, indicating specific areas of focus to be considered in trust-building. Scheme administrators and health authorities need to devise strategies to improve people's understanding of the basic principles of health insurance and promote access to high-quality care while minimizing expenditures at the point of receiving care.

Women's enrollment in community-based health insurance and its determinants in Sidama national regional state, Ethiopia, 2024: A multilevel analysis

INTRODUCTION

Accessing affordable and high-quality healthcare remains a persistent challenge in low- and middle-income countries like Ethiopia. Community-based health insurance (CBHI) programs offer a promising solution to expand healthcare coverage and provide financial protection, particularly for vulnerable populations such as women. This study aimed to investigate the factors that influence CBHI enrollment among women in Sidama National Regional State, Ethiopia, using a multilevel analysis.

METHODS

A community-based cross-sectional study was conducted using a multistage sampling technique from December 15th to January 12th, 2024, in the central Sidama zone, Sidama National Regional State. The study included 835 women aged 18 years and older, residing both in rural and urban areas. Face-to-face interviews were conducted using a pre-tested questionnaire to collect comprehensive data on socio-demographic, economic, and scheme-related factors. Data collection utilized the Open Data Kit mobile application, and data analysis was performed using Stata version 16, employing multilevel modified Poisson modeling to identify determinants of CBHI enrollment.

RESULTS

Among 845 samples, 835 women were interviewed, resulting in a response rate of 98.8%. Individual-level factors such as older age (APR = 1.02, 95%CI: 1.01-1.03, p<0.001), larger family size (APR = 1.09, 95%CI: 1.03-1.16, p = 0.001), and moderate wealth index (APR = 2.72, 95%CI: 1.28-5.79, p = 0.009) showed positive associations with CBHI enrollment, depicted a higher likelihood of individuals joining the insurance scheme. In addition, at the community level, higher rates of women's literacy (APR = 1.73, 1.18-2.55, p = 0.005), and women's autonomy (APR = 2.64, 95%CI: 1.50-4.65, p = 0.001) were positively correlated with CBHI enrollment.

CONCLUSIONS

The study revealed that the enrollment rate among women in the CBHI scheme was 35%, indicating a need for improved outreach efforts. Significant factors that affected enrollment included older age, larger family size, and moderate wealth. Additionally, positive community-level influences such as higher literacy rates and increased autonomy for women contributed to higher enrollment. To improve CBHI enrollment, the target should focus on younger women and those from smaller families. Financial support, such as subsidies for low-income women, can also encourage participation. Investing in women's literacy and empowerment programs will enable them to make informed health choices, thereby increasing enrollment. Finally, ongoing research is necessary to track enrollment trends and identify barriers. Utilizing qualitative methods will yield insights into women's perceptions of CBHI, facilitating more effective strategies. Implementing these recommendations can enhance women's access to healthcare through CBHI.

Risk of financial catastrophe for breast cancer patients in Nigeria: A retrospective analysis

INTRODUCTION

Cancer imposes significant financial burden on patients in low and middle-income countries like Nigeria, where breast cancer (BC) is the most common cancer and has the highest mortality. This study aims to investigate the financial burden of BC care at Lakeshore Cancer Center (LCC) in Nigeria and identify risk factors for financial catastrophe (FC).

METHODS

LCC was queried for uninsured patients diagnosed with breast cancers between 2013 and 2023, linked to cost data through chart abstraction of billing data and adjusted to 2023 USD. All costs were out-of-pocket costs (OOP) as all patients were uninsured. Risk for financial catastrophe was defined as OOP exceeding 20 ​% of Nigeria's 2023 per capita GDP ($467). Total OOP and risk for financial catastrophe were measured with descriptive statistics and stratified by clinical characteristics.

RESULTS

352 BC patients (99 ​% female, median age 47, 41 ​% stage 4, 28 ​% stage 3) were included. 260 (74 ​%) patients risked financial catastrophe, despite only 30 ​% completing treatment. Patients with HER2+/HR ​+ ​disease exhibited the highest treatment costs. Among patients that underwent multiple treatment modalities (n ​= ​130), the average OOP was $17992 with 100 ​% risking financial catastrophe. The highest contributors to the cohort's total costs were chemotherapy (29 ​%), immunotherapy (18 ​%), and other drugs (12 ​%). Surgery contributed 7 ​%.

DISCUSSION

Less than one-third of BC patients completed treatment, and the majority faced financial catastrophe, especially those with HER2+/HR ​+ ​disease and patients who underwent multiple treatment modalities or immunotherapy. Targeted efforts are essential to ensure equitable access to quality cancer care while minimizing risk of financial catastrophe.

12-month outcomes of ziv-aflibercept for neovascular age-related macular degeneration in eyes previously treated with aflibercept

PURPOSE

To investigate the 12-month outcomes of ziv-aflibercept for neovascular age-related macular degeneration (nAMD) in eyes previously treated with aflibercept.

METHODS

Retrospective chart review of patients with nAMD previously treated with aflibercept for at least 12 months and subsequently transitioned to ziv-aflibercept between January 1, 2019, and December 31, 2022, for a period of at least 12 months. Participants were identified, and their clinical and imaging information was extracted from our electronic health records system. Data on best corrected visual acuity (BCVA), intraocular pressure, injection intervals, central retinal thickness (CRT), volume cube presence of subretinal fluid (SRF), and intraretinal fluid (IRF) were obtained. Main outcome measures included changes in BCVA, injection intervals, CRT, SRF, and IRF before and after 12 months of ziv-aflibercept treatment.

RESULTS

Fifty-four eyes of 44 patients were included in the study. After 12 months of ziv-aflibercept treatment, BCVA decreased by 0.84 ETDRS letters (P = 0.424) compared to BCVA at the last visit prior to conversion from aflibercept. Injection intervals decreased by 1.18 weeks (P = 0.489). CRT significantly decreased by 15.66 µm (P = 0.005). SRF was present initially in 31.5% of eyes and decreased to 22.2% (P = 0.125). IRF was present initially in 42.6% of eyes and decreased to 35.2% (P = 0.219).

CONCLUSION

Ziv-aflibercept demonstrated effectiveness in maintaining treatment outcomes in nAMD eyes previously treated with aflibercept. The treatment was well-tolerated with no reported adverse events. Ziv-aflibercept may be a cost-effective alternative and a potential solution to the financial burden associated with conventional anti-VEGF agents.

Patterns and factors associated with healthcare utilisation in Cambodia: a cross-sectional study based on the World Health Survey Plus 2023

Background

The Cambodian government aims to boost healthcare utilisation in public facilities and reduce the spending burden for disadvantaged households. This study aims to describe patterns of public and private outpatient and inpatient healthcare use and investigate the factors associated with public healthcare usage in Cambodia.

Method

A cross-sectional study was conducted in all provinces in Cambodia, including the capital, Phnom Penh. The analysis included 4603 individuals aged ≥18 who had received care within the last 12 months.

Results

Around 9% of outpatient and 50% of inpatient visits were made to public healthcare facilities. The number of outpatient visits made to public healthcare compared with private healthcare facilities was significantly higher in women (aOR 1.4, 95% CI 1.1, 1.8), living in rural settings (aOR 1.4, 95% CI 1.1, 1.7), those in the poorest (aOR 1.7, 95% CI 1.2, 2.3) and poor (aOR 1.5, 95% CI 1.1, 2.1) compared with the richest wealth quintiles, and respondents with insurance coverage (aOR 2.0, 95% CI 1.6, 2.5). The number of inpatient visits made to public healthcare compared with private healthcare facilities was significantly higher in the poorest (aOR 2.4, 95% CI 1.4, 3.9), poor (aOR 2.4, 95% CI 1.5, 4.0) and middle (aOR 2.5, 95% CI 1.5, 4.1) compared with those in the richest wealth quintiles and respondents with insurance coverage (aOR 2.1, 95% CI 1.5, 3.2).

Conclusion

Our study shows that private healthcare dominates outpatient services in Cambodia, while public healthcare is more significant for inpatient care. Individuals with low socioeconomic status and those with insurance showed higher public healthcare utilisation for outpatient and inpatient services, with women more likely to use public outpatient care. To progress towards universal health coverage, it is essential to improve public healthcare quality, especially in rural areas, expand service coverage and social health protection and develop strategies to engage the private sector.

Patient's willingness to pay for improved community health insurance in Tanzania

Globally, achieving universal health coverage remains significant challenge. Health insurance coverage in low- and middle-income countries is still low with only a few African countries managed to reach 50% coverage. This study aimed to investigate the factors influencing patients' willingness to pay (WTP) for medication and various versions of the improved Community Health Insurance Fund (iCHF) in Tanzania. A facility-based cross-sectional study was conducted in all hospitals, health centres, and eight randomly sampled dispensaries, sampling participant from the queue, one out of every three patient based on their order of entry into consultation room, and interviewed 1,748 patients in Kilombero and Same districts in Tanzania. We used multi-stage Contingent Valuation Methods exploring data collected during client exit interviews. We employed a random utility model and estimated WTP through an ordered logit model. The independent variables were; patient's gender, age, marital status, education, employment status, Non-Communicable Disease (NCD) status, health insurance status, and the type of healthcare facility level. Our findings revealed that most patients exhibited a WTP of an amount equivalent to the current iCHF premiums and would also be willing to pay for an augmented iCHF premium inclusive of additional medication coverage. Upon adjusting for demographic characteristics, we observed that patients enrolled in an insurance program or benefiting from user fee waivers demonstrated a lower WTP for medication, while those with non-communicable diseases (NCDs) and seeking care in private facilities exhibited a higher WTP. Furthermore, patients with a secondary education level or above generally displayed higher WTP for premiums. Conversely, patients enrolled in private insurance and availing user fee waivers, along with those accessing care in public facilities, demonstrated a lowered WTP for iCHF premiums. These results highlight the need for targeted interventions to address systemic deficiencies and improve access to medicines. Our conclusions is that policies considering NCD status, education levels and income status are important when designing health insurance schemes for the informal sector in Tanzania, with the goal of increasing uptake of CHF.

A need for a comprehensive health financing strategy in Pakistan: an analysis of key health financing issues

PURPOSE

This study aims to analyze the challenges in financing the healthcare system of Pakistan and develop a comprehensive health financing strategy aimed at achieving universal health coverage (UHC).

DESIGN/METHODOLOGY/APPROACH

The paper utilizes World Health Organization (WHO) framework on health financing to build the argument. It uses qualitative research design involving focus group discussions and in-depth interviews with key stakeholders, including Federal Board of Revenue, Ministry of Finance, Planning Commission, development partners, academia and health ministries at federal and provincial levels, as well as social health insurance entities.

FINDINGS

The research findings highlight several critical issues within Pakistan's healthcare system: Firstly, health spending is inadequate to provide financial protection to 24 million people. Secondly, the available health funding is allocated in clusters and caters primarily to specific groups, which exacerbates inequities in healthcare provision. Thirdly, the existence of multiple purchasing agents who operate concurrently to buy health services results in duplication and wastage of resources. Fourthly, the public financial management system, intended to support the swift distribution of public funds to health facilities, is not aligned with the requirements of the health system. Lastly, the devolved health setup has led to governance issues in managing the health sector.

ORIGINALITY/VALUE

This study fills a significant gap in the literature on health financing within Pakistan and proposes a unique empirical approach using WHO's framework in a decentralized healthcare context. It also provides actionable recommendations for policymakers to develop strategies that improve the effectiveness of public financial management and health service delivery.

Can "the expanded free maternity services" enable Kenya to achieve universal health coverage by 2030: qualitative study on experiences of mothers and healthcare providers

Introduction

Universal health coverage is a global agenda within the sustainable development goals. While nations are attempting to pursue this agenda, the pathways to its realization vary across countries in relation to service, quality, financial accessibility, and equity. Kenya is no exception and has embarked on an initiative, including universal coverage of maternal health services to mitigate maternal morbidity and mortality rates. The implementation of expanded free maternity services, known as the Linda Mama (Taking Care of the Mother) targets pregnant women, newborns, and infants by providing cost-free maternal healthcare services. However, the efficacy of the Linda Mama (LM) initiative remains uncertain. This article therefore explores whether LM could enable Kenya to achieve UHC.

Methods

This descriptive qualitative study employs in-depth interviews, focus group discussions, informal conversations, and participant observation conducted in Kilifi County, Kenya, with mothers and healthcare providers.

Results and discussion

The findings suggest that Linda Mama has resulted in increased rates of skilled care births, improved maternal healthcare outcomes, and the introduction of comprehensive maternal and child health training for healthcare professionals, thereby enhancing quality of care. Nonetheless, challenges persist, including discrepancies and shortages in human resources, supplies, and infrastructure and the politicization of healthcare both locally and globally. Despite these challenges, the expanding reach of Linda Mama offers promise for better maternal health. Finally, continuous sensitization efforts are essential to foster trust in Linda Mama and facilitate progress toward universal health coverage in Kenya.

The coming of age of digital technologies in global health within the Indian context: a review

Digital approaches have been recognized as an essential instrument for improving health systems to fulfill the Sustainable Development Goals (SDGs) and the targets for universal health care. This review article discusses policy and regulatory developments in the arena of digital health, at the global level, with a particular focus on India. It also points out that there is a need for convergence among industry, policymakers, and civil society in addressing issues of privacy and accessibility to all individuals who require affordable and quality healthcare. For the best use of digital services, inter-sectoral collaboration is necessary to integrate organizational, human, financial, and technological resources.

Health insurance, social safety net and maternal health service utilisation in Pakistan: a population based cross-sectional study

OBJECTIVE

The objective of the study is to examine the impact of health insurance and social safety net programmes on maternal health service utilisation (MHSU) in Pakistan.

DESIGN

Cross-sectional.

SETTINGS

Data were obtained from Pakistan Demographic Health Survey 2017-2018.

PARTICIPANTS

Out of 12 364 Pakistani ever-married women aged 15-49 years included in the survey sample, 7752 were included in the study.

MAIN OUTCOME MEASURES

Three response variables (antenatal care (ANC) by skilled attendants (<4 visits=inadequate vs 4 or more visits=adequate), health facility-based delivery (home vs health) and postnatal care (yes vs no) were combined to assess MHSU. Health insurance was derived from the question 'are you covered with any health insurance?' and social safety net was derived from enrolment in social safety net programmes. Logistic regression analyses were conducted, and results were reported as ORs with 95% CIs. Results of adjusted logistic regression models were fit to control for individual and community-level factors.

RESULT

Prevalence of social safety net was larger than health insurance (7.7% vs 2.0%) while attendance of ANC+4, facility-based delivery and postnatal care was 48.5% (n=3760), 65.9% (n=5097) and 22.6% (n=1745) respectively, among respondents. Women were twice more likely to access maternal health services when they were covered by health insurance (adjusted OR 2.61, 95% CI 1.19 to 5.74, p<0.017) after adjusting for age at marriage, education level, wealth index, rural/urban area, parity, employment, empowerment status, exposure to media, visits and distance to health facility while no significant association of social safety net programmes with MHSU was found.

CONCLUSION

Expanding access to health insurance can provide comprehensive coverage for maternal healthcare services. Social safety net programmes can be made conditional, subject to regular health checkups for mothers and children to improve maternal and child health outcomes.

A retrospective cohort study of a community-based primary care program's effects on pharmacotherapy quality in low-income Peruvians with type 2 diabetes and hypertension

Little is known about the effects of the Chronic Care Model (CCM) and community health workers (CHWs) on pharmacotherapy of type 2 diabetes and hypertension in resource-poor settings. This retrospective cohort implementation study evaluated the effects of a community-based program consisting of CCM, CHWs, guidelines-based treatment protocols, and inexpensive freely accessible medications on type 2 diabetes and hypertension pharmacotherapy quality. A door-to-door household survey identified 856 adults 35 years of age and older living in a low-income Peruvian community, of whom 83% participated in screening for diabetes and hypertension. Patients with confirmed type 2 diabetes and/or hypertension participated in the program's weekly to monthly visits for < = 27 months. The program was implemented as two care periods employed sequentially. During home care, CHWs made weekly home visits and a physician made treatment decisions remotely. During subsequent clinic care, a physician attended patients in a centralized clinic. The study compared the effects of program (pre- versus post-) (N = 262 observations), and home versus clinic care periods (N = 211 observations) on standards of treatment with hypoglycemic and antihypertensive agents, angiotensin converting enzyme inhibitors, and low-dose aspirin. During the program, 80% and 50% achieved hypoglycemic and antihypertensive standards, respectively, compared to 35% and 8% prior to the program, RRs 2.29 (1.72-3.04, p <0.001) and 6.64 (3.17-13.9, p<0.001). Achievement of treatment standards was not improved by clinic compared to home care (RRs 1.0 +/- 0.08). In both care periods, longer retention in care (>50% of allowable time) was associated with achievement of all treatment standards. 85% compared to 56% achieved the hypoglycemic treatment standard with longer and shorter retention, respectively, RR 1.52 (1.13-2.06, p<0.001); 56% compared to 27% achieved the antihypertensive standard, RR 2.11 (1.29-3.45, p<0.001). In a dose-dependent manner, the community-based program was associated with improved guidelines-based pharmacotherapy of type 2 diabetes and hypertension.

Addressing neurosurgical challenges in war conflict countries

The Russo-Ukrainian war caused significant humanitarian and healthcare issues in the Russo-Ukrainian region, which were further aggravated by the escalation of the conflict on February 2022. Because of this ongoing confrontation between the two nations, which has its roots in geopolitical conflicts and historical events, there have been nearly 4 million refugees in only the first month, and 906 healthcare institutions have sustained significant damage. Consequently, the demand for medical services has increased, adding onto the burden of the pre-existing problems within the region's healthcare system, such as inequities, budget shortages, and corruption. With nearly 500,000 military deaths and an estimated 27,1499 civilian casualties, the war's immediate health effects are devastating. Due to inadequate disease surveillance and difficulties with immunization, the risk of infectious illnesses, particularly HIV/AIDS and tuberculosis, increased. Although there were originally few mental health problems, the long-term effects are yet unknown. Some of the indirect effects are the severe refugee situation, the burden on public infrastructure, and problems with the security of food and water. Unprecedented obstacles confronted neurosurgery in the Russo-Ukrainian region, including increased patient loads from war-related cases, resource limitations, and facility devastation. Many countries stepped up to aid in managing neurosurgeries however, the some of the problems still persisted, such as insufficient sterility and power outages. Strengthened security standards, financial incentives, telemedicine services, and cooperation with international medical organizations are the main points of recovery recommendations. Rebuilding the region's healthcare system and guaranteeing ongoing foreign support after the conflict require a comprehensive strategy that addresses both short- and long-term issues.

Global burden of young-onset gastric cancer: a systematic trend analysis of the global burden of disease study 2019

BACKGROUND

While gastric cancer is generally declining globally, the temporal trend of young-onset (< 40 years) gastric cancer remains uncertain. We performed this analysis to determine the temporal trends of young-onset gastric cancer compared to late-onset cancer (≥ 40 years).

METHODS

We extracted cross-sectional data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. The burden of gastric cancer from 1990 to 2019 was assessed through indicators including incidence and mortality rates, which were classified at global, national, and regional levels, and according to socio-demographic indexes (SDI) and age or sex groups. Joinpoint regression analysis was used to identify specific years with significant changes. The correlation between AAPC with countries' average SDI was tested by Pearson's Test.

RESULTS

The global incidence rate of young-onset gastric cancer decreased from 2.20 (per 100,000) in 1990 to 1.65 in 2019 (AAPC: - 0.95; 95% confidence interval [CI] - 1.25 to - 0.65; P < 0.001). Late-onset cancer incidence also decreased from 59.53 (per 100,000) in 1990 to 41.26 in 2019 (AAPC: - 1.23; 95% CI - 1.39 to - 1.06, P < 0.001). Despite an overall decreasing trend, the incidence rate of young-onset cancer demonstrated a significant increase from 2015 to 2019 (annual percentage change [APC]: 1.39; 95% CI 0.06 to 2.74; P = 0.041), whereas no upward trend was observed in late-onset cancer. Mortality rates of young- and late-onset cancer both exhibited a significant decline during this period (AAPC: - 1.82; 95% CI - 2.15 to - 1.56; P < 0.001 and AAPC: - 1.69, 95% CI - 1.79 to - 1.59; P < 0.001). The male-to-female rate ratio for incidence and mortality in both age groups have been increasing since 1990. While countries with high SDI have had a greater decline in the incidence of late-onset gastric cancer (slope of AAPC change: - 0.20, P = 0.004), it was not observed in young-onset cancer (slope of AAPC change: - 0.11, P = 0.13).

CONCLUSIONS

The global incidence and mortality rates of both young- and late-onset gastric cancer have decreased since 1990. However, the incidence rate of young-onset cancer has demonstrated a small but significant upward trend since 2015. There was disparity in the decline in young-onset gastric cancer among male and high SDI countries. These findings could help to inform future strategies in preventing gastric cancer in younger individuals.

The impact of the health microinsurance M-FUND on the utilization of health services among migrant workers and their dependents in Thailand: A case-control study

Background

Even though Thailand has launched multiple migrant health policies, migrants still face various barriers in accessing health care. To some extent, these barriers may be reduced by health microinsurance. The M-FUND is a low-cost, not-for-profit health protection scheme for migrant workers in Thailand, created by Dreamlopments Social Enterprise and Foundation to support sustainable access to quality healthcare services for migrants. We aimed to investigate the impact of the M-FUND on utilization of health services.

Methods

Over a period of three months, we conducted quantitative face-to-face interviews with 408 M-FUND members, and 452 age, sex and location matched non-member controls in Tak Province, Thailand. We compared utilization of health services between members and non-members using logistic regression controlling for a number of socio-demographic variables and variables related to migration such as years in Thailand, legal status, etc.

Findings

M-FUND members were more likely to have utilized outpatient services (adjusted odds ratio: 1·74, 95 % confidence interval: 1·24-2·44), inpatient services (2·96, 1.11-7·92), and emergency care (1·89, 0·78-4·56), although the latter was not statistically significant. Members were more likely not to have purchased medicines over-the-counter (1·67, 1·22-2·27) than non-members. Members were also more likely to have utilized any additional specific service during a consultation (2·31, 1·49-3·58) including any type of imaging method (2·62, 1·29-5·29) and blood tests (1·64, 0·99-2·71). There were some differences between men and women, but most were not statistically significant.

Interpretation

The M-FUND health microinsurance was positively associated with the utilization of all major types of health services among migrant workers and their dependents in Thailand. For migrants, particularly vulnerable migrant workers and their dependents, the M-FUND appears to be a good approach to reducing barriers to health care. This study of the impact of health microinsurance for migrants provides important information for policy and program planners in the field of migrant health. However, more research is needed on health microinsurance schemes for migrants in different settings and for other underserved communities as well as the sex-specific impact on health service utilization.

Willingness to pay for National Health Insurance Services and Associated Factors in Africa and Asia: a systematic review and meta-analysis

Background

Universal health coverage (UHC) is crucial for public health, poverty eradication, and economic growth. However, 97% of low- and middle-income countries (LMICs), particularly Africa and Asia, lack it, relying on out-of-pocket (OOP) expenditure. National Health Insurance (NHI) guarantees equity and priorities aligned with medical needs, for which we aimed to determine the pooled willingness to pay (WTP) and its influencing factors from the available literature in Africa and Asia.

Methods

Database searches were conducted on Scopus, HINARI, PubMed, Google Scholar, and Semantic Scholar from March 31 to April 4, 2023. The Joanna Briggs Institute's (JBI's) tools and the "preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 statement" were used to evaluate bias and frame the review, respectively. The data were analyzed using Stata 17. To assess heterogeneity, we conducted sensitivity and subgroup analyses, calculated the Luis Furuya-Kanamori (LFK) index, and used a random model to determine the effect estimates (proportions and odds ratios) with a p value less than 0.05 and a 95% CI.

Results

Nineteen studies were included in the review. The pooled WTP on the continents was 66.0% (95% CI, 54.0-77.0%) before outlier studies were not excluded, but increased to 71.0% (95% CI, 68-75%) after excluding them. The factors influencing the WTP were categorized as socio-demographic factors, income and economic issues, information level and sources, illness and illness expenditure, health service factors, factors related to financing schemes, as well as social capital and solidarity. Age has been found to be consistently and negatively related to the WTP for NHI, while income level was an almost consistent positive predictor of it.

Conclusion

The WTP for NHI was moderate, while it was slightly higher in Africa than Asia and was found to be affected by various factors, with age being reported to be consistently and negatively related to it, while an increase in income level was almost a positive determinant of it.

Asymmetric nexus between pandemic uncertainty and public health spendings: Evidence from quantile estimation

The COVID-19 pandemic has brought significant challenges to healthcare systems worldwide, prompting governments to allocate substantial resources toward public health spendings (PHS). However, the uncertainties surrounding the pandemic have raised questions about the effectiveness and sustainability of such expenditures. This research analyzes the nonlinear link between pandemic uncertainty (PNU) and PHS in countries with highest PNU (USA, India, France, Germany, UK, Saudi Arabia, South Korea, Indonesia, Japan, and China). Previous studies have employed panel data methodologies to establish consistent findings regarding the relationship between pandemics and health spendings, regardless of the fact that several countries have not autonomously recognized this connection. In contrast, this current research adopts a distinctive tool called "quantile-on-quantile," which enables the examination of time series dependency within each economy, providing both international and country-specific perspectives on the relationship between the variables. The estimations indicate that PNU leads to an increase in PHS in the vast majority of economies chosen by us, focusing on definite segments of the data distribution. Moreover, the data demonstrates that there are differences in the asymmetry between the variables across various nations. This underscores the need for policymakers to take careful deliberation when formulating policies related to health spendings and addressing the challenges posed by pandemic uncertainty.

Global inequalities in availability of systemic therapies for cancer care and strategies to address them

Many Low and middle-income countries face challenges in delivering chemotherapy services due to limitations in infrastructure, inadequate healthcare facilities, and a shortage of trained medical professionals. High-income countries often have well-developed healthcare systems and advanced technology.

Integrated Real-World Study Databases in 3 Diverse Asian Health Care Systems in Taiwan, India, and Thailand: Scoping Review

BACKGROUND

The use of real-world data (RWD) warehouses for research in Asia is on the rise, but current trends remain largely unexplored. Given the varied economic and health care landscapes in different Asian countries, understanding these trends can offer valuable insights.

OBJECTIVE

We sought to discern the contemporary landscape of linked RWD warehouses and explore their trends and patterns in 3 Asian countries with contrasting economies and health care systems: Taiwan, India, and Thailand.

METHODS

Using a systematic scoping review methodology, we conducted an exhaustive literature search on PubMed with filters for the English language and the past 5 years. The search combined Medical Subject Heading terms and specific keywords. Studies were screened against strict eligibility criteria to identify eligible studies using RWD databases from more than one health care facility in at least 1 of the 3 target countries.

RESULTS

Our search yielded 2277 studies, of which 833 (36.6%) met our criteria. Overall, single-country studies (SCS) dominated at 89.4% (n=745), with cross-country collaboration studies (CCCS) being at 10.6% (n=88). However, the country-wise breakdown showed that of all the SCS, 623 (83.6%) were from Taiwan, 81 (10.9%) from India, and 41 (5.5%) from Thailand. Among the total studies conducted in each country, India at 39.1% (n=133) and Thailand at 43.1% (n=72) had a significantly higher percentage of CCCS compared to Taiwan at 7.6% (n=51). Over a 5-year span from 2017 to 2022, India and Thailand experienced an annual increase in RWD studies by approximately 18.2% and 13.8%, respectively, while Taiwan's contributions remained consistent. Comparative effectiveness research (CER) was predominant in Taiwan (n=410, or 65.8% of SCS) but less common in India (n=12, or 14.8% of SCS) and Thailand (n=11, or 26.8% of SCS). CER percentages in CCCS were similar across the 3 countries, ranging from 19.2% (n=10) to 29% (n=9). The type of RWD source also varied significantly across countries, with India demonstrating a high reliance on electronic medical records or electronic health records at 55.6% (n=45) of SCS and Taiwan showing an increasing trend in their use over the period. Registries were used in 26 (83.9%) CCCS and 31 (75.6%) SCS from Thailand but in <50% of SCS from Taiwan and India. Health insurance/administrative claims data were used in most of the SCS from Taiwan (n=458, 73.5%). There was a consistent predominant focus on cardiology/metabolic disorders in all studies, with a noticeable increase in oncology and infectious disease research from 2017 to 2022.

CONCLUSIONS

This review provides a comprehensive understanding of the evolving landscape of RWD research in Taiwan, India, and Thailand. The observed differences and trends emphasize the unique economic, clinical, and research settings in each country, advocating for tailored strategies for leveraging RWD for future health care research and decision-making.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/43741.