Rural-urban inequalities in health care utilization in Bhutan: a decomposition analysis.

BACKGROUND AND OBJECTIVE: On the trajectory towards universal health coverage in Bhutan, health equity requires policy attention as significant disparities exist between urban and rural health outcomes. This paper examines health services utilization patterns, inequalities and their socio-economic determinants in rural and urban areas and decomposes the factors behind these differences. METHODS: We used the Bhutan Living Standard Survey 2017 to profile health services utilization patterns and equalities. We employed two different decomposition analyses: decomposition of mean differences in utilization using the Oaxaca-Blinder decomposition framework and differences in the income-related distribution in utilization using recentered influence function regressions between rural and urban areas. RESULTS: Significant differences exist in the type of outpatient services used by the rural and urban population groups, with those living in rural areas having 3.4 times higher odds of using primary health centers compared to outpatient hospital care. We find that the use of primary health care is pro-poor and that outpatient hospital resources is concentrated among the more affluent section of the population, with this observed inequality consistent across settings but more severe in rural areas. The rural-urban gap in utilization is primarily driven by income and residence in the eastern region, while income-related inequality in utilization is influenced, aside from income, by residence in the central region, household size, and marriage and employment status of the household head. We do not find evidence of significant mean differences in overall utilization or inequality in utilization of inpatient health care services. CONCLUSIONS: While the differences in average contacts with health services are insignificant, there are prominent differences in the level of services availed and the associated inequality among rural and urban settings in Bhutan. Besides, while there are obvious overlaps, factors influencing income-related inequality are not necessarily the same as those driving the utilization gaps. Cognizance of these differences may lead to better informed, targeted, and potentially more effective future research and policies for universal health coverage.

Early and unintended pregnancy in Eastern and Southern Africa: analysis of adolescent sexual and reproductive health and rights policies.

In 2019, there were 21 million pregnancies among adolescents aged 15-19 years globally; close to half of these pregnancies were unintended. Early and unintended pregnancy (EUP) remains a pressing concern with severe socioeconomic and health outcomes for adolescent girls aged 15-19 years, their offspring and society. In Eastern and Southern Africa (ESA), Zambia, the United Republic of Tanzania, the Democratic Republic of Congo, Malawi and Uganda have adolescent fertility rates (AFR) of more than 100 live births per 1000 adolescent girls aged 15-19 years. Ministers of Health and Education, through the ESA Ministerial Commitment, aimed to reduce EUP by 75% by 2020; the renewed ESA Ministerial Commitment aims to reduce EUP by 40% by 2030. This descriptive policy content analysis assesses the prioritisation of EUP within adolescent sexual and reproductive health and rights (ASRHR) policies. An assessment of nine countries in the region shows that EUP is a key policy priority among countries; however, other than Kenya, the majority of ASRHR policies in the region do not set out clear and costed interventions for EUP, and few have monitoring and evaluation frameworks in place. Despite AFRs declining in Kenya and strong policies in place, the gains made are at risk due to the rollback on SRHR, and the country has not renewed the ESA Ministerial Commitment. This policy content analysis points towards the gaps we are still to meet within the universal health coverage agenda: better planning, prioritisation, sound policy frameworks and long-term commitments to meet the needs of adolescents.

Emergency care visits at a South African hospital: Implications for healthcare services and policy.

BACKGROUND:  A robust knowledge on the pattern of use of emergency care resources not only serves as an indicator of universal access to care but also provides a basis for quality improvement within the health system. This study was undertaken to describe the pattern of emergency room visits at Brits District Hospital (BDH) in North West province, South Africa. The objectives of this study were to determine the sociodemographic characteristics of emergency department (ED) users and other patterns of ED use. METHODS:  This was a cross-sectional descriptive study that was conducted at a district hospital. All patients who reported for emergency care in the ED in 2016 were eligible for the study. Data were extracted and analysed from a systematic sample of 355 clinical notes and hospital administrative records. RESULTS:  The age group that visited the ED most frequently (25.3%) was 25-34 years old. A high proportion of the ED users (60%) were self-referred, and only 38% were transported by the emergency medical response services (EMRS). Few (5.6%) presentations were of a non-urgent nature. Trauma-related conditions accounted for the most frequent presentation at the ED (36.5%). CONCLUSION:  Although most ED users were self-referred, their clinical presentations were appropriate and underscore the need for policy strategies to reduce the burden of trauma in the catchment populationContribution: The study findings may have an impact on future health policies by providing decision-makers with baseline information on the pattern of use of ED resources, ensuring better resource deployment and greater access to care.

The views of family physicians on National Health Insurance in Gauteng Province, South Africa.

BACKGROUND:  Universal health coverage (UHC) improves national health outcomes while addressing social inequalities in access to quality healthcare services. The district health system (DHS) is critical to the success of UHC in South Africa through the National Health Insurance (NHI) scheme. Family physicians (FPs), as champions of primary care, are central to the DHS operation and implementation of NHI. METHODS:  This was a qualitative exploratory study that used semi-structured interviews to explore FPs views and engagement on NHI policy and implementation in their districts. Ten FPs were included through purposive sampling. RESULTS:  Most of the FPs interviewed were not engaged in either policy formulation or strategic planning. The NHI bill was seen as a theoretical ideology that lacked any clear plan. Family physicians expressed several concerns around corruption in governmental structures that could play out in NHI implementation. Family physicians felt unsupported within their district structures and disempowered to engage in rollout strategies. The FPs were able to provide useful solutions to health system challenges because of the design of their training programmes, as well as their experience at the primary care level. CONCLUSION:  Healthcare governance in South Africa remains located in national and provincial structures. Devolution of governance to the DHS is required if NHI implementation is to succeed. The FPs need to be engaged in NHI strategies, to translate plans into actionable objectives at the primary care level.Contribution: This study highlights the need to involve FPs as key actors in implementing NHI strategies at a decentralised DHS governance level.

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OBJECTIVES: To evaluate the incidence rate of Duchenne muscular dystrophy (DMD) in the male newborns in the Ningxia region and establish a critical threshold for screening DMD in newborns to distinguish between the normal population and affected individuals. METHODS: A total of 10 000 male newborns were screened using immunofluorescence analysis of creatine kinase isoenzyme concentrations in heel spot dried blood specimens. Newborns with the concentrations higher than the critical threshold were recalled for serum creatine kinase measurements. Genetic testing was performed to confirm diagnosis in cases showing abnormalities. RESULTS: Among the screened 10 000 male newborns, two were confirmed to have DMD through genetic testing, resulting in a preliminary estimated incidence rate of 1/5 000 for male newborns in the Ningxia region. The critical threshold for creatine kinase isoenzyme concentration in newborns in this region was determined to be 468.57 ng/mL. CONCLUSIONS: Screening for DMD in newborns is feasible in the Ningxia region. Early screening, diagnosis, and treatment of DMD can improve the quality of life for affected individuals and help families make informed decisions regarding further pregnancies.

Concordance in Molecular Tumor Board Case Reviews in the ASCO TAPUR Study.

PURPOSE: With the advent of precision medicine, molecular tumor boards (MTBs) were established to interpret genomic results and guide decision making for targeted therapy in oncology patients. There are currently no universal guidelines for how MTBs should operate and thus variance can be seen depending on which MTB is reviewing the case. This study assesses the concordance of MTB recommendations when a participant case is reviewed by two different MTBs, establishes potential reasons for discordance, and advocates for the establishment of standard MTB operating guidelines. PATIENTS AND METHODS: Participants with advanced cancer, who had exhausted all standard treatment options were screened for the Targeted Agent and Profiling Utilization Registry (TAPUR) Study. Cases were submitted for MTB review if the treatment proposal was outside the protocol genomic matching rules, or if multiple treatment options were identified. Of the 306 cases submitted for review by the TAPUR MTB from 2016 to 2018, 107 were randomly selected for secondary review by a different MTB group. Recommendations from the original review were not disclosed. Concordance between MTB group recommendations was assessed. Concordance was defined as agreement between MTB reviews on the genomic alteration and study drug match proposed by the clinical site. Thematic qualitative analysis was conducted for the discordant cases to assess reasons for discordance. RESULTS: Complete or partial concordance was observed in 79% of cases (95% CI, 70 to 86; one-sided P = .25). Most discordant analyses were due to disagreements on the strength of evidence regarding efficacy of the proposed treatment (32%). CONCLUSION: When presented with identical participant cases, different MTB review groups make the same or similar treatment recommendations approximately 80% of the time.

Postpandemic Sentinel Surveillance of Respiratory Diseases in the Context of the World Health Organization Mosaic Framework: Protocol for a Development and Evaluation Study Involving the English Primary Care Network 2023-2024.

BACKGROUND: Prepandemic sentinel surveillance focused on improved management of winter pressures, with influenza-like illness (ILI) being the key clinical indicator. The World Health Organization (WHO) global standards for influenza surveillance include monitoring acute respiratory infection (ARI) and ILI. The WHO's mosaic framework recommends that the surveillance strategies of countries include the virological monitoring of respiratory viruses with pandemic potential such as influenza. The Oxford-Royal College of General Practitioner Research and Surveillance Centre (RSC) in collaboration with the UK Health Security Agency (UKHSA) has provided sentinel surveillance since 1967, including virology since 1993. OBJECTIVE: We aim to describe the RSC's plans for sentinel surveillance in the 2023-2024 season and evaluate these plans against the WHO mosaic framework. METHODS: Our approach, which includes patient and public involvement, contributes to surveillance objectives across all 3 domains of the mosaic framework. We will generate an ARI phenotype to enable reporting of this indicator in addition to ILI. These data will support UKHSA's sentinel surveillance, including vaccine effectiveness and burden of disease studies. The panel of virology tests analyzed in UKHSA's reference laboratory will remain unchanged, with additional plans for point-of-care testing, pneumococcus testing, and asymptomatic screening. Our sampling framework for serological surveillance will provide greater representativeness and more samples from younger people. We will create a biomedical resource that enables linkage between clinical data held in the RSC and virology data, including sequencing data, held by the UKHSA. We describe the governance framework for the RSC. RESULTS: We are co-designing our communication about data sharing and sampling, contextualized by the mosaic framework, with national and general practice patient and public involvement groups. We present our ARI digital phenotype and the key data RSC network members are requested to include in computerized medical records. We will share data with the UKHSA to report vaccine effectiveness for COVID-19 and influenza, assess the disease burden of respiratory syncytial virus, and perform syndromic surveillance. Virological surveillance will include COVID-19, influenza, respiratory syncytial virus, and other common respiratory viruses. We plan to pilot point-of-care testing for group A streptococcus, urine tests for pneumococcus, and asymptomatic testing. We will integrate test requests and results with the laboratory-computerized medical record system. A biomedical resource will enable research linking clinical data to virology data. The legal basis for the RSC's pseudonymized data extract is The Health Service (Control of Patient Information) Regulations 2002, and all nonsurveillance uses require research ethics approval. CONCLUSIONS: The RSC extended its surveillance activities to meet more but not all of the mosaic framework's objectives. We have introduced an ARI indicator. We seek to expand our surveillance scope and could do more around transmissibility and the benefits and risks of nonvaccine therapies.

A mixed methods systematic literature review of barriers and facilitators to help-seeking among women with stigmatised pelvic health symptoms.

BACKGROUND: Women's pelvic health is a globally important subject, included in international and United Kingdom health policies, emphasising the importance of improving information and access to pelvic health services. Consequences of pelvic symptoms are intimate, personal, and varied, often causing embarrassment and shame, affecting women's quality of life and wellbeing. AIM: To understand the experience of seeking healthcare for stigmatised pelvic health symptoms by synthesising all types of published primary research and mapping the results to behavioural theory, to identify potential targets for intervention. METHODS: Systematic search of MEDLINE, CINAHL, PsycINFO, SocINDEX, PubMED databases, CDSR and CENTRAL registers, from inception to May 2023 for all types of research capturing women's views and experiences of seeking help with stigmatised urogenital and bowel symptoms. Studies only reporting prevalence, predictors of help-seeking, non-health related help-seeking, or written in languages other than English, German, French, Spanish and Swedish were excluded. Reference checking and forward citation searching for all included studies was performed. A results-based synthesis approach was used to integrate quantitative and qualitative data. Themes were mapped to the Common-Sense model and Candidacy framework. The Mixed Methods Appraisal Tool was used for critical appraisal. Grading of Recommendations Assessment, Development and Evaluation - Confidence in Evidence from Reviews of Qualitative research for assessing certainty of review findings. RESULTS: 86 studies representing over 20,000 women from 24 high income countries were included. Confidence was high that barriers to help-seeking were similar across all study types and pelvic symptoms: stigma, lack of knowledge, women's perception that clinicians dismissed their symptoms, and associated normalising and deprioritising of low bother symptoms. Supportive clinicians and increased knowledge were key facilitators. CONCLUSIONS: Using the Common-Sense Model to explore women's help-seeking behaviour with stigmatised pelvic symptoms reveals problems with cognitive representation of symptom identity, emotional representations of embarrassment and shame, and a subjective norm that women believe their symptoms will be trivialised by clinicians. Together these barriers frustrate women's identification of their candidacy for healthcare. Addressing these issues through behavioural change interventions for women and clinicians, will help to achieve universal access to pelvic healthcare services (United Nations Sustainable Development Goal 3.7). SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021256956.

Medical Insurance Representatives Perceptions on National Health Insurance Primary Healthcare Re-Engineering in South Africa: A Qualitative Study.

The South African government is moving toward universal health coverage (UHC) with the passing of the National Health Insurance (NHI) Bill. Access to quality primary healthcare (PHC) is the cornerstone of UHC principles. The South African governmental health department have begun focusing efforts on improving the efficiency and functionality of this system; that includes the involvement of private healthcare professionals and medical insurance companies. This study sought to explore perceptions of medical insurance company personnel on PHC re-engineering as part of NHI restructuring. A qualitative research design was adopted in this study. Semi-structured interviewed were conducted on 10 participants. Their responses were audio recorded and transcribed utilizing Microsoft Word® documents. Nvivo® was used to facilitate the analysis of data. A thematical approach was used to categories codes into themes. Although participants were in agreement with the current healthcare reform in South Africa. The findings of this study have highlighted several gaps in the NHI Bill at the current point in time. In order to achieve standardized quality of care at a primary level; it is imperative that reimbursement frameworks with clearly detailed service provision and accountability guidelines are developed.

Area-based disparities in non-small-cell lung cancer survival.

BACKGROUND: In the Nordic countries, universal healthcare access has been effective in reducing socioeconomic disparities in non-small-cell lung cancer (NSCLC) management. However, other factors, such as proximity to healthcare facilities, may still affect access to care. This study aimed at investigating the influence of residential area on NSCLC survival. METHODS: This population-based study utilized hospital records to identify NSCLC patients who underwent their initial treatment at Vaasa Central Hospital between January 1, 2016, and December 31, 2020. Patients were categorized based on their postal codes into urban areas (≤50 km from the hospital) and rural areas (>50 km from the hospital). Survival rates between these two groups were compared using Cox regression analysis. RESULTS: A total of 321 patients were included in the study. Patients residing in rural areas (n = 104) exhibited poorer 12-month survival rates compared to their urban counterparts (n = 217) (unadjusted Hazard Ratio [HR]: 1.38; 95% Confidence Interval [CI]: 1.01-1.89; p = 0.042). After adjusting for factors such as performance status, frailty, and stage at diagnosis in a multivariate Cox regression model, the adjusted HR increased to 1.47 (95% CI: 1.07-2.01; p = 0.017) for patients living in rural areas compared to those in urban areas. INTERPRETATION: The study findings indicate that the distance to the hospital is associated with increased lung cancer mortality. This suggests that geographical proximity may play a crucial role in the disparities observed in NSCLC survival rates. Addressing these disparities should involve strategies aimed at improving healthcare accessibility, particularly for patients residing in rural areas, to enhance NSCLC outcomes and reduce mortality.

Adolescent HIV Screening and Opt-Out Testing as a Standard of Care.

Despite the significant steps made in the diagnosis and treatment of HIV, there is still a notable amount of people living with HIV without being diagnosed, with a fair portion of these infections occurring in adolescents and young adults. For some individuals, by the time they are diagnosed they are living with advanced-staged disease, missing the opportunity for receiving antiretroviral treatment that would have markedly reduced their morbidity, mortality, and risk of transmission to others. Opt-out testing, or notifying the patient the test will be performed unless explicitly declined or deferred, increases the rates of testing while reducing the stigma of the disease. It is a universal recommendation for those between ages 13 and 55 years to have an HIV screening test. It should be standard of care for HIV tests in the adolescent population to be structured as an opt-out screening in both the ambulatory and acute care settings. [Pediatr Ann. 2024;53(4):e111-e113.].

Program evaluation of a school-based mental health and wellness curriculum featuring yoga and mindfulness.

BACKGROUND: Interest in the effectiveness of mindfulness-based interventions such as yoga in primary schools has grown. Evidence shows promise, as youth who engage in yoga to promote mindfulness show improved coping skills, increased socio-emotional competence and prosocial skills, academic performance, attention span, and ability to deal with stress. OBJECTIVE: This study reports the results of a program evaluation of a universal health and wellness curriculum, Pure Power, designed to teach youth yoga techniques, mindfulness, and emotion regulation. METHODS: A non-randomized comparison design examined outcomes among participants from schools that completed the intervention with highest fidelity of implementation (n = 461) and from students in matched comparison schools (n = 420). Standard measures of coping, emotion regulation and emotion dysregulation, spelling, and math achievement were collected. RESULTS: Analyses suggest the youth in the intervention schools demonstrated relative improvement on measures of emotion regulation, spelling, and math. CONCLUSIONS: Challenges in implementation in real-life settings are vital to identify. The data provide some real-world evidence for the effectiveness of a universal health and wellness curriculum on emotion regulation and positive academic outcomes. Training school staff to deliver the intervention may foster implementation. Future research should test the effectiveness of who delivers the intervention; for example, teacher-delivered groups vs. other wellness personnel.

Low long-lasting insecticidal net use in malaria elimination areas in Southern Ethiopia: results from community based cross-sectional study.

BACKGROUND: Despite remarkable progress in malaria burden reduction, malaria continues to be a major public health problem globally. Ethiopia has been distributing long-lasting insecticidal nets (LLINs) for free and nationwide distribution was completed in 2016. However, evidence suggests that the utilization of LLINs varies from setting to setting and from time to time due to different factors, and up-to-date evidence is required for LLIN related decision-making. Hence, this study was designed to assess LLIN utilization and its determinants in the Southern Nations, Nationalities, and People's Region (SNNPR) of Ethiopia. METHODS: A community-based cross-sectional study was conducted in Southern Ethiopia in 2019. Using multi-stage sampling, a total of 2466 households were included. The region was stratified based on the annual malaria index as high, moderate, low, and free strata. Cluster sampling was then applied to select households from high, moderate, and low strata. Data on LLIN ownership, utilization and different determinant factors were collected using household questionnaire. SurveyCTO was used to collect data and data was managed using Stata 15. Descriptive statistics and multilevel mixed-effects logistic regression were performed to identify the determinants of utilization of LLINs. Effect measures were reported using adjusted odds ratio (AOR) with 95% CI. RESULTS: From a total of 2466 households, 48.7% of households had at least one LLIN. LLIN adequacy based on family size was 23% while it was15.7% based on universal access and 29.2% based on sleeping space. From 1202 households that possessed LLIN(s), 66.0% of households reported that they slept under LLIN the night preceding the survey. However, when the total population in all surveyed households were considered, only 22.9% of household members slept under LLIN the night preceding the survey. Malaria endemicity, educational status, wealth status, and knowledge about malaria were associated with LLINs utilization. In addition, reasons for non-use included perceived absence of malaria, side effects of LLIN, conditions of LLINs, inconvenient space and low awareness. CONCLUSION: Low LLIN coverage and low utilization were noted. A low level of utilization was associated with malaria endemicity, wealth status and level of awareness. Distribution of LLIN and continuous follow-up with community awareness creation activities are vital to improve coverage and utilization of LLINs, and to ensure the country's malaria elimination goal.

Availability and readiness of healthcare facilities and their effects on antenatal care services uptake in Bangladesh.

BACKGROUND: Sustainable Development Goal (SDG) 3.7 aims to ensure universal access to sexual and reproductive healthcare services, where antenatal care (ANC) is a core component. This study aimed to examine the influence of health facility availability and readiness on the uptake of four or more ANC visits in Bangladesh. METHODS: The 2017/18 Bangladesh Demographic and Health Survey data were linked with the 2017 Health Facility Survey and analyzed in this study. The associations of health facility-level factors with the recommended number of ANC uptakes were determined. A multilevel mixed-effect logistic regression model was used to determine the association, adjusting for potential confounders. RESULTS: Nearly 44% of mothers reported four or more ANC uptakes, with significant variations across several areas in Bangladesh. The average distance of mothers' homes from the nearest health facilities was 6.36 km, higher in Sylhet division (8.25 km) and lower in Dhaka division (4.45 km). The overall uptake of the recommended number of ANC visits was positively associated with higher scores for the management (adjusted odds ratio (aOR) 1.85; 95% CI, 1.16-2.82) and infrastructure (aOR, 1.59; 95% CI, 1.09-2.19) of health facilities closest to mothers' homes. The odds of using the recommended number of ANC in mothers increased by 3.02 (95% CI, 2.01-4.19) and 2.36 (95% CI, 2.09-3.16) folds for each unit increase in the availability and readiness scores to provide ANC services at the closest health facilities, respectively. Every kilometer increase in the average regional-level distance between mothers' homes and the nearest health facilities reduced the likelihood of receiving the recommended number of ANC visits by nearly 42% (aOR, 0.58, 95% CI, 0.42-0.74). CONCLUSION: The availability of healthcare facilities close to residence, as well as their improved management, infrastructure, and readiness to provide ANC, plays a crucial role in increasing ANC services uptake. Policies and programs should prioritize increasing the availability, accessibility, and readiness of health facilities to provide ANC services.

Concept analysis of health system resilience.

BACKGROUND: There are several definitions of resilience in health systems, many of which share some characteristics, but no agreed-upon framework is universally accepted. Here, we review the concept of resilience, identifying its definitions, attributes, antecedents and consequences, and present the findings of a concept analysis of health system resilience. METHODS: We follow Schwarz-Barcott and Kim's hybrid model, which consists of three phases: theoretical, fieldwork and final analysis. We identified the concept definitions, attributes, antecedents and consequences of health system resilience and constructed an evidence-informed framework on the basis of the findings of this review. We searched PubMed, PsycINFO, CINAHL Complete, EBSCOhost-Academic Search and Premier databases and downloaded identified titles and abstracts on Covidence. We screened 3357 titles and removed duplicate and ineligible records; two reviewers then screened each title, and disagreements were resolved by discussion with the third reviewer. From the 130 eligible manuscripts, we identified the definitions, attributes, antecedents and consequences using a pre-defined data extraction form. RESULTS: Resilience antecedents are decentralization, available funds, investments and resources, staff environment and motivation, integration and networking and finally, diversification of staff. The attributes are the availability of resources and funds, adaptive capacity, transformative capacity, learning and advocacy and progressive leadership. The consequences of health system resilience are improved health system performance, a balanced governance structure, improved expenditure and financial management of health and maintenance of health services that support universal health coverage (UHC) throughout crises. CONCLUSION: A resilient health system maintains quality healthcare through times of crisis. During the coronavirus disease 2019 (COVID-19) epidemic, several seemingly robust health systems were strained under the increased demand, and services were disrupted. As such, elements of resilience should be integrated into the functions of a health system to ensure standardized and consistent service quality and delivery. We offer a systematic, evidence-informed method for identifying the attributes of health system resilience, intending to eventually be used to develop a measuring tool to evaluate a country's health system resilience performance.

Advancing disability-inclusive climate research and action, climate justice, and climate-resilient development.

Globally, more than 1 billion people with disabilities are disproportionately and differentially at risk from the climate crisis. Yet there is a notable absence of climate policy, programming, and research at the intersection of disability and climate change. Advancing climate justice urgently requires accelerated disability-inclusive climate action. We present pivotal research recommendations and guidance to advance disability-inclusive climate research and responses identified by a global interdisciplinary group of experts in disability, climate change, sustainable development, public health, environmental justice, humanitarianism, gender, Indigeneity, mental health, law, and planetary health. Climate-resilient development is a framework for enabling universal sustainable development. Advancing inclusive climate-resilient development requires a disability human rights approach that deepens understanding of how societal choices and actions-characterised by meaningful participation, inclusion, knowledge diversity in decision making, and co-design by and with people with disabilities and their representative organisations-build collective climate resilience benefiting disability communities and society at large while advancing planetary health.

The unique identifier as one of the essential tools for steering universal health coverage: The case of Morocco / L'identifiant unique comme un des instruments indispensables au pilotage de la couverture sanitaire universelle, le cas du Maroc.

INTRODUCTION: Morocco is carrying out several actions to generalize basic compulsory health insurance (CHI). Managing this project requires coordination, information sharing, and the commitment of all actors to the goal of covering an additional 22 million people. One of the key factors for achieving this objective is the implementation of a unified registration system. PURPOSE OF THE RESEARCH: The aim is to analyze the existing situation and the feasibility of implementing a unified registration system, and to describe the potential positive impact of the latter on the extension of CHI. RESULTS: This work is based on a diagnosis of the current situation. It draws on the legal framework, all available documents and figures, and on an analytical reading supported by existing literature. It reveals that due to the inadequacy or even the absence of an appropriate legal basis, each managing body has its own registration system. The lack of a unified system has given rise to a number of constraints. These concern, among other things: (i) mobility between or within schemes, which does not operate smoothly because it leads to re-registration (ii) inadequate monitoring of double benefit claims, which is the case for more than one scheme, due to insufficient and hesitant anti-fraud action (iii) the sharing and use of reliable data, which hinders decision making, evaluation, and monitoring. CONCLUSIONS: It is essential to adopt legal texts that will provide the basis for a unified system with regulations enabling the participation of all stakeholders, with the aim of steering the roll-out of CHI effectively and efficiently.

Introduction: Le Maroc mène, depuis quelques années, plusieurs actions permettant de généraliser l'assurance maladie obligatoire (AMO). Le pilotage de ce chantier nécessite la coordination, le partage d'informations et l'engagement de tous les acteurs afin de couvrir 22 millions de personnes supplémentaires. L'un des éléments clés pour optimiser la réalisation de cet objectif consiste à mettre en place un système unifié d'immatriculation. But de l'étude: Analyser l'existant et la faisabilité de la mise en place d'un système unifié d'immatriculation, tout en précisant ses retombées positives sur l'extension de l'AMO. Résultats: Ce travail, fondé sur un diagnostic, appuyé par l'arsenal juridique, des documents et des chiffres disponibles ainsi qu'une lecture analytique renforcée par la littérature existante, a permis de constater que, du fait de l'insuffisance voire l'absence d'un soubassement juridique adapté, chaque organisme gestionnaire a son propre système d'immatriculation. L'absence d'un système unifié gêne notamment : 1) la mobilité entre régimes ou intra-régimes, étant donné qu'elle ne se fait pas de manière fluide car elle génère la ré-immatriculation ; 2) le contrôle du double bénéfice d'un régime insuffisamment organisé et incapable de lutter contre la fraude ; 3) le partage et l'exploitation de données fiables empêchant d'assurer de manière appropriée le suivi, l'évaluation et la prise de décision. Conclusion: Il est indispensable d'adopter des textes juridiques pour fonder un système unifié qui permettra l'encadrement et l'engagement de toutes les parties prenantes dans l'objectif de piloter la généralisation de l'AMO avec efficacité et efficience.

The impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries: a systematic review of the evidence.

BACKGROUND: Low- and middle-income countries have committed to achieving universal health coverage (UHC) as a means to enhance access to services and improve financial protection. One of the key health financing reforms to achieve UHC is the introduction or expansion of health insurance to enhance access to basic health services, including maternal and reproductive health care. However, there is a paucity of evidence of the extent to which these reforms have had impact on the main policy objectives of enhancing service utilization and financial protection. The aim of this systematic review is to assess the existing evidence on the causal impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries. METHODS: The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search included six databases: Medline, Embase, Web of Science, Cochrane, CINAHL, and Scopus as of 23rd May 2023. The keywords included health insurance, impact, utilisation, financial protection, and maternal and reproductive health. The search was followed by independent title and abstract screening and full text review by two reviewers using the Covidence software. Studies published in English since 2010, which reported on the impact of health insurance on maternal and reproductive health utilisation and or financial protection were included in the review. The ROBINS-I tool was used to assess the quality of the included studies. RESULTS: A total of 17 studies fulfilled the inclusion criteria. The majority of the studies (82.4%, n = 14) were nationally representative. Most studies found that health insurance had a significant positive impact on having at least four antenatal care (ANC) visits, delivery at a health facility and having a delivery assisted by a skilled attendant with average treatment effects ranging from 0.02 to 0.11, 0.03 to 0.34 and 0.03 to 0.23 respectively. There was no evidence that health insurance had increased postnatal care, access to contraception and financial protection for maternal and reproductive health services. Various maternal and reproductive health indicators were reported in studies. ANC had the greatest number of reported indicators (n = 10), followed by financial protection (n = 6), postnatal care (n = 5), and delivery care (n = 4). The overall quality of the evidence was moderate based on the risk of bias assessment. CONCLUSION: The introduction or expansion of various types of health insurance can be a useful intervention to improve ANC (receiving at least four ANC visits) and delivery care (delivery at health facility and delivery assisted by skilled birth attendant) service utilization in low- and lower-middle-income countries. Implementation of health insurance could enable countries' progress towards UHC and reduce maternal mortality. However, more research using rigorous impact evaluation methods is needed to investigate the causal impact of health insurance coverage on postnatal care utilization, contraceptive use and financial protection both in the general population and by socioeconomic status. TRIAL REGISTRATION: This study was registered with Prospero (CRD42021285776).

Modelling spatiotemporal variation in under-five malaria risk in Ghana in 2016-2021.

BACKGROUND: Ghana is among the top 10 highest malaria burden countries, with about 20,000 children dying annually, 25% of which were under five years. This study aimed to produce interactive web-based disease spatial maps and identify the high-burden malaria districts in Ghana. METHODS: The study used 2016-2021 data extracted from the routine health service nationally representative and comprehensive District Health Information Management System II (DHIMS2) implemented by the Ghana Health Service. Bayesian geospatial modelling and interactive web-based spatial disease mapping methods were employed to quantify spatial variations and clustering in malaria risk across 260 districts. For each district, the study simultaneously mapped the observed malaria counts, district name, standardized incidence rate, and predicted relative risk and their associated standard errors using interactive web-based visualization methods. RESULTS: A total of 32,659,240 malaria cases were reported among children < 5 years from 2016 to 2021. For every 10% increase in the number of children, malaria risk increased by 0.039 (log-mean 0.95, 95% credible interval = - 13.82-15.73) and for every 10% increase in the number of males, malaria risk decreased by 0.075, albeit not statistically significant (log-mean - 1.82, 95% credible interval = - 16.59-12.95). The study found substantial spatial and temporal differences in malaria risk across the 260 districts. The predicted national relative risk was 1.25 (95% credible interval = 1.23, 1.27). The malaria risk is relatively the same over the entire year. However, a slightly higher relative risk was recorded in 2019 while in 2021, residing in Keta, Abuakwa South, Jomoro, Ahafo Ano South East, Tain, Nanumba North, and Tatale Sanguli districts was associated with the highest malaria risk ranging from a relative risk of 3.00 to 4.83. The district-level spatial patterns of malaria risks changed over time. CONCLUSION: This study identified high malaria risk districts in Ghana where urgent and targeted control efforts are required. Noticeable changes were also observed in malaria risk for certain districts over some periods in the study. The findings provide an effective, actionable tool to arm policymakers and programme managers in their efforts to reduce malaria risk and its associated morbidity and mortality in line with the Sustainable Development Goals (SDG) 3.2 for limited public health resource settings, where universal intervention across all districts is practically impossible.