Financial issues in times of a COVID-19 pandemic in a tertiary hospital in Mali.

BACKGROUND: This study examines how the functioning of healthcare providers during the COVID-19 pandemic was affected by the government financing response, which was shaped by existing healthcare financing systems. METHODS: The study applied a single case study design at a tertiary hospital in Bamako during the 1st and 2nd waves of the COVID-19 pandemic. Data were gathered through 51 in-depth interviews with hospital staff, participatory observation, and reviewing media articles and hospital financial records. RESULTS: The study revealed the disruptions experienced by hospital managers, human resources for health and patients in Mali during the early stages of the pandemic. While the government aimed to support universal access to COVID-19-related services, efforts were undermined by issues associated with complex public financing management procedures. The hospital experienced long delays in transferring government funds. The hospital suffered a decrease in revenue during the early stages of the pandemic. Government budgets were not effectively used because of complex, non-agile procedures that could not adapt to the emergency. The challenges faced by the hospitals led to the delays in the staff payments of salaries and promised bonuses, which created potential for unfair treatment of patients. Excluding some COVID-19 related items from the government funded benefit package created a financial burden on people receiving services. The managerial challenges experienced in the study hospital during the first wave continued in the second wave. CONCLUSIONS: Pre-existent issues in healthcare financing and governance constrained the effective management of COVID-19-related services and created confusion at the front line of healthcare service delivery.

Learning from public health and hospital resilience to the SARS-CoV-2 pandemic: protocol for a multiple case study (Brazil, Canada, China, France, Japan, and Mali).

BACKGROUND: All prevention efforts currently being implemented for COVID-19 are aimed at reducing the burden on strained health systems and human resources. There has been little research conducted to understand how SARS-CoV-2 has affected health care systems and professionals in terms of their work. Finding effective ways to share the knowledge and insight between countries, including lessons learned, is paramount to the international containment and management of the COVID-19 pandemic. The aim of this project is to compare the pandemic response to COVID-19 in Brazil, Canada, China, France, Japan, and Mali. This comparison will be used to identify strengths and weaknesses in the response, including challenges for health professionals and health systems. METHODS: We will use a multiple case study approach with multiple levels of nested analysis. We have chosen these countries as they represent different continents and different stages of the pandemic. We will focus on several major hospitals and two public health interventions (contact tracing and testing). It will employ a multidisciplinary research approach that will use qualitative data through observations, document analysis, and interviews, as well as quantitative data based on disease surveillance data and other publicly available data. Given that the methodological approaches of the project will be largely qualitative, the ethical risks are minimal. For the quantitative component, the data being used will be made publicly available. DISCUSSION: We will deliver lessons learned based on a rigorous process and on strong evidence to enable operational-level insight for national and international stakeholders.

Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya.

BACKGROUND: Kenya has prioritized the attainment of universal health coverage (UHC) through the expansion of health insurance coverage by the National Hospital Insurance Fund (NHIF). In 2015, the NHIF introduced reforms in premium contribution rates, benefit packages, and provider payment methods. We examined the influence of these reforms on NHIF's purchasing practices and their implications for strategic purchasing and health system goals of equity, efficiency and quality. METHODS: We conducted an embedded case study with the NHIF as the case and the reforms as embedded units of analysis. We collected data at the national level and in two purposively selected counties through 41 in-depth interviews with health financing stakeholders, facility managers and frontline providers; 4 focus group discussions with 51 NHIF members; and, document reviews. We analysed the data using a Framework approach. RESULTS: The new NHIF reforms were characterized by weak purchasing actions. Firstly, the new premium contribution rates were inadequately communicated and unaffordable for certain citizen groups. Secondly, while the new benefit packages were reported to be based on service needs, preferences and values of the population, they were inadequately communicated and unequally distributed across different citizen groups. In addition, the presence of service delivery infrastructure gaps in public healthcare facilities and the pro-urban and pro-private distribution of contracted health facilities compromised delivery of, and access to, these new services. Lastly, the new provider payment methods and rates were considered inadequate, with delayed payments and weak links to financial accountability mechanisms which compromised their ability to incentivize equity, efficiency and quality of healthcare delivery. CONCLUSION: While NHIF sought to expand population and service coverage and reduce out-of-pocket payments with the new reforms, weaknesses in the reforms' design and implementation limited NHIF's purchasing actions with negative implications for the health system goals of equity, efficiency and quality. For the reforms to accelerate the country's progress towards UHC, policy makers at the NHIF and, national and county government should make deliberate efforts to align the design and implementation of such reforms with strategic purchasing actions that are aimed at improving health system goals.

For more than money: willingness of health professionals to stay in remote Senegal.

BACKGROUND: Poor distribution of already inadequate numbers of health professionals seriously constrains equitable access to health services in low- and middle-income countries. The Senegalese Government is currently developing policy to encourage health professionals to remain in areas defined as 'difficult'. Understanding health professional's preferences is crucial for this policy development. METHODS: Working with the Senegalese Government, a choice experiment (CE) was developed to elicit the job preferences of physicians and non-physicians. Attributes were defined using a novel mixed-methods approach, combining interviews and best-worst scaling (Case 1). Six attributes were categorised as 'individual (extrinsic) incentive' attributes ('type of contract', 'provision of training opportunities', 'provision of an allowance' and 'provision of accommodation') or 'functioning health system' attributes ('availability of basic equipment in health facilities' and 'provision of supportive supervision by health administrators'). Using face-to-face interviews, the CE was administered to 55 physicians (3909 observations) and 246 non-physicians (17 961 observations) randomly selected from those working in eight 'difficult' regions in Senegal. Conditional logit was used to analyse responses. This is the first CE to both explore the impact of contract type on rural retention and to estimate value of attributes in terms of willingness to stay (WTS) in current rural post. RESULTS: For both physicians and non-physicians, a permanent contract is the most important determinant of rural job retention, followed by availability of equipment and provision of training opportunities. Retention probabilities suggest that policy reform affecting only a single attribute is unlikely to encourage health professionals to remain in 'difficult' regions. The relative importance of an allowance is low; however, the level of such financial incentives requires further investigation. CONCLUSION: Contract type is a key factor impacting on retention. This has led the Senegalese Health Ministry to introduce a new rural assignment policy that recruits permanent staff from the pool of annually contracted healthcare professionals on the condition that they take up rural posts. While this is a useful policy development, further efforts to retain rural health workers, considering both personal incentives and the functioning of health systems, are necessary to ensure health worker numbers are adequate to meet the needs of rural communities.

Detection of unusual very-long-chain fatty acid and ether lipid derivatives in the fibroblasts and plasma of patients with peroxisomal diseases using liquid chromatography-mass spectrometry.

Metabolic changes occur in patients with peroxisomal diseases owing to impairments in the genes involved in peroxisome function. For diagnostic purposes, saturated very-long-chain fatty acids (VLCFAs) such as C24:0 and C26:0, phytanic acid, pristanic acid, and plasmalogens are often measured as metabolic hallmarks. As the direct pathology of peroxisomal disease is yet to be fully elucidated, we sought to explore the fatty acid species that accumulate in patients with peroxisomal diseases. We developed a method for detecting a range of fatty acids implicated in peroxisomal diseases such as Zellweger syndrome (ZS) and X-linked adrenoleukodystrophy (X-ALD). To this end, we employed an ultra-performance liquid chromatography-mass spectrometry (LC-MS) coupled with negatively charged electrospray ionization. Fatty acids from patients and control subjects were extracted from total lipids by acid-hydrolysis and compared. In accordance with previous results, the amounts of VLCFAs, phytanic acid, and pristanic acid differed between the two groups. We identified extremely long and highly polyunsaturated VLCFAs (ultra-VLC-PUFAs) such as C44:12 in ZS samples. Moreover, three unknown molecules were prominent in control samples but scarcely detectable in ZS samples. LC-MS/MS analysis identified these as 1-alkyl-sn-glycerol 3-phosphates derived from ether lipids containing fatty alcohols such as C16:0, C18:0, or C18:1. Our method provides an approach to observing a wide range of lipid-derived fatty acids and related molecules in order to understand the metabolic changes involved in peroxisomal diseases. This technique can therefore be used in identifying metabolic markers and potential clinical targets for future treatment.

Do beneficiaries' views matter in healthcare purchasing decisions? Experiences from the Nigerian tax-funded health system and the formal sector social health insurance program of the National Health Insurance Scheme.

BACKGROUND: Purchasing is a health financing function that involves the transfer of pooled resources to providers on behalf of a covered population. Little attention has been paid to the extent to which the views of that population  are reflected in purchasing decisions. This article explores how purchasers in two financing mechanisms: the Formal Sector Social Health Insurance Programme (FSSHIP) operating under the Nigerian National Health Insurance Scheme (NHIS), and the tax-funded health system perform their roles in light of their responsibilities to the populations. METHODS: A case study approach was adopted in which each financing mechanism is a case. Sixteen (16) in-depth interviews with purchasers and eight (8) focus group discussions with beneficiaries were held. Agency and organizational behavioural theories were used to characterise the purchaser-citizen relationships. A deductive framework approach was used to assess whether actions identified in a model of 'ideal' strategic purchasing actions were undertaken in each case. RESULTS: For both cases, mechanisms exist to reflect people's health needs in purchasing decisions, including quantitative and qualitative needs assessment, mechanisms to raise awareness of benefit entitlements and allow choice. However, purchasers do not use the mechanisms to effectively engage with and hold themselves accountable to the people. In the tax-funded system, weak information systems and unclear communication channels between the purchaser and citizens constrain assessment of needs; while timeliness of health information and poor engagement practices of Health Maintenance Organisations (HMOs) are the main constraints in FSSHIP. Inadequate information sharing in both mechanisms limits beneficiaries' awareness of entitlements. Although beneficiaries of FSSHIP can choose providers, lack of information on the quality of services offered by providers constrains rational decision-making and the inability to change HMOs reduces HMO responsiveness to beneficiary needs. CONCLUSIONS: Responsiveness and accountability to beneficiaries are undervalued by purchasers in both financing mechanisms. In the tax-funded system, civil society organisations can facilitate engagement and accountability of purchasers and the people. In FSSHIP, NHIS needs to provide stronger stewardship of HMOs to promote effective engagement with members. Furthermore, the NHIS should introduce mechanisms that allow FSSHIP members to choose their own HMO, which could encourage HMOs to be more responsive to members.

New members of the mammalian glycerophosphodiester phosphodiesterase family: GDE4 and GDE7 produce lysophosphatidic acid by lysophospholipase D activity.

The known mammalian glycerophosphodiester phosphodiesterases (GP-PDEs) hydrolyze glycerophosphodiesters. In this study, two novel members of the mammalian GP-PDE family, GDE4 and GDE7, were isolated, and the molecular basis of mammalian GP-PDEs was further explored. The GDE4 and GDE7 sequences are highly homologous and evolutionarily close. GDE4 is expressed in intestinal epithelial cells, spermatids, and macrophages, whereas GDE7 is particularly expressed in gastro-esophageal epithelial cells. Unlike other mammalian GP-PDEs, GDE4 and GDE7 cannot hydrolyze either glycerophosphoinositol or glycerophosphocholine. Unexpectedly, both GDE4 and GDE7 show a lysophospholipase D activity toward lysophosphatidylcholine (lyso-PC). We purified the recombinant GDE4 and GDE7 proteins and show that these enzymes can hydrolyze lyso-PC to produce lysophosphatidic acid (LPA). Further characterization of purified recombinant GDE4 showed that it can also convert lyso-platelet-activating factor (1-O-alkyl-sn-glycero-3-phosphocholine; lyso-PAF) to alkyl-LPA. These data contribute to our current understanding of mammalian GP-PDEs and of their physiological roles via the control of lyso-PC and lyso-PAF metabolism in gastrointestinal epithelial cells and macrophages.

A mother's choice: a qualitative study of mothers' health seeking behaviour for their children with acute diarrhoea.

BACKGROUND: Diarrhoea presents a considerable health risk to young children and is one of the leading causes of infant mortality. Although proven cost-effective interventions exist, South Africa is yet to reach the Sustainable Development Goals set for the elimination of preventable under-five mortality and water-borne diseases. The rural study area in the Eastern Cape of South Africa continues to have a parallel health system comprising traditional and modern healthcare services. It is in this setting that this study aimed to qualitatively examine the beliefs surrounding and perceived quality of healthcare accessed for children's acute diarrhoea. METHODS: Purposive sampling was used to select participants for nine focus-group-discussions with mothers of children less than 5 years old and 11 key-informant-interviews with community members and traditional and modern practitioners. The focus-group-discussions and interviews were held to explore the reasons why mothers seek certain types of healthcare for children with diarrhoea. Data was analysed using manual thematic coding methods. RESULTS: It was found that seeking healthcare from traditional practitioners is deeply ingrained in the culture of the society. People's beliefs about the causative agents of diarrhoea are at the heart of seeking care from traditional practitioners, often in order to treat supposed supernatural causes. A combination of care-types is acceptable to the community, but not necessarily to modern practitioners, who are concerned about the inclusion of unknown ingredients and harmful substances in some traditional medicines, which could be toxic to children. These factors highlight the complexity of regulating traditional medicine. CONCLUSION: South African traditional practitioners can be seen as a valuable human resource, especially as they are culturally accepted in their communities. However due to the variability of practices amongst traditional practitioners and some reluctance on the part of modern practitioners regulation and integration may prove complex.

Incentives for non-physician health professionals to work in the rural and remote areas of Mozambique--a discrete choice experiment for eliciting job preferences.

BACKGROUND: Successfully motivating and retaining health workers is critical for the effective performance of health systems. In Mozambique, a shortage of health care professionals and low levels of staff motivation in rural and remote areas pose challenges to the provision of equitable health care delivery. This study provides quantitative information on the job preferences of non-physician health professionals in Mozambique, examining how different aspects of jobs are valued and how health professionals might respond to policy options that would post them to district hospitals in rural areas. METHODS: The study used a discrete choice experiment (DCE) to elicit the job preferences of non-physician health professionals. Data collection took place in four Mozambique provinces: Maputo City, Maputo Province, Sofala and Nampula. DCE questionnaires were administered to 334 non-physician health professionals with specialized or university training ('mid-level specialists' and N1 and N2 categories). In addition, questionnaires were administered to 123 N1 and N2 students to enable comparison of the results for those with work experience with those without and determine how new N1 and N2 graduates can be attracted to rural posts. RESULTS: The results indicate that the provision of basic government housing has the greatest impact on the probability of choosing a job at a public health facility, followed by the provision of formal education opportunities and the availability of equipment and medicine at a health facility. The sub-group analysis suggests that job preferences vary according to stage of life and that incentive packages should vary accordingly. Recruitment strategies to encourage non-clinical professionals to work in rural/remote areas should also consider birthplace, as those born in rural/remote areas are more willing to work remotely. CONCLUSION: The study was undertaken within an overarching project that aimed to develop incentive packages for non-physician health professionals assigned to work in remote/rural areas. Based on the DCE results, the project team, together with the Mozambique Ministry of Health, has developed a range of health workforce retention strategies focusing on the provision of housing benefits and professional development opportunities to be utilized when assigning non-physician health professionals to rural/remote areas.

[Successful Extracorporeal Membrane Oxygenation for a Patient with Nearly Fatal Hypoxemia Induced by Transfusion-related Acute Lung Injury].

Transfusion-related acute lung injury (TRALI) is known to be the leading cause of transfusion-related mortality. A nearly fatal case of postoperative TRALI, successfully managed with extracorporeal membrane oxygenation (ECMO), is reported. The patient was a 70-year-old woman for whom laparoscopic nephrectomy was planned. She received several units of packed red blood cells and fresh-frozen plasma (FFP) intraoperatively due to massive bleeding. At the end of the operation, her PaO2/FIO2 ratio was 504, and she was extubated. Shortly after extubation, she developed severe hypoxemia. A chest X-ray showed bilateral infiltrates without cardiac enlargement. After entering the ICU, her respiratory condition deteriorated rapidly despite treatment with noninvasive positive pressure ventilation followed by re-intubation 8 hours after the operation. Even with very high positive pressure ventilation above 35 mmHg, her oxygenation decreased to PaO2 39.9 mmHg (FIO2 1.0). As a lifesaving measure, venovenous ECMO was started 15 hours after the operation. The pulmonary infiltration improved significantly over the next 5 days. Anti-HLA antibodies were detected in the FFP donor serum, that was transfused at the time of extubation. Now that TRALI is thought to be reversible, ECMO might be useful for even what was previously fatal hypoxemia.

2-Alkyloxazoles as potent and selective PI4KIIIß inhibitors demonstrating inhibition of HCV replication.

Synthesis and SAR of 2-alkyloxazoles as class III phosphatidylinositol-4-kinase beta (PI4KIIIß) inhibitors is described. These compounds demonstrate that inhibition of PI4KIIIß leads to potent inhibition of HCV replication as observed in genotype (GT) 1a and 1b replicon and GT2a JFH1 virus assays in vitro.

Identification of broad-spectrum antiviral compounds and assessment of the druggability of their target for efficacy against respiratory syncytial virus (RSV).

The search for novel therapeutic interventions for viral disease is a challenging pursuit, hallmarked by the paucity of antiviral agents currently prescribed. Targeting of viral proteins has the inextricable challenge of rise of resistance. Safe and effective vaccines are not possible for many viral pathogens. New approaches are required to address the unmet medical need in this area. We undertook a cell-based high-throughput screen to identify leads for development of drugs to treat respiratory syncytial virus (RSV), a serious pediatric pathogen. We identified compounds that are potent (nanomolar) inhibitors of RSV in vitro in HEp-2 cells and in primary human bronchial epithelial cells and were shown to act postentry. Interestingly, two scaffolds exhibited broad-spectrum activity among multiple RNA viruses. Using the chemical matter as a probe, we identified the targets and identified a common cellular pathway: the de novo pyrimidine biosynthesis pathway. Both targets were validated in vitro and showed no significant cell cytotoxicity except for activity against proliferative B- and T-type lymphoid cells. Corollary to this finding was to understand the consequences of inhibition of the target to the host. An in vivo assessment for antiviral efficacy failed to demonstrate reduced viral load, but revealed microscopic changes and a trend toward reduced pyrimidine pools and findings in histopathology. We present here a discovery program that includes screen, target identification, validation, and druggability that can be broadly applied to identify and interrogate other host factors for antiviral effect starting from chemical matter of unknown target/mechanism of action.

Lower Dose of 5 mL of 1% Lidocaine is More Suitable than the Conventional 10 mL for Caudal Block in Transrectal Prostate Biopsy: A Retrospective Cohort Study.

Objectives: In Japan, caudal block with 1% lidocaine is commonly used for transrectal prostate biopsy. Although 10 mL of 1% lidocaine is commonly used, the appropriate dosage of 1% lidocaine has not been studied. Our hospital routinely uses two different doses (5 or 10 mL) of 1% lidocaine for caudal block for transrectal prostate biopsy. Herein, we retrospectively evaluated the efficacy and safety of both doses of 1% lidocaine. Methods: This retrospective study included 869 patients who underwent transrectal prostate biopsy with caudal block at our hospital. The amount of 1% lidocaine was determined by the day of the week on which the biopsy was performed, and the patient voluntarily chose the day of the biopsy, unaware of the dose of 1% lidocaine used on that day. Pain, anal sphincter tonus, cancer diagnosis rate, and early complications were compared. Results: In total, 466 and 403 patients received 5 and 10 mL of 1% lidocaine for a caudal block, respectively. After propensity-score matching for patient characteristics, each group contained 395 patients. The pain score, anal sphincter tonus score, or prostate cancer diagnosis rate were not significantly different between the two groups. However, rectal bleeding was significantly more frequent and severe in the 10-mL than the 5-mL group (p=0.018 and p=0.0036, respectively). The incidence of other complications was not significantly different between the groups. Conclusions: Our results suggest that 5 mL of 1% lidocaine may be more suitable than 10 mL for caudal block during transrectal prostate biopsy.

Novel point-of-care cytokine biomarker lateral flow test for the screening for sexually transmitted infections and bacterial vaginosis: study protocol of a multicentre multidisciplinary prospective observational clinical study to evaluate the performance and feasibility of the Genital InFlammation Test (GIFT).

INTRODUCTION: A prototype lateral flow device detecting cytokine biomarkers interleukin (IL)-1α and IL-1ß has been developed as a point-of-care test-called the Genital InFlammation Test (GIFT)-for detecting genital inflammation associated with sexually transmitted infections (STIs) and/or bacterial vaginosis (BV) in women. In this paper, we describe the rationale and design for studies that will be conducted in South Africa, Zimbabwe and Madagascar to evaluate the performance of GIFT and how it could be integrated into routine care. METHODS AND ANALYSIS: We will conduct a prospective, multidisciplinary, multicentre, cross-sectional and observational clinical study comprising two distinct components: a biomedical ('diagnostic study') and a qualitative, modelling and economic ('an integration into care study') part. The diagnostic study aims to evaluate GIFT's performance in identifying asymptomatic women with discharge-causing STIs (Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV) and Mycoplasma genitalium (MG)) and BV. Study participants will be recruited from women attending research sites and family planning services. Several vaginal swabs will be collected for the evaluation of cytokine concentrations (ELISA), STIs (nucleic acid amplification tests), BV (Nugent score) and vaginal microbiome characteristics (16S rRNA gene sequencing). The first collected vaginal swab will be used for the GIFT assay which will be performed in parallel by a healthcare worker in the clinic near the participant, and by a technician in the laboratory. The integration into care study aims to explore how GIFT could be integrated into routine care. Four activities will be conducted: user experiences and/or perceptions of the GIFT device involving qualitative focus group discussions and in-depth interviews with key stakeholders; discrete choice experiments; development of a decision tree classification algorithm; and economic evaluation of defined management algorithms. ETHICS AND DISSEMINATION: Findings will be reported to participants, collaborators and local government for the three sites, presented at national and international conferences, and disseminated in peer-reviewed publications.The protocol and all study documents such as informed consent forms were reviewed and approved by the University of Cape Town Human Research Ethics Committee (HREC reference 366/2022), Medical Research Council of Zimbabwe (MRCZ/A/2966), Comité d'Ethique pour la Recherche Biomédicale de Madagascar (N° 143 MNSAP/SG/AMM/CERBM) and the London School of Hygiene and Tropical Medicine ethics committee (LSHTM reference 28046).Before the start, this study was submitted to the Clinicaltrials.gov public registry (NCT05723484). TRIAL REGISTRATION NUMBER: NCT05723484.

Contiguous ABCD1 DXS1357E deletion syndrome: report of an autopsy case.

Contiguous ABCD1 DXS1357E deletion syndrome (CADDS) is a contiguous deletion syndrome involving the ABCD1 and DXS1357E/BAP31 genes on Xq28. Although ABCD1 is responsible for X-linked adrenoleukodystrophy (X-ALD), its phenotype differs from that of CADDS, which manifests with many features of Zellweger syndrome (ZS), including severe growth and developmental retardation, liver dysfunction, cholestasis and early infantile death. We report here the fourth case of CADDS, in which a boy had dysmorphic features, including a flat orbital edge, hypoplastic nose, micrognathia, inguinal hernia, micropenis, cryptorchidism and club feet, all of which are shared by ZS. The patient achieved no developmental milestones and died of pneumonia at 8 months. Biochemical studies demonstrated abnormal metabolism of very long chain fatty acids, which was higher than that seen in X-ALD. Immunocytochemistry and Western blot showed the absence of ALD protein (ALDP) despite the presence of other peroxisomal proteins. Pathological studies disclosed a small brain with hypomyelination and secondary hypoxic-ischemic changes. Neuronal heterotopia in the white matter and leptomeningeal glioneuronal heterotopia indicated a neuronal migration disorder. The liver showed fibrosis and cholestasis. The thymus and adrenal glands were hypoplastic. Array comparative genomic hybridization (CGH) analysis suggested that the deletion was a genomic rearrangement in the 90-kb span starting in DXS1357E/BACP31 exon 4 and included ABCD1, PLXNB3, SRPK3, IDH3G and SSR4, ending in PDZD4 exon 8. Thus, the absence of ALDP, when combined with defects in the B-cell antigen receptor associated protein 31 (BAP31) and other factors, severely affects VLCFA metabolism on peroxisomal functions and produces ZS-like pathology.

Promoting universal financial protection: evidence from seven low- and middle-income countries on factors facilitating or hindering progress.

Although universal health coverage (UHC) is a global health policy priority, there remains limited evidence on UHC reforms in low- and middle-income countries (LMICs). This paper provides an overview of key insights from case studies in this thematic series, undertaken in seven LMICs (Costa Rica, Georgia, India, Malawi, Nigeria, Tanzania, and Thailand) at very different stages in the transition to UHC.These studies highlight the importance of increasing pre-payment funding through tax funding and sometimes mandatory insurance contributions when trying to improve financial protection by reducing out-of-pocket payments. Increased tax funding is particularly important if efforts are being made to extend financial protection to those outside formal-sector employment, raising questions about the value of pursuing contributory insurance schemes for this group. The prioritisation of insurance scheme coverage for civil servants in the first instance in some LMICs also raises questions about the most appropriate use of limited government funds.The diverse reforms in these countries provide some insights into experiences with policies targeted at the poor compared with universalist reform approaches. Countries that have made the greatest progress to UHC, such as Costa Rica and Thailand, made an explicit commitment to ensuring financial protection and access to needed care for the entire population as soon as possible, while this was not necessarily the case in countries adopting targeted reforms. There also tends to be less fragmentation in funding pools in countries adopting a universalist rather than targeting approach. Apart from limiting cross-subsidies, fragmentation of pools has contributed to differential benefit packages, leading to inequities in access to needed care and financial protection across population groups; once such differentials are entrenched, they are difficult to overcome. Capacity constraints, particularly in purchasing organisations, are a pervasive problem in LMICs. The case studies also highlighted the critical role of high-level political leadership in pursuing UHC policies and citizen support in sustaining these policies.This series demonstrates the value of promoting greater sharing of experiences on UHC reforms across LMICs. It also identifies key areas of future research on health care financing in LMICs that would support progress towards UHC.

Understanding factors influencing the use of clinical guidelines in low-income and middle-income settings: a scoping review.

OBJECTIVE: A scoping review was undertaken to determine the extent to which existing studies have examined factors influencing healthcare providers' use of clinical guidelines in low and middle-income country (LMIC) settings and determine which factors constrain or facilitate the use of clinical guidelines by healthcare providers. DESIGN: Scoping review. DATA SOURCES: The literature search was conducted using PubMed in January 2021. ELIGIBILITY CRITERIA: We identified empirical studies, published between 2011-2021 in English, which included clinicians and/or nurses as healthcare providers, used a health facility as the study site, and were located in an LMIC. DATA EXTRACTION AND SYNTHESIS: Information extracted from the literature review was organised using themes and the findings synthesised using thematic analysis. RESULTS: The review identified five types of interacting factors that influence healthcare providers' use of and compliance with clinical guidelines. The factors identified are organisational factors, factors relating to individual healthcare providers, attributes of the clinical guidelines, patient-related factors and institutional factors. Organisational factors can be further divided into the physical work environment, organisational culture and working conditions. The effective use of clinical guidelines in LMIC settings is greatly impacted by the contextualisation of clinical guidelines, end-user engagement and alignment of the implementation of clinical guidelines with the institutional arrangements in the broader health system. CONCLUSION: The development and evaluation of concrete interventions is vital to facilitate the implementation of clinical guidelines and improve healthcare service quality. Further studies are necessary to examine the relative importance of the five identified factors on the effective use of clinical guidelines in different contexts.

How Hospitals Overcame Disruptions in the Early Stages of the COVID-19 Pandemic: A Case Study from Tokyo, Japan.

The COVID-19 pandemic has caused serious disruptions to health systems across the world. While the pandemic has not ended, it is important to better understand the resilience of health systems by looking at the response to COVID-19 by hospitals and hospital staff. Part of a multi-country study, this study looks at the first and second waves of the pandemic in Japan and examines disruptions experienced by hospitals because of COVID-19 and the processes through which they overcame those disruptions. A holistic multiple case study design was employed, and two public hospitals were selected for the study. A total of 57 interviews were undertaken with purposively selected participants. A thematic approach was used in the analysis. The study found that in the early stages of the pandemic, faced with a previously unknown infectious disease, to facilitate the delivery of care to COVID-19 patients while also providing limited non-COVID-19 health care services, the case study hospitals undertook absorptive, adaptive, and transformative actions in the areas of hospital governance, human resources, nosocomial infection control, space and infrastructure management, and management of supplies. The process of overcoming the disruptions caused by the pandemic was complex, and the solution to one issue often caused other problems. To inform preparations for future health shocks and promote resilience, it is imperative to further investigate both organizational and broader health system factors that build absorptive, adaptive, and transformative capacity in hospitals.

Factors for Consideration When Setting Prices for Private Healthcare Providers Operating in Public Systems: A Comparison of France and Japan.

Background: Most publicly-funded health systems purchase healthcare from private providers, but the optimal purchasing arrangements between public purchasers and private healthcare providers are yet to be determined. Objective: This study compares the healthcare purchasing arrangements made with private providers in 2 social health insurance (SHI)-based systems to identify factors that influence the prices paid for private healthcare service provision. Results: France and Japan use different approaches to determine the payment arrangements with public and private providers. The presence of for-profit healthcare providers in the French health system explains the different payment rates for public and private healthcare providers in that country. In both France and Japan, in addition to payment rates, several policy tools are used to assure the provision of public good services and the availability of necessary healthcare for all, which public providers are required to deliver but private providers can choose to deliver. Conclusion: This study highlights the importance of considering the profit-making status of the private healthcare providers operating in the healthcare market, and clarity in the roles and responsibilities of the public, for-profit and not-for-profit providers when determining healthcare purchasing arrangements. Regulatory policy instruments, used alongside payment rates, are essential to influence efficiency, equity, and quality in mixed (public-private) health systems.

Attributes and Organizational Factors that Enabled Innovation in Health Care Service Delivery during the COVID-19 Pandemic - Case Studies from Brazil, Canada and Japan.

Innovation by health service organizations can enable adaptation to and transformation of challenges caused by health shocks. Drawing on results from case studies in Brazil, Canada, and Japan, this study looked at innovations the study hospitals introduced in response to challenges caused by COVID-19 to identify: 1) attributes of the innovations that make them conducive to adoption; and 2) organizational factors that facilitate the creation and implementation of innovative health care approaches during health system shocks. Qualitative information was gathered using key informant interviews, participatory observations at the study hospitals and a review of relevant documentation. A thematic approach was used for analysis, and a cross-country comparison framework was prepared to synthesize findings from the case studies in the three countries. In response to the disruptions caused by COVID-19, the study hospitals undertook innovative changes in services, processes, organizational structures, and operational policy. The driving force behind the innovations was the need and urgency generated by the unprecedented nature of the pandemic. With COVID-19, if an innovation met the perceived needs of hospitals and provided an operational advantage, some level of complexity in the implementation appeared to be acceptable. The study findings suggest that for hospitals to create and implement innovations in response to health shocks, they need to: have adaptive and flexible organizational structures; build and maintain functioning communication systems; have committed leadership; ensure all staff share an understanding of hospital organizational and professional missions; and establish social networks that facilitate the creation and implementation of new ideas.