Assessment of the compliance with minimum quality standards by public primary healthcare facilities in Nigeria.

Achieving universal health coverage (UHC) and the Sustainable Development Goals (SDG) by 2030 relies on the delivery of quality healthcare services through effective primary healthcare (PHC) systems. This necessitates robust infrastructure, adequately skilled health workers and the availability of essential medicines and commodities. Despite the critical role of minimum standards in benchmarking PHC quality, no global consensus on these standards exists. Nigeria has established minimum standards to enhance healthcare accessibility and quality, including the Revised Ward Health System Strategy (RWHSS) by the National Primary Health Care Development Agency (NPHCDA). This paper outlines the evolution of PHC minimum standards in Nigeria, evaluates compliance with RWHSS standards across all public PHC facilities, and examines the implications for ongoing PHC revitalization efforts. The study used a cross-sectional descriptive design to assess compliance across 25 736 public PHC facilities in Nigeria. Data collection involved a national survey using a standardized assessment tool focussing on infrastructure, staffing, essential medicines and service delivery. Compliance with RWHSS minimum standards was found to be below 50% across all facilities, with median compliance scores of 40.7%. Outreach posts had a median compliance of 32.6%, level 1 facilities 31.5% and level 2+ facilities 50.9%. Key findings revealed major gaps in health infrastructure, human resources and availability of essential medicines and equipment. Compliance varied regionally, with the North-west showing the highest number of facilities but varied performance across standards. The lessons learned underscore the urgent need for targeted interventions and resource allocation to address the identified deficiencies. This study highlights the critical need for regular, comprehensive compliance assessments to guide policy-makers in identifying gaps and strengthening PHC systems in Nigeria. Recommendations include enhancing monitoring mechanisms, improving resource distribution and focussing on infrastructure and human resource development to meet UHC and SDG targets. Addressing these gaps is essential for advancing Nigeria's healthcare system and ensuring equitable, quality care for all.

Revisiting a decade of inequality in healthcare financial burden in Cambodia, 2009-19: trends, determinants and decomposition.

BACKGROUND: Out-of-pocket healthcare expenditure (OOPHE) without adequate social protection often translates to inequitable financial burden and utilization of services. Recent publications highlighted Cambodia's progress towards Universal Health Coverage (UHC) with reduced incidence of catastrophic health expenditure (CHE) and improvements in its distribution. However, departing from standard CHE measurement methods suggests a different storyline on trends and inequality in the country. OBJECTIVE: This study revisits the distribution and impact of OOPHE and its financial burden from 2009-19, employing alternative socio-economic and economic shock metrics. It also identifies determinants of the financial burden and evaluates inequality-contributing and -mitigating factors from 2014-19, including coping mechanisms, free healthcare, and OOPHE financing sources. METHODS: Data from the Cambodian Socio-Economic Surveys of 2009, 2014, and 2019 were utilized. An alternative measure to CHE is proposed: Excessive financial burden (EFB). A household was considered under EFB when its OOPHE surpassed 10% or 25% of total consumption, excluding healthcare costs. A polychoric wealth index was used to rank households and measure EFB inequality using the Erreygers Concentration Index. Inequality shifts from 2014-19 were decomposed using the Recentered Influence Function regression followed by the Oaxaca-Blinder method. Determinants of financial burden levels were assessed through zero-inflated ordered logit regression. RESULTS: Between 2009-19, EFB incidence increased from 10.95% to 17.92% at the 10% threshold, and from 4.41% to 7.29% at the 25% threshold. EFB was systematically concentrated among the poorest households, with inequality sharply rising over time, and nearly a quarter of the poorest households facing EFB at the 10% threshold. The main determinants of financial burden were geographic location, household size, age and education of household head, social health protection coverage, disease prevalence, hospitalization, and coping strategies. Urbanization, biased disease burdens, and preventive care were key in explaining the evolution of inequality. CONCLUSION: More efforts are needed to expand social protection, but monitoring those through standard measures such as CHE has masked inequality and the burden of the poor. The financial burden across the population has risen and become more unequal over the past decade despite expansion and improvements in social health protection schemes. Health Equity funds have, to some extent, mitigated inequality over time. However, their slow expansion and the reduced reliance on coping strategies to finance OOPHE could not outbalance inequality.

Role and promise of health policy and systems research in integrating rehabilitation into the health systems.

Despite recognized need and reasonable demand, health systems and rehabilitation communities keep working in silos, independently with minimal recognition to the issues of those who require rehabilitation services. Consolidated effort by health systems and rehabilitation parties, recognizing the value, power and promise of each other, is a need of the hour to address this growing issue of public health importance. In this paper, the importance and the need for integration of rehabilitation into health system is emphasized. The efforts being made to integrate rehabilitation into health systems and the potential challenges in integration of these efforts were discussed. Finally, the strategies and benefits of integrating rehabilitation in health systems worldwide is proposed. Health policy and systems research (HPSR) brings a number of assets that may assist in addressing the obstacles discussed above to universal coverage of rehabilitation. It seeks to understand and improve how societies organize themselves to achieve collective health goals; considers links between health systems and social determinants of health; and how different actors interact in policy and implementation processes. This multidisciplinary lens is essential for evidence and learning that might overcome the obstacles to the provision of rehabilitation services, including integration into health systems. Health systems around the world can no longer afford to ignore rehabilitation needs of their populations and the World Health Assembly (WHA) resolution marked a global call to this effect. Therefore, national governments and global health community must invest in setting a priority research agenda and promote the integration of rehabilitation into health systems. The context-specific, need-based and policy-relevant knowledge about this must be made available globally, especially in low- and middle-income countries. This could help integrate and implement rehabilitation in health systems of countries worldwide and also help achieve the targets of Rehabilitation 2030, universal health coverage and Sustainable Development Goals.

Digital entanglements: Medical drones in African healthcare systems.

The intensified scramble for the digitalisation of healthcare across Africa, coupled with the general drive for digital economies, has ushered in digital health innovations that are reconfiguring national discourses on humanitarian and development contexts. Through these innovations, imaginaries of health have become entangled with aspirations for universal health coverage (UHC) and the actualisation of the health-related sustainable development goals (SDGs). Among these innovations, drones promise to leapfrog and transform conventional African healthcare systems, which have suffered from structural bottlenecks for years, offering citizens on the margins of care critical biomedical gazes. By using drones, African states hope to improve revenue collection, curb corruption, redress health insecurities and deliver life-saving medicines, vaccines and laboratory diagnostics through a last-mile distribution schedule. Ethnographic fieldwork from 2022 to 2023 in Ghana and Malawi on the use of drones found distortions to the health workforce, disruptions to health work, and a pervasive internal brain drain, all exacerbating health-worker shortages. This paper explores how drones are reconfiguring health work and its available labour force in practice amid persistent shortages of health-workers.

Imbalances in the oral health workforce: a Canadian population-based study.

BACKGROUND: In Canada, a new federal public dental insurance plan, being phased in over 2022-2025, may help enhance financial access to dental services. However, as in many other countries, evidence is limited on the supply and distribution of human resources for oral health (HROH) to meet increasing population needs. This national observational study aimed to quantify occupational, geographical, institutional, and gender imbalances in the Canadian dental workforce to help inform benchmarking of HROH capacity for improving service coverage. METHODS: Sourcing microdata from the 2021 Canadian population census, we described workforce imbalances for three groups of postsecondary-qualified dental professionals: dentists, dental hygienists and therapists, and dental assistants. To assess geographic maldistribution relative to population, we linked the person-level census data to the geocoded Index of Remoteness for all inhabited communities. To assess gender-based inequities in the dental labour market, we performed Blinder-Oaxaca decompositions for examining differences in professional earnings of women and men. RESULTS: The census data tallied 3.4 active dentists aged 25-54 per 10,000 population, supported by an allied workforce of 1.7 dental hygienists/therapists and 1.6 dental assistants for every dentist. All three professional groups were overrepresented in heavily urbanized communities compared with more rural and remote areas. Almost all dental service providers worked in ambulatory care settings, except for male dental assistants. The dentistry workforce was found to have achieved gender parity numerically, but women dentists still earned 21% less on average than men, adjusting for other characteristics. Despite women representing 97% of dental hygienists/therapists, they earned 26% less on average than men, a significant difference that was largely unexplained in the decomposition analysis. CONCLUSIONS: Accelerating universal coverage of oral healthcare services is increasingly advocated as an integral, but often neglected, component toward achieving the health-related Sustainable Development Goals. In the Canadian context of universal coverage for medical (but not dentistry) services, the oral health workforce was found to be demarcated by considerable geographic and gendered imbalances. More cross-nationally comparable research is needed to inform innovative approaches for equity-oriented HROH planning and financing, often critically overlooked in public policy for health systems strengthening.

Pharmaceutical procurement profits and universal health coverage: Reform to a sustainable healthcare and financing system.

BACKGROUND: In this study, using Taiwan's National Health Insurance (NHI) as an example of a single-payer system, we examined the extent of pharmaceutical procurement profits (PPP) and evaluated their impact on the financial performance of healthcare institutions. METHODS: We extracted data from financial statements and healthcare service declarations of NHI-contracted hospitals from 2015 to 2021. Financial data concerning PPP, health service profits (HSP), and total operating profits (TOP) from each hospital were analyzed. The impact of PPP on hospitals with positive and negative HSP was further investigated. RESULTS: The total PPP across all hospitals studied gradually increased from NT$30.6 billion in 2015 to NT$47.0 billion in 2021. In 2021, 28.1% of all hospitals reported a deficit in HSP. PPP appeared to have a significantly positive impact on the financial performance of these hospitals. It not only enhanced positive profits, but also helped mitigate or completely offset the negative profits from HSP. The effect of PPP seems to be more pronounced for hospitals with larger HSP values, suggesting that larger hospitals benefit more from PPP in absolute terms. DISCUSSION: Average PPP increased during the study period, increasingly affecting hospitals' financial stability across all strata. The gap between TOP and HSP in medical centers has gradually widened, suggesting an increase in non-health service profits. In this study, we propose a payment policy reform that fosters sustainability of the healthcare and financing system under universal health coverage and corrects the potential distortions caused by PPP.

Equity considerations for the implementation of health insurance benefit package in Ethiopia: result of expert Delphi exercise.

BACKGROUND: Efficiency, equity and financial risk protection are key health systems objectives. Equitable distribution of health care is among the priority strategic initiative of the government of Ethiopia. However, data on the distribution of interventions benefits or on disease burden disaggregated by subpopulations to guide health care priority setting is not available in Ethiopia. METHODS: Aligned with policy documents, we identified the following groups to be the worse off in the Ethiopian context: under-five children, women of reproductive age, the poor, and rural residents. We used the Delphi technique by a panel of 28 experts to assign a score for 253 diseases/conditions over a period of two days, in phases. The expert panel represented different institutes and professional mix. Experts assigned a score 1 to 4; where 4 indicates disease/condition predominantly affecting the poor and rural residents and 1 indicates a condition more prevalent among the wealthy and urban residents. Subsequently, the average equity score was computed for each disease/condition. RESULTS: The average scores ranged from 1.11 (for vitiligo) to 3.79 (for obstetric fistula). We standardized the scores to be bounded between 1 and 2; 1 the lowest equity score and 2 the highest equity score. The scores for each disease/condition were then assigned to their corresponding interventions. We used these equity scores to adjust the CEA values for each of the interventions. To adjust the CEA values for equity, we multiplied the health benefits (the denominator of the cost-effectiveness value) of each intervention by the corresponding equity scores, resulting in equity adjusted CEA values. The equity adjusted CEA was then used to rank the interventions using a league table. CONCLUSIONS: The Delphi method can be useful in generating equity scores for prioritizing health interventions where disaggregated data on the distribution of diseases or access to interventions by subpopulation groups are not available.

Universal coverage for oral health care in 27 low-income countries: a scoping review.

BACKGROUND: Low-income countries bear a growing and disproportionate burden of oral diseases. With the World Health Organization targeting universal oral health coverage by 2030, assessing the state of oral health coverage in these resource-limited nations becomes crucial. This research seeks to examine the political and resource commitments to oral health, along with the utilization rate of oral health services, across 27 low-income countries. METHODS: We investigated five aspects of oral health coverage in low-income countries, including the integration of oral health in national health policies, covered oral health services, utilization rates, expenditures, and the number of oral health professionals. A comprehensive search was conducted across seven bibliographic databases, three grey literature databases, and national governments' and international organizations' websites up to May 2023, with no linguistic restrictions. Countries were categorized into "full integration", "partial integration", or "no integration" based on the presence of dedicated oral health policies and the frequency of oral health mentions. Covered oral health services, utilization rates, expenditure trends, and the density of oral health professionals were analyzed using evidence from reviews and data from World Health Organization databases. RESULTS: A total of 4242 peer-reviewed and 3345 grey literature texts were screened, yielding 12 and 84 files respectively to be included in the final review. Nine countries belong to "full integration" and thirteen countries belong to "partial integration", while five countries belong to "no integration". Twelve countries collectively covered 26 types of oral health care services, with tooth extraction being the most prevalent service. Preventive and public health-based oral health interventions were scarce. Utilization rates remained low, with the primary motivation for seeking care being dental pain relief. Expenditures on oral health were minimal, predominantly relying on domestic private sources. On average, the 27 low-income countries had 0.51 dentists per 10,000 population, contrasting with 2.83 and 7.62 in middle-income and high-income countries. CONCLUSIONS: Oral health care received little political and resource commitment toward achieving universal health coverage in low-income countries. Urgent action is needed to mobilize financial and human resources, and integrate preventive and public health-based interventions.

Impact on Fatality Rates and Years of Life Lost During the COVID-19 Pandemic: The Experience of the Mexican Public Health Incident Management Command.

BACKGROUND: The SARS-CoV-2 pandemic challenged health systems worldwide. In Mexico, the Public Health Incident Management Command (COISS) strategy was implemented to improve health care for patients with COVID-19 who required hospitalization. AIM: To evaluate the impact of the COISS strategy on case fatality rates (CFR) and years of life lost (YLL) in hospitalized patients with COVID-19. MATERIALS AND METHODS: The COISS strategy included eight actions implemented in states with high epidemic risk (COISS states). A secondary analysis of the public database from the Mexican Ministry of Health was performed considering patients with confirmed diagnoses of SARS-CoV-2 infection. The COISS strategy effectiveness was evaluated by its impact on in-hospital CFR and YLL at the beginning (T0) and end (T1) of the third wave, and at the end of the fourth wave (T2) and compared to states without intervention (non-COISS states). RESULTS: At T0, COISS states showed a higher CFR for hospitalized patients than non-COISS states, which decreased after the strategy implementation. After correction for baseline conditions, lower relative CFR at T1 and T2, compared to T0, and a protective effect in different age groups, especially in those ≥65 years, were found in hospitalized patients in COISS states. The COISS strategy was associated with lower CFR in hospitalized patients with COVID-19 at both T1 and T2. At T0, YLLs were higher in COISS states, but there were no significant differences at T1 and T2. CONCLUSIONS: COISS interventions effectively reduced CFR in hospitalized patients with COVID-19, providing protection to vulnerable patients and reducing the YLL gap.

'The national health insurance policy provides little to no benefit to young persons living with type 1 diabetes (T1D)': a qualitative study of T1D management cost-burden in Southern Ghana.

BACKGROUND: Type 1 diabetes (T1D) management exerts a considerable financial burden on patients, caregivers, and developing nations at large. In Ghana, a key governments effort to attenuate the financial burden of T1D on patients was to fashion safety-net mechanisms through financial risk pooling/sharing known as the National Health Insurance Scheme (NHIS). However, there is limited research on patients and caregivers' experiences with the cost of managing T1D within the NHIS in Ghana. OBJECTIVE: This study explored the cost of T1D management, and the impact of the NHIS policy on mitigating costs of care. METHODS: A semi-structured interview guide was developed to collect qualitative data from 28 young people living with T1D (PLWD), 12 caregivers, 6 healthcare providers, and other stakeholders in Western, Central and the Greater Accra regions. Multiple data collection techniques including mystery client and in-depth interviews were used to collect data. Thematic content analysis was performed with QSR NVivo 14. RESULTS: Five key domains/themes which are: cost of T1D management supplies; cost of clinical care; cost of transportation; cost of diet; and NHIS were identified. The daily cost of blood glucose testing and insulin injection per day was between GHC 5-7 (US$ 0.6 to 1.0). The NHIS did not cover supplies such as strips, glucometers, HbA1c tests, and periodic medical tests. Even for those cost which were covered by the NHIS (mainly pre-mixed insulin), marked government delays in funds reimbursement to accredited NHIS facilities compelled providers to push the financial obligation onto patients and caregivers. Such cost obligations were fulfilled through out-of-pocket top-up or full payment of insulin of about GHC 15-25 (US$ 2-4), and GHC 25-50 (US$4-8) depending on the region and place of residence. CONCLUSION: The cost of managing T1D was a burden for patients and their caregivers. There was a commodification of life-saving insulin on the Ghanaian market, and the NHIS did not function well to ease the cost-burden of T1D management on patients and caregivers. The findings call for the need to scale up NHIS services to include simple supplies, particularly test strips, and always ensure the availability of life-saving insulin in healthcare facilities.

Operational description of rare diseases: a reference to improve the recognition and visibility of rare diseases.

Improving health and social equity for persons living with a rare disease (PLWRD) is increasingly recognized as a global policy priority. However, there is currently no international alignment on how to define and describe rare diseases. A global reference is needed to establish a mutual understanding to inform a wide range of stakeholders for actions. A multi-stakeholder, global panel of rare disease experts, came together and developed an Operational Description of Rare Diseases. This reference describes which diseases are considered rare, how many persons are affected and why the rare disease population demands specific attention. The operational description of rare diseases is framed in two parts: a core definition of rare diseases, complemented by a descriptive framework of rare diseases. The core definition includes parameters that permit the identification of which diseases are considered rare, and how many persons are affected. The descriptive framework elaborates on the impact and burden of rare diseases on patients, their caregivers and families, healthcare systems, and society overall. The Operational Description of Rare Diseases establishes a common point of reference for decision-makers across the world who strive to understand and address the unmet needs of persons living with a rare disease. Adoption of this reference is essential to improving the visibility of rare conditions in health systems across the world. Greater recognition of the burden of rare diseases will motivate new actions and policies to address the unmet needs of the rare disease community.

The gender gap in outpatient care for non-communicable diseases in Mexico between 2006 and 2022.

BACKGROUND: Equitable health service utilization is key to health systems' optimal performance and universal health coverage. The evidence shows that men and women use health services differently. However, current analyses have failed to explore these differences in depth and investigate how such gender disparities vary by service type. This study examined the gender gap in the use of outpatient health services by Mexican adults with non-communicable diseases (NCDs) from 2006 to 2022. METHODS: A cross-sectional population-based analysis of data drawn from National Health and Nutrition Surveys of 2006, 2011-12, 2020, 2021, and 2022 was performed. Information was gathered from 300,878 Mexican adults aged 20 years and older who either had some form of public health insurance or were uninsured. We assessed the use of outpatient health services provided by qualified personnel for adults who reported having experienced an NCD and seeking outpatient care in the 2 weeks before the survey. Outpatient service utilization was disaggregated into four categories: non-use, use of public health services from providers not corresponding to the user's health insurance, use of public health services from providers not corresponding to the user's health insurance, and use of private services. This study reported the mean percentages (with 95% confidence intervals [95% CIs]) for each sociodemographic covariate associated with service utilization, disaggregated by gender. The percentages were reported for each survey year, the entire study period, the types of service use, and the reasons for non-use, according to the type of health problem. The gender gap in health service utilization was calculated using predictive margins by gender, type of disease, and survey year, and adjusted through a multinomial logistic regression model. RESULTS: Overall, we found that women were less likely to fall within the "non-use" category than men during the entire study period (21.8% vs. 27.8%, P < 0.001). However, when taking into account the estimated gender gap measured by incremental probability and comparing health needs caused by NCDs against other conditions, compared with women, men had a 7.4% lower incremental likelihood of falling within the non-use category (P < 0.001), were 10.8% more likely to use services from providers corresponding to their health insurance (P < 0.001), and showed a 12% lower incremental probability of using private services (P < 0.001). Except for the gap in private service utilization, which tended to shrink, the others remained stable throughout the period analyzed. CONCLUSION: Over 16 years of outpatient service utilization by Mexican adults requiring care for NCDs has been characterized by the existence of gender inequalities. Women are more likely either not to receive care or resort to using private outpatient services, often resulting in catastrophic out-of-pocket expenses for them and their families. Such inequalities are exacerbated by the segmented structure of the Mexican health system, which provides health insurance conditional on formal employment participation. These findings should be considered as a key factor in reorienting NCD health policies and programs from a gender perspective.

Analyzing stroke burden and risk factors in India using data from the Global Burden of Disease Study.

Stroke remains a critical global health issue, significantly impacting India with substantial contributions to mortality and disability. This study comprehensively analyses stroke incidence, mortality, and disability-adjusted life years (DALYs) across India from 1990 to 2021, using the latest Global Burden of Disease (GBD) 2021 data. We evaluate how Universal Health Coverage (UHC), health expenditure, human development index (HDI), and gross national income (GNI) influence stroke outcomes. Our findings reveal significant regional disparities, with higher stroke rates in urban areas and states like Goa and Kerala. Higher health expenditure and HDI are linked to lower stroke rates, while higher GNI per capita correlates with increased stroke incidence, likely due to lifestyle changes. Risk factors include air pollution, tobacco use, dietary risks, and high blood pressure. Air pollution notably impacts stroke mortality in Bihar and Jharkhand, while tobacco use is a major risk factor in Mizoram and Manipur. Dietary risks and hypertension are prevalent in Maharashtra and Jammu & Kashmir. The study highlights the need for targeted public health strategies addressing regional disparities and socioeconomic factors. Policymakers should focus on lifestyle modification programs, public awareness campaigns, and enhanced access to quality stroke care to reduce stroke-related morbidity and mortality effectively.

Impact of health benefit package policy interventions on service utilisation under government-funded health insurance in Punjab, India: analysis of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY).

Background: The design of health benefits package (HBP), and its associated payment and pricing system, is central to the performance of government-funded health insurance programmes. We evaluated the impact of revision in HBP within India's Pradhan Mantri Jan Arogya Yojana (PM-JAY) on provider behaviour, manifesting in terms of utilisation of services. Methods: We analysed the data on 1.35 million hospitalisation claims submitted by all the 886 (222 government and 664 private) empanelled hospitals in state of Punjab, from August 2019 to December 2022, to assess the change in utilisation from HBP 1.0 to HBP 2.0. The packages were stratified based on the nature of revision introduced in HBP 2.0, i.e., change in nomenclature, construct, price, or a combination of these. Data from National Health System Cost Database on cost of each of the packages was used to determine the cost-price differential for each package during HBP 1.0 and 2.0 respectively. A dose-response relationship was also evaluated, based on the multiplicity of revision type undertaken, or based on extent of price correction done. Change in the number of monthly claims, and the number of monthly claims per package was computed for each package category using an appropriate seasonal autoregressive integrated moving average (SARIMA) time series model. Findings: Overall, we found that the HBP revision led to a positive impact on utilisation of services. While changes in HBP nomenclature and construct had a positive effect, incorporating price corrections further accentuated the impact. The pricing reforms highly impacted those packages which were originally significantly under-priced. However, we did not find statistically significant dose-response relationship based on extent of price correction. Thirdly, the overall impact of HBP revision was similar in public and private hospitals. Interpretation: Our paper demonstrates the significant positive impact of PM-JAY HBP revisions on utilisation. HBP revisions need to be undertaken with the anticipation of its long-term intended effects. Funding: Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ).

Strengthening the effectiveness of community health system: Assessing the factors that enhance or constrain the delivery of health services within communities in Nigeria.

INTRODUCTION: Sub-optimal community health service delivery (CHSD) has been a challenge constraining community health systems (CHS) globally, especially in developing countries such as Nigeria. This paper examined the key factors that either enhance or constrain CHSD in Nigeria at the individual, community/facility and governmental levels while recommending evidence-based solutions for sustaining and improving CHSD within the framework of CHS. METHODS: Data were collected through a qualitative study undertaken in three states (Anambra, Akwa-Ibom and Kano) in Nigeria. Respondents were formal/informal health providers, community leaders and representatives of civil society organizations all purposively sampled. There were 90 in-depth interviews and 12 focus group discussions, which were audio-recorded, transcribed verbatim and analysed thematically using codes to identify key themes. RESULTS: Factors constraining community health service delivery at the individual level were poor health-seeking behaviour, preference for quacks and male dominance of service delivery; at the community/facility level were superstitious/cultural beliefs and poor attitude of facility workers; at the governmental level were inadequate financial support, embezzlement of funds and inadequate social amenities. Conversely, the enabling factors at the individual level were community members' participation and the compassionate attitude of informal providers. At the community and facility levels, the factors that enhanced service delivery were synergy between formal and informal providers and support from community-based organizations and structures. At the governmental level, the enhancing factors were the government's support of community-based formal/informal providers and a clear line of communication. CONCLUSIONS: Community health service delivery through a functional community-health system can improve overall health systems strengthening and lead to improved community health. Policy-makers should integrate community health service delivery in all program implementation and ultimately work with the community health system as a veritable platform for effective community health service delivery.

Scaling Up Departmental Health Insurance Units in Senegal: A Mixed-Method Study.

In response to the failure of community-based health insurance (CBHI) at the municipal level, some African countries are implementing district or departmental CBHIs to improve universal health coverage. After creating two CBHIs at the departmental level in 2014, Senegal launched a campaign to disseminate the model in 2022. This article presents the stakeholders' perspectives on the factors and challenges of scaling up CBHI departmentalization in Senegal. The study uses a mixed-methods approach, utilizing concept mapping and a focus group to examine scaling up departmentalization. The sample size consists of 22 individuals involved in the process. The quantitative analysis includes hierarchical cluster analysis, multidimensional scaling analysis, and the Pearson coefficient test. The qualitative analysis involves content analysis to triangulate the findings. Participants identified 125 factors to consider for the departmentalization of CBHI. They were categorized into nine clusters according to their degree of importance (I) and ease to organize (F): service package (I: 4.07; F: 2,26), communication (I: 4.05; F: 2.96), governance (I: 3.96; F: 2,94), human and logistical resources (I: 3.94; F: 2,82), financing (I: 3.90; F: 2,31), involvement of the authorities (I: 3.82; F: 2.75), community involvement (I: 3.81; F: 2.76), membership (I: 3.70; F: 2.24, strategic planning and implementation (I: 3.57; F: 2,62). The main challenges faced were a process perceived as precipitous and vertical and needing more negotiation and consultation. The conditions for accompaniment and public funding availability need to be sufficiently considered. The study proposes avenues for action to promote the scaling up of CBHI departmentalization in Senegal.

Un/met: a mixed-methods study on primary healthcare needs of the poorest population in Khyber Pakhtunkhwa province, Pakistan.

BACKGROUND: Access of all people to the healthcare they need, without financial hardship is the goal of Universal Health Coverage (UHC). As UHC initiatives expand, assessing the needs of vulnerable populations can reveal gaps in the system which may be covered by relevant policies. In this study we (i) identify the met and unmet primary healthcare needs of the poorest population of Khyber Pakhtunkhwa province (KP), Pakistan, and (ii) explore why the gaps exist. METHODS: We used Leveque's Framework of Patient-centred Access to Healthcare to examine unmet primary healthcare (PHC) needs and their underlying causes for the poorest population in four districts of Khyber Pakhtunkhwa province, Pakistan. Using a triangulation mixed methods design, we analysed data from a quantitative household survey of744 households, 17 focus group discussions with household members and, 11 interviews with healthcare providers. RESULTS: Our results show that indicate that despite service utilization, PHC needs were not met, primarily due to prohibitively high costs at each stage of access. Furthermore, gaps in outreach and information (approachability), and varying availability of medicines and diagnostics at facilities (appropriateness) the supply side as well as difficulties in navigating the system (inability to perceive) and adhering to prescriptions (inability to engage) on the demand side, also led to unmet PHC needs. Going beyond utilization, our findings highlight that engagement with care is an important determinant of met needs for vulnerable populations. CONCLUSION: Social health protection policies can contribute to advancing UHC for primary care. However, in our setting, enhancing communication and outreach, addressing gender and age disparities, and improving quality of care and health infrastructure are necessary to fully meet the needs of the poorest populations.

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.

Measuring progress towards universal health coverage in 22 Middle East and North African countries.

Purpose: Monitoring progress towards universal health coverage (UHC) has become increasingly important, especially given the centrality of UHC in achieving the sustainable development goals. We sought to estimate the progress towards UHC in the 22 Middle East and North Africa (MENA) countries. Methods: Employing the Joint World Bank and World Health Organization Framework for Monitoring UHC, we estimated the UHC index for MENA countries using both service coverage and financial protection indicators. We also explored the correlation between the UHC index with government expenditure/investment in health. Results: The 2021 UHC index ranged from 48.2 (Somalia) to 90.3 (United Arab Emirates) with a mean, median, and standard deviation of 74.9, 77.4, and 11.1, respectively, with significant differences between low-income and high-income countries. Service coverage lags behind financial protection in most MENA countries. There is a significant positive relationship between UHC and government health spending/investments. Conclusion: The majority of MENA countries are yet to achieve UHC. There is a need to expand healthcare services, especially PHC services, and adopt strategies that address concerns related to financial protection.

Joseph William Bhore (1878-1960): The Architect Behind the Bhore Committee Legacy.

Sir Joseph William Bhore was a civil official from India. He pioneered the health survey and development committee, known as the Bhore Committee, which set the direction for India's public health facilities and investments. The chairmanship of the Health Survey and Development Committee, which the British colonial administration formed in 1943, is arguably the most well-known role Bhore has held. The committee was founded in 1943 and produced a thorough report in 1946. The committee's suggestions shaped India's health policy and planning and the course of the country's health care growth.