Pharmaceutical messianism and the politics of COVID-19 in the United States.

Throughout the COVID-19 pandemic, public officials in the United States - from the President to governors, mayors, lawmakers, and even school district commissioners - touted unproven treatments for COVID-19 alongside, and sometimes as opposed to, mask and vaccine mandates. Utilising the framework of 'pharmaceutical messianism', our article focuses on three such cures - hydroxychloroquine, ivermectin, and monoclonal antibodies - to explore how pharmaceuticals were mobilised within politicised pandemic discourses. Using the states of Utah, Texas, and Florida as illustrative examples, we make the case for paying attention to pharmaceutical messianism at the subnational and local levels, which can very well determine pandemic responses and outcomes in contexts such as the US where subnational governments have wide autonomy. Moreover, we argue that aside from the affordability of the treatments being studied and the heterodox knowledge claiming their efficacy, the widespread uptake of these cures was also informed by popular medical (including immunological) knowledge, pre-existing attitudes toward 'orthodox' measures like vaccines and masks, and mistrust toward authorities and institutions identified with the 'medical establishment'. Taken together, our case studies affirm the recurrent nature of pharmaceutical messianism in times of health crises - while also refining the concept and exposing its limitations.

Health reform in Nigeria: the politics of primary health care and universal health coverage.

Over the past decade, Nigeria has seen major attempts to strengthen primary health care, through the Saving One Million Lives (SOML) initiative, and to move towards universal health care, through the National Health Act. Both initiatives were successfully adopted, but faced political and institutional challenges in implementation and sustainability. We analyse these programmes from a political economy perspective, examining barriers to and facilitators of adoption and implementation throughout the policy cycle, and drawing on political settlement analysis (PSA) to identify structural challenges which both programmes faced. The SOML began in 2012 and was expanded in 2015. However, the programme's champion left government in 2013, a key funding source was eliminated in 2015, and the programme did not continue after external funding elapsed in 2021. The National Health Act passed in 2014 after over a decade of advocacy by proponents. However, the Act's governance reforms led to conflict between health sector agencies, about both reform content and process. Nine years after the Act's passage, disbursements have been sporadic, and implementation remains incomplete. Both programmes show the promise of major health reforms in Nigeria, but also the political and institutional challenges they face. In both cases, health leaders crafted evidence-based policies and managed stakeholders to achieve policy adoption. Yet political and institutional challenges hindered implementation. Institutionally, horizontal and vertical fragmentation of authority within the sector impeded coordination. Politically, electoral cycles led to frequent turnover of sectoral leadership, while senior politicians did not intervene to support fundamental institutional reforms. Using PSA, we identify these as features of a 'competitive clientelist' political settlement, in which attempts to shift from clientelist to programmatic policies generate powerful opposition. Nonetheless, we highlight that some policymakers sought to use health reforms to change institutions at the margin, suggesting future avenues for governance-oriented health reforms.

Using a Stages Model to Reveal the Politics in the Health Policy Process Comment on "Modelling the Health Policy Process: One Size Fits All or Horses for Courses?"

Models of the health policy process have largely developed in isolation from political studies more widely. Of the models which Powell and Mannion's editorial considers, a stages model of the policy process offers a framework for combining these specifically health-focused models with empirical findings and more general explanatory models of the policy process drawn from other political studies. This commentary uses a stages model to assemble a bricolage which combines some of these components. That identifies a further research task and suggests ways of revealing in more life-like ways the politics involved in the health policy process: that is, how that process channels wider, often conflicting, non-health interests, actors, policies, conflicts, ideologies and sources of power from outside the health system into health policy formation, and introduces non-rationality.

The Politics of Health Policy Agenda Setting in India: The Case of the PMJAY Program.

In 2018, India's Prime Minister announced a new health insurance program, Pradhan Mantri Jan Arogya Yojana (PMJAY), aiming to cover over 500 million people. This paper seeks to document and explain the emergence of PMJAY on India's political and policy agendas. We analyze media, election manifestos, legislative debates, and health budgets to compare PMJAY's presence on India's policy agenda to previous health programs. We then apply Kingdon's Multiple Streams Framework to explain the program's emergence and adoption, validating our data and interpretations through consultations with Indian health policy experts. Comparing respective launch years, PMJAY was covered in national newspapers 37 to 212 times more than previous flagship health programs, although it was not more prominent in parliamentary debates or in the health budget. Events in the problem, politics, and policy streams converged to enable its prominence. Health policy elites who favored insurance as a policy to address out-of-pocket health expenditures gained influence after the 2014 election victory of the Bharatiya Janata Party (BJP). PMJAY's naming and branding, scale, timing, implementation style, and design aligned with both the BJP's ideology and political strategy. PMJAY represents the increased prominence of health programs in Indian politics, although primarily on the political and media agenda, rather than on the budgetary and legislative agenda during this period. The political forces that facilitated its emergence also shaped its design in ways that are likely to affect the Indian health system's ability to provide comprehensive financial protection in the future.

'Kontra-partido': untangling oppositional local politics and healthcare devolution in the Philippines.

A long-recognized problem of healthcare devolution in many developing countries is its inextricability from the influences of local politics. This has been particularly self-evident in the Philippines, where, since the adoption of the Local Government Code of 1991, the devolution of health governance, planning, administration and service delivery has placed the health system largely under the control of individual provinces, cities, municipalities and villages or barangays. In this article, we utilize the notion of 'kontra-partido' (the Filipino term connoting 'oppositional politics') to concretize local, oppositional politics as a lived experience of health workers, government officials and ordinary citizens in the country. Through multi-sited qualitative fieldwork, we demonstrate how 'kontra-partido' politics ultimately worsens health outcomes in any locality. We show how such politics figures in the relational dynamics of health governance, often resulting in petty infighting and strained relationships among local health authorities; how it leads to the politicization of appointments and prevents the local workforce, especially those at the grassroots, from doing their jobs efficiently amid environments rife with hostile patronage; and how it impedes service delivery as politicians prioritize 'visible' projects (over sustainable ones) and selectively deliver health care to their known supporters. In turn, health workers and ordinary citizens alike have been actively negotiating their roles within this political milieu, either by joining the so-called political frontlines or by engaging in the transactional relationships that develop between politicians and their constituents during perennial election seasons. We conclude with a reflection on the vulnerability of health to politicization and the visceral consequences of 'kontra-partido' politics to health workers, as well as an identification of possible areas of intervention for future policy reform, given the deepening political polarization in the country and the upcoming implementation of the recently passed Universal Health Care Law.

Antibiotic Culture: A History of Antibiotic Use in the Second Half of the 20th and Early 21st Century in the People's Republic of China.

Antimicrobial resistance is now widely regarded as a global public health threat. A growing number of studies suggest that antibiotic resistance is higher in China than in most western countries. Despite the current official regulation prohibiting pharmacies from the unrestricted selling of antibiotics, there is little sign of declining consumer demand. China now ranks as the second largest consumer of antibiotics in the world, after India. Drawing on published historical data, unpublished archival documents, and recently collected oral interviews, this paper provides a historical overview of antibiotic use and abuse in the People's Republic of China (PRC) from the second half of the 20th century to the present. It demonstrates how the political demand for health improvement, along with the state-sponsored popularization of allopathic medicine, on the one hand, and the lack of access to adequate medical care for the majority of the population, as well as the existing culture of self-medication, on the other hand, are working in tandem to create antibiotic dependency in China. In addition, the privatization and marketization of biomedicine and health care in post-Mao China have helped to build a new and ever-thriving network of production, distribution, and marketing of antibiotics, which has often proven difficult for the authorities to monitor. At the same time, increased purchasing power and easier accessibility created by this new network of production, distribution, and marketing have further contributed to the prevalence of antibiotic overuse in the late 20th and early 21st centuries.

Employing innovative evidence-backed community processes for maternal health services by Dalit women.

BACKGROUND: Health care services express social and structural inequalities, especially for Dalits and women, due to the indignity and discrimination experienced in health care facilities. Jagrutha Mahila Sanghatane (JMS), a grass-roots organization led by neo-literate Dalit women in rural Karnataka in India, adopted a human rights-based social accountability (SA) approach to address discrimination and dignity in accessing maternal health services. This approach integrated community-based evidence with multi-pronged and multi-level accountability processes with their goal of socio-political empowerment. METHODS: The methodological approach is qualitative and uses document analysis, including thematic and content analysis, in-depth group discussions with the campaign leaders, participant observation and interviews with the community health workers. RESULTS: JMS embedded the practice and processes of SA in the politics of empowerment which was central to addressing the structural issues of discrimination and social exclusion faced by Dalit women. The human rights perspective and the pathway of conscientize-organize-struggle provided by the Dalit liberation leader, Dr B. R. Ambedkar, facilitated the organization to conceptualize SA as a process of claiming dignity and justice for Dalit women. Integrating the evidence generation and its deployment into the community campaign cycles, Dalit women could use the accountability process for intensifying mobilization and empowerment. The cumulative impact of the community enquiry relentlessly pursued through the framework of a campaign brought changes in several aspects of primary health care and specific dimensions of maternal health care. Community ownership of the SA process, participation and empowerment were integral to the generation, synthesis and deploying of evidence. Deploying evidence in multiple forms, both horizontally with the communities and vertically with the authorities deepened communities' mobilization and intensified Dalit women's negotiating power with the authorities. The iterative and persistent process of SA provides insights into re-articulating SA beyond the usual recognition of outputs such as report cards into the politics of meaning-making by the mobilized community of the marginalized. The community-based organization posited the SA itself as the process of resistance to structural injustice and as an avenue or their empowerment. CONCLUSIONS: For marginalized communities, the SA process has the potential to be a tool for their empowerment in addressing structural power inequities. For such a repositioning of SA, it is critical to focus not only on the technicality of generating evidence but also on the framework driving such a process, the mode of evidence generation and deployment, and integration into the organizational strategy. Such a process can be equally empowering, efficient in addressing the systemic challenges of increasing marginalized community's access to health care services, and valuable in sustaining those changes. The analysis of the strategies of JMS offers significant insights for researchers and practitioners working on SA and maternal health to re-articulate SA from the point of politics of empowerment of the marginalized communities.

Power across the global health landscape: a network analysis of development assistance 1990-2015.

Power distribution across the global health landscape has undergone a fundamental shift over the past three decades. What was once a system comprised largely of bilateral and multilateral institutional arrangements between nation-states evolved into a varied landscape where these traditional actors were joined by a vast assemblage of private firms, philanthropies, non-governmental organizations and public-private partnerships. Financial resources are an explicit power source within global health that direct how, where and to whom health interventions are delivered, which health issues are (de)prioritized, how and by whom evidence to support policies and interventions is developed and how we account for progress. Financial resource allocations are not isolated decisions but rather outputs of negotiation processes and dynamics between actors who derive power from a multiplicity of sources. The aims of this paper are to examine the changes in the global health actor landscape and the shifts in power using data on disbursements of development assistance for health (DAH). A typology of actors was developed from previous literature and refined through an empirical analysis of DAH. The emergent network structure of DAH flows between global health actors and positionality of actors within the network were analysed between 1990 and 2015. The results reflect the dramatic shift in the numbers of actors, relationships between actors, and funding dispersal over this time period. Through a combination of the massive influx of new funding sources and a decrease in public spending, the majority control of financial resources in the DAH network receded from public entities to a vast array of civil society organizations and public-private partnerships. The most prominent of these was the Bill and Melinda Gates Foundation and the Global Fund for AIDS, TB and malaria, which rose to the third and fourth most central positions within the DAH network by 2015.

Medical populism and the politics of dengue epidemics in the Global South.

With millions of cases and thousands of deaths every year in Asia and Latin America, dengue fever continues to be of global public health significance. This article uses the concept of 'medical populism' to analyse the political construction of the 2019 dengue epidemics in Bangladesh, the Philippines, and Honduras. Through this framework, we examine the narratives of these outbreaks by reconstructing how political actors simplified the discourse, spectacularised the crises, offered multiple knowledge claims, and forged divisions between the people and 'dangerous others'. Taken together, our case studies, obtained through government, journalistic, and scholarly sources, illuminate the role of medical populists (who are almost always politicians) in defining and responding to public health emergencies, underscoring the performative dimension of disease outbreaks. By detracting attention from less spectacular but more substantive policies and programs, these 'performances' of health crises perpetuate health inequities, especially in fragile democracies like the aforementioned Global South countries. We conclude by reflecting on the implications of medical populism to public health, health communications, and the inevitable recurrence of epidemics.

Pharmaceutical messianism and the COVID-19 pandemic.

As part of their populist performances during disease outbreaks, public officials and politicians tend to offer 'miracle cures' or 'wonder drugs' that can supposedly treat or prevent the disease in question. This article analyzes contemporary instances of what we call 'pharmaceutical messianism' and proposes four characteristics for this phenomenon, namely, that it: (1) emerges during times of extraordinary health crisis; (2) builds on pre-existing knowledge, practices, and sentiments; (3) borrows from medical, often heterodox, authority; and (4) involves accessible, affordable, and/or familiar substances. Demonstrating the analytic value of our framework, we present three case studies, constructed using academic and journalistic sources, during the COVID-19 pandemic: hydroxychloroquine in France, ivermectin in the Philippines, and Covid-Organics in Madagascar. We conclude by identifying some implications of our findings on public health and avenues for future research.

Globalization and health policy space: Introducing the WTOhealth dataset of trade challenges to national health regulations at World Trade Organization, 1995-2016.

Do international trade rules and agreements constrain health policy space? A multitude of global actors and institutions with different interests and power can shape national health policy, and trade rules provide one means through which to exert pressure on governments. Yet, the full scope of political pressure on health policy within the global trade regime is insufficiently understood, as previous research largely focussed on challenges to food, alcohol, and tobacco regulations and used small-N case studies. This potentially overlooks other domains of influence and we lack an understanding of quantitative trends and patterns therein. In this article we introduce a novel dataset, WTOhealth, comprising all challenges to national health regulations at the WTO Technical Barriers to Trade (TBT) Committee between 1995 and 2016. The dataset is based on 1496 pages of minutes from 71 TBT meetings. We describe how we developed this dataset and present an exploratory analysis of key patterns within the data. Our analysis shows that WTO members raised 250 trade challenges to health regulations between 1995 and 2016. 83.6% of challenges to low- or lower-middle income country (LMIC) members were raised by high-income countries (HICs). Many challenges centred on food (16.4% challenges), alcohol (10.4%), and tobacco (4.2%) policies, but a substantial proportion concerned other products, including toxic chemicals (9.1%), pharmaceuticals and medical devices (8.1%), machinery (7.8%), and motor vehicles (7.3%). This includes measures targeting medical device safety, increased access to pharmaceuticals, and reduced exposure to toxins harmful to both health and the environment. We further examine these challenges, finding that HIC members made claims with contentious scientific support. In short, diverse health regulations may be changed or delayed following contentious challenges at the TBT Committee. There is a need for further research investigating the nature and influence of WTO challenges to diverse health regulations.

Right Wing Politics and Public Policy: The Need for a Broad Frame and Further Research Comment on "A Scoping Review of Populist Radical Right Parties' Influence on Welfare Policy and its Implications for Population Health in Europe".

Our paper responds to a narrative review on the influence of populist radical right parties (PRRPs) on welfare policy and its implications for population health in Europe. Five aspects of their review are striking: (i) welfare chauvinism is higher in tax-funded healthcare systems; (ii) PRRPs in coalition with liberal or social democratic parties are able to shift welfare reform in a more chauvinistic direction; (iii) coalitions involving PRRPs can buffer somewhat the drift to welfare chauvinism, but not by much; (iv) the European Union (EU) and its healthcare policies has served somewhat as a check on PRRPs' direct influence on healthcare welfare chauvinism; (v) PRRPs perform a balancing act between supporting their base and protecting elected power. We note that PRRPs are not confined to Europe and examine the example of Trump's USA, arguing that the Republican Party he dominates now comes close to the authors' definition of a PRRP. We applaud the authors' scoping review for adding to the literature on political determinants of health but note the narrow frame on welfare policy could be usefully expanded to other areas of public policy. We examine three of such areas: the extent to which policy protects those who are different from mainstream society in terms of race, ethnicity, gender or sexuality; the debate between free trade and protectionism; and the rejection of climate change science by many PRRPs. Our analysis concludes that PRRPs promote agendas which are antithetical to eco-socially just population health, and conclude for a call for more research on the political determinants of health.

Medical populism and immunisation programmes: Illustrative examples and consequences for public health.

Various factors have been implicated in vaccine hesitancy and loss of vaccine confidence, but the specific ways and particular moments in which immunisation programmes and vaccine scares are politicised, exacerbating negative attitudes about vaccines and leading to retrogressive policies, have been relatively under-examined. This paper applies the concept of 'medical populism' [Lasco, G., & Curato, N. (2019). Medical populism. Social Science & Medicine, 221(1), 1-8. doi:10.1016/j.socscimed.2018.12.006] to examine these under-studied dynamics, looking at political actors and how they 'construct antagonistic relations between "the people" whose lives have been put at risk by "the establishment"' in the performance of vaccine-related crises. Four illustrative cases - from Nigeria, Italy, Ukraine, and the Philippines - are presented to demonstrate the descriptive and analytic value of medical populism beyond the framing and characterisation of the politics of health. The study underscores the need to understand people's perceptions and 'explanatory models' of vaccines and vaccine failures, to look at the political milieux that underpin immunisation programmes, and to anticipate and address knowledge claims made by political actors.

Beyond the anti-racist reason: a postcolonial perspective on pandemic politics.

This article interrogates the politics of the COVID-19 pandemic from a postcolonial perspective. One alarming concern during the pandemic is the rise of racism against Asians all over the world. However, little explored behind media reports are the legacies, tensions and challenges left by imperial domination inherited from the past, especially within the postcolonial regimes in Asia, such as Hong Kong and China. Drawing upon postcolonialism as a critical lens, this article makes perceptible the intractable issues of health politics. Postcolonial challenges shown by COVID-19 include immigration, changing politico-juridical definitions of identity, the legacy left by the Soviet era which poses an obstacle to modernising China's healthcare system, and the boom of birth tourism welcomed by the marketised turn of health and tourism policy in Hong Kong in the post-SARS era. A postcolonial perspective invites health sociologists to scratch beneath the surface of political problems such as racism, and attend to the complex heterogeneity of health politics in the pandemic.

Gender equality policies, nursing professionalization, and the nursing workforce: A cross-sectional, time-series analysis of 22 countries, 2000-2015.

BACKGROUND: Nursing professionalization has substantial benefits for patients, health care systems, and the nursing workforce. Currently, however, there is limited understanding of the macro-level factors, such as policies and other country-level determinants, influencing both the professionalization process and the supply of nursing human resources. OBJECTIVES: Given the significance of gender to the development of nursing, a majority-female occupation, the purpose of this analysis was to investigate the relationship between gender regimes and gender equality policies, as macro-level determinants, and nursing professionalization indicators, in this case the regulated nurse and nurse graduate ratios. DESIGN: This cross-sectional, time-series analysis covered 16 years, from 2000 to 2015, and included 22 high-income countries, members of the Organisation for Economic Co-operation and Development. We divided countries into three clusters, using the gender policy model developed by Korpi, as proxy for gender regimes. The countries were grouped as follows: (a) Traditional family - Austria, Belgium, France, Germany, Greece, Italy, Netherlands, Portugal, and Spain; (b) Market-oriented - Australia, Canada, Ireland, Japan, New Zealand, South Korea, Switzerland, United Kingdom, and the United States; and (c) Earner-carer - Denmark, Finland, Norway, and Sweden. METHODS: We used fixed-effects linear regression models and ran Prais-Winsten regressions with panel-corrected standard errors, including a first-order autocorrelation correction to examine the effect of gender equality policies on nursing professionalization indicators. Given the existence of missing observations, we devised and implemented a multiple imputation strategy, with the help of the Amelia II program. We gathered our data from open access secondary sources. RESULTS: Both the regulated nurse and nurse graduate ratios had averages that differed across gender regimes, being the highest in Earner-carer regimes and the lowest in Traditional family ones. In addition, we identified a number of indicators of gender equality policy in education, the labour market, and politics that are predictive of the regulated nurse and nurse graduate ratios. CONCLUSION: This study's findings could add to existing upstream advocacy efforts to strengthen nursing and the nursing workforce through healthy public policy. Given that the study consists of an international comparative analysis of nursing, it should be relevant to both national and global nursing communities.

The influence of welfare state factors on nursing professionalization and nursing human resources: A time-series cross-sectional analysis, 2000-2015.

AIM: The aim of this study was to examine the relationship between welfare states and nursing professionalization indicators. DESIGN: We used a time-series, cross-sectional design. The analysis covered 16 years and 22 countries: Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Japan, Netherlands, New Zealand, Norway, Portugal, South Korea, Spain, Sweden, Switzerland, United Kingdom, and the United States, allocated to five welfare state regimes: Social Democratic, Christian Democratic, Liberal, Authoritarian Conservative, and Confucian. METHODS: We used fixed-effects linear regression models and conducted Prais-Winsten regressions with panel-corrected standard errors, including a first-order autocorrelation correction. We applied the Amelia II multiple imputation strategy to replace missing observations. Data were collected from March-December 2017 and subsequently updated from August-September 2018. RESULTS: Our findings highlight positive connections between the regulated nurse and nurse graduate ratios and welfare state measures of education, health, and family policy. In addition, both outcome variables had averages that differed among welfare state regimes, the lowest being in Authoritarian Conservative regimes. CONCLUSION: Additional country-level and international comparative research is needed to further study the impact of a wide range of structural political and economic determinants of nursing professionalization. IMPACT: We examined the effects of welfare state characteristics on nursing professionalization indicators and found support for the claim that such features affect both the regulated nurse and nurse graduate ratios. These findings could be used to strengthen nursing and the nursing workforce through healthy public policies and increase the accuracy of health human resources forecasting tools.

Service Delivery Transformation for UHC in Asia and the Pacific.

This article was drafted as part of a review of strategies for making progress toward universal health coverage in the countries of Asia and the Pacific. It focuses on strengthening the delivery of services, in the context of population aging. It argues that it is important to take into account big differences in development contexts and also the rapid, interconnected changes that many countries are experiencing. The article focuses especially on countries with relatively undeveloped institutions and pluralistic and highly segmented health sectors. It argues that attempts by these countries to import institutional arrangements from outside are likely to be complicated. It argues that government needs to focus on both short-term measures to meet immediate needs and the longer-term aim of establishing effective institutional arrangements. This means that they need to take into account the political factors that influence the direction of health system change. The article emphasizes the need to strengthen the capacity of the health system to address the growing challenge of chronic noncommunicable diseases to avoid heavy political pressure to expand hospital services. It then explores the opportunities and challenges associated with the rapid expansion of digital health services. It concludes with a discussion of government stewardship and management of health system transformation to address the major challenges associated with population aging.

Nursing professionalization and welfare state policies: A critical review of structural factors influencing the development of nursing and the nursing workforce.

Nursing professionalization is both ongoing and global, being significant not only for the nursing workforce but also for patients and healthcare systems. For this reason, it is important to have an in-depth understanding of this process and the factors that could affect it. This literature review utilizes a welfare state approach to examine macrolevel structural determinants of nursing professionalization, addressing a previously identified gap in this literature, and synthesizes research on the relevance of studying nursing professionalization. The use of a welfare state framework facilitates the understanding that the wider social, economic, and political system exercises significant power over the distribution of resources in a society, providing a glimpse into the complex politics of health and health care. The findings shed light on structural factors outside of nursing, such as country-level education, health, labor market, and gender policies that could impact the process of professionalization and thus could be utilized to strengthen nursing through facilitating increased professionalization levels. Addressing gender inequalities and other structural determinants of nursing professionalization could contribute to achieving health equity and could benefit health systems through enhanced availability, skill-level, and sustainability of nursing human resources, improved and efficient access to care, improved patient outcomes, and cost savings.

Punching above their weight: a network to understand broader determinants of increasing life expectancy.

BACKGROUND: Life expectancy initially improves rapidly with economic development but then tails off. Yet, at any level of economic development, some countries do better, and some worse, than expected - they either punch above or below their weight. Why this is the case has been previously researched but no full explanation of the complexity of this phenomenon is available. NEW RESEARCH NETWORK: In order to advance understanding, the newly formed Punching Above Their Weight Research Network has developed a model to frame future research. It provides for consideration of the following influences within a country: political and institutional context and history; economic and social policies; scope for democratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles and power dynamics; the extent of civil society activity and disease burdens. CONCLUSION: Further research using this framework has considerable potential to advance effective policies to advance health and equity.

Universal Health Coverage and Primary Healthcare: Lessons From Japan Comment on "Achieving Universal Health Coverage by Focusing on Primary Care in Japan: Lessons for Low- and Middle-Income Countries".

A recent editorial by Naoki Ikegami has proposed three key lessons from Japan's experience of achieving virtually universal coverage with primary healthcare services: the need to integrate the existing providers of primary healthcare services into the organised health system; the need to limit government commitments to finance hospital services and the need to empower providers of primary healthcare to influence decisions that influence their livelihoods. Although the context of low- and middle-income countries (LMICs) differs in many ways from Japan in the late 19th and early 20th centuries, the lesson that short-term initiatives to achieve universal coverage need to be complemented by an understanding of the factors influencing long-term change management remains highly relevant.