"Hospitals respond to demand. Public health needs to respond to risk": health system lessons from a case study of northern Queensland's COVID-19 surveillance and response.

BACKGROUND: The vast region of northern Queensland (NQ) in Australia experiences poorer health outcomes and a disproportionate burden of communicable diseases compared with urban populations in Australia. This study examined the governance of COVID-19 surveillance and response in NQ to identify strengths and opportunities for improvement. METHODS: The manuscript presents an analysis of one case-unit within a broader case study project examining systems for surveillance and response for COVID-19 in NQ. Data were collected between October 2020-December 2021 comprising 47 interviews with clinical and public health staff, document review, and observation in organisational settings. Thematic analysis produced five key themes. RESULTS: Study findings highlight key strengths of the COVID-19 response, including rapid implementation of response measures, and the relative autonomy of NQ's Public Health Units to lead logistical decision-making. However, findings also highlight limitations and fragility of the public health system more generally, including unclear accountabilities, constraints on local community engagement, and workforce and other resourcing shortfalls. These were framed by state-wide regulatory and organisational incentives that prioritise clinical health care rather than disease prevention, health protection, and health promotion. Although NQ mobilised an effective COVID-19 response, findings suggest that NQ public health systems are marked by fragility, calling into question the region's preparedness for future pandemic events and other public health crises. CONCLUSIONS: Study findings highlight an urgent need to improve governance, resourcing, and political priority of public health in NQ to address unmet needs and ongoing threats.

Interacting Genomic Landscapes of REC8-Cohesin, Chromatin, and Meiotic Recombination in Arabidopsis.

Meiosis recombines genetic variation and influences eukaryote genome evolution. During meiosis, DNA double-strand breaks (DSBs) enter interhomolog repair to yield crossovers and noncrossovers. DSB repair occurs as replicated sister chromatids are connected to a polymerized axis. Cohesin rings containing the REC8 kleisin subunit bind sister chromatids and anchor chromosomes to the axis. Here, we report the genomic landscape of REC8 using chromatin immunoprecipitation sequencing (ChIP-seq) in Arabidopsis (Arabidopsis thaliana). REC8 associates with regions of high nucleosome occupancy in multiple chromatin states, including histone methylation at H3K4 (expressed genes), H3K27 (silent genes), and H3K9 (silent transposons). REC8 enrichment is associated with suppression of meiotic DSBs and crossovers at the chromosome and fine scales. As REC8 enrichment is greatest in transposon-dense heterochromatin, we repeated ChIP-seq in kyp suvh5 suvh6 H3K9me2 mutants. Surprisingly, REC8 enrichment is maintained in kyp suvh5 suvh6 heterochromatin and no defects in centromeric cohesion were observed. REC8 occupancy within genes anti-correlates with transcription and is reduced in COPIA transposons that reactivate expression in kyp suvh5 suvh6 Abnormal axis structures form in rec8 that recruit DSB-associated protein foci and undergo synapsis, which is followed by chromosome fragmentation. Therefore, REC8 occupancy correlates with multiple chromatin states and is required to organize meiotic chromosome architecture and interhomolog recombination.

Factors influencing the community participation approaches used in Aedes mosquito management in the Torres Strait, Australia.

BACKGROUND: Aedes-borne disease risk is increasing in tropical and sub-tropical regions across the globe. While Aedes-borne disease continues to disproportionally affect low- and middle-income countries, parts of high-income countries, such as the Torres Strait region in Australia are also at risk. The Torres Strait is a group of islands located between Cape York Peninsula in far north Queensland, Australia and Papua New Guinea. The Torres Strait has both Aedes albopictus and Aedes aegypti and is close to Papua New Guinea where dengue fever is endemic. Managing Aedes-borne disease risk requires a range of strategies, including community participation. Existing research shows that high-income countries tend to favour government-led (top-down) informing approaches when engaging communities in Aedes mosquito management. Little is known about the factors that influence the choice of community participation approaches in Aedes mosquito management particularly in a high-income country setting, such as Australia. This research contributes to filling this knowledge gap by exploring the community participation approaches used in Aedes mosquito management and the factors influencing these choices in the Torres Strait. METHODS: 16 semi-structured interviews were conducted with local government and state government agencies working in Aedes mosquito management in the Torres Strait. Six key mosquito management plans and policies were also reviewed. Thematic analysis was used to identify, analyse and attribute meaning from the data collected. RESULTS: A range of community participation approaches were used within the two main Aedes mosquito management programs (Aedes albopictus Elimination Program and the Torres Strait Island Regional Council, Environmental Health Program) in the Torres Strait. These approaches included door-to-door inspections, awareness raising strategies, and community clean-up events. Approaches were chosen for reasons related to regulations, attitude and beliefs, and resourcing. CONCLUSIONS: This study revealed the use of both top-down and bottom-up approaches to engaging the community in Aedes mosquito management in the Torres Strait. These findings contribute to a better understanding of why bottom-up approaches are used, which is valuable for shaping future policy decisions. This study also provides suggestions on ways to enhance community participation in the Torres Strait, which could also be considered in other similar tropical regions.

ASY1 acts as a dosage-dependent antagonist of telomere-led recombination and mediates crossover interference in Arabidopsis.

During meiosis, interhomolog recombination produces crossovers and noncrossovers to create genetic diversity. Meiotic recombination frequency varies at multiple scales, with high subtelomeric recombination and suppressed centromeric recombination typical in many eukaryotes. During recombination, sister chromatids are tethered as loops to a polymerized chromosome axis, which, in plants, includes the ASY1 HORMA domain protein and REC8-cohesin complexes. Using chromatin immunoprecipitation, we show an ascending telomere-to-centromere gradient of ASY1 enrichment, which correlates strongly with REC8-cohesin ChIP-seq data. We mapped crossovers genome-wide in the absence of ASY1 and observe that telomere-led recombination becomes dominant. Surprisingly, asy1/+ heterozygotes also remodel crossovers toward subtelomeric regions at the expense of the pericentromeres. Telomeric recombination increases in asy1/+ occur in distal regions where ASY1 and REC8 ChIP enrichment are lowest in wild type. In wild type, the majority of crossovers show interference, meaning that they are more widely spaced along the chromosomes than expected by chance. To measure interference, we analyzed double crossover distances, MLH1 foci, and fluorescent pollen tetrads. Interestingly, while crossover interference is normal in asy1/+, it is undetectable in asy1 mutants, indicating that ASY1 is required to mediate crossover interference. Together, this is consistent with ASY1 antagonizing telomere-led recombination and promoting spaced crossover formation along the chromosomes via interference. These findings provide insight into the role of the meiotic axis in patterning recombination frequency within plant genomes.

A qualitative study of senior management perspectives on the leadership skills required in regional and rural Australian residential aged care facilities.

BACKGROUND: With increasing recognition of the quality and safety issues in residential aged care, there is an urgent need to better understand what skills senior managers require to deliver on the spectrum of leadership functions in residential aged care facilities. This qualitative study sought to explore the leadership skills that positively influence the quality of care within Australian residential aged care facilities and better understand the professional development needs of senior managers to positively influence care within these complex environments. METHODS: We conducted semi-structured interviews with 19 senior managers purposively recruited from 14 high-performing non-government residential aged care facilities of varying geographical remoteness in northern Queensland, Australia. Participants held a range of professional roles, including Chief Executive Officer, Director of Nursing and Facility Manager, and had various professional qualifications. We used inductive thematic analysis to identify and categorise senior managers' perspectives on the leadership skills and related strategies to promote quality of care. RESULTS: Senior managers reported leadership skills in five major domains: i) communication and relationship management, ii) stewardship, iii) professional development, iv) health care knowledge and v) information technology and finance. Most participants highlighted communication and relationship management skills and responding to regulatory change as influential to residential aged care quality performance. Participants with different professional backgrounds often emphasised different skills. CONCLUSIONS: Participants identified a broad range of skills and strategies required by senior managers in Australian residential aged care facilities. Identifying different skills by differently trained individuals suggests more work is needed to understand and develop sector-specific professional development approaches to better prepare individuals to lead in this complex service environment.

Community-facility linkage models and maternal and infant health outcomes in Malawi's PMTCT/ART program: A cohort study.

BACKGROUND: In sub-Saharan Africa, 3 community-facility linkage (CFL) models-Expert Clients, Community Health Workers (CHWs), and Mentor Mothers-have been widely implemented to support pregnant and breastfeeding women (PBFW) living with HIV and their infants to access and sustain care for prevention of mother-to-child transmission of HIV (PMTCT), yet their comparative impact under real-world conditions is poorly understood. METHODS AND FINDINGS: We sought to estimate the effects of CFL models on a primary outcome of maternal loss to follow-up (LTFU), and secondary outcomes of maternal longitudinal viral suppression and infant "poor outcome" (encompassing documented HIV-positive test result, LTFU, or death), in Malawi's PMTCT/ART program. We sampled 30 of 42 high-volume health facilities ("sites") in 5 Malawi districts for study inclusion. At each site, we reviewed medical records for all newly HIV-diagnosed PBFW entering the PMTCT program between July 1, 2016 and June 30, 2017, and, for pregnancies resulting in live births, their HIV-exposed infants, yielding 2,589 potentially eligible mother-infant pairs. Of these, 2,049 (79.1%) had an available HIV treatment record and formed the study cohort. A randomly selected subset of 817 (40.0%) cohort members underwent a field survey, consisting of a questionnaire and HIV biomarker assessment. Survey responses and biomarker results were used to impute CFL model exposure, maternal viral load, and early infant diagnosis (EID) outcomes for those missing these measures to enrich data in the larger cohort. We applied sampling weights in all statistical analyses to account for the differing proportions of facilities sampled by district. Of the 2,049 mother-infant pairs analyzed, 62.2% enrolled in PMTCT at a primary health center, at which time 43.7% of PBFW were ≤24 years old, and 778 (38.0%) received the Expert Client model, 640 (31.2%) the CHW model, 345 (16.8%) the Mentor Mother model, 192 (9.4%) ≥2 models, and 94 (4.6%) no model. Maternal LTFU varied by model, with LTFU being more likely among Mentor Mother model recipients (adjusted hazard ratio [aHR]: 1.45; 95% confidence interval [CI]: 1.14, 1.84; p = 0.003) than Expert Client recipients. Over 2 years from HIV diagnosis, PBFW supported by CHWs spent 14.3% (95% CI: 2.6%, 26.1%; p = 0.02) more days in an optimal state of antiretroviral therapy (ART) retention with viral suppression than women supported by Expert Clients. Infants receiving the Mentor Mother model (aHR: 1.24, 95% CI: 1.01, 1.52; p = 0.04) and ≥2 models (aHR: 1.44, 95% CI: 1.20, 1.74; p < 0.001) were more likely to undergo EID testing by age 6 months than infants supported by Expert Clients. Infants receiving the CHW and Mentor Mother models were 1.15 (95% CI: 0.80, 1.67; p = 0.44) and 0.84 (95% CI: 0.50, 1.42; p = 0.51) times as likely, respectively, to experience a poor outcome by 1 year than those supported by Expert Clients, but not significantly so. Study limitations include possible residual confounding, which may lead to inaccurate conclusions about the impacts of CFL models, uncertain generalizability of findings to other settings, and missing infant medical record data that limited the precision of infant outcome measurement. CONCLUSIONS: In this descriptive study, we observed widespread reach of CFL models in Malawi, with favorable maternal outcomes in the CHW model and greater infant EID testing uptake in the Mentor Mother model. Our findings point to important differences in maternal and infant HIV outcomes by CFL model along the PMTCT continuum and suggest future opportunities to identify key features of CFL models driving these outcome differences.

A cascade of interventions: A classification tree analysis of the determinants of primary cesareans in Australian public hospitals.

BACKGROUND: Both globally and in Australia, there has been a sharp rise in cesarean births (CB). Commonly, this rise has been attributed to the changing epidemiology of women giving birth. A significant body of knowledge exists on the risk factors associated with a greater need for cesarean. Yet, we have little information on the reasons recorded by clinicians as to why cesareans are provided. This study aimed to explore the drivers of primary cesareans in Australian public hospitals. METHODS: Using a linked administrative data set, the frequency and percent of mothers' characteristics were compared between those who had a cesarean birth and those who had a vaginal birth (n = 98 967) with no history of previous cesareans in Queensland public hospitals between July 1, 2012, and June 30, 2015. The top 10 reasons recorded by clinicians for a primary cesarean were reported. Using a machine-learning algorithm, two decision trees were built to determine factors driving primary cesarean birth. RESULTS: "Labour and delivery complicated by fetal heart rate anomaly" (23%) and "primary inadequate contractions" (22.8%) were the top two reasons for a primary cesarean birth. The most common characteristics among mothers who had fetal heart rate anomalies were as follows: artificial rupture of membranes (39%), oxytocin (32%), no obstruction of labor (42%), and epidural (52%). For women who had primary inadequate contractions, the most common characteristics were as follows: epidural (33%), oxytocin (49%), artificial rupture of membranes (45%), and fetal stress (56%). CONCLUSIONS: Efforts should be made by health practitioners during the antenatal period to maximize the use of preventative measures that minimize the need for medical interventions.

Massive crossover elevation via combination of HEI10 and recq4a recq4b during Arabidopsis meiosis.

During meiosis, homologous chromosomes undergo reciprocal crossovers, which generate genetic diversity and underpin classical crop improvement. Meiotic recombination initiates from DNA double-strand breaks (DSBs), which are processed into single-stranded DNA that can invade a homologous chromosome. The resulting joint molecules can ultimately be resolved as crossovers. In Arabidopsis, competing pathways balance the repair of ∼100-200 meiotic DSBs into ∼10 crossovers per meiosis, with the excess DSBs repaired as noncrossovers. To bias DSB repair toward crossovers, we simultaneously increased dosage of the procrossover E3 ligase gene HEI10 and introduced mutations in the anticrossovers helicase genes RECQ4A and RECQ4B As HEI10 and recq4a recq4b increase interfering and noninterfering crossover pathways, respectively, they combine additively to yield a massive meiotic recombination increase. Interestingly, we also show that increased HEI10 dosage increases crossover coincidence, which indicates an effect on interference. We also show that patterns of interhomolog polymorphism and heterochromatin drive recombination increases distally towards the subtelomeres in both HEI10 and recq4a recq4b backgrounds, while the centromeres remain crossover suppressed. These results provide a genetic framework for engineering meiotic recombination landscapes in plant genomes.

Community participation and empowerment approaches to Aedes mosquito management in high-income countries: a scoping review.

High-income countries (HICs) in sub-tropical and tropical regions are at an increasing risk of Aedes mosquito-borne disease (MBD) outbreaks such as dengue fever. As the Aedes mosquito predominately lives and breeds in and around people's homes, community participation in MBD management is an important part of preventing MBD outbreaks. Historically, government-led strategies have dominated community participation efforts as opposed to strategies co-designed or led by the community. A scoping review was conducted to describe the community participation and empowering approaches used in Aedes mosquito management specifically in HICs, and to identify any reported outcomes of these methods. A systematic search of peer-reviewed literature using electronic databases Medline (OVID), Web of Science, Scopus and ProQuest-Science and Technology as well as grey literature, found 19 studies that matched the review criteria. The review findings highlight a lack of empirical evidence to inform participatory and empowering approaches to mosquito management in HICs. Moreover, the rationale for using predominantly government-led approaches is not clear. Further research is required to better understand best approaches and barriers to employing empowering approaches in mosquito management in HICs.

Ethnic, socio-economic and geographic inequities in maternal health service coverage in Australia.

BACKGROUND: Disparities in health service use exist in many sectors of Australia's health system, particularly affecting the most vulnerable people in the population, who are typically those with the greatest healthcare needs. Understanding patterns of health service coverage is critical for acknowledging the underlying, systemic drivers including racialised practices that inhibit the uptake of health services for certain population groups. This study aims to determine whether there are disparities in health service utilisation between socioeconomic, geographic and ethnic groups of mothers who experience hypertension, diabetes and mental health conditions. METHODS: This study utilised a linked administrative healthcare dataset containing data of all mothers who gave birth in Queensland, Australia, between 2012 and 2015 (n = 186,789), plus their resultant babies (n = 189,909). The study compared health service utilisation for mothers with maternal health conditions between population groups. RESULTS: The results of this study showed a broad trend of inequitable health service utilisation, with mothers who experienced the greatest healthcare needs-First Nations, rural and remote and socio-economically disadvantaged mothers-being less likely to access health services and in some cases when care was accessed, fewer services being utilised during the perinatal period. CONCLUSION: Access to health care during the perinatal period is a reflection of Australia's general health system strengths and weaknesses, in particular a failure of the government to translate national and state policy intent into acceptable and accessible care in rural and remote areas, for First Nations women and for mothers experiencing socio-economic disadvantage.

Participation in adherence clubs and on-time drug pickup among HIV-infected adults in Zambia: A matched-pair cluster randomized trial.

BACKGROUND: Current models of HIV service delivery, with frequent facility visits, have led to facility congestion, patient and healthcare provider dissatisfaction, and suboptimal quality of services and retention in care. The Zambian urban adherence club (AC) is a health service innovation designed to improve on-time drug pickup and retention in HIV care through off-hours facility access and pharmacist-led group drug distribution. Similar models of differentiated service delivery (DSD) have shown promise in South Africa, but observational analyses of these models are prone to bias and confounding. We sought to evaluate the effectiveness and implementation of ACs in Zambia using a more rigorous study design. METHODS AND FINDINGS: Using a matched-pair cluster randomized study design (ClinicalTrials.gov: NCT02776254), 10 clinics were randomized to intervention (5 clinics) or control (5 clinics). At each clinic, between May 19 and October 27, 2016, a systematic random sample was assessed for eligibility (HIV+, age ≥ 14 years, on ART >6 months, not acutely ill, CD4 count not <200 cells/mm3) and willingness to participate in an AC. Clinical and antiretroviral drug pickup data were obtained through the existing electronic medical record. AC meeting attendance data were collected at intervention facilities prospectively through October 28, 2017. The primary outcome was time to first late drug pickup (>7 days late). Intervention effect was estimated using unadjusted Kaplan-Meier survival curves and a Cox proportional hazards model to derive an adjusted hazard ratio (aHR). Medication possession ratio (MPR) and implementation outcomes (adoption, acceptability, appropriateness, feasibility, and fidelity) were additionally evaluated as secondary outcomes. Baseline characteristics were similar between 571 intervention and 489 control participants with respect to median age (42 versus 41 years), sex (62% versus 66% female), median time since ART initiation (4.8 versus 5.0 years), median CD4 count at study enrollment (506 versus 533 cells/mm3), and baseline retention (53% versus 55% with at least 1 late drug pickup in previous 12 months). The rate of late drug pickup was lower in intervention participants compared to control participants (aHR 0.26, 95% CI 0.15-0.45, p < 0.001). Median MPR was 100% in intervention participants compared to 96% in control participants (p < 0.001). Although 18% (683/3,734) of AC group meeting visits were missed, on-time drug pickup (within 7 days) still occurred in 51% (350/683) of these missed visits through alternate means (use of buddy pickup or early return to the facility). Qualitative evaluation suggests that the intervention was acceptable to both patients and providers. While patients embraced the convenience and patient-centeredness of the model, preference for traditional adherence counseling and need for greater human resources influenced intervention appropriateness and feasibility from the provider perspective. The main limitations of this study were the small number of clusters, lack of viral load data, and relatively short follow-up period. CONCLUSIONS: ACs were found to be an effective model of service delivery for reducing late ART drug pickup among HIV-infected adults in Zambia. Drug pickup outside of group meetings was relatively common and underscores the need for DSD models to be flexible and patient-centered if they are to be effective. TRIAL REGISTRATION: ClinicalTrials.gov NCT02776254.

Addressing Common Mental Health Disorders Among Incarcerated People Living with HIV: Insights from Implementation Science for Service Integration and Delivery.

PURPOSE: Despite evidence of disproportionate burden of HIV and mental health disorders among incarcerated people, scarce services exist to address common mental health disorders, including major depressive and anxiety disorders, post-traumatic stress disorder, and substance use disorders, among incarcerated people living with HIV (PLHIV) in sub-Saharan Africa (SSA). This paper aims to summarize current knowledge on mental health interventions of relevance to incarcerated PLHIV and apply implementation science theory to highlight strategies and approaches to deliver mental health services for PLHIV in correctional settings in SSA. RECENT FINDINGS: Scarce evidence-based mental health interventions have been rigorously evaluated among incarcerated PLHIV in SSA. Emerging evidence from low- and middle-income countries and correctional settings outside SSA point to a role for cognitive behavioral therapy-based talking and group interventions implemented using task-shifting strategies involving lay health workers and peer educators. Several mental health interventions and implementation strategies hold promise for addressing common mental health disorders among incarcerated PLHIV in SSA. However, to deliver these approaches, there must first be pragmatic efforts to build corrections health system capacity, address human rights abuses that exacerbate HIV and mental health, and re-conceptualize mental health services as integral to quality HIV service delivery and universal access to primary healthcare for all incarcerated people.

Global Prison Health Care Governance and Health Equity: A Critical Lack of Evidence.

The large and growing population of people who experience incarceration makes prison health an essential component of public health and a critical setting for reducing health inequities. People who experience incarceration have a high burden of physical and mental health care needs and have poor health outcomes. Addressing these health disparities requires effective governance and accountability for prison health care services, including delivery of quality care in custody and effective integration with community health services.Despite the importance of prison health care governance, little is known about how prison health services are structured and funded or the methods and processes by which they are held accountable. A number of national and subnational jurisdictions have moved prison health care services under their ministry of health, in alignment with recommendations by the World Health Organization and the United Nations Office on Drugs and Crime. However, there is a critical lack of evidence on current governance models and an urgent need for evaluation and research, particularly in low- and middle-income countries.Here we discuss why understanding and implementing effective prison health governance models is a critical component of addressing health inequities at the global level.

Out-of-pocket expenditure on health care by Australian mothers: Lessons for maternal universal health coverage from a long-established system.

BACKGROUND: Designing effective universal health care systems has challenges, including the use of patient co-payments and the role of the public and private systems. This study sought to quantify the total amount of out-of-pocket fees incurred by women who gave birth in private and public hospitals within Australia-a country with universal health coverage-and assess the impact that variation in birth type has on out-of-pocket fees. METHODS: Data came from a linked administrative data set of all women who gave birth in the Australian state Queensland between July 1, 2012, and June 30, 2015, plus their resultant children. Propensity score matching was used to create two similar cohorts of women who gave birth in private and public hospitals. RESULTS: The mean total out-of-pocket fees for care from conception to the child's first birthday was $2813 (±2683 standard deviation) and $623 (±1202) for women who gave birth in private and public hospitals, respectively. Total fees were higher in both public and private hospitals for women who had a cesarean birth ($716 [±1419] and $3010 [±2988]) than for women who had a vaginal birth without instruments ($556 [±1044] and $2560 [±2284]). DISCUSSION: Australia's strong policy incentives for women to take out private health insurance are leaving women with large out-of-pocket costs. This should hold important lessons for other countries implementing a universal health care system, to ensure that using a combination of public and private practitioners does not undermine the intention of universal care.

How might improved estimates of HIV programme outcomes influence practice? A formative study of evidence, dissemination and response.

BACKGROUND: While HIV programmes have started millions of persons on life-saving antiretroviral therapy in Africa, longitudinal health information systems are frail and, therefore, data about long-term survival is often inaccurate or unknown to HIV programmes. The 'Better Information for Health in Zambia' (BetterInfo) Study - a regional sampling-based survey to assess retention and mortality in HIV programmes in Zambia - found both retention and mortality to be higher than prevailing estimates from national surveillance systems. We sought to understand how Zambian health decision-makers at different health system levels would respond to these new data, with a view to informing research translation. METHODS: We interviewed 25 purposefully sampled health decision-makers from community, facility, district, provincial and national levels. During the interviews, we shared retention and mortality estimates from both routine programme surveillance and those generated by the study. Transcripts were analysed for inductive and deductive themes, the latter drawing on Weiss's framework that policy-makers interpret and apply evidence as 'warning', 'guidance', 'reconceptualisation' or 'mobilisation of support'. FINDINGS: All decision-makers found study findings relevant and important. Decision-makers viewed the underestimates of mortality to be a warning about the veracity and informativeness of routine data systems. Decision-makers felt guided by the findings to improve data monitoring and, acknowledging limitations of routine data, utilised episodic patient tracing to support improved data accuracy. Findings catalysed renewed motivation and mobilisation by national level decision-makers for differentiated models of HIV care to improve patient outcomes and also improved data management systems to better capture patient outcomes. Inductive analysis highlighted a programmatic application data interpretation, in which study findings can influence facility and patient-level decision-making, quality of care and routine data management. CONCLUSIONS: New epidemiological data on patient outcomes were widely seen as informative and relevant and can potentially catalyse health system action such as using evaluations to supplement electronic medical record data to improve HIV programmes. Formative evidence suggests that targeting research dissemination at different levels of the health system will elicit different responses. Researchers supporting the translation of evidence to action should leverage all relevant levels of the health system to facilitate both policy and programmatic action.

Health service delivery and workforce in northern Australia: a scoping review.

INTRODUCTION: Delivering health services and improving health outcomes of the 1.3 million people residing in northern Australia, a region spanning 3 million km2 across the three jurisdictions of Western Australia, Northern Territory and Queensland, presents specific challenges. This review addresses a need for systems level analysis of the issues influencing the coverage, quality and responsiveness of health services across this region by examining the available published literature and identifying key policy-relevant gaps. METHODS: A scoping review design was adopted with searches incorporating both peer-reviewed and grey literature (eg strategy documents, annual reports and budgets). Grey literature was predominantly sourced from websites of key organisations in the three northern jurisdictions, with peer-reviewed literature sourced from electronic database searches and reference lists. Key articles and documents were also contributed by health sector experts. Findings were synthesised and reported narratively using the WHO health system 'building blocks' to categorise the data. RESULTS: From the total of 324 documents and data sources included in the review following screening and eligibility assessment, 197 were peer-reviewed journal articles and 127 were grey literature. Numerous health sector actors across the north - comprising planning bodies, universities and training organisations, peak bodies and providers - deliver primary, secondary and tertiary healthcare and workforce education and training in highly diverse contexts of care. Despite many exemplar health service and workforce models in the north, this synthesis describes a highly fragmented sector with many and disjointed stakeholders and funding sources. While the many strengths of the northern health system include expertise in training and supporting a fit-for-purpose health workforce, health systems in the north are struggling to meet the health needs of highly distributed populations with poorly targeted resources and ill-suited funding models. Ageing of the population and rising rates of chronic disease and mental health issues, underpinned by complex social, cultural and environmental determinants of health, continue to compound these challenges. CONCLUSION: Policy goals about developing northern Australia economically need to build from a foundation of a healthy and productive population. Improving health outcomes in the north requires political commitment, local leadership and targeted investment to improve health service delivery, workforce stability and evidence-based strengthening of community-led comprehensive primary health care. This requires intersectoral collaboration across many organisations and the three jurisdictions, drawing from previous collaborative experiences. Further evaluative research, linking structure to process and outcomes, and responding to changes in the healthcare landscape such as the rapid emergence of digital technologies, is needed across a range of policy areas to support these efforts.

Long-term out of pocket expenditure of people with cancer: comparing health service cost and use for indigenous and non-indigenous people with cancer in Australia.

BACKGROUND: Indigenous Australians diagnosed with cancer have poorer survival compared to non-Indigenous Australians. We aim to: 1) identify differences by Indigenous status in out-of-pocket expenditure for the first three-years post-diagnosis; 2) identify differences in the quantity and cost of healthcare services accessed; and 3) estimate the number of additional services required if access was equal between Indigenous and non-Indigenous people with cancer. METHODS: We used CancerCostMod, a model using linked administrative data. The base population was all persons diagnosed with cancer in Queensland, Australia (01JUL2011 to 30JUN2012) (n = 25,553). Each individual record was then linked to their Admitted Patient Data Collection, Emergency Data Information System, Medicare Benefits Schedule (MBS), and Pharmaceutical Benefits Scheme (PBS) records (01JUL2011 to 30JUN2015). We then weighted the population to be representative of the Australian population (approximately 123,900 Australians, 1.7% Indigenous Australians). The patient co-payment charged for each MBS service and PBS prescription was summed for each month from date of diagnosis to 36-months post-diagnosis. We then limited our model to MBS items to identify the quantity and type of healthcare services accessed during the first three-years. RESULTS: On average Indigenous people with cancer had less than half the out-of-pocket expenditure for each 12-month period (0-12 months: mean $401 Indigenous vs $1074 non-Indigenous; 13-24 months: mean $200 vs $484; and 25-36 months: mean $181 vs $441). A stepwise generalised linear model of out-of-pocket expenditure found that Indigenous status was a significant predictor of out of pocket expenditure. We found that Indigenous people with cancer on average accessed 236 services per person, however, this would increase to 309 services per person if Indigenous people had the same rate of service use as non-Indigenous people. CONCLUSIONS: Indigenous people with cancer had lower out-of-pocket expenditure, but also accessed fewer Medicare services compared to their non-Indigenous counterparts. Indigenous people with cancer were less likely to access specialist attendances, pathology tests, and diagnostic imaging through MBS, and more likely to access primary health care, such as services provided by general practitioners.

Evidence of overuse? Patterns of obstetric interventions during labour and birth among Australian mothers.

BACKGROUND: There is global concern for the overuse of obstetric interventions during labour and birth. Of particular concern is the increasing amount of mothers and babies experiencing morbidity and mortality associated with caesarean section compared to vaginal birth. In high-income settings, emerging evidence suggests that overuse of obstetric intervention is more prevalent among wealthier mothers with no medical need of it. In Australia, the rates of caesarean section and other obstetric interventions are rising. These rising rates of intervention have been mirrored by a decreasing rate of unassisted non-instrumental vaginal deliveries. In the context of rising global concern about rising caesarean section rates and the known health effects of caesarean section on mothers and children, we aim to better characterise the use of obstetric intervention in the state of Queensland, Australia by examining the characteristics of mothers receiving obstetric intervention. Identifying whether there is overuse of obstetric interventions within a population is critical to improving the quality, value and appropriateness of maternity care. METHODS: The association between demographic characteristics (at birth) and birth delivery type were compared with chi-square. The percentage of mothers based on their socioeconomic characteristics were reported and differences in percentages of obstetric interventions were compared. Multivariate analysis was undertaken using multiple logistic regression to assess the likelihood of receiving obstetric intervention and having a vaginal (non-instrumental) delivery after accounting for key clinical characteristics. RESULTS: Indigenous mothers, mothers in major cities and mothers in the wealthiest quintile all had higher percentages of all obstetric interventions and had the lowest percentages of unassisted (non-instrumental) vaginal births. These differences remained even after adjusting for other key sociodemographic and clinical characteristics. CONCLUSIONS: Differences in obstetric practice exist between economic, ethnic and geographical groups of mothers that are not attributable to medical or lifestyle risk factors. These differences may reflect health system, organisational and structural conditions and therefore, a better understanding of the non-clinical factors that influence the supply and demand of obstetric interventions is required.

A review of the impact of financing mechanisms on maternal health care in Australia.

BACKGROUND: The World Health Organization states there are three interrelated domains that are fundamental to achieving and maintaining universal access to care - raising sufficient funds for health care, reducing financial barriers to access by pooling funds in a way that prevents out-of-pocket costs, and allocating funds in a way that promotes quality, efficiency and equity. In Australia, a comprehensive account of the mechanisms for financing the health system have not been synthesised elsewhere. Therefore, to understand how the maternal health system is financed, this review aims to examine the mechanisms for funding, pooling and purchasing maternal health care and the influence these financing mechanisms have on the delivery of maternal health services in Australia. METHODS: We conducted a scoping review and interpretative synthesis of the financing mechanisms and their impact on Australia's maternal health system. Due to the nature of the study question, the review had a major focus on grey literature. The search was undertaken in three stages including; searching (1) Google search engine (2) targeted websites and (3) academic databases. Executive summaries and table of contents were screened for grey literature documents and Titles and Abstracts were screened for journal articles. Screening of publications' full-text followed. Data relating to either funding, pooling, or purchasing of maternal health care were extracted for synthesis. RESULTS: A total of 69 manuscripts were included in the synthesis, with 52 of those from the Google search engine and targeted website (grey literature) search. A total of 17 articles we included in the synthesis from the database search. CONCLUSION: Our study provides a critical review of the mechanisms by which revenues are raised, funds are pooled and their impact on the way health care services are purchased for mothers and babies in Australia. Australia's maternal health system is financed via both public and private sources, which consequentially creates a two-tiered system. Mothers who can afford private health insurance - typically wealthier, urban and non-First Nations women - therefore receive additional benefits of private care, which further exacerbates inequity between these groups of mothers and babies. The increasing out of pocket costs associated with obstetric care may create a financial burden for women to access necessary care or it may cause them to skip care altogether if the costs are too great.