Barriers, facilitators and proposed solutions to equitable mental health financing and service delivery for the Lebanese populations and displaced Syrians in Lebanon: Findings from a qualitative study.

Forcibly displaced populations experience an increased burden of mental illness. Scaling up mental health (MH) services places new resource demands on health systems in crises-affected settings and raises questions about how to provide equitable MH services for refugee and host populations. Our study investigates barriers, facilitators, and proposed solutions to MH financing and access for Lebanese populations and Syrian refugees in Lebanon, a protracted crisis setting. We collected qualitative data via 73 interviews and 3 focus group discussions. Participants were purposively selected from: (i) national, United Nations and NGO stakeholders; (ii) frontline MH service providers; (iii) insurance company representatives; (iv) Lebanese and Syrian adults and parents of children aged 12-17 years using MH services. Data were analysed using inductive and deductive approaches. Our results highlight challenges facing Lebanon's system of financing MH care in the face of ongoing multiple crises, including inequitable coverage, dependence on external humanitarian funds, and risks associated with short-term funding and their impact on sustainability of services. The built environment presents additional challenges to individuals trying to navigate, access and use existing MH services, and the social environment and service provider factors enable or hinder individuals accessing MH care. Registered Syrian refugees have better financial coverage to secondary MH care than Lebanese populations. However, given the economic crisis, both populations are facing similar challenges in paying for and accessing MH care at primary health care (PHC) level. Multiple crises in Lebanon have exacerbated challenges in financing MH care, dependence on external humanitarian funds, and risks and sustainability issues associated with short-term funding. Urgent reforms are needed to Lebanon's health financing system, working with government and external donors to equitably and efficiently finance and scale up MH care with a focus on PHC, and to reduce inequities in MH service coverage between Lebanese and Syrian refugee populations.

Exposure to volatile organic compounds in offices and in residential and educational buildings in the European Union between 2010 and 2023: A systematic review and health risk assessment.

Chronic exposure to indoor volatile organic compounds (VOCs) can result in several adverse effects including cancers. We review reports of levels of VOCs in offices and in residential and educational buildings in the member states of the European Union (EU) published between 2010 and 2023. We use these data to assess the risk to population health by estimating lifetime exposure to indoor VOCs and resulting non-cancer and cancer risks and, from that, the burden of cancer attributable to VOC exposure and associated economic losses. Our systematic review identified 1783 articles, of which 184 were examined in detail, with 58 yielding relevant data. After combining data on VOC concentrations separately for EU countries and building types, non-cancer and cancer risks were assessed in terms of hazard quotient and lifetime excess cancer risk (LECR) using probabilistic Monte Carlo Simulations. The LECR was used to estimate disability adjusted life years (DALYs) from VOC-related cancers and associated costs. We find that the LECR associated with formaldehyde exposure was above the acceptable risk level (ARL) in France and Germany and that of from exposure to benzene was also above the ARL in Spanish females. The sum of DALYs and related costs/1,000,000 population/year from exposure to acetaldehyde, benzene, formaldehyde, tetrachloroethylene, and trichloroethylene were 4.02 and €41,010, respectively, in France, those from exposure to acetaldehyde, benzene, carbon tetrachloride, formaldehyde, and trichloroethylene were 3.91 and €39,590 in Germany, and those from exposure to benzene were 0.1 and €1030 in Spain. Taken as a whole, these findings show that indoor exposure to VOCs remains a public health concern in the EU. Although the EU has set limits for certain VOCs, further measures are needed to restrict the use of these chemicals in consumer products.

Expanding eligibility and improving quality of cervical cancer screening in Estonia: The 2021 reforms.

Estonia has one of the highest death rates from cervical cancer in the European Union despite having had a population-based screening programme for over 15 years. In 2021, this high disease burden, alongside a new national cancer prevention plan, prompted a series of cervical cancer screening programme reforms to address low screening uptake and evidence of variable screening test quality. The reforms had three main elements: expansion of eligibility to all women aged 30-65 regardless of insurance status; increasing test provision by enabling family physicians to take screening samples and introducing self-sampling; and improving testing procedures, replacing cytology with HPV testing as the primary screening test. Although the impact of these changes is yet to be seen, early signs suggest increased programme participation. However, at 51 %, further action to address barriers to uptake will likely be necessary. If Estonia is to avoid another period of policy dormancy, as happened between 2006 and 2021, greater clarity on screening programme accountability is required. The establishment of the National Cancer Screening Group may enable this. The first test will be the delivery of an end-to-end evaluation of the reformed programme, with an emphasis on equity of access. The next step will be to develop and deliver solutions that respond to these needs.

The role of global health partnerships in vaccine equity: A scoping review.

The emergence of global health partnerships (GHPs) towards the end of the twentieth century reflected concerns about slow progress in access to essential medicines, including vaccines. These partnerships bring together governments, private philanthropic foundations, NGOs, and international agencies. Those in the vaccine field seek to incentivise the development and manufacture of new vaccines, raise funds to pay for them and develop and support systems to deliver them to those in need. These activities became more critical during the COVID-19 pandemic, with the COVAX Facility Initiative promoting global vaccine equity. This review identifies lessons from previous experiences with GHPs. Findings contribute to understanding the emergence of GHPs, the mechanisms they leverage to support global access to vaccines, and the inherent challenges associated with their implementation. Using Arksey and O'Malley's method, we conducted a scoping review to identify and synthesise relevant articles. We analysed data thematically to identify barriers and opportunities for success. We included 68 eligible articles of 3,215 screened. Most (65 [95%]) were discussion or review articles describing partnerships or programmes they supported, and three (5%) were commentaries. Emerging themes included policy responses (e.g., immunisation mandates), different forms of partnerships arising in vaccine innovation (e.g., product development partnerships, public-private partnerships for access), and influence on global governance decision-making processes (e.g., the rising influence of foundations, diminishing authority of WHO, lack of accountability and transparency, creation of disease silos). If global health partnerships are to maximise their contributions, they should: (1) increase transparency, especially regarding their impacts; (2) address the need for health systems strengthening; and (3) address disincentives for cooperative vaccine research and development partnerships and encourage expansion of manufacturing capacity in low and middle-income countries.

'Government don't know me and if I stop, they won't know': A qualitative study on the lived experiences of volunteer health workers in the Nigerian health system and their implications for the sustainable development goals.

BACKGROUND: Volunteer health workers play an important, but poorly understood role in the Nigerian health system. We report a study of their lived experiences, enabling us to understand their motivations, the nature of their work, and their relationships with formally employed health workers in Primary Healthcare Centres (PHCs) in Nigeria, the role of institutional incentives, and the implications for attaining the health-related sustainable development goals (SDGs) targets. METHODS: The study used ethnographic observation of PHCs in Enugu State, supplemented with in-depth interviews with volunteers, formally employed health workers and health managers. The analysis employed a combination of narrative and reflexive thematic approaches. FINDINGS: The lived experiences of most volunteers unfold in four stages as they move into and out of their volunteering status. The first stage signifies hope, arising from the ease with which they are accepted and integrated into the PHC space. The anger stage emerges when volunteers confront the marked disparity in their treatment compared to formal staff, despite their substantial contributions to healthcare. Then, the bargaining stage sets in, where they strive for recognition and respect by pursuing formal employment and advocating for fair treatment and improved stipends. A positive response, such as improved stipends, can reignite hope among volunteers. If not, most volunteers transition to the acceptance stage - the acknowledgement that their status may never be formalised, prompting many to lose hope and disengage. CONCLUSION: There should be a clear policy on recruitment, compensation, and protection of volunteers in the health systems, to enhance the contribution they can make to the achievement of the health-related SDG targets.

Trends in inequalities in avoidable hospitalisations across the COVID-19 pandemic: a cohort study of 23.5 million people in England.

OBJECTIVE: To determine whether periods of disruption were associated with increased 'avoidable' hospital admissions and wider social inequalities in England. DESIGN: Observational repeated cross-sectional study. SETTING: England (January 2019 to March 2022). PARTICIPANTS: With the approval of NHS England we used individual-level electronic health records from OpenSAFELY, which covered ~40% of general practices in England (mean monthly population size 23.5 million people). PRIMARY AND SECONDARY OUTCOME MEASURES: We estimated crude and directly age-standardised rates for potentially preventable unplanned hospital admissions: ambulatory care sensitive conditions and urgent emergency sensitive conditions. We considered how trends in these outcomes varied by three measures of social and spatial inequality: neighbourhood socioeconomic deprivation, ethnicity and geographical region. RESULTS: There were large declines in avoidable hospitalisations during the first national lockdown (March to May 2020). Trends increased post-lockdown but never reached 2019 levels. The exception to these trends was for vaccine-preventable ambulatory care sensitive admissions which remained low throughout 2020-2021. While trends were consistent by each measure of inequality, absolute levels of inequalities narrowed across levels of neighbourhood socioeconomic deprivation, Asian ethnicity (compared with white ethnicity) and geographical region (especially in northern regions). CONCLUSIONS: We found no evidence that periods of healthcare disruption from the COVID-19 pandemic resulted in more avoidable hospitalisations. Falling avoidable hospital admissions has coincided with declining inequalities most strongly by level of deprivation, but also for Asian ethnic groups and northern regions of England.

The paradoxical surplus of health workers in Africa: The need for research and policy engagement.

In many countries in Africa, there is a 'paradoxical surplus' of under and unemployed nurses, midwives, doctors and pharmacists which exists amidst a shortage of staff within the formal health system. By 2030, the World Health Organisation Africa Region may find itself with a shortage of 6.1 million health workers alongside 700,000 un- or underemployed health staff. The emphasis in policy debates about human resources for health at most national and global levels is on staff shortage and the need to train more health workers. In contrast, these 'surplus' health workers are both understudied and underacknowledged. Little time is given over to understand the economic, political and social factors that have driven their emergence; the ways in which they seek to make a living; the governance challenges that they raise; nor potential interventions that could be implemented to improve employment rates and leverage their expertise. This short communication reflects on current research findings and calls for improved quantitative and qualitative research to support policy engagement at national, regional and global levels.

Integration of migrant and refugee data in health information systems in Europe: advancing evidence, policy and practice.

Coverage of migrant and refugee data is incomplete and of insufficient quality in European health information systems. This is not because we lack the knowledge or technology. Rather, it is due to various political factors at local, national and European levels, which hinder the implementation of existing knowledge and guidelines. This reflects the low political priority given to the topic, and also complex governance challenges associated with migration and displacement. We review recent evidence, guidelines, and policies to propose four approaches that will advance science, policy, and practice. First, we call for strategies that ensure that data is collected, analyzed and disseminated systematically. Second, we propose methods to safeguard privacy while combining data from multiple sources. Third, we set out how to enable survey methods that take account of the groups' diversity. Fourth, we emphasize the need to engage migrants and refugees in decisions about their own health data. Based on these approaches, we propose a change management approach that narrows the gap between knowledge and action to create healthcare policies and practices that are truly inclusive of migrants and refugees. We thereby offer an agenda that will better serve public health needs, including those of migrants and refugees and advance equity in European health systems. Funding: No specific funding received.

The nature, drivers and equity consequences of informal payments for maternal and child health care in primary health centres in Enugu, Nigeria.

In Nigeria, most basic maternal and child health services in public primary health-care facilities should be either free of charge or subsidized. In practice, additional informal payments made in cash or in kind are common. We examined the nature, drivers and equity consequences of informal payments in primary health centres (PHC) in Enugu State. We used three interlinked qualitative methods: participant observation in six PHC facilities and two local government area (LGA) headquarters; in-depth interviews with frontline health workers (n = 19), managers (n = 4) and policy makers (n = 10); and focus group discussions (n = 2) with female service users. Data were analysed thematically using NVivo 12. Across all groups, informal payments were described as routine for immunization, deliveries, family planning consultations and birth certificate registration. Health workers, managers and policy makers identified limited supervision, insufficient financing of facilities, and lack of receipts for formal payments as enabling this practice. Informal payments were seen by managers and health workers as a mechanism to generate discretionary revenue to cover operational costs of the facility but, in practice, were frequently taken as extra income by health workers. Health workers rationalized informal payments as being of small value, and not a burden to users. However, informal payments were reported to be inequitable and exclusionary. Although they tended to be lower in rural PHCs than in wealthier urban facilities, participant observation revealed how, within a PHC, the lowest earners paid the same as others and were often left unattended if they failed to pay. Some female patients reported that extra payments excluded them from services, driving them to seek help from retail outlets or unlicensed health providers. As a result, informal payments reduced equity of access to essential services. Targeted policies are needed to improve financial risk protection for the poorest groups and address drivers of informal payments and unfairness in the health system.

"I can't kill myself": Local narratives and meanings that foster absenteeism in Nigerian primary health centres.

Background: Absenteeism in the health sector is increasingly seen as a form of harmful rule-breaking, with health workers receiving a salary although they are not present to provide care. It is a barrier to achieving universal health coverage yet remains widespread in primary health centres (PHCs) in Nigeria and many other low-resource settings. Traditional approaches to combatting absenteeism have relied on anti-corruption measures such as promoting accountability and transparency. However, more needs to be understood about the social and cultural realities, including perceptions and norms enabling or constraining the application of such measures in Nigeria and in similar contexts. Methods: We conducted 34 in-depth interviews (IDIs) with frontline health workers and their managers/supervisors and two focus group discussions (FDGs) with service users (n = 22) in Enugu State, South Eastern Nigeria. We discussed their experiences and views about absenteeism, allowing the respondents' framings to emerge. We adopted a mixed approach of narrative analysis and phenomenology to examine respondents' narratives - identifying the concepts and social constructs within the narratives that manifested through the language used. Results: Stakeholders acknowledged the problem of absenteeism but had differing perspectives on its dynamics. Health workers distinguished two forms of absenteeism: one as a mundane, everyday response to the poorly funded health system; and the other, brazen and often politically enabled absenteeism, where health workers whom powerful politicians protect are absent without facing consequences. There is a general feeling of powerlessness among both health service providers and service users confronted by politically backed absentees as the power dynamics in the health sector resonate with experiences in other spheres of life in Nigeria. Health workers rationalised mundane, technical absenteeism, adjusted to it and felt it should be accommodated in the health system. Service users are often unsure about who is absent and why, but when they notice absenteeism, they often ascribe it to wider system malpractices that characterise public services. Conclusion: Interventions to tackle absenteeism and other forms of health sector corruption should be sensitive to socio-cultural and political contexts that shape everyday lives in specific contexts. Challenging narratives/beliefs that normalise absenteeism should be part of reform plans.

Re-aligning Incentives to Address Informal Payments in Tanzania Public Health Facilities: A Discrete Choice Experiment.

BACKGROUND: Informal payments for healthcare are typically regressive and limit access to quality healthcare while increasing risk of catastrophic health expenditure, especially in developing countries. Different responses have been proposed, but little is known about how they influence the incentives driving this behaviour. We therefore identified providers' preferences for policy interventions to overcome informal payments in Tanzania. METHODS: We undertook a discrete choice experiment (DCE) to elicit preferences over various policy options with 432 health providers in 42 public health facilities in Pwani and Dar es Salaam region. DCE attributes were derived from a multi-stage process including a literature review, qualitative interviews with key informants, a workshop with health stakeholders, expert opinions, and a pilot test. Each respondent received 12 unlabelled choice sets describing two hypothetical job-settings that varied across 6-attributes: mode of payment, supervision at facility, opportunity for private practice, awareness and monitoring, measures against informal payments, and incentive payments to encourage noninfraction. Mixed multinomial logit (MMNL) models were used for estimation. RESULTS: All attributes, apart from supervision at facility, significantly influenced providers' choices (P<.001). Health providers strongly and significantly preferred incentive payments for non-infraction and opportunities for private practice, but significantly disliked disciplinary measures at district level. Preferences varied across the sample, although all groups significantly preferred the opportunity to practice privately and cashless payment. Disciplinary measures at district level were significantly disliked by unit in-charges, those who never engaged in informal payments, and who were not absent from work for official trip. 10% salary top-up were preferred incentive by all, except those who engaged in informal payments and absent from work for official trip. CONCLUSION: Better working conditions, with improved earnings and career paths, were strongly preferred by all, different respondents groups had distinct preferences according to their characteristics, suggesting the need for adoption of tailored packages of interventions.

Comparing estimates of household expenditures between pictorial diaries and surveys in three low- and middle-income countries.

In most low- and middle-income countries (LMICs), household out-of-pocket (OOP) health spending constitutes a major source of healthcare financing. Household surveys are commonly used to monitor OOP health spending, but are prone to recall bias and unable to capture seasonal variation, and may underestimate expenditure-particularly among households with long-term chronic health conditions. Household expenditure diaries have been developed as an alternative to overcome the limitations of surveys, and pictorial diaries have been proposed where literacy levels may render traditional diary approaches inappropriate. This study compares estimates for general household and chronic healthcare expenditure in South Africa, Tanzania and Zimbabwe derived using survey and pictorial diary approaches. We selected a random sub-sample of 900 households across urban and rural communities participating in the Prospective Urban and Rural Epidemiology study. For a range of general and health-specific categories, OOP expenditure estimates use cross-sectional survey data collected via standardised questionnaire, and data from these same households collected via two-week pictorial diaries repeated four times over 2016-2019. In all countries, average monthly per capita expenditure on food, non-food/non-health items, health, and consequently, total household expenditure reported by pictorial diaries was consistently higher than that reported by surveys (each p<0.001). Differences were greatest for health expenditure. The share of total household expenditure allocated to health also differed by method, accounting for 2% in each country when using survey data, and from 8-20% when using diary data. Our findings suggest that the choice of data collection method may have significant implications for estimating OOP health spending and the burden it places on households. Despite several practical challenges to their implementation, pictorial diaries offer a method to assess potential bias in surveys or triangulate data from multiple sources. We offer some practical guidance when considering the use of pictorial diaries for estimating household expenditure.

The public health implications of the cost-of-living crisis: outlining mechanisms and modelling consequences.

The UK, and other high-income countries, are experiencing substantial increases in living costs. Several overlapping and intersecting economic crises threaten physical and mental health in the immediate and longer term. Policy responses may buffer against the worst effects (e.g. welfare support) or further undermine health (e.g. austerity). We explore fundamental causes underpinning the cost-of-living crisis, examine potential pathways by which the crisis could impact population health and use a case study to model potential impacts of one aspect of the crisis on a specific health outcome. Our modelling illustrates how policy approaches can substantially protect health and avoid exacerbating health inequalities. Targeting support at vulnerable households is likely to protect health most effectively. The current crisis is likely to be the first of many in era of political and climate uncertainty. More refined integrated economic and health modelling has the potential to inform policy integration, or 'health in all policies'.

Commercial determinants of health: future directions.

This paper is about the future role of the commercial sector in global health and health equity. The discussion is not about the overthrow of capitalism nor a full-throated embrace of corporate partnerships. No single solution can eradicate the harms from the commercial determinants of health-the business models, practices, and products of market actors that damage health equity and human and planetary health and wellbeing. But evidence shows that progressive economic models, international frameworks, government regulation, compliance mechanisms for commercial entities, regenerative business types and models that incorporate health, social, and environmental goals, and strategic civil society mobilisation together offer possibilities of systemic, transformative change, reduce those harms arising from commercial forces, and foster human and planetary wellbeing. In our view, the most basic public health question is not whether the world has the resources or will to take such actions, but whether humanity can survive if society fails to make this effort.

Defining and conceptualising the commercial determinants of health.

Although commercial entities can contribute positively to health and society there is growing evidence that the products and practices of some commercial actors-notably the largest transnational corporations-are responsible for escalating rates of avoidable ill health, planetary damage, and social and health inequity; these problems are increasingly referred to as the commercial determinants of health. The climate emergency, the non-communicable disease epidemic, and that just four industry sectors (ie, tobacco, ultra-processed food, fossil fuel, and alcohol) already account for at least a third of global deaths illustrate the scale and huge economic cost of the problem. This paper, the first in a Series on the commercial determinants of health, explains how the shift towards market fundamentalism and increasingly powerful transnational corporations has created a pathological system in which commercial actors are increasingly enabled to cause harm and externalise the costs of doing so. Consequently, as harms to human and planetary health increase, commercial sector wealth and power increase, whereas the countervailing forces having to meet these costs (notably individuals, governments, and civil society organisations) become correspondingly impoverished and disempowered or captured by commercial interests. This power imbalance leads to policy inertia; although many policy solutions are available, they are not being implemented. Health harms are escalating, leaving health-care systems increasingly unable to cope. Governments can and must act to improve, rather than continue to threaten, the wellbeing of future generations, development, and economic growth.

Global financing for health policy and systems research: a review of funding opportunities.

Health policy and systems research (HPSR) is a neglected area in global health financing. Despite repeated calls for greater investment, it seems that there has been little growth. We analysed trends in reported funding and activity between 2015 and 2021 using a novel real-time source of global health data, the Devex.com database, the world's largest source of funding opportunities related to international development. We performed a systematic search of the Devex.com database for HPSR-related terms with a focus on low- and middle-income countries. We included 'programs', 'tenders & grants' and 'contract awards', covering all call statuses (open, closed or forecast). Such funding opportunities were included if they were related specifically to HPSR funding or had an HPSR component; pure biomedical funding was excluded. Our findings reveal a relative neglect of HPSR, as only ∼2% of all global health funding calls included a discernible HPSR component. Despite increases in funding calls until 2019, this situation reversed in 2020, likely reflecting the redirection of resources to rapid assessments of the impacts of the coronavirus disease 2019 (COVID-19) pandemic. Most identified projects represented small-scale opportunities-commonly for consultancies or technical assistance. To the extent that new data were generated, these projects were either tied to a specific large intervention or were narrow in scope to meet a specific challenge-with many examples informing policy responses to the Covid-19 pandemic. Nearly half of advertised funding opportunities were multi-country projects, usually addressing global policy priorities like health systems strengthening or development of coordinated public health policies at a regional level. The Covid-19 pandemic has shown why investing in HPSR is more important than ever to enable the delivery of effective health interventions and avoid costly implementation failures. The evidence presented here highlights the need to scale up efforts to convince global health funders to institutionalize the inclusion of HPSR components in all funding calls.