Is the national health insurance scheme a pathway to sustained access to medicines in Nigeria?

OBJECTIVE: The debate surrounding access to medicines in Nigeria has become increasingly necessary due to the high cost of essential medicine drugs and the prevalence of counterfeit medicines in the country. The Nigerian government has proposed the implementation of the National Health Insurance Scheme (NHIS) to address these issues and guarantee universal access to essential medicines. Access was investigated using the 3 A's (accessibility, affordability, and availability). This paper investigates whether the NHIS is a viable pathway to sustained access to medicines in Nigeria. DESIGN: This was a cross-sectional study using a mixed-methods design. Both qualitative and quantitative methods were utilized for the study. SETTING: This study was conducted at NHIS-accredited public and private facilities in Enugu State. PARTICIPANTS: 296 randomly selected enrollees took part in the quantitative component, while, 6 participants were purposively selected for the qualitative component, where in-depth interviews (IDIs) were conducted face-to-face with NHIS desk officers in selected public and private health facilities. RESULTS: The quantitative findings showed that 94.9% of respondents sought medical help. Our data shows that 78.4% of the respondents indicated that the scheme improved their access to care (accessibility, affordability, and availability). The qualitative results from the NHIS desk officers showed that respondents across all the socio-economic groups reported that the NHIS had marginally improved access to medicine over the years. It was also observed that most of the staff in NHIS-accredited facilities were not adequately trained on the scheme's requirements and that most times, essential drugs were not readily available at the accredited facilities. CONCLUSION: The study findings revealed that although the NHIS has successfully expanded access to medicines, there remain several challenges to its effective implementation and sustainability. Additionally, the scheme's coverage of essential medicines is could be improved even more, leading to reduced access to needed drugs for many Nigerians. A focus on the 3As for the scheme means that all facility categories (private and public) and their interests (where necessary) must be considered in further planning of the scheme to ensure that things work out well.

Sustainable financing for vaccination towards advancing universal health coverage in the WHO African region: The strategic role of national health insurance.

There is a growing political interest in health reforms in Africa, and many countries are choosing national health insurance as their main financing mechanism for universal health coverage. Although vaccination is an essential health service that can influence progress toward universal health coverage, it is not often prioritized by these national health insurance systems. This paper highlights the potential gains of integrating vaccination into the package of health services that is provided through national health insurance and recommends practical policy actions that can enable countries to harness these benefits at population level.

Indian Model of Integrated Healthcare (IMIH): a conceptual framework for a coordinated referral system in resource-constrained settings.

INTRODUCTION: With the escalating burden of chronic disease and multimorbidity in India, owing to its ageing population and overwhelming health needs, the Indian Health care delivery System (HDS) is under constant pressure due to rising public expectations and ambitious new health goals. The three tired HDS should work in coherence to ensure continuity of care, which needs a coordinated referral system. This calls for optimising health care through Integrated care (IC). The existing IC models have been primarily developed and adopted in High-Income Countries. The present study attempts to review the applicability of existing IC models and frame a customised model for resource-constrained settings. METHODS: A two-stage methodology was used. Firstly, a narrative literature review was done to identify gaps in existing IC models, as per the World Health Organization framework approach. The literature search was done from electronic journal article databases, and relevant literature that reported conceptual and theoretical concepts of IC. Secondly, we conceptualised an IC concept according to India's existing HDS, validated by multiple rounds of brainstorming among co-authors. Further senior co-authors independently reviewed the conceptualised IC model as per national relevance. RESULTS: Existing IC models were categorised as individual, group and disease-specific, and population-based models. The limitations of having prolonged delivery time, focusing only on chronic diseases and being economically expensive to implement, along with requirement of completely restructuring and reorganising the existing HDS makes the adoption of existing IC models not feasible for India. The Indian Model of Integrated Healthcare (IMIH) model proposes three levels of integration: Macro, Meso, and Micro levels, using the existing HDS. The core components include a Central Gateway Control Room, using existing digital platforms at macro levels, a bucket overflow model at the meso level, a Triple-layered Concentric Circle outpatient department (OPD) design, and a three-door OPD concept at the micro level. CONCLUSION: IMIH offers features that consider resource constraints and local context of LMICs while being economically viable. It envisages a step toward UHC by optimising existing resources and ensuring a continuum of care. However, health being a state subject, various socio-political and legal/administrative issues warrant further discussion before implementation.

The Paradox of the Ugandan Health Insurance System: Challenges and Opportunities for Health Reform.

For nearly four decades, Ugandans have experienced a period marked by hope, conflict, and resilience across various aspects of healthcare reform. The health insurance system in Uganda lacks a legal framework and does not extend benefits to the entire population. In Uganda, community-based health insurance is common among those in the informal sector, while private medical insurance is typically provided to employees by their workplaces and agencies. The National Health Insurance Scheme Bill, introduced in 2019, was passed in 2021. If the President of Uganda gives his assent to the National Health Insurance Bill, it will become a significant policy driving health and universal health coverage. However, this bill is not without its shortcomings. In this perspective, we aim to explore the complex interplay of challenges and opportunities facing Uganda's health sector.

Towards an integrated type 1 diabetes management in low-resource settings: barriers faced by patients and their caregivers in healthcare facilities in Ghana.

BACKGROUND: In Low-Middle-Income Countries (LMICs), young people living with Type 1 Diabetes Mellitus (T1DM) face structural barriers which undermine adequate T1DM management and lead to poor health outcomes. However, research on the barriers faced by young people living with T1DM have mostly focused on patient factors, neglecting concerns regarding plausible barriers that may exist at the point of healthcare service delivery. OBJECTIVE: This study sought to explore barriers faced by young people living with T1DM and their caregivers at the point of healthcare service delivery. METHODS: Data were drawn from a qualitative research in southern Ghana. The research was underpinned by a phenomenological study design. Data were collected from 28 young people living with T1DM, 12 caregivers, and six healthcare providers using semi-structured interview guides. The data were collected at home, hospital, and support group centres via face-to-face interviews, telephone interviews, and videoconferencing. Thematic and framework analyses were done using CAQDAS (QSR NVivo 14). RESULTS: Eight key barriers were identified. These were: shortage of insulin and management logistics; healthcare provider knowledge gaps; lack of T1DM care continuity; poor healthcare provider-caregiver interactions; lack of specialists' care; sharing of physical space with adult patients; long waiting time; and outdated treatment plans. The multiple barriers identified suggest the need for an integrated model of T1DM to improve its care delivery in low-resource settings. We adapted the Chronic Care Model (CCM) to develop an Integrated Healthcare for T1DM management in low-resource settings. CONCLUSION: Young people living with T1DM, and their caregivers encountered multiple healthcare barriers in both in-patient and outpatient healthcare facilities. The results highlight important intervention areas which must be addressed/improved to optimise T1DM care, as well as call for the implementation of a proposed integrated approach to T1DM care in low-resource settings.

Assessing public health sector performance in Bangladesh: Implications for health systems strengthening and universal health coverage - A secondary data analysis.

The Ministry of Health and Family Welfare has established a health systems strengthening initiative for measuring the performance of public sector health facilities in Bangladesh. The objective of the performance management initiative is to establish routine systems for measuring and scoring health facility performance and promote best practices in public health service management. The performance initiative includes a set of assessments conducted across the four tiers of the public health sector. The findings of assessments demonstrate improvements in the quality of health services and a sharp increase in the utilisation of services across all tiers during the period 2017-2019. The performance management initiative has also identified areas for improvement in the supply-side health system readiness, including ensuring an adequate supply of human resources, essential medicines, and functioning medical equipment and technologies. This initiative outlines the need to systematically address the issue of high health workforce vacancy rates through effective human resource planning and management strategies. The reporting of these ongoing health systems successes and challenges through the performance management initiative in Bangladesh provides an opportunity to develop evidence-based policy reforms for strengthening supply-side health systems. The initiative results, particularly in the context of growing public demand for services, also justifies a monitoring and evaluation mechanism focusing on the quality and coverage of frontline health facilities and the development of more integrated health systems. The performance management initiative will facilitate the maintenance of essential health services while addressing emergency health needs and tracking progress towards achieving the Universal Health Coverage goal.

Revision of Malawi's Health Benefits Package: A Critical Analysis of Policy Formulation and Implementation.

OBJECTIVES: Health benefits packages (HBPs), which define specific health services that can be offered for free or at a reduced cost to fit within public revenues, have been recommended for over 30 years to maximize population health in resource-limited settings. However, there remain gaps in defining and operationalizing HBPs. We propose a combination of design and prioritization methods along with practical strategies to improve the implementation of future iterations of the HBP in Malawi. METHODS: For HBP development for Malawi's Third Health Sector Strategic Plan, we combined cost-effectiveness analysis with a quantitative, consultative multicriteria decision analysis. Throughout the process of development, we documented challenges and opportunities to improve HBP design and application. RESULTS: The primary and secondary HBP included 115 interventions. However, the definition of an HBP is just one step toward focusing limited resources, with functional operationalization as the most critical component. Full implementation of previous HBPs has been limited by challenges in aid coordination with the misalignment of nonfungible vertical donor funding for the HBP without accounting for the complexity and interconnectedness of the health system. Opportunities for improved application include creation of a complementary minimum health service package to guide overall resource inputs through an integrative approach. CONCLUSIONS: We believe that expanded participatory HBP methods that consider value, equity, and social considerations, along with a shift to providing integrated health service packages at all levels of care, will improve the efficiency of using scarce resources along the journey to universal health coverage.

Economic inequalities in health insurance subscription renewal: Evidence from Ghana's National Health Insurance Scheme.

Ghana's national health insurance scheme (NHIS) is considered a major step towards achieving Universal Health Coverage (UHC) in the country. However, over the years the scheme has faced challenges, including subscription non-renewal, that threaten its sustenance. In this study, we estimate and analyse the nature of economic inequalities in NHIS subscription renewal and determine factors that contribute to the observed inequality. Data from the seventh round of the Ghana Living Standard Survey (GLSS) was used for the study. A sample of 40,170 ever insured individuals was included in the analysis comprising 18,066 males and 22,104 females. We computed concentration indices (CIs) and used linear regression techniques to decompose the CIs. The results show that NHIS renewal is pro-rich [CI = 0.126; P < 0.01] and favored males [CI = 0.110; P < 0.01] and urban dwellers [CI = 0.066; p < 0.01]. Major contributors to the observed inequality in subscription renewal include premium and processing fees payment, access to information, and economic wellbeing. The observed rural-urban and male-female differences in subscription renewal were explained by differences in premium and processing fee payments, education outcomes, employment status and access to information. The findings suggest that interventions that reduce cost barriers to NHIS subscription for the poor, improve physical access to healthcare and improve sensitization efforts should be encouraged.

Assessing the Determinants of Compliance with Contribution Payments to the National Health Insurance Scheme among Informal Workers in Indonesia.

This study aimed to investigate the determinants of compliance with contribution payments to the National Health Insurance (NHI) scheme among informal workers in Bogor Regency, West Java Province, Indonesia. Surveys of 418 informal workers in Bogor Regency from April to May 2023 were conducted. Multivariate logistic regression analyses were performed to assess the factors associated with informal workers' compliance with NHI contribution payments. The results revealed that being female, having lower secondary education or below, perceiving good health of family members, having negative attitudes toward and poor knowledge of the NHI, experiencing financial difficulties, preferring to visit health facilities other than public ones, and utilizing fewer outpatient services were significantly associated with the noncompliance of informal workers with NHI contribution payments. It was concluded that economic factors alone cannot contribute to informal workers' payment compliance and that motivational factors (knowledge, attitudes toward the insurance system, and self-related health status) also encourage them to comply with contribution payments. Improving people's knowledge, especially on the risk-sharing concept of the NHI, should be done through extensive health insurance education using methods that are appropriate for the population's characteristics.

Income Disparity and Healthcare Utilization: Lessons from Indonesia's National Health Insurance Claim Data.

BACKGROUND: Indonesia's National Health Insurance Program, known as Jaminan Kesehatan Nasional (JKN), has a variety of membership pathways for those wishing to gain access. Claim data from JKN offers a cost-effective way of observing who is accessing healthcare services and what types of services are being used. This study is a novel attempt to measure disparities amongst JKN users in their engagement with services, providing an opportunity to reflect on patterns of use. METHODS: Using claims data collected from JKN users between 2015-2016, we used the Ordinary Least Square estimation model to compare health services utilization among subsidized and non-subsidized users. We focused primarily on the individual use of the hospital for outpatient and inpatient treatment. RESULTS: Analysis reveals that subsidized users access primary healthcare services more frequently than non-subsidized users. Conversely, non-subsidized users access secondary and tertiary health care services more frequently than other users. Subsidized users who utilize secondary and tertiary health care tend to suffer more severe health illnesses than non-subsidized members. CONCLUSIONS: This study concludes that income disparity affects healthcare utilization. Non-subsidized members are more likely than subsidized members to access secondary and tertiary health care services. Our study offers evidence of the potential underutilization of secondary and tertiary healthcare (STHC) by subsidized members, which could lead to inefficiency since subsidized members seeking STHC treatment had severe health conditions, thus needing to be treated longer and requiring higher healthcare expenditures.

Piercing the veil on the functioning and effectiveness of district health system governance structures: perspectives from a South African province.

BACKGROUND: Leadership and governance are critical for achieving universal health coverage (UHC). In South Africa, aspirations for UHC are expressed through the proposed National Health Insurance (NHI) system, which underscores the importance of primary health care, delivered through the district health system (DHS). Consequently, the aim of this study was to determine the existence of legislated District Health Councils (DHCs) in Gauteng Province (GP), and the perceptions of council members on the functioning and effectiveness of these structures. METHODS: This was a mixed-methods, cross-sectional study in GP's five districts. The population of interest was members of existing governance structures who completed an electronic-self-administered questionnaire (SAQ). Using a seven-point Likert scale, the SAQ focuses on members' perceptions on the functioning and effectiveness of the governance structures. In-depth interviews with the chairpersons of the DHCs and its technical committees complemented the survey. STATA® 13 and thematic analysis were used to analyze the survey data and interviews respectively. RESULTS: Only three districts had constituted DHCs. The survey response rate was 73%. The mean score for perceived functioning of the structures was 4.5 (SD = 0.7) and 4.8. (SD = 0.7) for perceived effectiveness. The interviews found that a collaborative district health development approach facilitated governance. In contrast, fraught inter-governmental relations fueled by the complexity of governing across two spheres of government, political differences, and contestations over limited resources constrained DHS governance. Both the survey and interviews identified gaps in accountability to communities. CONCLUSION: In light of South Africa's move toward NHI, strengthening DHS governance is imperative. The governance gaps identified need to be addressed to ensure support for the implementation of UHC reforms.

Effects of the Indian National Health Insurance Scheme (PM-JAY) on Hospitalizations, Out-of-pocket Expenditures and Catastrophic Expenditures.

India launched one of the world's largest health insurance programs, the Pradhan Mantri Jan Arogya Yojana (PM-JAY), targeting more than 500 million economically and socially disadvantaged Indians. PM-JAY is publicly funded and covers hospitalization costs in public and private facilities. We examine how PM-JAY has affected hospitalizations and out-of-pocket expenditures (OOPE), and given the high use of private health care in India, we compare these outcomes across public and private facilities. We conducted a household survey to collect data on socioeconomic and demographic information, health status and hospitalizations for more than 57,000 PM-JAY eligible individuals in six Indian states. Using multivariate regression models, we estimated whether PM-JAY was associated with any changes in hospitalizations, OOPE and catastrophic health expenditures (CHE) and whether these differed across public and private facilities. We found that PM-JAY was not associated with an increase in hospitalizations, but it increased the probability of visiting a private facility by 4.6% points (p < .05). PM-JAY was associated with a relative reduction of 13% in OOPE (p < .1) and 21% in CHE (p < .01). This was entirely driven by private facilities, where relative OOPE was reduced by 17% (p < .01) and CHE by 19% (p < .01). This implied that PM-JAY has shifted use from public to private hospitalizations. Given the complex healthcare system with the presence of parallel public and private systems in India, our study concludes that for economically and socially disadvantaged groups, PM-JAY contributes to improved access to secondary and tertiary care services from private providers.

[Recommendations for the development of resilient health systems in the AmericasRecomendações para o desenvolvimento de sistemas de saúde resilientes nas Américas]. / Recomendaciones para el desarrollo de sistemas de salud resilientes en las Américas.

This article offers opinion and analysis outlining strategic lines of action to build resilient health systems while promoting recovery in the post-COVID-19 pandemic period, with a view to maintaining and protecting public health gains. It contextualizes the challenges and opportunities in the Region of the Americas and offers recommendations for implementation of the strategic lines.It is urgent to promote the development of resilient health systems through the implementation of four lines of action defined in the strategy adopted by the Member States of the Pan American Health Organization in September 2021. The transformation of health systems must be based on the adoption of an integrated model of primary health care, a priority focus on the essential public health functions, strengthening of integrated health service networks, and increased public funding, especially for the first level of care. Implementation of these lines of action is focused not only on consolidating immediate crisis response; it is also framed within efforts toward the recovery and sustainable development of health systems, reducing their structural vulnerabilities to better prepare the response to future crises.

Este artigo de opinião e análise descreve linhas de ação estratégicas para desenvolver sistemas de saúde resilientes ao mesmo tempo em que se promove a recuperação pós-pandemia de COVID-19 a fim de manter e proteger os ganhos em saúde pública. Além disso, apresenta uma contextualização dos desafios e oportunidades na região das Américas e oferece recomendações para sua implementação. Há uma necessidade urgente de promover o desenvolvimento de sistemas de saúde resilientes por meio da implementação das quatro linhas de ação definidas na estratégia adotada pelos Estados Membros da Organização Pan-Americana da Saúde em setembro de 2021. A transformação dos sistemas de saúde deve se basear na adoção de um modelo integral de atenção primária à saúde; na priorização das funções essenciais de saúde pública; no fortalecimento de redes integrais de serviços de saúde; e no aumento do financiamento público, especialmente para o primeiro nível de atenção. A implementação dessas linhas de ação busca não apenas consolidar a resposta imediata à crise, mas também enquadrá-la nos esforços de recuperação e desenvolvimento sustentável dos sistemas de saúde, reduzindo suas vulnerabilidades estruturais para que fiquem mais bem preparados para responder a futuras crises.

Perceptions, health seeking behavior and utilization of maternal and newborn health services among an indigenous tribal community in Northeast India-a community-based mixed methods study.

Background: Evidence suggests that healthcare utilization among tribal communities in isolated regions can be influenced by social determinants of health, particularly cultural and geographical factors. The true mortality and morbidity due to these factors in remote tribal communities are often underestimated due to facility-dependent reporting systems often difficult to access. We studied the utilization of health services for maternal and newborn care and explored how cultural beliefs, perceptions, and practices influence the health-seeking behavior (HSB) of an indigenous tribal community in Northeast India. Methods: Within a concurrent triangulation design, the combined results from 7 focus group discussions and 19 in-depth interviews, and the 109 interviews of mothers from a community-based survey were interpreted in a complementary manner. The qualitative data were analyzed using a conceptual framework adapted from the socio-ecological and three-delays model, using a priori thematic coding. Multivariable logistic regression was carried out to identify factors associated with home delivery. Results: Only 3.7% of the interviewed mothers received the four recommended antenatal check-ups in health centers, and 40.1% delivered at home. Mothers residing in the villages without a health center or one that was not operational were more likely to deliver at home. HSB was influenced significantly by available finances, the mother's education, low self-esteem, and a strong belief in traditional medicine favored by its availability and religious affiliation. The community sought health services in facilities only in emergency situations, determined primarily by the tribe's poor perception of the quality of health services provided in the irregularly open centers, locally available traditional medicine practitioners, and challenges in geographical access. National schemes intended to incentivize access to facilities failed to impact this community due to flawed program implementation that did not consider this region's cultural, social, and geographical differences. Conclusion: The health-seeking behavior of the tribe is a complex, interrelated, and interdependent process framed in a medical pluralistic context. The utilization of health centers and HSBs of indigenous communities may improve when policymakers adopt a "bottom-up approach," addressing structural barriers, tailoring programs to be culturally appropriate, and guaranteeing that the perceived needs of indigenous communities are met before national objectives.

Improvement studies for equitable and evidence-based innovation: an overview of the 'IM-SEEN' model.

BACKGROUND: Health inequalities are ubiquitous, and as countries seek to expand service coverage, they are at risk of exacerbating existing inequalities unless they adopt equity-focused approaches to service delivery. MAIN TEXT: Our team has developed an equity-focused continuous improvement model that reconciles prioritisation of disadvantaged groups with the expansion of service coverage. Our new approach is based on the foundations of routinely collecting sociodemographic data; identifying left-behind groups; engaging with these service users to elicit barriers and potential solutions; and then rigorously testing these solutions with pragmatic, embedded trials. This paper presents the rationale for the model, a holistic overview of how the different elements fit together, and potential applications. Future work will present findings as the model is operationalised in eye-health programmes in Botswana, India, Kenya, and Nepal. CONCLUSION: There is a real paucity of approaches for operationalising equity. By bringing a series of steps together that force programme managers to focus on groups that are being left behind, we present a model that can be used in any service delivery setting to build equity into routine practice.

Measurement of unmet healthcare needs to assess progress on universal health coverage - exploring a novel approach based on household surveys.

BACKGROUND: Universal Health Coverage (UHC) aims to ensure universal access to quality healthcare according to health needs. The extent to which population health needs are met should be a key measure for progress on UHC. The indicators in use for measuring access mostly relate to physical accessibility or insurance coverage. Or, utilization of services is taken as indirect measure for access but it is assessed against only the perceived healthcare needs. The unperceived needs do not get taken into account. The present study was aimed at demonstrating an approach for measuring the unmet healthcare needs using household survey data as an additional measure of UHC. METHODS: A household survey was conducted in Chhattisgarh state of India, covering a multi-stage sample of 3153 individuals. Healthcare need was measured in terms of perceived needs which would be self-reported and unperceived needs where clinical measurement supplemented the interview response. Estimation of unperceived healthcare needs was limited to three tracer conditions- hypertension, diabetes and depression. Multivariate analysis was conducted to find the determinants of the various measures of the perceived and unperceived needs. RESULTS: Of the surveyed individuals, 10.47% reported perceived healthcare needs for acute ailments in the last 15 days. 10.62% individuals self-reported suffering from chronic conditions. 12.75% of those with acute ailment and 18.40% with chronic ailments received no treatment, while 27.83% and 9.07% respectively received treatment from unqualified providers. On an average, patients with chronic ailments received only half the medication doses required annually. The latent need was very high for chronic ailments. 47.42% of individuals above 30 years age never had blood pressure measured. 95% of those identified with likelihood of depression had not sought any healthcare and they did not know they could be suffering from depression. CONCLUSION: To assess progress on UHC more meaningfully, better methods are needed to measure unmet healthcare needs, taking into account both the perceived and unperceived needs, as well as incomplete care and inappropriate care. Appropriately designed household surveys offer a significant potential to allow its periodic measurement. Their limitations in measuring the 'inappropriate care' may necessitate supplementation with qualitative methods.

Developing technical support and strategic dialogue at the country level to achieve Primary Health Care-based health systems beyond the COVID-19 era.

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. Pursuing the objectives of the Declaration of Alma-Ata for Primary Health Care (PHC), the World Health Organization (WHO) and global health partners are supporting national authorities to improve governance to build resilient and integrated health systems, including recovery from public health stressors, through the long-term deployment of WHO country senior health policy advisers under the Universal Health Coverage Partnership (UHC Partnership). For over a decade, the UHC Partnership has progressively reinforced, via a flexible and bottom-up approach, the WHO's strategic and technical leadership on Universal Health Coverage, with more than 130 health policy advisers deployed in WHO Country and Regional Offices. This workforce has been described as a crucial asset by WHO Regional and Country Offices in the integration of health systems to enhance their resilience, enabling the WHO offices to strengthen their support of PHC and Universal Health Coverage to Ministries of Health and other national authorities as well as global health partners. Health policy advisers aim to build the technical capacities of national authorities, in order to lead health policy cycles and generate political commitment, evidence, and dialogue for policy-making processes, while creating synergies and harmonization between stakeholders. The policy dialogue at the country level has been instrumental in ensuring a whole-of-society and whole-of-government approach, beyond the health sector, through community engagement and multisectoral actions. Relying on the lessons learned during the 2014-2016 Ebola outbreak in West Africa and in fragile, conflict-affected, and vulnerable settings, health policy advisers played a key role during the COVID-19 pandemic to support countries in health systems response and early recovery. They brought together technical resources to contribute to the COVID-19 response and to ensure the continuity of essential health services, through a PHC approach in health emergencies. This policy and practice review, including from the following country experiences: Colombia, Islamic Republic of Iran, Lao PDR, South Sudan, Timor-Leste, and Ukraine, provides operational and inner perspectives on strategic and technical leadership provided by WHO to assist Member States in strengthening PHC and essential public health functions for resilient health systems. It aims to demonstrate and advise lessons and good practices for other countries in strengthening their health systems.

Prevalence and risk distribution of schistosomiasis among adults in Madagascar: a cross-sectional study.

BACKGROUND: The goal to eliminate the parasitic disease of poverty schistosomiasis as a public health problem is aligned with the 2030 United Nations agenda for sustainable development goals, including universal health coverage (UHC). Current control strategies focus on school-aged children, systematically neglecting adults. We aimed at providing evidence for the need of shifting the paradigm of schistosomiasis control programs from targeted to generalized approaches as key element for both the elimination of schistosomiasis as a public health problem and the promotion of UHC. METHODS: In a cross-sectional study performed between March 2020 and January 2021 at three primary health care centers in Andina, Tsiroanomandidy and Ankazomborona in Madagascar, we determined prevalence and risk factors for schistosomiasis by a semi-quantitative PCR assay from specimens collected from 1482 adult participants. Univariable and multivariable logistic regression were performed to evaluate odd ratios. RESULTS: The highest prevalence of S. mansoni, S. haematobium and co-infection of both species was 59.5%, 61.3% and 3.3%, in Andina and Ankazomborona respectively. Higher prevalence was observed among males (52.4%) and main contributors to the family income (68.1%). Not working as a farmer and higher age were found to be protective factors for infection. CONCLUSIONS: Our findings provide evidence that adults are a high-risk group for schistosomiasis. Our data suggests that, for ensuring basic health as a human right, current public health strategies for schistosomiasis prevention and control need to be re-addressed towards more context specific, holistic and integrated approaches.

Developing and Implementing an Action Plan among the "Orang Asali" Minority in Southernmost Thailand for Equitable Accessibility to Public Health Care and Public Services Following the United Nations Sustainable Development Goals.

Ending social inequality by 2030 is a goal of the United Nations' endorsed sustainable development agenda. Minority or marginalized people are susceptible to social inequality. This action research qualitatively evaluated the requirements for and barriers to full access to public services of the Orang Asali (OA), a minority people living in the Narathiwas province in southernmost Thailand. With the cooperation of the staff of the Southern Border Provinces Administrative Center (SBPAC), we interviewed the OA, local governmental officers and Thai community leaders regarding the OA's living conditions and health status. Then, an action plan was developed and implemented to raise their living standards with minimal disruption to their traditional cultural beliefs and lifestyle. For systematic follow-ups, a Thai nationality registration process was carried out before the assistance was provided. Living conditions and livelihood opportunities, health care and education were the main targets of the action plan. Universal health coverage (UHC), according to Thai health policy, was applied to OA for holistic health care. The OA were satisfied with the assistance provided to them. While filling the gap of social inequality for the OA is urgent, a balance between the modern and traditional living styles should be carefully considered.

Factors related to women's use of health insurance cover in Navakholo, Kakamega County, Kenya: sub-county level results based on community household register.

BACKGROUND: In concert with international commitments, the Government of Kenya identified Universal Health Coverage (UHC), mainly through the National Health Insurance Fund (NHIF), as one of its four priority agenda to enable its populations access health care without financial duress. Nevertheless, only about 19.5% of the Kenyan population is enrolled in any insurance health cover. Since 2016, Amref Health Africa and PharmAccess Foundation have been implementing the Innovative Partnership for Universal and Sustainable Healthcare (iPUSH) programme in Navakholo sub-county of Kakamega County. The main objective of this study is to examine use of health insurance cover among Women of Reproductive Age (WRA) in Navakholo sub-county, Kakamega County. METHODS: We analysed data captured during household registration conducted in February 2021 which embraced a question on use of health insurance cover including NHIF. The dataset consisted 148,957 household members within 32,262 households, 310 villages, and 32 community health units. The data had been collected using mobile phones by trained Community Health Volunteers (CHVs) and transmitted using the Amref electronic data management platform and reposited in a server. Data were analysed through frequency distributions and logistic regression (descriptive and causal methods) using STATA software. RESULTS: Insurance coverage, all providers included, in Navakholo sub-county stood at 11% among women aged 15-49 years. This is much lower than the national aggregate reported from sample surveys, but higher than the 7% found in the same survey for the region where Navakholo is situated. Social determinant variables - age, perceived condition of the household, and wealth ranking - are highly significant in the relationship with use of health insurance cover while measures of reproductive health and health vulnerability are not. CONCLUSION: In Navakholo sub-county of Western Kenya, all-health-insurance coverage is lower than the national aggregate estimated from sample surveys. Age, perception of household condition, and wealth ranking are very significantly related to use of a health insurance cover. Frequent household registrations should be conducted to help monitor the trends and impact of health insurance campaigns. Training - upstream and downstream - on community household registration and data processing should be conducted to arrive at better quality data.