Burden of overweight and obesity in Mexico from 1990 to 2021.

BACKGROUND: Overweight and obesity (OW/OB) represent a serious challenge in Mexico, with effects on health, society and economy. Demographic, epidemiological, nutritional, social and economic factors have exacerbated this problem. OBJECTIVE: To analyze mortality and years of healthy life lost in Mexico due to OW/OB in the 1990-2021 period. MATERIAL AND METHODS: The Global Burden of Disease and Risk Factors 2021 study was used to analyze data on elevated body mass index (BMI) as a risk factor and its evolution in Mexico. RESULTS: In 2021, 118 thousand deaths attributable to high BMI were recorded, which accounted for 10.6% of total deaths and more than 4.2 million disability-adjusted life years lost. CONCLUSIONS: The obesogenic environment, influenced by social determinants of health, has had a significant impact on mortality, burden of disease, and economic costs. Addressing OW/OB requires multisector interventions to strengthen the Mexican health system.

ANTECEDENTES: El sobrepeso y la obesidad constituyen un grave desafío en México, con efectos en la salud, sociedad y economía. Factores demográficos, epidemiológicos, nutricionales, sociales y económicos han agravado esta problemática. OBJETIVO: Analizar la mortalidad y los años de vida saludable perdidos en México por sobrepeso y obesidad en el período de 1990 a 2021. MATERIAL Y MÉTODOS: Se utilizó el Global Burden of Disease 2021 para analizar los datos sobre índice de masa corporal elevado como factor de riesgo y su evolución en México. RESULTADOS: En 2021 se registraron 118 mil muertes atribuibles a índice de masa corporal elevado, que representaron 10.6 % del total de muertes y más de 4.2 millones de años de vida perdidos ajustados por discapacidad. CONCLUSIONES: El ambiente obesogénico, influido por determinantes sociales, ha tenido un impacto significativo en la mortalidad, la carga de enfermedad y los costos económicos. Abordar el sobrepeso y la obesidad requiere intervenciones multisectoriales para fortalecer el sistema de salud mexicano.

Social inequalities in supportive care needs and quality of patient-centered care of cancer patients in Mexico.

PURPOSE: To evaluate educational and health insurance-related inequalities in supportive care (SC) needs and quality of patient-centered care (PCC) for cancer patients in Mexico. METHODS: We conducted a cross-sectional survey in one Mexican Institute of Social Security (IMSS) and one Ministry of Health (MoH) oncology hospital in Mexico City. Formal labor market workers and their families have access to social health insurance that IMSS provides, while unemployed and informal workers receive care at the MoH. The study population comprised breast, colorectal, prostate, and hematologic cancer patients, aged ≥ 18 years, who attended outpatient consultations. Patients responded a short-form SC-needs questionnaire and a quality of PCC questionnaire. We used multiple logistic regression models to determine the independent association between educational attainment and high SC-needs and quality of PCC after controlling for sociodemographic and clinical covariates. RESULTS: We included 1058 IMSS and 606 MoH cancer patients. MoH patients perceived higher SC-needs and lower quality of PCC than IMSS patients. MoH patients with low education had a greater probability of high psychological and health system SC needs and lower likelihood of being informed for treatment decision-making and care for their biopsychosocial needs. IMSS patients with low educational levels had lower probability of receiving timely care and clarity of information than those with high education. Receiving high-quality PCC was associated with decreased SC needs. CONCLUSION: Uninsured cancer patients with low educational attainment have higher SC-needs and receive lower quality of PCC than their counterparts. Health services should face these challenges to reduce inequalities in Mexico.

Harvesting Health Knowledge: Breast Cancer Perceptions in the South Florida Latinx Farmworker Community.

South Florida agricultural regions, home to Latinx immigrant farmworkers, report higher rates of late-stage breast cancer diagnosis than national, state, and county-level averages. We conducted a community-based qualitative study on the needs, health knowledge gaps, barriers to breast cancer screening, and the role of community health workers (CHWs) in supporting the community's access to early detection services. We conducted three CHW focus groups (FGs) (n = 25) and in-depth interviews (n = 15), two FGs (n = 18) and in-depth interviews (n = 3) with farmworker community members, and informal interviews with cancer clinicians (n = 7). Using a grounded theory approach, five core themes regarding the community's barriers to accessing health care services emerged: (a) lack of information; (b) social and economic barriers; (c) cultural factors; (d) fears and mistrust; and (e) psychosocial concerns. Findings yield implications for community health practice, the potential impact of CHWs, and the production of breast cancer education to improve health equity along with the care continuum.

Scale-up of radiotherapy for cervical cancer in the era of human papillomavirus vaccination in low-income and middle-income countries: a model-based analysis of need and economic impact.

BACKGROUND: Radiotherapy is standard of care for cervical cancer, but major global gaps in access exist, particularly in low-income and middle-income countries. We modelled the health and economic benefits of a 20-year radiotherapy scale-up to estimate the long-term demand for treatment in the context of human papillomavirus (HPV) vaccination. METHODS: We applied the Global Task Force on Radiotherapy for Cancer Control investment framework to model the health and economic benefits of scaling up external-beam radiotherapy and brachytherapy for cervical cancer in upper-middle-income, lower-middle-income, and low-income countries between 2015 and 2035. We estimated the unique costs of external-beam radiotherapy and brachytherapy and included a specific valuation of women's caregiving contributions. Model outcomes life-years gained and the human capital and full income net present value of investment. We estimated the effects of stage at diagnosis, radiotherapy delivery system, and simultaneous HPV vaccination (75% coverage) up to a time horizon set at 2072. FINDINGS: For the period from 2015 to 2035, we estimated that 9·4 million women in low-income and middle-income countries required treatment with external-beam radiotherapy, of which 7·0 million also required treatment with brachytherapy. Incremental scale-up of radiotherapy in these countries from 2015 to meet optimal radiotherapy demand by 2035 yielded 11·4 million life-years gained, $59·3 billion in human capital net present value (-$1·5 billion in low-income, $19·9 billion in lower-middle-income, and $40·9 billion in upper-middle-income countries), and $151·5 billion in full income net present value ($1·5 billion in low-income countries, $53·6 billion in lower-middle-income countries, and $96·4 billion in upper-middle-income countries). Benefits increased with advanced stage of cervical cancer and more efficient scale up of radiotherapy. Bivalent HPV vaccination of 12-year-old girls resulted in a 3·9% reduction in incident cases from 2015-2035. By 2072, when the first vaccinated cohort of girls reaches 70 years of age, vaccination yielded a 22·9% reduction in cervical cancer incidence, with 38·4 million requiring external-beam radiotherapy and 28·8 million requiring brachytherapy. INTERPRETATION: Effective cervical cancer control requires a comprehensive strategy. Even with HPV vaccination, radiotherapy treatment scale-up remains essential and produces large health benefits and a strong return on investment to countries at different levels of development. FUNDING: None.

Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition.

The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.

Training Primary Health Professionals in Breast Cancer Prevention: Evidence and Experience from Mexico.

To analyze the key successful factors of a national educational strategy for early breast cancer detection developed in Mexico for primary health care personnel from 2008 to 2014, an educational strategy to train physicians, nurses, health promoters, and medical students from local ministries of health with a competency-based approach was developed and implemented using diverse educational modalities, face-to-face, blended, and a massive open online course (MOOC). Formative and summative evaluations were used during the implementation of the course. A total of 19,563 health professionals were trained from 2008 to 2014. The graduation rate, an average of all educational modalities, was 91 %, much higher than those previously reported in the literature. The factors that might have influenced this success were (1) the training strategy, which was designed according to the characteristics and specific needs of the target groups; (2) the political will and commitment of the country's health authorities; (3) the technological and educational models used; and (4) the punctual follow-up of participants. This study shows that carefully designed educational interventions can improve service professionals' competencies and that regardless of the modality, face-to-face, blended learning, or MOOC, high graduation rates can be achieved. Further evaluation is required to demonstrate that the competencies remained in all target groups after 6 months of the intervention and that the women served by the trained personnel were provided accurate information and timely diagnoses of breast cancer.

Radiotherapy for Metastatic Breast Cancer in Mexico: Results from the 2015 National Survey.

BACKGROUND: Radiation therapy is a keystone to improve survival and quality of life in breast cancer patients. In Mexico, however, scarce information is available on the obstacles faced by radio-oncologists to provide appropriate treatment. OBJECTIVE: To determine the most frequent issues faced by physicians to provide radiation therapy for metastatic breast cancer in Mexico. METHODS: A survey of 16 multiple-choice questions to be answered electronically by 167 radio-oncologists currently working in Mexico was designed and thereafter analyzed for differences between private and public practices, based on the responses from the surveyed participants. RESULTS: 98.5% of surveyed responders attended patients with breast cancer. We observed a significant difference between private vs. public practice for the main difficulties in providing radiation therapy, with an increased frequency (85.8%) of "treatment cost by itself" in private practice vs. 50.7% in public practice (p < 0.05). Significant differences were observed in the "Time to initiate treatment" question, with "Less than one week" as the response in 86% of those physicians in private practice vs. 50% for those in public practice (p < 0.001). CONCLUSIONS: Using a survey targeted at radio-oncologists, we analyzed the most important obstacles for accessing radiation therapy for metastatic breast cancer in Mexico. This information may be useful for healthcare decisions related to radiation therapy in women with breast cancer in Mexico.

Health-system reform and universal health coverage in Latin America.

Starting in the late 1980s, many Latin American countries began social sector reforms to alleviate poverty, reduce socioeconomic inequalities, improve health outcomes, and provide financial risk protection. In particular, starting in the 1990s, reforms aimed at strengthening health systems to reduce inequalities in health access and outcomes focused on expansion of universal health coverage, especially for poor citizens. In Latin America, health-system reforms have produced a distinct approach to universal health coverage, underpinned by the principles of equity, solidarity, and collective action to overcome social inequalities. In most of the countries studied, government financing enabled the introduction of supply-side interventions to expand insurance coverage for uninsured citizens--with defined and enlarged benefits packages--and to scale up delivery of health services. Countries such as Brazil and Cuba introduced tax-financed universal health systems. These changes were combined with demand-side interventions aimed at alleviating poverty (targeting many social determinants of health) and improving access of the most disadvantaged populations. Hence, the distinguishing features of health-system strengthening for universal health coverage and lessons from the Latin American experience are relevant for countries advancing universal health coverage.

Expanding global access to radiotherapy.

Radiotherapy is a critical and inseparable component of comprehensive cancer treatment and care. For many of the most common cancers in low-income and middle-income countries, radiotherapy is essential for effective treatment. In high-income countries, radiotherapy is used in more than half of all cases of cancer to cure localised disease, palliate symptoms, and control disease in incurable cancers. Yet, in planning and building treatment capacity for cancer, radiotherapy is frequently the last resource to be considered. Consequently, worldwide access to radiotherapy is unacceptably low. We present a new body of evidence that quantifies the worldwide coverage of radiotherapy services by country. We show the shortfall in access to radiotherapy by country and globally for 2015-35 based on current and projected need, and show substantial health and economic benefits to investing in radiotherapy. The cost of scaling up radiotherapy in the nominal model in 2015-35 is US$26·6 billion in low-income countries, $62·6 billion in lower-middle-income countries, and $94·8 billion in upper-middle-income countries, which amounts to $184·0 billion across all low-income and middle-income countries. In the efficiency model the costs were lower: $14·1 billion in low-income, $33·3 billion in lower-middle-income, and $49·4 billion in upper-middle-income countries-a total of $96·8 billion. Scale-up of radiotherapy capacity in 2015-35 from current levels could lead to saving of 26·9 million life-years in low-income and middle-income countries over the lifetime of the patients who received treatment. The economic benefits of investment in radiotherapy are very substantial. Using the nominal cost model could produce a net benefit of $278·1 billion in 2015-35 ($265·2 million in low-income countries, $38·5 billion in lower-middle-income countries, and $239·3 billion in upper-middle-income countries). Investment in the efficiency model would produce in the same period an even greater total benefit of $365·4 billion ($12·8 billion in low-income countries, $67·7 billion in lower-middle-income countries, and $284·7 billion in upper-middle-income countries). The returns, by the human-capital approach, are projected to be less with the nominal cost model, amounting to $16·9 billion in 2015-35 (-$14·9 billion in low-income countries; -$18·7 billion in lower-middle-income countries, and $50·5 billion in upper-middle-income countries). The returns with the efficiency model were projected to be greater, however, amounting to $104·2 billion (-$2·4 billion in low-income countries, $10·7 billion in lower-middle-income countries, and $95·9 billion in upper-middle-income countries). Our results provide compelling evidence that investment in radiotherapy not only enables treatment of large numbers of cancer cases to save lives, but also brings positive economic benefits.

Exploring Knowledge, Attitudes, and Practices Related to Breast and Cervical Cancers in Mongolia: A National Population-Based Survey.

BACKGROUND: Mongolia bears the second-highest cancer burden in the world (5,214 disability-adjusted life years per 100,000 people, age standardized). To determine drivers of the growing burden of noncommunicable diseases, including breast and cervical cancers, a national knowledge, attitudes, and practices (KAP) survey was implemented in 2010. METHODS: This paper analyzed the results of the 2010 KAP survey, which sampled 3,450 households nationally. Reflecting Mongolian screening policies, women aged 30 and older were included in analyses of questions regarding breast and cervical cancer (n = 1,193). Univariate and multivariate odds ratios (MORs) were derived through logistic regression to determine associations between demographic covariables (residence, age, education, employment) and survey responses. RESULTS: This study found that 25.7% (95% confidence interval [CI]: 23.3-28.3) and 22.1% (95% CI: 19.8-24.5) of female participants aged 30 years or older self-rated their knowledge of breast and cervical cancers, respectively, as "none." Employment and education were associated with greater awareness of both cancers and participation in screening examinations (p < .05). Clinical breast examinations were more common among rural than urban participants (MOR: 1.492; 95% CI: 1.125-1.979). Of all female participants, 17% (95% CI: 15.3-18.5) knew that cervical cancer is vaccine preventable. CONCLUSION: Our results suggest that cancer control in Mongolia should emphasize health education, particularly among lower-educated, rural, and unemployed women. The health infrastructure should be strengthened to reflect rural to urban migration. Finally, although there is awareness that early detection improves outcomes, a significant proportion of women do not engage in screening. These trends warrant further research on barriers and solutions. IMPLICATIONS FOR PRACTICE: The rising burden of breast and cervical cancers, particularly in low- and middle-income countries, necessitates the development of effective strategies for cancer control. This paper examines barriers to health service use in Mongolia, a country with a high cancer burden. The 2010 national knowledge, attitude and practices survey data indicate that cancer control efforts should focus on improving health education among lower-educated, rural, and unemployed populations, who display the least knowledge of breast and cervical cancers. Moreover, the findings support the need to emphasize individual risk for disease in cancer education and ensure that the health-care infrastructure reflects Mongolia's urbanization.

Report from a symposium on catalyzing primary and secondary prevention of cancer in India.

PURPOSE: Oral, breast, and cervical cancers are amenable to early detection and account for a third of India's cancer burden. We convened a symposium of diverse stakeholders to identify gaps in evidence, policy, and advocacy for the primary and secondary prevention of these cancers and recommendations to accelerate these efforts. METHODS: Indian and global experts from government, academia, private sector (health care, media), donor organizations, and civil society (including cancer survivors and patient advocates) presented and discussed challenges and solutions related to strategic communication and implementation of prevention, early detection, and treatment linkages. RESULTS: Innovative approaches to implementing and scaling up primary and secondary prevention were discussed using examples from India and elsewhere in the world. Participants also reflected on existing global guidelines and national cancer prevention policies and experiences. CONCLUSIONS: Symposium participants proposed implementation-focused research, advocacy, and policy/program priorities to strengthen primary and secondary prevention efforts in India to address the burden of oral, breast, and cervical cancers and improve survival.

Redesigning primary care to tackle the global epidemic of noncommunicable disease.

Noncommunicable diseases (NCDs) have become the major contributors to death and disability worldwide. Nearly 80% of the deaths in 2010 occurred in low- and middle-income countries, which have experienced rapid population aging, urbanization, rise in smoking, and changes in diet and activity. Yet the health systems of low- and middle-income countries, historically oriented to infectious disease and often severely underfunded, are poorly prepared for the challenge of caring for people with cardiovascular disease, diabetes, cancer, and chronic respiratory disease. We have discussed how primary care can be redesigned to tackle the challenge of NCDs in resource-constrained countries. We suggest that four changes will be required: integration of services, innovative service delivery, a focus on patients and communities, and adoption of new technologies for communication.

Beyond the bench and the bedside: economic and health systems dimensions of global childhood cancer outcomes.

Globally, the number of new cases of childhood cancer continues to rise, with a widening gulf in outcomes across countries, despite the availability of effective cure options for many pediatric cancers. Economic forces and health system realities are deeply embedded in the foundation of disparities in global childhood cancer outcomes. A truly global effort to close the childhood cancer divide therefore requires systemic solutions. Analysis of the economic and health system dimensions of childhood cancer outcomes is essential to progress in childhood cancer survival around the globe. The conceptual power of this approach is significant. It provides insight into how and where pediatric oncology entwines with broader political and economic conditions, and highlights the mutual benefit derived from systems-oriented solutions.

Novel Framework of Financial Hardship in Childhood Cancer: Incorporating Stakeholder Perspectives.

PURPOSE: Although financial hardship in childhood cancer contributes to poor outcomes, no standardized tool to assess its impact exists. Existing methods are heterogeneous and designed using high-income country (HIC), adult perspectives. This project aimed to construct a stakeholder-informed conceptual framework of financial hardship in childhood cancer with global relevancy. METHODS: Group concept mapping, a participatory mixed-methods approach, was used. Participants were parents or caregivers of a child with cancer, childhood cancer survivors, and clinical or nonclinical support personnel, fluent in English, Spanish, or Portuguese. A representative panel established a comprehensive list of relevant items. Participants individually sorted these items into concepts and then rated each item for impact using a four-point Likert scale. Multidimensional scaling and hierarchical cluster analysis identified concepts. Descriptive statistics were calculated for impact ratings. RESULTS: One fourth (21/80) of participants were parents/caregivers or childhood cancer survivors. Participants worked in clinical (44/80), charity/volunteer (27/80), and other nonclinical (13/80) roles. Of the 41 represented countries, 78.0% (32) were low- and middle-income countries (LMICs). Conceptual themes spanned six distinct clusters: medical, nonmedical, assistance and support, treatment impact, family impact, and caregiver impact. These were distinct in composition compared with an existing framework for adult oncology. Caregiver impact (mean, 3.39) and treatment impact (mean, 3.29) were the highest rated clusters, and impact ratings were higher in LMICs compared with HICs. CONCLUSION: We developed a framework for financial hardship in childhood cancer that reflects the voices of stakeholders, including parents and caregivers, from diverse global contexts. The findings lay a foundation for the development and validation of tools to systematically assess financial hardship in families of children with cancer and inform effective policies and interventions.

Increase of catastrophic and impoverishing health expenditures in Mexico associated to policy changes and the COVID-19 pandemic.

Background: In 2003, the Mexican Congress approved a major reform to provide health care services to the poor population through the public insurance scheme Seguro Popular. This program was dismantled in 2019 as part of a set of health system reforms and substituted with the Health Institute for Welfare (INSABI). These changes were implemented during the initial phases of the coronavirus (COVID-19) pandemic. We aimed to examine the impact of these reforms and the COVID-19 pandemic on financial risk protection in Mexico between 2018 and 2020. Methods: We performed a population-based analysis using cross-sectional data from the 2018 and 2020 rounds of the National Household Income and Expenditures Survey. We used a pooled fixed-effects multivariable two-stage probit model to determine the likelihood of catastrophic health expenditure (CHE), impoverishing health expenditure (IHE), and excessive health expenditure (EHE) among Mexican households. We also mapped the quintiles of changes in EHE in households without health insurance by state. Results: The percentage of households without health insurance almost doubled from 8.8% (three million households) in 2018 to 16.5% (5.8 million households) in 2020. We also found large increases in the proportion of households incurring in CHE (18.4%; 95% confidence interval (CI) = 6.1, 30.7) and EHE (18.7%; 95% CI = 7.9, 29.5). Significant increases in CHE, IHE, and EHE were only observed among households without health insurance (CHE: 90.7%; 95% CI = 31.6, 149.7, EHE: 73.5%; 95% CI = 25.3, 121.8). Virtually all Mexican states (n/N = 31/32) registered an increase in EHE among households without health insurance. This increase has a systematic territorial component affecting mostly central and southern states (range = -1.0% to 194.4%). Conclusions: The discontinuation of the Seguro Popular Program and its substitution with INSABI during the first stages of the COVID-19 pandemic reduced the levels of health care coverage in Mexico. This reduction and the pandemic increased out-of-pocket expenditure in health and the portion of CHE and EHE in the 2018-2020 period. The effect was higher in households without health insurance and households in central and southern states of the country. Further studies are needed to determine the specific effect both of recent policy changes and of the COVID-19 pandemic on the levels of financial protection in health in Mexico.

Bridging gaps to universal palliative care access in Chile: serious health-related suffering and the cost of expanding the package of care services.

Background: The Lancet Commission on Palliative Care (PC) and Pain Relief quantified the burden of serious health-related suffering (SHS), proposing an Essential Package of PC (EPPC) to narrow the global PC divide. We applied the EPPC framework to analyze PC access in Chile, identify gaps in coverage, and provide recommendations to improve PC access. Methods: Total SHS and population in need of PC was estimated using official 2019 government data. We differentiated between cancer and non-cancer related SHS given guaranteed Chilean PC coverage for cancer. We calculated differences between the Chilean PC package and the Lancet Commission EPPC to estimate the cost of expanding to achieve national coverage of palliative care. Findings: In 2019, nearly 105,000 decedent and non-decedent Chileans experienced SHS with a lower-bound estimate of 12.1 million days and an upper-bound estimate of 42.4 million days of SHS. Each individual experienced between 116 and 520 days of SHS per year. People living with a cancer diagnosis had PC access with financial protection, accounting for almost 42% of patients in need. People with non-cancer diagnoses-about 61 thousand patients-lacked PC coverage. Expanding coverage of the EPPC for all patients in need would cost just above $123 million USD, equivalent to 0.47% of Chilean National Health Expenditure. Interpretation: Achieving universal PC access is urgent and feasible for Chile, classified as a high-income country. Expanding PC services and coverage to the EPPC standard are affordable and critical health system responses to ensuring financial protection for patients with SHS. In Chile, this requires closing large gaps in PC coverage pertaining to patients with non-cancer conditions and treatment of symptoms that go beyond pain. Our research provides an empirical approach for applying the Lancet Commission SHS framework to estimate the cost of achieving national universal PC access anchored in a package of health care services. Funding: This research was partially funded by the Chilean Government through the Fondo Nacional de Ciencia y Tecnología (Fondecyt Regular) grant number 1201721, the U.S. Cancer Pain Relief Committee grant AWD-003806 awarded to the University of Miami and by the University of Miami Institute for Advanced Study of the Americas. We acknowledge NIH/NCI award P30CA008748.

Palliative care need in the Eastern Mediterranean Region and human resource requirements for effective response.

Integration of palliative care into health care systems is considered an ethical responsibility, yet no country in the Eastern Mediterranean Region (EaMReg) has achieved integration. Data on palliative care need and cost are crucial forEaMReg health care planners and implementers in the region. Using data from the Lancet Commission on Palliative Care and Pain Relief, we estimated the number of people in each EaMReg country who needed palliative care in 2015 and their degree of access. In three countries, we estimated the number of days during which an encounter for palliative care was needed at each level of the health care system. This enabled calculation of the number of full-time equivalents (FTEs) of clinical and non-clinical staff members needed at each level to administer the essential package of palliative care recommended by WHO. In 2015, 3.2 million people in the EaMReg needed palliative care, yet most lacked access to it. The most common types of suffering were pain, fatigue, weakness, anxiety or worry, and depressed mood. To provide safe, effective palliative care at all levels of health care systems, between 5.4 and 11.1 FTEs of trained and supervised community health workers per 100,000 population would be needed in addition to 1.0-1.9 FTEs of doctors, 2.2-4.3 FTEs of nurses, and 1.4-2.9 FTEs of social workers. Data from our study enables design of palliative care services to meet the specific needs of each EaMReg country and to calculate the cost or cost savings.

A diagonal and social protection plus approach to meet the challenges of the COVID-19 syndemic: cash transfers and intimate partner violence interventions in Latin America.

Latin America has been particularly hard hit by the COVID-19 syndemic, including the associated economic fallout that has threatened the livelihoods of most families. Social protection platforms and policies should have a crucial role in safeguarding individual and family wellbeing; however, the response has been insufficient to address the scale of the crisis. In this Viewpoint, we focus on two policy challenges of the COVID-19 syndemic: rapidly and effectively providing financial support to the many families that lost livelihoods, and responding to and mitigating the increased risk of intimate partner violence (IPV). We argue that building programmatic linkages between social protection platforms, particularly cash transfers, and IPV prevention, mitigation, and response services, creates synergies that can promote freedom from both poverty and violence.