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.

Os movimentos sociais e a gênese de propostas para a saúde da população LGBT na Bahia, Brasil (1979-2014): disputas iniciais e alternativas possíveis / Social movements and the genesis of LGBT health policy in Bahia, Brazil (1979-2014): initial disputes and possible alternatives

Resumo Com o objetivo de descrever a gênese de propostas para a saúde da população de LGBT na Bahia, foi realizado um estudo sócio histórico entre 1979 e 2014. Adotou-se as proposições de Patrice Pinell para a análise sociológica de políticas públicas. A análise do espaço social compreendeu a identificação das trajetórias dos agentes envolvidos com as propostas no estado da Bahia e as relações entre esses agentes e o espaço social nacional, assim como, o campo do poder do Estado. Na Bahia, destacaram-se agentes com trajetórias vinculadas ao campo científico, dos direitos humanos, dos direitos sexuais, do feminismo e do espaço AIDS, com alto capital burocrático e militante, que propiciou aproximação às questões relacionadas a saúde LGBT local. As condições de possibilidade que permitiram a formulação de propostas políticas baseadas na integralidade e na universalidade da atenção à saúde foram a formalização do Comitê Técnico Estadual de Saúde Integral LGBT da Bahia, em 2014, onde buscou-se ampliar a Atenção Integral à Saúde voltada às populações de maior vulnerabilidade; e o Plano Bahia sem homofobia, que permitiu ampliar o diálogo com a sociedade civil e os movimentos sociais e abarcar as principais críticas para a formulação de propostas políticas.

Abstract We conducted a socio-historical study covering the period 1979-2014 to explore the genesis of LGBT health policy in Bahia, Brazil, drawing on Pinell's theoretical framework for the sociological analysis of public policy. To analyze the social space, we investigated the trajectories of the agents involved in policy formulation and the relations between these agents and the national social space and field of State power. The agents were predominantly from the scientific, human rights, sexual rights, feminism and AIDS fields, and had a high level of bureaucratic and militant capital, meaning they were well-versed in LGBT health issues. The historical conditions of possibility underlying the formulation of LGBT health policy included the formalization of the State Technical Committee on LGBT Health in 2014, in an effort to improve access to comprehensive health care for vulnerable groups; and the Bahia without Homophobia plan, which helped expand dialogue around with civil society and social movements and address the main criticisms of policy making.

The Pitfalls of Genomic Data Diversity.

Biomedical research recruitment today focuses on including participants representative of global genetic variation-rightfully so. But ethnographic attention to practices of inclusion highlights how this agenda often transforms into "predatory inclusion," simplistic pushes to get Black and brown people into genomic databases. As anthropologists of medicine, we argue that the question of how to get from diverse data to concrete benefit for people who are marginalized cannot be presumed to work itself out as a byproduct of diverse datasets. To actualize the equitable translation of genomics, practitioners need to place the impacts of ancestral genetic difference in the scope of much more impactful social determinants. For this to happen, multidisciplinary expertise needs to be leveraged, and current, structurally unequal health care systems ultimately need to transform. As modest steps toward this goal, new models for benefit-sharing must be developed and implemented to mitigate existing inequality between data donors and the entities profiting from that data.

Equity assessment of maternal and child healthcare benefits utilization and distribution in public healthcare facilities in Bangladesh: a benefit incidence analysis.

BACKGROUND: The distribution of healthcare services should be based on the needs of the population, regardless of their ability to pay. Achieving universal health coverage implies first ensuring that people of all income levels have access to quality healthcare, and then allocating resources reasonably considering individual need. Hence, this study aims to understand how public benefits in Bangladesh are currently distributed among wealth quintiles considering different layers of healthcare facilities and to assess the distributional impact of public benefits. METHODS: To conduct this study, data were extracted from the recent Bangladesh Demographic and Health Survey 2017-18. We performed benefit incidence analysis to determine the distribution of maternal and child healthcare utilization in relation to wealth quintiles. Disaggregated and national-level public benefit incidence analysis was conducted by the types of healthcare services, levels of healthcare facilities, and overall utilization. Concentration curves and concentration indices were estimated to measure the equity in benefits distribution. RESULTS: An unequal utilization of public benefits observed among the wealth quintiles for maternal and child healthcare services across the different levels of healthcare facilities in Bangladesh. Overall, upper two quintiles (richest 19.8% and richer 21.7%) utilized more benefits from public facilities compared to the lower two quintiles (poorest 18.9% and poorer 20.1%). Benefits utilization from secondary level of health facilities was highly pro-rich, while benefit utilization found pro-poor at primary levels. The public benefits in Bangladesh were also not distributed according to the needs of the population; nevertheless, poorest 20% household cannot access 20% share of public benefits in most of the maternal and child healthcare services even if we ignore their needs. CONCLUSIONS: Benefit incidence analysis in public health spending demonstrates the efficacy with which the government allocates constrained health resources to satisfy the needs of the poor. Public health spending in Bangladesh on maternal and child healthcare services were not equally distributed among wealth quintiles. Overall health benefits were more utilized by the rich relative to the poor. Hence, policymakers should prioritize redistribution of resources by targeting the socioeconomically vulnerable segments of the population to increase their access to health services to meet their health needs.

Performing up to Nordic principles? Geographic and socioeconomic equity in ambulatory care sensitive conditions among older adults in capital areas of Denmark, Finland and Sweden in 2000-2015.

BACKGROUND: Denmark, Finland and Sweden pursue equity in health for their citizens through universal health care. However, it is unclear if these services reach the older adult population equally across different socioeconomic positions or living areas. Thus, we assessed geographic and socioeconomic equity in primary health care (PHC) performance among the older adults in the capital areas of Denmark (Copenhagen), Finland (Helsinki) and Sweden (Stockholm) in 2000-2015. Hospitalisations for ambulatory care sensitive conditions (ACSC) were applied as a proxy for PHC performance. METHODS: We acquired individual level ACSCs for those aged ≥ 45 in 2000-2015 from national hospitalisation registers. To identify whether the disparities varied by age, we applied three age groups (those aged 45-64, 65-75 and ≥ 75). Socioeconomic disparities in ACSCs were described with incidence rate ratios (IRR) and annual rates by education, income and living-alone; and then analysed with biennial concentration indices by income. Geographic disparities were described with biennial ACSC rates by small areas and analysed with two-level Poisson multilevel models. These models provided small area estimates of IRRs of ACSCs in 2000 and their slopes for development over time, between which Pearson correlations were calculated within each capital area. Finally, these models were adjusted for income to distinguish between geographic and socioeconomic disparities. RESULTS: Copenhagen had the highest IRR of ACSCs among those aged 45-64, and Helsinki among those aged ≥ 75. Over time IRRs decreased among those aged ≥ 45, but only in Helsinki among those aged ≥ 75. All concentration indices slightly favoured the affluent population but in Stockholm were mainly non-significant. Among those aged ≥ 75, Pearson correlations were low in Copenhagen (-0.14; p = 0.424) but high in both Helsinki (-0.74; < 0.001) and Stockholm (-0.62; < 0.001) - with only little change when adjusted for income. Among those aged ≥ 45 the respective correlations were rather similar, except for a strong correlation in Copenhagen (-0.51, 0.001) after income adjustment. CONCLUSIONS: While socioeconomic disparities in PHC performance persisted among older adults in the three Nordic capital areas, geographic disparities narrowed in both Helsinki and Stockholm but persisted in Copenhagen. Our findings suggest that the Danish PHC incorporated the negative effects of socio-economic segregation to a lesser degree.

O uso dos serviços odontológicos no último ano na população brasileira: revisão sistemática com metanálise / The use of dental services in the past year in the brazilian population: a systematic review with meta-analysis

Resumo O objetivo foi analisar os fatores associados ao uso dos serviços odontológicos no Brasil. A estratégia de revisão incluiu as bases PubMed, SciELO, LILACS, BBO, EMBASE, Scopus, WOS e Google Scholar, além de repositórios e bancos de dissertações e teses. Os estudos foram selecionados ​​usando a estratégia PEO (população/exposição/desfechos). O desfecho deste estudo foi o uso dos serviços odontológicos no último ano pela população brasileira, tratado como variáveis dicotômicas para as análises: ≤ 1 ano e > 1 ano. Foi realizada uma metanálise de efeito randômico de Mantel-Haenszel, estimando-se razões de prevalência (RP) e intervalos de confiança de 95% (IC95%). Foram selecionados 94 estudos. A maioria (98%) tinha delineamento transversal, sendo 63% oriundos de dados primários. Para a metanálise, 25 estudos foram incluídos. O uso dos serviços odontológicos no último ano esteve associado com maior escolaridade (≥ 8 anos de estudo) (RP = 0,49, (IC95%: 0,39-0,60)); maior renda familiar (≥ 2 salários-mínimos) (RP = 0,79, (IC95%: 0,74-0,84)); e residir na zona urbana (RP = 0,79, (IC95%: 0,64-0,97)). A oferta de serviços odontológicos no Sistema Único de Saúde precisa ser ampliada entre pessoas com menor renda, menor escolaridade e moradores da zona rural.

Abstract The scope of this study was to analyze the factors associated with the use of dental services in Brazil. The review strategy included PubMed, SciELO, LILACS, BBO, EMBASE, Scopus, WOS and Google Scholar databases, in addition to repositories and databases of dissertations and theses. Studies were selected using the PEO (Population/Exposure/Outcomes) strategy. The outcome of this study was the use of dental services in the last year by the Brazilian population, treated as dichotomous variables for the following analyses: ≤ 1 year and > 1 year. Mantel-Haenszel random effect meta-analysis was performed, estimating Prevalence Ratios (PR) and 95% confidence intervals (95%CI). A total of 94 studies were selected. The majority (98%) had a cross-sectional design, with 63% derived from primary data. For the meta-analysis, 25 studies were included. The use of oral health services in the last year was associated with higher education (≥ 8 years of schooling) (PR = 0.49, (95%CI: 0.39-0.60)); higher family income (≥ 2 minimum wages) (RP = 0.79, (95%CI: 0.74-0.84)); and living in urban areas (RP = 0.79, (95%CI: 0.64-0.97)). The availability of dental services in the Unified Health System needs to be made readily accessible to people with lower income, less education and those living in rural areas.

Fatores associados às desigualdades das condições sociais na saúde de idosos brancos, pardos e pretos na cidade de São Paulo, Brasil / Factors associated with inequalities in social conditions in the health of elderly white, brown and black people in the city of São Paulo, Brazil

Resumo O objetivo deste estudo é identificar fatores determinantes das disparidades das condições sociais na saúde de idosos não institucionalizados na cidade de São Paulo, sob a perspectiva da autodeclaração da cor da pele. Estudo transversal com amostra representativa de 1.017 idosos participantes do "Inquérito de Saúde do Município de São Paulo 2015". A análise utilizou modelos de regressão de Poisson brutas e ajustadas, relatando a razão de prevalências e seus intervalos de 95% de confiança como medida de associação entre as variáveis. Na análise ajustada, a cor da pele parda e preta associou-se, positivamente, com a pior escolaridade, a autoavaliação do estado de saúde negativa, o plano de saúde e o acesso ao serviço de saúde público. De um lado, a cor da pele preta perdeu a associação com a pior renda, no entanto, associou-se com a hipertensão arterial. De outro lado, a cor da pele parda não se associou com a hipertensão arterial, mas com a renda baixa. Idosos pretos e pardos tiveram menos acesso a recursos socioeconômicos, às piores condições de saúde e, também, a serviços de saúde privados. Esses resultados são compatíveis com a hipótese de racismo estrutural na sociedade paulistana e podem instruir políticas sociais na saúde dirigidas à promoção de saúde e justiça social.

Abstract The scope of this study is to identify determining factors of disparities in social conditions in the health of non-institutionalized elderly people in the city of São Paulo, from the standpoint of self-declaration of skin color. It is a cross-sectional study with a representative sample of 1,017 elderly participants in the "2015 Health Survey of the Municipality of São Paulo". The analysis used crude and adjusted Poisson regression models, reporting the prevalence ratio and 95% confidence intervals as a measure of association between the variables. In the adjusted analysis, brown and black skin color was positively associated with worse schooling, negative self-assessment of health status, health insurance and access to public health services. On the one hand, black skin color was no longer associated with the lowest income, however, it was associated with arterial hypertension. On the other hand, brown skin color was associated with low income, but not with arterial hypertension. Elderly black and brown people had worse health conditions, less access to private health services and socioeconomic resources. These results are compatible with the hypothesis of structural racism in São Paulo's society and may inform social health policies aimed at promoting health and social justice.

How to do (or not to do) how to embed equity in the conduct of health research: lessons from piloting the 8Quity tool.

Global health research reflects and can either perpetuate or challenge the complex power hierarchies and inequities that characterize our health systems and the societies in which they are situated. The imperative to embed equity in health research aligns with broader efforts globally to promote equitable partnerships among researchers, and between researchers and the communities potentially impacted by their research, or with whom knowledge is co-produced. We describe lessons learnt from piloting a heuristic and diagnostic tool for researchers to assess integration of equity considerations into their research practices. The '8Quity' tool comprises eight domains of equity we developed which roughly correspond to the typical stages in the research process-from team formation to capacity strengthening, research ethics and governance to relationships with research partners, participants and stakeholders beyond the project period. Resources that detail how this can be done on a practical level are also shared, corresponding to each of the eight domains. We acknowledge that tools like 8Quity may be helpful, even necessary, but are insufficient for the broader societal changes required to ensure equity in the research enterprise. However, by firmly setting intentions and accountabilities within our research practices, we (as researchers) can play a role, however modest, in turning the tide of the injustices that leave some communities behind.

Inserção de médicas na formação de especialidades da comissão de residência médica do Hospital Geral Roberto Santos / Inclusion of female physicians in the HGRS medical residency committee's medical specialties / Inserción de médicas en la formación de la especialidad del comité de residencia médica del Hospital General Roberto Santos

A inserção das mulheres na medicina tem sido progressiva, com média de 5,2% de aumento a cada década nos últimos trinta anos. As mulheres já são maioria entre as faixas etárias até 34 anos (55,3%) e até 29 anos, representando 58,5% dos graduandos, segundo o Conselho Federal de Medicina. A abordagem do tipo quantiqualitativa e exploratória, com levantamento e análise de dados secundários, buscou evidenciar uma amostra temporal sobre a inserção das mulheres na formação de especialidades médicas da Comissão de Residência Médica (Coreme) do Hospital Geral Roberto Santos (HGRS). Apesar da formação da graduação ser equânime e da entrada das médicas na residência no HGRS permanecer com média de 69,2%, os quantitativos de preceptoras, supervisoras e coordenadoras de serviço relacionados aos programas de residência médica na instituição são bem inferiores (40,5%; 17,4% e 26,1%, respectivamente), não oportunizando a progressão das médicas para os espaços de decisão e gestão. Quanto à coordenação da Coreme, não há registro de mulheres médicas na função da instituição. Trabalhar as questões de gênero em unidade hospitalar no contexto da medicina, profissão surgida da hegemonia masculina e patriarcal, enquanto cultura, não é simples, mas necessário. O estudo traz uma reflexão para o diálogo sobre a construção de políticas de desenvolvimento na gestão do trabalho, que envolva equidade e justiça social quanto ao gênero no ensino da residência médica, com equiparação de direitos e valores que possam beneficiar a igualdade no desenvolvimento social nos dias atuais.

Women have been progressively integrating medicine programs, with an average increase of 5.2% each decade in the past 30 years. Female physicians are already the majority among the age groups of up to 34 years (55.3%) and up to 29 years, representing 58.5% of undergraduates, according to the Federal Council of Medicine. This quantitative, qualitative and exploratory research, based on survey and analysis of secondary data, sought to highlight a temporal sample on the inclusion of women in the medical specialties of the Geral Roberto Santos Hospital's (HGRS) Medical Residency Committee (Coreme). Despite an equanimous graduation education and a fixed average entry of female physicians (69.2%) into the HGRS residency, the number of female preceptors, supervisors and service coordinators related to the residency programs are much lower (40.5%,17.4% and 26.1%, respectively), hindering their carrier progression to decision and management roles. As for the Coreme coordination, there is no record of female physicians exercising this role. Discussing gender issues in medicine­ a profession that emerged from male and patriarchal hegemony­within a hospital setting as a cultural phenomenon is complex and necessary. The study reflects on the development of management policies to include gender-based equity and social justice in medical residency, fostering equal rights and values in today's society.

La creciente inserción de la mujer en la medicina ha sido progresiva, con un aumento promedio del 5,2% cada década en los últimos 30 años. Las mujeres predominan entre los grupos de edad de los 34 años (55,3%) y de los 29 años, y representa el 58,5% de los estudiantes de grado según el Consejo Federal de Medicina. El enfoque cuantitativo-cualitativo, exploratorio, con encuesta y análisis de datos secundarios, buscó destacar una muestra temporal sobre la inclusión de mujeres en la formación de especialidades médicas de la Comisión de Residencia Médica (Coreme) del Hospital General Roberto Santos (HGRS). A pesar de que la formación de graduación es ecuánime y de que el ingreso de médicas a la residencia en el HGRS se mantiene en un promedio del 69,2%, el número de preceptoras, supervisoras y coordinadoras de servicios relacionado con los programas de residencia en la institución es muy inferior (el 40,5%; el 17,4% y el 26,1%, respectivamente), lo que no permite la progresión de las médicas a los espacios de decisión y gestión. En cuanto a la coordinación del Coreme, no existe registro de mujeres médicas en el rol de la institución. No es sencillo sino necesario trabajar temas de género en una unidad del hospital en el contexto de la medicina, una profesión que surgió de la hegemonía masculina patriarcal como cultura. Este estudio permite reflexionar sobre el diálogo de la formación de políticas de desarrollo en la gestión del trabajo, que incluya la equidad y la justicia social respecto al género en la enseñanza de residencia médica, con igualdad de derechos y valores que pueden favorecer la igualdad al desarrollo social en la actualidad.

Socio-economic inequality in prevalence of type 2 diabetes among adults in north-west of Iran: a Blinder-Oaxaca decomposition.

Background: The aim of this study was to estimate the socio-economic inequality in prevalence of type 2 diabetes among adults in north-west of Iran. Methods: A cross-sectional study was conducted in Ardabil with data from the PERSIAN Cohort Study. Diabetes has been measured by combining self-reported and clinical records. Based on the socio-economic status score, households divided into five quintiles. A multiple logistic regression model was used to examine the association between having diabetes and independent variables and the Blinder-Oaxaca (BO) method was used to decompose the socioeconomic inequality, respectively. Results: The Overall age-adjusted prevalence of diabetes among 20,419 Ardabil's adults was 14.3% (95% CI: 13.6 to 14.9). The prevalence of type 2 diabetes for the poorest and richest groups was 16.07% and 7.60%, the gap between the poorest and richest groups was 8.47%. The prevalence type 2 diabetes was significantly increasing with increasing in age (OR = 4.05, 95% CI = 3.27-5.02), BMI (OR: 3.10, 95%CI = 1.25-7.68), blood pressure (OR: 2.61, 95% CI = 2.37-2.88), and decreases with higher education level (OR = 0.78, 95% CI = 0.63-0.97). The richest-economic group has lower prevalence of diabetes (OR = 0.73, 95% CI = 0.60-0.88). The decomposition showed that most important factors affecting the difference between poorest and richest group in the prevalence of type 2 diabetes were age (86.1%), years of schooling (46.9%) and having chronic diseases such as hypertension (26.9%). Conclusions: The present study showed that the prevalence of type 2 diabetes was significantly higher among the elderly, women, uneducated, obese, and poor populations. Policies that address people poverty such as increasing job opportunities, increasing the minimum income etc. could reduce diabetes risk for poor people.

Explaining regional variation in elective hip and knee arthroplasties in Finland 2010 - 2017-a register-based cohort study.

BACKGROUND: A persistent research finding in industrialised countries has been regional variation in medical practices including elective primary hip and knee arthroplasty. The aim of the study was to examine regional variations in elective total hip and knee arthroplasties over time, and the proportions of these variations which can be explained by individual level or area-level differences in need. METHODS: We obtained secondary data from the Care Register for Health Care to study elective primary hip and knee arthroplasties in total Finnish population aged 25 + years between 2010 and 2017. Two-level Poisson regression models - individuals and hospital regions - were used to study regional differences in the incidence of elective hip and knee arthroplasties in two time periods: 2010 - 2013 and 2014 - 2017. The impact of several individual level explanatory factors (age, socioeconomic position, comorbidities) and area-level factors (need and supply of operations) was measured with the proportional change in variance. Predictions of incidence were measured with incidence rate ratios. The relative differences in risk of the procedures in regions were described with median rate ratios. RESULTS: We found small and over time relatively stable regional variation in hip arthroplasties in Finland, while the variation was larger in knee arthroplasties and decreased during the study period. In 2010 - 2013 individual socioeconomic variables explained 10% of variation in hip and 4% in knee arthroplasties, an effect that did not emerge in 2014 - 2017. The area-level musculoskeletal disorder index reflecting the need for care explained a further 44% of the variation in hip arthroplasties in 2010 - 2013, but only 5% in 2014 - 2017 and respectively 22% and 25% in knee arthroplasties. However, our final models explained the regional differences only partially. CONCLUSIONS: Our results suggest that eligibility criteria in total hip and knee arthroplasty are increasingly consistent between Finnish hospital districts. Factors related to individual level and regional level need both had an important role in explaining regional variations. Further study is needed on the effect of health policy on equity in access to care in these operations.

Characterizing key misconceptions of equity in health financing for universal health coverage.

Fairness or equity in health financing is critical to ensuring universal health coverage (UHC). While equity in health financing is generally about financing health services according to ability-to-pay, misconceptions exist among policymakers, decision-makers and some researchers about what constitutes financing health services according to ability-to-pay or an equitably financed health system. This commentary characterizes three misconceptions of equitable health financing-(1) the misconception of fair contribution, (2) the pro-poor misconception and (3) the misconception of cross-subsidization. The paper also uses these misconceptions to clearly illustrate what constitutes equity in health financing, highlighting the importance of income distribution. The misconceptions come from the authors' extensive engagements with policymakers and practitioners, especially in Africa. A clear understanding of equity in health financing provides an avenue to significant progress towards UHC and improving a country's income distribution.

Black and Waiting: Bioethics and Care during the Covid-19 Pandemic.

In this essay, a Black scholar of the cultural histories of Black women's reproductive lives launches a discussion of generations of racism, health inequities, and violence against Black bodies by looking at Black poet and essayist Dionne Brand's critique of the notion of returning to "the normal" after the Covid-19 pandemic. To what, the essay asks, is everyone so eager to return? The intergenerational wait for Black people's moment of racial reckoning is its own unique biomedical warfare, which cannot end with the end of a pandemic. This warfare undercuts Black people's daily health with anxiety and depression, altering the very chromosomes passed down to their children. To health care providers, bioethicists, and those who practice antiracist health work the author poses these questions: How will you confront anti-Black racism within every formulation of "treatment"-diagnosis, care, medication distribution, physical therapy? How long will the violence against Black lives be dissolved into talking points about our bodies? How can one listen, ethically, to Black people? These, she asserts, are questions of practice, of politics, and of care.

Do Migrant Residents Really Achieve Health Equity by Obtaining Urban Hukou? A Comparative Study on Health Service Utilization and Urbanization in Central China.

Introduction: With more than 120 million rural-to-urban migrants, urbanization of the rural population requires deeply exploration in China. Objective: This study focused on settled citizens who obtained urban Hukou (household registration) during urbanization and investigated their perceptions of health services in China. Method: A cross-sectional comparison study with an original, closed questionnaire was conducted in two major cities of Hubei, central China, covering health status and both the satisfaction with and utilization of health services. In total, 863 residents with urban Hukou participated in this study; migrants formed the study group and original city residents formed the control group. Propensity score matching (PSM) was used to reduce choice bias in the analysis steps. Besides basic description of the data, ordinary least squares regression (OLS regression) was used to discover the relationship between basic demographic indicators and health expenditure. Results: PSM yielded 290 effective pairs for analysis. The results indicated an improvement in health status for migrant residents (study group) with a higher average score of self-reported health status and lower prevalence of chronic diseases than the control group. These scores were also better than the standard urban level in central China. The study group showed a higher clinic visit utility (69.63%), lower hospitalization utility (8.28%), less convenience of health service utility, and lower health expenditure than the control group. For the study group, the biggest difference was observed in satisfaction with health service costs, which was the least improved aspect after they obtained urban Hukou. The regression results demonstrated that age, family size, living expenditures, and marital status impacted health costs in the overall model and the influences of these factors differed between the study and control groups. Conclusions: Obtaining urban Hukou helps migrant residents to meet their health service needs and receive equal access to health services. However, after obtaining urban Hukou, migrants also face great pressure in terms of health consumption. This study therefore offers guidance on the next steps for progressing China's urbanization.

Ethnic inequalities in reproductive, maternal, newborn and child health interventions in Ecuador: A study of the 2004 and 2012 national surveys.

Background: Analysis of health inequalities by ethnicity is critical to achieving the Sustainable Development Goals. In Ecuador, similar to other Latin American countries, indigenous and afro-descendant populations have long been subject to racism, discrimination, and inequitable treatment. Although in recent years, Ecuador has made progress in health indicators, particularly those related to the coverage of Reproductive, Maternal, Neonatal and Child Health (RMNCH) interventions, little is known as to whether inequalities by ethnicity persist. Methods: Analysis was based on two nationally representative health surveys (2004 and 2012). Ethnicity was self-reported and classified into three categories (Indigenous/Afro-Ecuadorian/Mixed ancestry). Coverage data for six RMNCH health interventions were stratified for each ethnic group by level of education, area of residence and wealth quintiles. Absolute inequality measures were computed and multivariate analysis using Poisson regression was undertaken. Findings: In 2012, 74.4% of women self-identifying as indigenous did not achieve the secondary level of education and 50.7% were in the poorest quintile (Q1); this profile was relatively unchanged since 2004. From 2004 to 2012, the coverage of RMNCH interventions increased for all ethnic groups, and absolute inequality decreased. However, in 2012, regardless of education level, area of residence and wealth quintiles, ethnic inequalities remained for almost all RMNCH interventions. Indigenous women had 24% lower prevalence of modern contraceptive use (Prevalence ratio [PR] = 0.76; 95% IC: 0.7-0.8); 28% lower prevalence of antenatal care (PR = 0.72; 95% IC: 0.6-0.8); and 35% lower prevalence of skilled birth attendance and institutional delivery (PR = 0.65; 95% IC: 0.6-0.7 and PR = 0.65; 95% IC: 0.6-0.7 respectively), compared with the majority ethnic group in the country. Interpretation: While the gaps have narrowed, indigenous people in Ecuador continue in a situation of structural racism and are left behind in terms of access to RMNCH interventions. Strategies to reduce ethnic inequalities in the coverage services need to be collaboratively redesigned/co-designed. Funding: This paper was made possible with funds from the Bill & Melinda Gates Foundation [Grant Number: INV-007,594/OPP1148933].

Creating equity in health research to drive more and better evidence.

Health research is rapidly changing with evidence being gathered through new agile methods. This evolution is critical but must be globally equitable so the poorest nations do not lose out. We must harness this change to better tackle the daily burden of diseases that affect the most impoverished populations and bring research capabilities to every corner of the world so that rapid and fair responses to new pathogen are possible; anywhere they appear. We must seize this opportunity to make research easier, better and more equitable. Currently too many nations are unable to generate the evidence or translate it to directly change health outcomes in their own communities. It is essential to act and harness this emerging change in how research data can be generated and shared, so that all nations sustainably gain from this development. There are positive examples to draw on from COVID-19, but we now need to act. Here we present an initiative to develop a new framework that can guide researchers in the design and execution of their studies. This highly agile system will work by adapting to risk and complexity in any given study, whilst generating quality, safe and ethical data.

Barriers in access to services and information gaps by genders and key populations in the national Tuberculosis programme in Cambodia.

Approximately 34% of people with tuberculosis (TB) were undiagnosed in Cambodia in 2017. This study explored barriers in access to TB services and information gaps by genders and key populations in the Cambodian national TB programme. In 2017, we conducted a consensus and validation workshop, desk reviews, 19 in-depth interviews, and 30 focus group discussions with representatives of stakeholder groups, affected populations, and communities. Content analyses were performed for qualitative interviews. We employed the consensus development methods during the workshop to define and prioritise key populations. Key themes that inhibited access to TB services included the lack of knowledge, awareness, time and financial means, and gender-specific vulnerabilities. Systemic barriers included inconsistencies in policy and guideline implementation and lack of resources required for effective TB management. We did not find indications of coercive practices against women and key populations. However, stigma and discrimination did exist in healthcare institutions, the workplace, and the community. There were significant gaps in gender and key population-specific data and reporting systems at all levels. Data availability is vital for understanding gender and key population-specific gaps, and they should be duly utilised. Mechanisms to ensure equality and inclusivity are necessary to end TB in Cambodia.

Trade, uneven development and people in motion: Used territories and the initial spread of COVID-19 in Mesoamerica and the Caribbean.

Mesoamerica and the Caribbean form a region comprised by middle- and low-income countries affected by the COVID-19 pandemic differently. Here, we ask whether the spread of COVID-19, measured using early epidemic growth rates (r), reproduction numbers (R t ), accumulated cases, and deaths, is influenced by how the 'used territories' across the regions have been differently shaped by uneven development, human movement and trade differences. Using an econometric approach, we found that trade openness increased cases and deaths, while the number of international cities connected at main airports increased r, cases and deaths. Similarly, increases in concentration of imports, a sign of uneven development, coincided with increases in early epidemic growth and deaths. These results suggest that countries whose used territory was defined by a less uneven development were less likely to show exacerbated COVID-19 patterns of transmission. Health outcomes were worst in more trade-dependent countries, even after controlling for the impact of transmission prevention and mitigation policies, highlighting how structural effects of economic integration in used territories were associated with the initial COVID-19 spread in Mesoamerica and the Caribbean.