The redistributive effect of the public health system: the case of Sierra Leone.

Universal health coverage (UHC), health equity and reduction of income inequalities are key objectives for the Sierra Leone government. While investing in health systems may drive economic growth, it is less clear whether investing in health systems reduces income inequality. Therefore, a crucial issue is to what extent the Sierra Leone public healthcare system reduces income inequality, and finances and provides healthcare services equitably. We use data from the Sierra Leone Integrated Household Survey 2018 to complete a financing and benefit incidence analysis of the Sierra Leone public healthcare system. We extend these analyses by assessing the redistributive effect of the public healthcare system (i.e. fiscal incidence analysis). We compute the redistributive effect as the change in Gini index induced by the payments for, and provision of, public healthcare services. The financing incidence of the Sierra Leone public healthcare system is marginally progressive (i.e. Kakwani index: 0.011*, P-value <0.1). With regard to public healthcare benefits, while primary healthcare (PHC) benefits are pro-poor, secondary/tertiary benefits are pro-rich. The result is that overall public healthcare benefits are equally distributed (concentration index (CI): 0.008, not statistically different from zero). However, needs are concentrated among the poor, so benefits are pro-rich when needs are considered. We find that the public healthcare system redistributes resources from better-off quintiles to worse-off quintiles (Gini coefficient reduction induced by public healthcare system = 0.5%). PHC receives less financing than secondary/tertiary care but delivers a larger reduction in income inequality. The Sierra Leone public healthcare system redistributes resources and reduces income inequality. However, the redistributive effect occurs largely thanks to PHC services being markedly pro-poor, and the Sierra Leone health system could be more equitable. Policy-makers interested in improving Sierra Leone public health system equity and reducing income inequalities should prioritize PHC investments.

Health System Financing and Resource Allocation in Humanitarian Settings: Toward a Collaborative Policy Research Agenda in the Eastern Mediterranean Region.

This article discusses key policy questions around health system financing in humanitarian settings, with specific reference to the Eastern Mediterranean region. We discuss key financing functions in the context of different challenges and the potential policy options for addressing these effectively. We also identify areas of collaborative research between academics, policy- and decision-makers and other stakeholders to inform appropriate policy choices that are aligned to universal health coverage in such challenging contexts.

How Does Tobacco Use Affect the Cognition of Older Adults? A Propensity Score Matching Analysis Based on a Large-Scale Survey.

INTRODUCTION: Tobacco is a well-established risk factor for cancer, but its association with other morbidities needs consideration. The low-income and middle-income countries (LMICs) with unprecedented demographic transformation lack evidence on tobacco use and its impact on cognitive health. AIMS AND METHODS: Using a propensity score matching approach, we utilized data from the Longitudinal Ageing Study of India. Study employed 1:1 nearest neighbor matching with the replacement methodology. We estimated the odds of the poor cognitive score and tobacco use among older adults based on five different models for ever tobacco user, former tobacco user, current tobacco user, current smokers, and current smokeless tobacco users with reference to never tobacco users. RESULTS: The estimated average treatment effect for the treated and the untreated group has shown a higher likelihood of cognitive decline among ever (OR -0.26; 95%CI -0.43 to -0.09), current (OR -0.28; 95%CI -0.45 to -0.10), and former (OR -0.53; 95%CI -0.87 to -0.19) tobacco users compared to never tobacco users. The finding further suggests the odds of lower cognitive scores among older adults who were smokers (OR -0.53; 95%CI -0.87 to -0.19) and smokeless tobacco users (OR -0.22; 95%CI -0.43 to -0.01) as compared to never tobacco users. CONCLUSIONS: Interventions designed to prevent the incidence of cognitive impairment should focus on limiting the use of tobacco. Strategies under the tobacco-free generation initiative should be amplified in order to prevent future generations from productivity loss, premature ageing and to promote healthy aging. IMPLICATIONS: Evidence of a definitive association between tobacco consumption and cognition among older adults is sporadic in LMICs. Though tobacco is a risk factor for various diseases including cancer, the extent of its impact on cognitive health among the older population is limited. This study contributes to the existing literature by highlighting poor cognitive outcomes among older adults who smoke tobacco and/or consume smokeless tobacco as compared to never-tobacco users. Our findings emphasize the need to accelerate programmes related to tobacco-free generation in LMICs to reach a higher quality of life and healthy aging in pursuit of achieving the sustainable development goal of "good health and well-being."

Cost-effectiveness of One Health interventions for rabies elimination: a systematic review.

The 'One Health' (OH) approach is the most promising idea in realising the global goal of eliminating canine-mediated human rabies by 2030. However, taking an OH approach to rabies elimination can mean many different things to different people. We conducted a systematic review scrutinizing economic evaluations (EEs) retrieved from MEDLINE OVID, Embase OVID, Global Health OVID, CINAHL EBSCO and ECONLIT EBSCO that used the OH approach with the intent of identifying cost-effective sets of interventions that can be combined to implement an optimal OH-based rabies elimination program and highlight key gaps in the knowledge base. Our review suggests that an optimal OH program to tackle rabies should incorporate mass dog vaccination and integrated bite case management in combination with efficient use of post-exposure prophylaxis along with a shift to a 1-week abbreviated intradermal rabies vaccine regimen in humans. We recommend that future EEs of OH interventions for rabies elimination should be performed alongside implementation research to ensure proposed interventions are feasible and adopt a wider societal perspective taking into account costs and outcomes across both the human health and animal welfare sectors. The systematic review has been registered with PROSPERO.

Health aid displacement during a decade of conflict (2011-19) in Syria: an exploratory analysis.

BACKGROUND: Syria has been in continuous conflict since 2011, resulting in more than 874,000 deaths and 13.7 million internally displaced people (IDPs) and refugees. The health and humanitarian sectors have been severely affected by the protracted, complex conflict and have relied heavily on donor aid in the last decade. This study examines the extent and implications of health aid displacement in Syria during acute humanitarian health crises from 2011 to 2019. METHODS: We conducted a trend analysis on data related to humanitarian and health aid for Syria between 2011 and 2019 from the OECD's Creditor Reporting System. We linked the data obtained for health aid displacement to four key dimensions of the Syrian conflict. The data were compared with other fragile states. We conducted a workshop in Turkey and key informants with experts, policy makers and aid practitioners involved in the humanitarian and health response in Syria between August and October 2021 to corroborate the quantitative data obtained by analysing aid repository data. RESULTS: The findings suggest that there was health aid displacement in Syria during key periods of crisis by a few key donors, such as the EU, Germany, Norway and Canada supporting responses to certain humanitarian crises. However, considering that the value of humanitarian aid is 50 times that of health aid, this displacement cannot be considered as critical. Also, there was insufficient evidence of health displacement across all donors. The results also showed that the value of health aid as a proportion of aggregate health and humanitarian aid is only 2% in Syria, compared to 22% for the combined average of fragile states, which further indicates the predominance of humanitarian aid over health aid in the Syrian crisis context. CONCLUSION: This study highlights that in very complex conflict-affected contexts such as Syria, it is difficult to suggest the use of health aid displacement as an effective tool for aid-effectiveness for donors as it does not reflect domestic needs and priorities. Yet there seems to be evidence of slight displacement for individual donors. However, we can suggest that donors vastly prefer to focus their investment in the humanitarian sector rather than the health sector in conflict-affected areas. There is an urgent need to increase donors' focus on Syria's health development aid and adopt the humanitarian-development-peace nexus to improve aid effectiveness that aligns with the increasing health needs of local communities, including IDPs, in this protracted conflict.

Quantum interference effects elucidate triplet-pair formation dynamics in intramolecular singlet-fission molecules.

Quantum interference (QI)-the constructive or destructive interference of conduction pathways through molecular orbitals-plays a fundamental role in enhancing or suppressing charge and spin transport in organic molecular electronics. Graphical models were developed to predict constructive versus destructive interference in polyaromatic hydrocarbons and have successfully estimated the large conductivity differences observed in single-molecule transport measurements. A major challenge lies in extending these models to excitonic (photoexcited) processes, which typically involve distinct orbitals with different symmetries. Here we investigate how QI models can be applied as bridging moieties in intramolecular singlet-fission compounds to predict relative rates of triplet pair formation. In a series of bridged intramolecular singlet-fission dimers, we found that destructive QI always leads to a slower triplet pair formation across different bridge lengths and geometries. A combined experimental and theoretical approach reveals the critical considerations of bridge topology and frontier molecular orbital energies in applying QI conductance principles to predict rates of multiexciton generation.

The effect of health financing systems on health system outcomes: A cross-country panel analysis.

Several low- and middle-income countries are considering health financing system reforms to accelerate progress toward universal health coverage (UHC). However, empirical evidence of the effect of health financing systems on health system outcomes is scarce, partly because it is difficult to quantitatively capture the 'health financing system'. We assign country-year observations to one of three health financing systems (i.e., predominantly out-of-pocket, social health insurance (SHI) or government-financed), using clustering based on out-of-pocket, contributory SHI and non-contributory government expenditure, as a percentage of total health expenditures. We then estimate the effect of these different systems on health system outcomes, using fixed effects regressions. We find that transitions from OOP-dominant to government-financed systems improved most outcomes more than did transitions to SHI systems. Transitions to government financing increases life expectancy (+1.3 years, p < 0.05) and reduces under-5 mortality (-8.7%, p < 0.05) and catastrophic health expenditure incidence (-3.3 percentage points, p < 0.05). Results are robust to several sensitivity tests. It is more likely that increases in non-contributory government financing rather than SHI financing improve health system outcomes. Notable reasons include SHI's higher implementation costs and more limited coverage. These results may raise a warning for policymakers considering SHI reforms to reach UHC.

The economics of healthcare access: a scoping review on the economic impact of healthcare access for vulnerable urban populations in low- and middle-income countries.

BACKGROUND: The growing urban population imposes additional challenges for health systems in low- and middle-income countries (LMICs). We explored the economic burden and inequities in healthcare utilisation across slum, non-slum and levels of wealth among urban residents in LMICs. METHODS: This scoping review presents a narrative synthesis and descriptive analysis of studies conducted in urban areas of LMICs. We categorised studies as conducted only in slums, city-wide studies with measures of wealth and conducted in both slums and non-slums settlements. We estimated the mean costs of accessing healthcare, the incidence of catastrophic health expenditures (CHE) and the progressiveness and equity of health expenditures. The definitions of slums used in the studies were mapped against the 2018 UN-Habitat definition. We developed an evidence map to identify research gaps on the economics of healthcare access in LMICs. RESULTS: We identified 64 studies for inclusion, the majority of which were from South-East Asia (59%) and classified as city-wide (58%). We found severe economic burden across health conditions, wealth quintiles and study types. Compared with city-wide studies, slum studies reported higher direct costs of accessing health care for acute conditions and lower costs for chronic and unspecified health conditions. Healthcare expenditures for chronic conditions were highest amongst the richest wealth quintiles for slum studies and more equally distributed across all wealth quintiles for city-wide studies. The incidence of CHE was similar across all wealth quintiles in slum studies and concentrated among the poorest residents in city-wide studies. None of the definitions of slums used covered all characteristics proposed by UN-Habitat. The evidence map showed that city-wide studies, studies conducted in India and studies on unspecified health conditions dominated the current evidence on the economics of healthcare access. Most of the evidence was classified as poor quality. CONCLUSIONS: Our findings indicated that city-wide and slums residents have different expenditure patterns when accessing healthcare. Financial protection schemes must consider the complexity of healthcare provision in the urban context. Further research is needed to understand the causes of inequities in healthcare expenditure in rapidly expanding and evolving cities in LMICs.

Economics of healthcare access in low-income and middle-income countries: a protocol for a scoping review of the economic impacts of seeking healthcare on slum-dwellers compared with other city residents.

INTRODUCTION: People living in slums face several challenges to access healthcare. Scarce and low-quality public health facilities are common problems in these communities. Costs and prevalence of catastrophic health expenditures (CHE) have also been reported as high in studies conducted in slums in developing countries and those suffering from chronic conditions and the poorest households seem to be more vulnerable to financial hardship. The COVID-19 pandemic may be aggravating the economic impact on the extremely vulnerable population living in slums due to the long-term consequences of the disease. The objective of this review is to report the economic impact of seeking healthcare on slum-dwellers in terms of costs and CHE. We will compare the economic impact on slum-dwellers with other city residents. METHODS AND ANALYSIS: This scoping review adopts the framework suggested by Arksey and O'Malley. The review is part of the accountability and responsiveness of slum-dwellers (ARISE) research consortium, which aims to enhance accountability to improve the health and well-being of marginalised populations living in slums in India, Bangladesh, Sierra Leone and Kenya. Costs of accessing healthcare will be updated to 2020 prices using the inflation rates reported by the International Monetary Fund. Costs will be presented in International Dollars by using purchase power parity. The prevalence of CHE will also be reported. ETHICS AND DISSEMINATION: Ethical approval is not required for scoping reviews. We will disseminate our results alongside the events organised by the ARISE consortium and international conferences. The final manuscript will be submitted to an open-access international journal. Registration number at the Research Registry: reviewregistry947.

Areca nut consumption with and without tobacco among the adult population: a nationally representative study from India.

OBJECTIVE: Areca nut is one of the most widely consumed substances globally, after nicotine, ethanol and caffeine and classified as carcinogenic to humans. This study examines the disparity and determinants of areca nut consumption with and without tobacco in India. DESIGN: Nationally representative cross-sectional study. PARTICIPANTS: We used the nationally representative Global Adult Tobacco Survey 2016-2017. The analytical sample size was 74 037 individual's aged 15 years and above with a response rate of 92.9%. MEASURES: Current consumption of areca nut without tobacco and with tobacco. METHOD: We examined determinants of areca nut consumption (without tobacco and with tobacco) using multinomial logistic regression, accounting for the survey design. RESULTS: About 23.9% (95% CI 23.1 to 24.8) of the adult population consume areca nut, that is, approximately 223.79 million people in India; majority of users (14.2%-95% CI 13.5 to 14.9) consumed areca nut with tobacco. When compared with women, men were more likely to consume areca nut (with tobacco relative risk (RR)=2.02; 95% CI 1.85 to 2.21 and without tobacco RR=1.13; 95% CI 1.07 to 1.20). Age, marital status, education, occupation, caste, religion and region were significantly associated with areca nut consumption. However, the direction and magnitude of association differ with respect to the areca nut consumption with and without tobacco. CONCLUSION: The ongoing tobacco control efforts would not address the majority of areca nut users until greater attention to areca nut consumption with and without tobacco is reflected in health policies in India.

Wave Function Based Analysis of Dynamics versus Yield of Free Triplets in Intramolecular Singlet Fission.

Experiments in several intramolecular singlet fission materials have indicated that the triplet-triplet spin biexciton has a much longer lifetime than believed until recently, opening up loss mechanisms that can annihilate the biexciton prior to its dissociation to free triplets. We have performed many-body calculations of excited state wave functions of hypothetical phenylene-linked anthracene molecules to better understand linker-dependent behavior of dimers of larger acenes being investigated as potential singlet fission candidates. The calculations reveal unanticipated features that we show carry over to the real covalently linked pentacene dimers. Dissociation of the correlated triplet-triplet spin biexciton and free triplet generation may be difficult in acene dimers where the formation of the triplet-triplet spin biexciton is truly ultrafast. Conversely, relatively slower biexciton formation may indicate smaller spin biexciton binding energy and greater yield of free triplets. Currently available experimental results appear to support this conclusion. Whether or not the two distinct behaviors are consequences of distinct mechanisms of triplet-triplet generation from the optical singlet is an interesting theoretical question.

Self-reported tuberculosis in India: evidence from NFHS-4.

This paper reports self-reported levels and socioeconomic patterns in the distribution of tuberculosis (TB) cases in India, based on information collected under the National Family Health Survey-Round 4 (NFHS-4, 2014-2015). Based on a nationally representative sample of over 600 000 households comprising of about 2.9 million individuals, we estimate a self-reported point prevalence of 304 TB cases per 100 000 population, with a higher burden evident among households with poorer wealth status and among individuals with low educational levels. About 55% of the reported TB cases sought treatment from public services, with higher public service use observed in West Bengal, Kerala and Tamil Nadu. However, more than a third of the patients from poorest groups sought treatment from private sources. Results indicate a significant proportion of the general population, including those with completed school-level education continue to have incomplete knowledge on the routes of the spread of TB infection. Social stigma, such as reluctance to disclose about a family member being infected with the disease to others, also remains high. Imminent need for appropriate policy mechanisms for involving the private sector and raising consciousness through suitable advocacy measures is re-emphasised.

"Without antibiotics, I cannot treat": A qualitative study of antibiotic use in Paschim Bardhaman district of West Bengal, India.

BACKGROUND: Misuse of antibiotics is a well-known driver of antibiotic resistance. Given the decentralized model of the Indian health system and the shortage of allopathic doctors in rural areas, a wide variety of healthcare providers cater to the needs of patients in urban and rural settings. This qualitative study explores the drivers of antibiotic use among formal and informal healthcare providers as well as patients accessing care at primary health centers across Paschim Bardhaman district in West Bengal. MATERIALS AND METHODS: We conducted 28 semi-structured, in-depth interviews with four groups of healthcare providers (allopathic doctors, informal health providers, nurses, and pharmacy shopkeepers) as well as patients accessing care at primary health centers and hospitals across Paschim Bardhaman district. Qualitative data was analyzed using the framework method in an inductive and deductive manner. RESULTS: Our results indicate that patients demand antibiotics from healthcare providers and seek the fastest cure possible, which influences the prescription choices of healthcare providers, particularly informal health providers. Many allopathic doctors provide antibiotics without any clinical indication due to inconsistent follow up, lack of testing facilities, risk of secondary infections, and unhygienic living conditions. Pharmaceutical company representatives actively network with informal health providers and formal healthcare providers alike, and regularly visit providers even in remote areas to market newer antibiotics. Allopathic doctors and informal health providers frequently blame the other party for being responsible for antibiotic resistance, and yet both display interdependence in referring patients to one another. CONCLUSIONS: A holistic approach to curbing antibiotic resistance in West Bengal and other parts of India should focus on strengthening the capacity of the existing public health system to deliver on its promises, improving patient education and counseling, and including informal providers and pharmaceutical company representatives in community-level antibiotic stewardship efforts.

Socioeconomic inequality in life expectancy in India.

INTRODUCTION: Concern for health inequalities is an important driver of health policy in India; however, much of the empirical evidence regarding health inequalities in the country is piecemeal focusing only on specific diseases or on access to particular treatments. This study estimates inequalities in health across the whole life course for the entire Indian population. These estimates are used to calculate the socioeconomic disparities in life expectancy at birth in the population. METHODS: Population mortality data from the Indian Sample Registration System were combined with data on mortality rates by wealth quintile from the National Family Health Survey to calculate wealth quintile specific mortality rates. Results were calculated separately for males and females as well as for urban and rural populations. Life tables were constructed for each subpopulation and used to calculate distributions of life expectancy at birth by wealth quintile. Absolute gap and relative gap indices of inequality were used to quantify the health disparity in terms of life expectancy at birth between the richest and poorest fifths of households. RESULTS: Life expectancy at birth was 65.1 years for the poorest fifth of households in India as compared with 72.7 years for the richest fifth of households. This constituted an absolute gap of 7.6 years and a relative gap of 11.7 %. Women had both higher life expectancy at birth and narrower wealth-related disparities in life expectancy than men. Life expectancy at birth was higher across the wealth distribution in urban households as compared with rural households with inequalities in life expectancy widest for men living in urban areas and narrowest for women living in urban areas. CONCLUSION: As India progresses towards Universal Health Coverage, the baseline social distributions of health estimated in this study will allow policy makers to target and monitor the health equity impacts of health policies introduced.

Knowledge, attitudes, and practices related to antibiotic use in Paschim Bardhaman District: A survey of healthcare providers in West Bengal, India.

INTRODUCTION: Antibiotic misuse is widespread and contributes to antibiotic resistance, especially in less regulated health systems such as India. Although informal providers are involved with substantial segments of primary healthcare, their level of knowledge, attitudes, and practices is not well documented in the literature. OBJECTIVES: This quantitative study systematically examines the knowledge, attitudes, and practices of informal and formal providers with respect to antibiotic use. METHODS: We surveyed a convenience sample of 384 participants (96 allopathic doctors, 96 nurses, 96 informal providers, and 96 pharmacy shopkeepers) over a period of 8 weeks from December to February using a validated questionnaire developed in Italy. Our team created an equivalent, composite KAP score for each respondent in the survey, which was subsequently compared between providers. We then performed a multivariate logistic regression analysis to estimate the odds of having a low composite score (<80) based on occupation by comparing allopathic doctors (referent category) with all other study participants. The model was adjusted for age (included as a continuous variable) and gender. RESULTS: Doctors scored highest in questions assessing knowledge (77.3%) and attitudes (87.3%), but performed poorly in practices (67.6%). Many doctors knew that antibiotics were not indicated for viral infections, but over 87% (n = 82) reported prescribing them in this situation. Nurses, pharmacy shopkeepers, and informal providers were more likely to perform poorly on the survey compared to allopathic doctors (OR: 10.4, 95% CI 5.4, 20.0, p<0.01). 30.8% (n = 118) of all providers relied on pharmaceutical company representatives as a major source of information about antibiotics. CONCLUSIONS: Our findings indicate poor knowledge and awareness of antibiotic use and functions among informal health providers, and dissonance between knowledge and practices among allopathic doctors. The nexus between allopathic doctors, pharmaceutical company representatives, and informal health providers present promising avenues for future research and intervention.

Correlated Electronic Properties of a Graphene Nanoflake: Coronene.

We report studies of the correlated excited states of coronene and substituted coronene within the Pariser⁻Parr⁻Pople (PPP) correlated π -electron model employing the symmetry-adapted density matrix renormalization group technique. These polynuclear aromatic hydrocarbons can be considered as graphene nanoflakes. We review their electronic structures utilizing a new symmetry adaptation scheme that exploits electron-hole symmetry, spin-inversion symmetry, and end-to-end interchange symmetry. The study of the electronic structures sheds light on the electron correlation effects in these finite-size graphene analogues, which diminishes going from one-dimensional to higher-dimensional systems, yet is significant within these finite graphene derivatives.

Theory of Transient Excited State Absorptions in Pentacene and Derivatives: Triplet-Triplet Biexciton versus Free Triplets.

Recent experiments in several singlet-fission materials have found that the triplet-triplet biexciton either is the primary product of photoexcitation or has a much longer lifetime than believed until now. It thus becomes essential to determine the difference in the spectroscopic signatures of the bound triplet-triplet and free triplets to distinguish between them optically. We report calculations of excited state absorptions (ESAs) from the singlet and triplet excitons and from the triplet-triplet biexciton for a pentacene crystal with the herringbone structure and for nanocrystals of bis(triisopropylsilylethynyl) (TIPS)-pentacene. The triplet-triplet biexciton absorbs in both the visible and the near-infrared (NIR), while the monomer free triplet absorbs only in the visible. The intensity of the NIR absorption depends on the extent of intermolecular coupling, in agreement with observations in TIPS-pentacene nanocrystals. We predict additional weak ESA from the triplet-triplet but not from the triplet, at still lower energy.

Diagrammatic Exciton Basis Theory of the Photophysics of Pentacene Dimers.

Covalently linked acene dimers are of interest as candidates for intramolecular singlet fission. We report many-electron calculations of the energies and wave functions of the optical singlets, the lowest triplet exciton, and the triplet-triplet biexciton, as well as the final states of excited state absorptions from these states in a family of phenyl-linked pentacene dimers. While it is difficult to distinguish the triplet and the triplet-triplet from their transient absorptions in the 500-600 nm region, by comparing theoretical transient absorption spectra against earlier and very recent experimental transient absorptions in the near- and mid-infrared, we conclude that the end product of photoexcitation in these particular bipentacenes is the bound triplet-triplet and not free triplets. We predict additional transient absorptions at even longer wavelengths, beyond 1500 nm, to the equivalent of the classic 21Ag- in linear polyenes.