Pandemic preparedness and response: exploring the role of universal health coverage within the global health security architecture.

In response to the COVID-19 pandemic, several international initiatives have been developed to strengthen and reform the global architecture for pandemic preparedness and response, including proposals for a pandemic treaty, a Pandemic Fund, and mechanisms for equitable access to medical countermeasures. These initiatives seek to make use of crucial lessons gleaned from the ongoing pandemic by addressing gaps in health security and traditional public health functions. However, there has been insufficient consideration of the vital role of universal health coverage in sustainably mitigating outbreaks, and the importance of robust primary health care in equitably and efficiently safeguarding communities from future health threats. The international community should not repeat the mistakes of past health security efforts that ultimately contributed to the rapid spread of the COVID-19 pandemic and disproportionately affected vulnerable and marginalised populations, especially by overlooking the importance of coherent, multisectoral health systems. This Health Policy paper outlines major (although often neglected) gaps in pandemic preparedness and response, which are applicable to broader health emergency preparedness and response efforts, and identifies opportunities to reconceptualise health security by scaling up universal health coverage. We then offer a comprehensive set of recommendations to help inform the development of key pandemic preparedness and response proposals across three themes-governance, financing, and supporting initiatives. By identifying approaches that simultaneously strengthen health systems through global health security and universal health coverage, we aim to provide tangible solutions that equitably meet the needs of all communities while ensuring resilience to future pandemic threats.

[Health care access barriers and facilitators: a qualitative systematic review]. / Barreras y facilitadores de acceso a la atención de salud: una revisión sistemática cualitativa.

OBJECTIVE: To determine whether health care access barriers and facilitators cut across different populations, countries, and pathologies, and if so, at which stages of health care access they occur most frequently. METHODS: A qualitative systematic review of literature published between 2000 and 2010 was undertaken drawing on six international sources: Fuente Académica, MEDLINE (full-text), Academic Search Complete (a full-text multidisciplinary academic database), PubMed, SciELO, and LILACS. Scientific appraisal guidelines from the Critical Appraisal Skills Programme Español (CASPe) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) were applied. Gray literature was also reviewed. RESULTS: From the review of scientific literature, 19 of 1 160 articles and 8 of 12 gray literature documents were selected. A total of 230 barriers and 35 facilitators were identified in countries with different contexts and degrees of development. The 230 barriers were classified according to the Tanahashi framework: 25 corresponded to availability, 67 to access, 87 to acceptability, and 51 to contact. Most of the barriers were related to acceptability and access. The facilitating elements that were identified had to do with personal factors, the provider-client relationship, social support, knowledge about diseases, and adaptation of the services to patients. CONCLUSIONS: The barriers and facilitators were seen mostly in people who initiated contact with the health systems, and they occurred at all stages of health care access. Only a few of the studies looked at people who did not initiate contact with the health services. The barriers and facilitators identified were socially determined and largely a reflection of existing social inequities in the countries. To reduce or eliminate them, joint action with other non-health sectors will be necessary.

Barreras y facilitadores de acceso a la atención de salud: una revisión sistemática cualitativa / Health care access barriers and facilitators: a qualitative systematic review

OBJETIVO: Determinar si las barreras y los elementos facilitadores de acceso a la atención de salud son transversales a distintas poblaciones, países y patologías, e identificar en qué etapas del proceso de acceso a la atención sanitaria se presentan con más frecuencia. MÉTODOS: Revisión sistemática cualitativa de literatura publicada durante el período 2000-2010. Se consultaron seis fuentes internacionales: Fuente Académica, Medline en texto completo, Base de datos académica multidisciplinaria en texto completo (Academic Search Complete), PubMed, SciELO y LILACS. Se aplicaron criterios de valoración científica del Programa CASPe y la declaración STROBE. En paralelo se revisó literatura gris. RESULTADOS: Se seleccionaron 19 de 1 160 resultados de la revisión de artículos científicos, y 8 de 12 documentos de la revisión de literatura gris. Se identificaron 230 barreras y 35 facilitadores en países con diferentes contextos y grados de desarrollo. Las 230 barreras se clasificaron acorde al modelo de Tanahashi: 25 corresponden a la dimensión disponibilidad, 67 a accesibilidad, 87 a aceptabilidad y 51 a contacto. La mayor proporción de barreras correspondió a la dimensión de aceptabilidad y de accesibilidad. Los elementos facilitadores identificados tienen relación con factores personales, relación entre prestadores y usuarios, apoyo social, información sobre la enfermedad y adaptación de los servicios al paciente. CONCLUSIONES: La identificación de barreras y facilitadores se realiza mayoritariamente en personas que han contactado los sistemas sanitarios y en todas las etapas del proceso de acceso a la atención de salud. Se identificaron pocos estudios orientados a quienes no contactan los servicios. Las barreras y facilitadores identificados están socialmente determinados, y la mayoría son expresión de inequidades sociales que existen en los países y requieren una acción conjunta con otros sectores distintos de salud para ser reducidas o eliminadas.

OBJECTIVE: To determine whether health care access barriers and facilitators cut across different populations, countries, and pathologies, and if so, at which stages of health care access they occur most frequently. METHODS: A qualitative systematic review of literature published between 2000 and 2010 was undertaken drawing on six international sources: Fuente Académica, MEDLINE (full-text), Academic Search Complete (a full-text multidisciplinary academic database), PubMed, SciELO, and LILACS. Scientific appraisal guidelines from the Critical Appraisal Skills Programme Español (CASPe) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) were applied. Gray literature was also reviewed. RESULTS: From the review of scientific literature, 19 of 1 160 articles and 8 of 12 gray literature documents were selected. A total of 230 barriers and 35 facilitators were identified in countries with different contexts and degrees of development. The 230 barriers were classified according to the Tanahashi framework: 25 corresponded to availability, 67 to access, 87 to acceptability, and 51 to contact. Most of the barriers were related to acceptability and access. The facilitating elements that were identified had to do with personal factors, the provider-client relationship, social support, knowledge about diseases, and adaptation of the services to patients. CONCLUSIONS: The barriers and facilitators were seen mostly in people who initiated contact with the health systems, and they occurred at all stages of health care access. Only a few of the studies looked at people who did not initiate contact with the health services. The barriers and facilitators identified were socially determined and largely a reflection of existing social inequities in the countries. To reduce or eliminate them, joint action with other non-health sectors will be necessary.

Inequidad de ingreso y autopercepción de salud: un análisis desde la perspectiva contextual en las comunas chilenas / Income inequality and self rated health in Chile

Background: The correlation between income inequality and life expectancy was demonstrated 10 years ago, but later, several studies suggested that the negative impact of a low economic income on the health status was disappearing. Aim: To assess the independent effects of community income inequality on self rated health in Chile. Material and methods : Multilevel analysis of the 2000 National Socio Economic Characterization Survey (CASEN) data from Chile. Individual level information included self rated health, age, sex, ethnicity, marital status, education, income, type of health insurance and residential setting (urban/rural). Community level variables included the Gini coefficient and median income. The main outcome measure was dichotomized self rated health (0 if excellent, very good or good; 1 if fair or poor). Results: 101,374 individuals (at level 1) aged 18 and above, nested within 285 communities (at level 2) and 13 regions (at level 3) were studied. Controlling for a range of individual level predictors, a significant gradient was observed between income and poor self rated health, with very poor most likely to report poor health (10.5 percent) followed by poor (9.5 percent) low (9 percent) middle (7 percent), high (6 percent) and very high (4.5 percent) income earners. Controlling for individual and community effects of income, a significant non linear effect of community income inequality was observed, with the most unequal communities being associated with approximately 5 percent higher likelihood of reporting poor health compared to the most equal communities. Conclusions : Individual income does not explain any of the between community differences and neither does it wash the significant effects of income inequality on poor self rated health. The contextual effect of inequality is almost as large as the differential observed in poor health comparing the very poor to the very rich individual income categories

Actividad plasmática de la enzima convertidora de angiotensina I en población chilena normal y relación con el genotipo inserción/deleción de la enzima convertidora de angiotensina / Plasma activity of angiotensin I converting enzyme in a normal chilean population and it relation to de I/D polymorphism

El objetivo del estudio fue estimar la prevalencia de los distintos alelos del polimorfismo del gen de la enzima convertidora de angiotensina (ECA), inserción/deleción (I/D) y simultáneamente la actividad de ECA plasmática (pl) asociada en población sana chilena normotensa. 117 sujetos sanos normotensos (entre 45 y 60 años, de nivel socioeconómico medio, no obesos ni diabéticos) fueron seleccionados de un estudio poblacional sobre prevalencia de factores de riesgo de enfermedades crónicas. Las frecuencias de los alelos I y D fueron 0,57 y 0,43 respectivamente. La actividad de ECApl fue en promedio 15,3ñ3,9 U/mL. Comparado con sujetos con genotipo II, la actividad de ECApl fue significativamente mayor en sujetos con genotipo ID y DD sin diferencias entre ellos. No se observó correlación entre actividad de ECApl y masa VI en ningún sexo ni en los distintos genotipos. El análisis de regresión lineal multivariado (que usó masa VI e índice de masa VI como variables dependientes mostró efectos independientes (p<0,05) del sexo (mayor masa VI en varones) y de la presión diastólica, pero no del genotipo DD. En conclusión, en esta población la presencia del alelo D del gen de la ECA determina mayor actividad de ECA circulante, lo cual podría estar asociado a mayor morbilidad cardiovascular. En esta población sana normotensa, el sexo masculino y la presión diastólica, pero no la presencia del alelo D, están asociados a mayor masa VI

Hábitos alimentarios de la población de Valparaíso: encuesta de base CARMEN conjunto de acciones para la reducción multifactorial de las enfermedades no transmisibles / Eating habits of the population from Valparaíso: CARMEN base survey actions for the multifactorial reduction of noncommunicable chronic diseases

Las enfermedades crónicas no transmisibles (ECNT) han tenido un aumento progresivo durante en las últimas décadas en nuestro país, ocupando los primeros lugares como causas de morbilidad y mortalidad de los adultos. Estas causas se pueden modificar si intervenimos sobre los factores de riesgo que predicen o anticipan el daño. Dentro de los factores de riesgo de la población, la alimentación tiene una preponderancia como un vehículo de prevención. Sin embargo, no existen cifras claras del consumo de alimentos a escala nacional, contando sólo con algunos datos parciales derivados de trabajos de investigación. El proyecto CARMEN (conjunto de acciones para la reducción multifactorial de las enfermedades no transmisibles), tuvo por objeto medir los factores de riesgo y hábitos conductuales de una población representativa de la comuna de Valparaíso. El estudio se efectúo a una muestra de 3120 sujetos (1020 hombres y 2100 mujeres) entre 25 y 64 años. Más del 94 por ciento de la población consumía aceite como su principal fuente de grasa, un 71,7 por ciento de los hombres y un 63,7 por ciento de las mujeres indica no consumir leche y un 98 por ciento de los encuestados consume pan diariamente. Se discute la relación de los hábitos alimentarios con las ECNT

Exposición severa a plomo ambiental en una población infantil de Antofagasta, Chile / Childhood environmental lead exposure in Antofagasta, Chile

Background: In Antofagasta, Chile, lead is gathered in bulk in urban zones, contaminating surrounding schools and houses. Aim: To verify if the environmental lead exposure results in high blood lead levels in children living near lead storage sites. Material and methods: Four hundred eighty six children under 7 years old, living near lead storage sites and 75 children living far away form these sites, were studied. An inquiry was applied and venous blood was drawn. Air, soil and water lead concentrations were also measured. Results: Lead geometric mean concentrations in exposed children were 8.7 µg/dL and 4.22 µg/dL in unexposed children. Forty seven percent of exposed children and no unexposed children had lead levels over 10 µg/dL. The distance of dwellings from lead storage sites, their geographic location and their antiquity were significantly associated with high blood lead levels. Multivariate models disclosed that people living in contaminated sites have an odds ratio of 24.9 for high blood lead levels. Conclusions: Environmental lead contamination is significantly associated with high blood lead levels

Factores de riesgo para las enfermedades no transmisibles: metodología y resultados globales de la encuesta de base del programa CARMEN: conjunto de acciones para la reducción multifactorial de las enfermedades no transmisibles / Risk factors for chronic non communicable diseases: methods and results of CARMEN program basal survey

Background: In the last decades, chronic non communicable diseases are becoming the main cause of disability and mortality among adults. The risk factor surveillance and management is the most efficient mean of reducing the impact of these diseases. Aim: To report the results of a non communicable disease risk factor surveillance program in Valparaiso, Chile. Material and methods: a random samples of people aged 25 to 64 years old living in Valparaiso, Chile was studied. Subjects were questioned about smoking and physical activity habits. Blood pressure, height and weight were measured using standardized techniques at their homes and blood samples were obtained to measure serum lipid levels and oral glucose tolerance test at the nearest outpatient clinic. Results: Of the initial 3852 homes selected, 752 individuals did no agree to answer the inquiry, therefore 3120 subjects were finally interviewed. Of these, 40.6 percent were smokers, 15 percent drank alcohol in two or more occasions per month, 84.6 percent were physically inactive, 19.7 percent had a body mass index over 30 kg/m2, 11.1 percent had high blood pressure, 3.9 percent were diabetic and 46.9 percent had high serum cholesterol levels. Conclusions: The basal survey for the CARMEN program shows a high prevalence of cardiovascular risk factors among chileans

Prevalencia de hipertensión arterial en Valparaíso: resultados de la encuesta de base el programa CARMEN: conjunto de acciones para la reducción multifactorial de las enfermedades no transmisibles / Prevalence of hypertension in Valparaíso: results of the base survey of CARMEN program

Background: There is little information about the real prevalence of hypertension in Chile. Aim: To assess the adjusted prevalence of hypertension and its main therapeutic measures among adults living in Valparaiso, Chile. Material and methods: A random sample of dwellings in Valparaiso was chosen. Among these, an individual of 25 to 64 years old was randomly surveyed for risk factors for chronic diseases and sociodemographic parameters. Blood pressure, weight, height, oral glucose tolerance test, fasting cholesterol and triglycerides were also measured. Prevalence was pondered according to age, sex, and probability of selection in the dwelling interior. Results: Three thousand one hundred twelve individuals were studied. The adjusted prevalence of hypertension was 11.4 percent (11.6 percent among females and 10.6 percent among men). The prevalence increased along with age from 3 and 1.9 percent in men and women of 25 to 34 years old respectively, to 18.2 and 27.4 percent among men and women of 55 to 64 years old (p< 0.01). People of low socioeconomic level had a higher prevalence of hypertension than those of high socioeconomic level (14.2 and 9.3 percent respectively, p < 0.05). Diabetes, obesity and hypercholesterolemia were significantly more frequent in subjects with hypertension than in the general population. Forty four percent of diagnosed hypertensives were receiving medications (angiotensin converting enzyme inhibitors 40 percent, calcium antagonists 34 percent, beta blockers 22 percent). Twenty five percent of patients were treated with a combination of medications. Of those treated, only 22 percent had normal blood pressure levels at the moment of examination. Conclusions: High blood pressure is an important public health problem that requires more efficient detection and treatment programs

Estado inmunitario de 4 grupos de edad de población chilena contra sarampión y rubeola / Immune status against measles and rubella among chilean subjects of different ages

Background: Results of clinical and epidemiological studies confirm that no cases of measles have occurred in Chile since 1993. However, since covering of vaccination programs do not exceed 95 percent, an immunological surveillance for this disease is warranted. Aim: To know the immune status against measles and rubella in the Chilean population. Material and methods: A serological census of a representative sample of communities with high (90 percent or more) or low immunization coverings was performed. Four sub samples along the country were selected: 122 children aged 18 months of age (stratum A), 1,276 children attending the first year of basic school (stratum B), 899 teenagers in their last high school year (stratum C) and 399 women attending a family planning clinic (stratum D). IgG antibodies against measles and rubella were measured using ELISA and hemagglutination inhibition techniques, respectively. Results: Antibodies against measles and rubella were found in 96 percent and 94 percent of study subjects. No differences in these titres were found between different strata or communities with high or low vaccination covering. There is a high percentage of positive antibodies against measles among children of 18 months of age and a high percentage of antibodies against rubella among teenagers and women in family planning. Only 3 percent of the sample had not received any vaccine at the moment of the study. Conclusions: The high prevalence of antibodies against rubella allows to conclude that it is not necessary to consider this antigen in the next vaccination campaign. Due to the high prevalence of antibodies against measles, only the population older than 20 years old should be affected by the disease if this virus enters the country

Exposición crónica a plomo ambiental en lactantes chilenos II: efectos en el desarrollo psicomotor / Effects of chronic lead exposure on neurobehavioral development of Chilean lactating children

Background: Lactating children are specially susceptible to lead toxicity due to their underdeveloped nervous system, lower body mass, higher intestinal absorption and lower elimination rates. Aim: To determine the effects of lead exposure, comparing Chilean lactating children residing in rural areas with low lead exposure, and in urban areas with high lead exposure. Material and methods: Newborns from public maternity hospitals of the rural locality of San Felipe and from Metropolitan Santiago, were recruited for the study. On admission to the study, umbilical cord and maternal blood samples were obtained and an inquiry about perinatal, sociohereditary and lead exposure history was done. Children were followed every 6 months until 24 months of age, measuring blood parameters and neurobehavioral development using Bayley scales. Results: Three hundred twelve children from Santiago and 113 from San Felipe were studied. Maternal and children blood lead levels were higher in Santiago, but lower than those reported in other international studies. At 24 months of age, 4.5 percent of children from Santiago and 0.7 percent of children from San Felipe had levels over 10 µg/dl. No differences in neurobehavioral development were observed between children of both cities. At 24 months, scores of MDI scales were 91 in Santiago and 97 in San Felipe. The figures for PDI scale were 93 in Santiago and 93 in San Felipe. Main risk factors for a retarded neurobehavioral development were socioeconomic level with a mean Odds ratio of 3.5 (0.99-12.4), male sex with an Odds ratio of 2.3 (1.09-5.07) and stimulation at home with an Odds ratio of 0.7 (0.53-0.82. Conclusions: In this cohort of children, no effect of lead levels on neurobehavioral development was found

Desigualdades sociales y salud: nivel socioeconómico y mortalidad infantil en Chile, 1985-1995 / Socioeconomic level and infant mortality in Chile in the period 1985-1995

Background: The strong relationship between, social inequalities and health have extensively reported. Aim: to measure the effects of social inequalities, assessed through maternal educational level,on infant mortality in Chile. Material and methods: Using death and birth electronic databases of the Instituto Nacional de Estadísticas, the annual rates of infant mortality per years of approved studies of both parents and per cause were calculated. Results: In the 1990-1995 period,there is a clear gradient of infant mortality according to the level of education of the mother (38.2 per 1000 born alive among those without education versus 7.8 per 1000 born alive among those with university education). The same tendency is maintained for neonatal and post-neonatal mortality . All groups of causes had a similar affect, standing out disease of the respiratory system with a relative risk (RR) of 14.3 and a population attributable risk (PAR) of 73 percent, trauma with a RR of 11.3 and a PAR of 69 percent and infectious disease with a RR of 10.8 and a PAR of 62percent. Between 1985 and 1995, absolute inequalities decreased but relative inequalities remained constant. Conclusions: The great social inequality in infant mortality has persisted in Chile during the last years. To adequately asses the national progresses in population healt using infant mortality as an indicator, the gaps between social groups must be born in mind

Exposición crónica a plomo ambiental en lactantes chilenos / Chronic exposure to environmental lead in Chilean nursing infants

Background: in Chile, there are several sources of environmental lead exposure. However, the few studies about lead levels in Chilean infants, do not allow to establish the prevalence of high lead in this population. Aim: to measure blood lead levels in nursing infants, living in rural and urban areas, from birth until two years of age. Subjects and methods: newborns from public maternity hospitals in Santiago and a rural area were selected for the study. An umbilical cord blood sample was obtained at bird and venous blood samples thereafter, every 6 months until the age of 24 months. Lead levels were measured by atomic absorption spectrophotometry atmospheric lead was measured simultaneously every week in Santiago and the rural area. Results: three hundred twelve children from Santiago and 113 from the rural area completed the 24 months follow-up. The mean lead exposure for infants living in Santiago and in the rural area was 1.23 ñ 0.66 and 0.19 ñ 0.15 µg/m3 respective (p < 0.001). Mean blood levels were always higher in infants from Santiago, compared to those from the rural area. At 24 months, 4,5 percent of children from Santiago and 0,7 percent of children from the rural area had blood lead levels over 10 µg/dl. Significant risk factors for high lead levels were recent paining of the house where the infant lives, eating soil bitting banisters and familiar labor exposure to lead. Conclusions: infants living in an urban area and exposed to increased atmospheric lead levels have higher blood lead levels than infants living in a rural area