Understanding health system resilience in responding to COVID-19 pandemic: experiences and lessons from an evolving context of federalization in Nepal.

INTRODUCTION: The COVID-19 pandemic has tested the resilience capacities of health systems worldwide and highlighted the need to understand the concept, pathways, and elements of resilience in different country contexts. In this study, we assessed the health system response to COVID-19 in Nepal and examined the processes of policy formulation, communication, and implementation at the three tiers of government, including the dynamic interactions between tiers. Nepal was experiencing the early stages of federalization reform when COVID-19 pandemic hit the country, and clarity in roles and capacity to implement functions were the prevailing challenges, especially among the subnational governments. METHODS: We adopted a cross-sectional exploratory design, using mixed methods. We conducted a desk-based review of all policy documents introduced in response to COVID-19 from January to December 2020, and collected qualitative data through 22 key informant interviews at three tiers of government, during January-March 2021. Two municipalities were purposively selected for data collection in Lumbini province. Our analysis is based on a resilience framework that has been developed by our research project, ReBUILD for Resilience, which helps to understand pathways to health system resilience through absorption, adaptation and transformation. RESULTS: In the newly established federal structure, the existing emergency response structure and plans were utilized, which were yet to be tested in the decentralized system. The federal government effectively led the policy formulation process, but with minimal engagement of sub-national governments. Local governments could not demonstrate resilience capacities due to the novelty of the federal system and their consequent lack of experience, confusion on roles, insufficient management capacity and governance structures at local level, which was further aggravated by the limited availability of human, technical and financial resources. CONCLUSIONS: The study findings emphasize the importance of strong and flexible governance structures and strengthened capacity of subnational governments to effectively manage pandemics. The study elaborates on the key areas and pathways that contribute to the resilience capacities of health systems from the experience of Nepal. We draw out lessons that can be applied to other fragile and shock-prone settings.

Sand cat swarm optimization algorithm and its application integrating elite decentralization and crossbar strategy.

Sand cat swarm optimization algorithm is a meta-heuristic algorithm created to replicate the hunting behavior observed by sand cats. The presented sand cat swarm optimization method (CWXSCSO) addresses the issues of low convergence precision and local optimality in the standard sand cat swarm optimization algorithm. It accomplished this through the utilization of elite decentralization and a crossbar approach. To begin with, a novel dynamic exponential factor is introduced. Furthermore, throughout the developmental phase, the approach of elite decentralization is incorporated to augment the capacity to transcend the confines of the local optimal. Ultimately, the crossover technique is employed to produce novel solutions and augment the algorithm's capacity to emerge from local space. The techniques were evaluated by performing a comparison with 15 benchmark functions. The CWXSCSO algorithm was compared with six advanced upgraded algorithms using CEC2019 and CEC2021. Statistical analysis, convergence analysis, and complexity analysis use statistics for assessing it. The CWXSCSO is employed to verify its efficacy in solving engineering difficulties by handling six traditional engineering optimization problems. The results demonstrate that the upgraded sand cat swarm optimization algorithm exhibits higher global optimization capability and demonstrates proficiency in dealing with real-world optimization applications.

Blockchain Based Decentralized and Proactive Caching Strategy in Mobile Edge Computing Environment.

In the mobile edge computing (MEC) environment, the edge caching can provide the timely data response service for the intelligent scenarios. However, due to the limited storage capacity of edge nodes and the malicious node behavior, the question of how to select the cached contents and realize the decentralized security data caching faces challenges. In this paper, a blockchain-based decentralized and proactive caching strategy is proposed in an MEC environment to address this problem. The novelty is that the blockchain was adopted in an MEC environment with a proactive caching strategy based on node utility, and the corresponding optimization problem was built. The blockchain was adopted to build a secure and reliable service environment. The employed methodology is that the optimal caching strategy was achieved based on the linear relaxation technology and the interior point method. Additionally, in a content caching system, there is a trade-off between cache space and node utility, and the caching strategy was proposed to solve this problem. There was also a trade-off between the consensus process delay of blockchain and the caching latency of content. An offline consensus authentication method was adopted to reduce the influence of the consensus process delay on the content caching. The key finding was that the proposed algorithm can reduce latency and can ensure the security data caching in an IoT environment. Finally, the simulation experiment showed that the proposed algorithm can achieve up to 49.32%, 43.11%, and 34.85% improvements on the cache hit rate, the average content response latency, and the average system utility, respectively, compared to the random content caching algorithm, and it achieved up to 9.67%, 8.11%, and 5.95% increases, successively, compared to the greedy content caching algorithm.

Why does a public health issue (not) get priority? Agenda-setting for the national burns program in India.

There is growing scholarly interest in what leads to global or national prioritisation of specific health issues. By retrospectively analysing agenda-setting for India's national burn program, this study aimed to better understand how the agenda-setting process influenced its design, implementation, and performance. We conducted document review and key informant interview with stakeholders and used a combination of analytical frameworks on policy prioritisation and issue framing for analysis. The READ (Readying material, Extracting data, Analysing data and Distilling findings) approach was used for document reviews, and qualitative thematic analysis was used for coding and analysis of documents and interviews. The findings suggest three critical features of burns care policy prioritisation in India: challenges of issue characteristics, divergent portrayal of ideas and its framing as a social and/or health issue, and over-centralisation of agenda setting. First, lack of credible indicators on the magnitude of the problem and evidence on interventions limited issue framing, advocacy, and agenda-setting. Second, the policy response to burns has two dimensions in India: response to gender-based intentional injuries and the healthcare response. While intentional burns have received policy attention, the healthcare response was limited until the national program was initiated in 2010 and scaled up in 2014. Third, over-centralisation of agenda setting (dominated by a few homogenous actors, located in the national capital, with attention focussed on the national ministry of health) contributed to limitations in program design and implementation. We note following elements to consider when analysing issues of significant burden but limited priority: the need to analyse how actors influence issue framing, the particularities of issues, the inadequacy of any one dominant frame, and the limited intersection of frames. Based on this analysis in India, we recommend a decentralised approach to agenda setting and for the design and implementation of national programs from the outset.

Vertical policy coordination of COVID-19 testing in Sweden: an analysis of policy-specific demands and institutional barriers.

PURPOSE: The build-up of large-scale COVID-19 testing required an unprecedented effort of coordination within decentralized healthcare systems around the world. The aim of the study was to elucidate the challenges of vertical policy coordination between non-political actors at the national and regional levels regarding this policy issue, using Sweden as our case. DESIGN/METHODOLOGY/APPROACH: Interviews with key actors at the national and regional levels were analyzed using an adapted version of a conceptualization by Adam et al. (2019), depicting barriers to vertical policy coordination. FINDINGS: Our results show that the main issues in the Swedish context were related to parallel sovereignty and a vagueness regarding responsibilities and mandates as well as complex governmental structures and that this was exacerbated by the unfamiliarity and uncertainty of the policy issue. We conclude that understanding the interaction between the comprehensiveness and complexity of the policy issue and the institutional context is crucial to achieving effective vertical policy coordination. ORIGINALITY/VALUE: Many studies have focused on countries' overall pandemic responses, but in order to improve the outcome of future pandemics, it is also important to learn from more specific response measures.

Decentralization and Integration of Advanced Cardiac Care for the World's Poorest Billion Through the PEN-Plus Strategy for Severe Chronic Non-Communicable Disease.

Rheumatic and congenital heart disease, cardiomyopathies, and hypertensive heart disease are major causes of suffering and death in low- and lower middle-income countries (LLMICs), where the world's poorest billion people reside. Advanced cardiac care in these counties is still predominantly provided by specialists at urban tertiary centers, and is largely inaccessible to the rural poor. This situation is due to critical shortages in diagnostics, medications, and trained healthcare workers. The Package of Essential NCD Interventions - Plus (PEN-Plus) is an integrated care model for severe chronic noncommunicable diseases (NCDs) that aims to decentralize services and increase access. PEN-Plus strategies are being initiated by a growing number of LLMICs. We describe how PEN-Plus addresses the need for advanced cardiac care and discuss how a global group of cardiac organizations are working through the PEN-Plus Cardiac expert group to promote a shared operational strategy for management of severe cardiac disease in high-poverty settings.

Toward Verification of DAG-Based Distributed Ledger Technologies through Discrete-Event Simulation.

As the potential of directed acyclic graph (DAG)-based distributed ledgers in IoT systems unfolds, a need arises to understand their intricate dynamics in real-world scenarios. It is well known that discrete event simulations can provide high-fidelity evaluations of protocols. However, there is a lack of public discrete event simulators capable of assessing DAG-based distributed ledgers. In this paper, a discrete-event-based distributed ledger simulator is introduced, with which we investigate a custom Python-based implementation of IOTA's Tangle DAG protocol. The study reveals the dynamics of Tangle (particularly Poisson processes in transaction dynamics), the efficiency and intricacies of the random walk in Tangle, and the quantitative assessment of node convergence. Furthermore, the research underscores the significance of weight updates without depth limitations and provides insights into the role, challenges, and implications of the coordinator/validator in DAG architectures. The results are striking, and although the findings are reported only for Tangle, they demonstrate the need for adaptable and versatile discrete event simulators for DAG architectures and tip selection methodologies in general.

The determinants of legislation for radiofrequency electromagnetic fields (RF-EMFs) with the onset of 5G: An empirical analysis with a worldwide cross-sectional dataset.

The unprecedented exposure of radiofrequency electromagnetic field (RF-EMF) to humans from mobile communications raises serious public concern about the possibility of unexpected adverse health effects and has stimulated authorities to adopt precautionary exposure limits. These limits are distinctly different across countries, and the causes of these differences are unclear from the literature. This article is the first empirical analysis on the determinants of RF-EMF exposure legislation, using a novel cross-sectional database of 164 countries worldwide. The analysis shows that decentralization and mobile competition in countries with low mobile network deployment tend to promote more stringent RF-EMF exposure limits across the dataset with 164 countries. In more decentralized countries, the regions had a greater influence on national legislation and could accommodate local demands with the advent of mobile technology in the 2000s. In contrast, decentralization and mobile competition in countries with high levels of mobile network deployment tend to relax RF-EMF exposure limits in the sample of 61 countries with fifth-generation (5G) technology. Indeed, restrictive RF-EMF exposure limits are constraining 5G deployment in a context of the widespread adoption of mobile-broadband technologies. These results should be useful for policymakers and mobile operators alike to anticipate the outcome of legislation in countries that have yet to introduce 5G technology. The results should also be useful when reviewing policies and strategies for the implementation of the upcoming 6G technology in frequency bands that will be increasingly higher (above 6 GHz up to THz for very local usage), and hence where the health effects on humans are less well studied.

Decentralizing Health Care: History and Opportunities of Web3.

This paper explores the relationship between the development of the internet and health care, highlighting their parallel growth and mutual influence. It delves into the transition from the early, static days of Web 1.0, akin to siloed physician expertise in health care, to the more interactive and patient-centric era of Web 2.0, which was accompanied by advancements in medical technologies and patient engagement. This paper then focuses on the emerging era of Web3-the decentralized web-which promises a transformative shift in health care, particularly in how patient data are managed, accessed, and used. This shift toward Web3 involves using blockchain technology for decentralized data storage to enhance patient data access, control, privacy, and value. This paper also examines current applications and pilot projects demonstrating Web3's practical use in health care and discusses key questions and considerations for its successful implementation.

Does the healthcare decentralization provide better public health security capacity and health services satisfaction? An analysis of OECD countries.

PURPOSE: Decentralization has profound implications for many health systems. This study investigates the effect of health system decentralization in Organization for Economic Co-operation and Development (OECD) countries on public health security capacity and health service satisfaction. DESIGN/METHODOLOGY/APPROACH: Multiple linear regression analyses were employed for variables related to the level of health security capacity and satisfaction with the healthcare system while controlling for all socio-demographic variables from the European Social Survey, including over 44,000 respondents from 25 OECD countries. The Health Systems in Transition series of countries were used for assessing the decentralization level. FINDINGS: The result of multiple linear regression analyses showed that the level of decentralization in health systems was significantly associated with higher health security capacity (ß-coefficient 3.722, 95% confidence interval (CI) [3.536 3.908]; p=<0.001) and health service satisfaction (ß-coefficient 1.463, 95% CI [1.389 1.536]; p=<0.001) in the study. Countries with a higher level of decentralization in health policy tasks and areas were significantly likely to have higher health services satisfaction, whereas this satisfaction had a significant negative relation with the lower level of decentralization status of secondary/tertiary care services in OECD countries (ß-coefficient -5.250, 95% CI [-5.757-4.743]; p = 0.001). ORIGINALITY/VALUE: This study contributes to a better understanding of the extent to which decentralization of health services affects public health safety capacity and satisfaction with health services, whereas the level of decentralization in OECD countries varies considerably. Overall, the findings highlight the importance of public health security and satisfaction with health care delivery in assessing the effects of decentralization in health services.

Decentralised, collaborative, and privacy-preserving machine learning for multi-hospital data.

BACKGROUND: Machine Learning (ML) has demonstrated its great potential on medical data analysis. Large datasets collected from diverse sources and settings are essential for ML models in healthcare to achieve better accuracy and generalizability. Sharing data across different healthcare institutions or jurisdictions is challenging because of complex and varying privacy and regulatory requirements. Hence, it is hard but crucial to allow multiple parties to collaboratively train an ML model leveraging the private datasets available at each party without the need for direct sharing of those datasets or compromising the privacy of the datasets through collaboration. METHODS: In this paper, we address this challenge by proposing Decentralized, Collaborative, and Privacy-preserving ML for Multi-Hospital Data (DeCaPH). This framework offers the following key benefits: (1) it allows different parties to collaboratively train an ML model without transferring their private datasets (i.e., no data centralization); (2) it safeguards patients' privacy by limiting the potential privacy leakage arising from any contents shared across the parties during the training process; and (3) it facilitates the ML model training without relying on a centralized party/server. FINDINGS: We demonstrate the generalizability and power of DeCaPH on three distinct tasks using real-world distributed medical datasets: patient mortality prediction using electronic health records, cell-type classification using single-cell human genomes, and pathology identification using chest radiology images. The ML models trained with DeCaPH framework have less than 3.2% drop in model performance comparing to those trained by the non-privacy-preserving collaborative framework. Meanwhile, the average vulnerability to privacy attacks of the models trained with DeCaPH decreased by up to 16%. In addition, models trained with our DeCaPH framework achieve better performance than those models trained solely with the private datasets from individual parties without collaboration and those trained with the previous privacy-preserving collaborative training framework under the same privacy guarantee by up to 70% and 18.2% respectively. INTERPRETATION: We demonstrate that the ML models trained with DeCaPH framework have an improved utility-privacy trade-off, showing DeCaPH enables the models to have good performance while preserving the privacy of the training data points. In addition, the ML models trained with DeCaPH framework in general outperform those trained solely with the private datasets from individual parties, showing that DeCaPH enhances the model generalizability. FUNDING: This work was supported by the Natural Sciences and Engineering Research Council of Canada (NSERC, RGPIN-2020-06189 and DGECR-2020-00294), Canadian Institute for Advanced Research (CIFAR) AI Catalyst Grants, CIFAR AI Chair programs, Temerty Professor of AI Research and Education in Medicine, University of Toronto, Amazon, Apple, DARPA through the GARD project, Intel, Meta, the Ontario Early Researcher Award, and the Sloan Foundation. Resources used in preparing this research were provided, in part, by the Province of Ontario, the Government of Canada through CIFAR, and companies sponsoring the Vector Institute.

Decentralized Clinical Trials: Scientific Considerations Through the Lens of the Estimand Framework.

While industry and regulators' interest in decentralized clinical trials (DCTs) is long-standing, the Covid-19 pandemic accelerated and broadened the adoption and experience with these trials. The key idea in decentralization is bringing the clinical trial design, typically on-site, closer to the patient's experience (on-site or off-site). Thus, potential benefits of DCTs include reducing the burden of participation in trials, broadening access to a more diverse population, or using innovative endpoints collected off-site. This paper helps researchers to carefully evaluate the added value and the implications of DCTs beyond the operational aspects of their implementation. The proposed approach is to use the ICH E9(R1) estimand framework to guide the strategic decisions around each decentralization component. Furthermore, the framework can guide the process for clinical trialists to systematically consider the implications of decentralization, in turn, for each attribute of the estimand. We illustrate the use of this approach with a fully DCT case study and show that the proposed systematic process can uncover the scientific opportunities, assumptions, and potential risks associated with a possible use of decentralization components in the design of a trial. This process can also highlight the benefits of specifying estimand attributes in a granular way. Thus, we demonstrate that bringing a decentralization component into the design will not only impact estimators and estimation but can also correspond to addressing more granular questions, thereby uncovering new target estimands.

Exploring the nexus between fiscal decentralization and ecological sustainability: a fresh perspective from the moderating role of geopolitical risk and updated international evidence.

Fiscal decentralization has been long employed to enhance the utilization of financial resources for sustainable development. Nevertheless, its effectiveness in limiting ecological degradation is ambiguous, especially when a country faces geopolitical risks. Different from previous works which separately examine the impacts of either fiscal decentralization or geopolitical risks on ecological sustainability, this research examines the moderating role of geopolitical risks on the non-linear relationship between fiscal decentralization and ecological footprints across different levels of environmental condition. An advanced panel quantile regression is applied to a sample of 23 advanced and emerging market economies from 1990 to 2018. The empirical results indicate that the nexus between revenue decentralization and ecological footprint follows an inverted U-shaped pattern at the 20th to 60th quantiles of ecological footprint. Meanwhile, the linkage between expenditure and ecological footprint reflects a U-shaped pattern across all quantiles. Notably, geopolitical risk strongly moderates the connection between fiscal decentralization and ecological footprint with the role being stronger in the case of revenue decentralization. This research provides valuable implementations to tailor policies for transferring revenue and expenditure responsibilities to sub-governmental bodies towards sustainability targets based on their current ecological conditions and contexts of geopolitical instability.

Implementing health system and the new federalism in Somalia: challenges and opportunities.

In the 21st century, healthcare stands out as a formidable, contentious social responsibility for governments due to its high costs. This study delves into Somalia's healthcare system under Federal Government leadership, scrutinizing the complexities of health governance and financing. The Federal Government (FGS), along with governmental states (FMS) and regional authorities, collectively shoulder leadership and governance roles within Somalia's healthcare framework. Vital to resilient and inclusive development, the health sector holds a pivotal role. A strategic investment in healthcare not only drives substantial demographic dividends through enhanced life expectancy and reduced fertility rates, but also paves Somalia's trajectory toward progress. The Federal Government of Somalia confronts a multitude of challenges in its pursuit of effective healthcare implementation. A prominent obstacle lies in health financing. Somalia relies heavily on international and private sources for health support, primarily due to limited government revenue generation. This financial shortfall restrains the government's capacity to allocate ample funds for public services and critical investments, including healthcare. This paper sheds light on the present healthcare landscape in Somalia and expounds on the hurdles confronted by healthcare systems under federal governance. Moreover, it delves into the historical evolution of Somalia's healthcare system and the advent of new federalist principles. In doing so, this study comprehensively examines the dynamics of healthcare governance, financing, and historical progression in Somalia.

Impact of fiscal decentralization and local government competition on the supply of basic public services: Based on the empirical evidence of prefecture-level cities in China.

Promoting equal access to public services and improving people's well-being is a key link in building a modern national governance system in China. However, under the Chinese-style fiscal decentralization system, local governments face the "dilemma" of economic growth goals and the improvement of people's livelihoods. China's basic public services still have the problems of insufficient supply quantity, unbalanced structure and low efficiency. This paper aims to explore the impact of fiscal decentralization and local government competition on basic public services, and provide a theoretical and practical basis for deepening the reform of China's fiscal and taxation system, perfecting the transfer payment system, and improving the public service provision at the present stage. Under the premise of theoretical hypothesis, based on the panel data of 178 prefecture-level cities in China from 2008 to 2019, which is obtained from the Statistical Yearbook and the Work report of prefecture-level governments, the fixed effect model and threshold model are used for the empirical test. The results show that: first, the increase of fiscal decentralization has a negative impact on supply of basic public services in prefecture-level cities; second, the local government competition aiming at economic growth will intensify the negative impact, and make the relationship between fiscal decentralization and basic public services show nonlinear characteristics; Third, compared with developed areas, the strengthening regulatory effect of local government competition is more obvious in less-developed areas, such as western and northeastern regions, and third-tier, fourth-tier, and fifth-tier cities. Based on these findings, this paper draws the following policy implications: strengthen the reform of the fiscal and taxation system below the provincial level, promote the construction of a direct transfer payment mechanism, adjust the standards and methods of performance appraisal, and use modern information technology to improve the public service demand and interest expression mechanisms.

Do community health committees participate in governing health workers in primary healthcare facilities under fiscal decentralization?-An explanatory qualitative study from Tanzania.

Background: Decentralization is implemented at the local level to increase community participation in improving service delivery. Majority of developing countries are implementing Fiscal decentralization in primary healthcare through various approaches such as Direct Health Facility Financing, among other things, to empower Community governance structures to govern Primary Health Facility operations to improve the responsiveness of health service delivery and achieve Universal Health Coverage. One of the primary functions of these governance committees is to oversee health workers in their health facilities. Aims: This aimed at assessing how empowered governance committees govern health workers in their facilities under fiscal decentralization. Methods: To collect data for this study, an explanatory qualitative design with phenomenology traditions was used. To select the area of study, health facilities, and participants, a purposeful sampling procedure was used. Data were gathered through interviews and Focus Group Discussions to explore committee participation in governing health workers in primary care. Thematic analysis was used to analyze the collected data. Result: The findings of the study suggest that community governance committees' participation in governing health workers under fiscal decentralization remains limited. Majority of the committees have found to have low limited participation in governing different aspects of health workers. The majority of the committees have discovered that hiring casual workers such as security guards and cleaners is more important than other functions. Conclusion: The study implies that lower and middle-income countries' willingness to implement fiscal reforms at the local level and empower communities to take the lead in governing health workers still there are very limited specific powers granted to them to govern health workers. Therefore, capacity building to the governance actors is critical if we are to achieve the benefit of fiscal decentralization.

Spatial spillover effects of manufacturing agglomeration on China's total factor carbon productivity: evidence from the regulatory role of fiscal decentralization.

Based on the theory of new economic geography, this paper used panel data from 284 cities in China from 2006 to 2019 to determine the effects of spatial spillover and heterogeneity of manufacturing agglomeration (MA) on urban total factor carbon productivity (TFCP) and the regulatory effect of fiscal decentralization on the outcome. The results showed that (1) MA shifted from the eastern region of China to the central and western regions, with the center of gravity moving towards the south. The spatial pattern of urban TFCP displayed the solidifying characteristics of "low-level agglomeration and high-level dispersion," with technological progress being the primary driver. (2) The MA had a significant U-shaped effect on the TFCP of local and nearby cities, promoting the improvement of urban TFCP through Jacobs' and Porter's externalities but not MAR externalities. (3) Regarding regional differences, MA had a significant U-shaped impact on urban TFCP in the eastern and central regions. At different levels of manufacturing development, there was an inverted U-shaped relationship in both manufacturing and non-manufacturing metropolitan areas. For varying degrees of manufacturing industry agglomeration, increasing the level of MA improved urban TFCP in low agglomeration areas, but inhibited it in high agglomeration areas. (4) The implementation of fiscal decentralization nationwide and in the eastern and central regions significantly weakened the impact of MA on TFCP. Furthermore, fiscal decentralization significantly enhanced the influence of MA on TFCP in cities exhibiting high levels of economic development, advanced industrial structure and strict environmental regulations. Therefore, based on the unique developmental characteristics of the manufacturing industry in various cities, fiscal policies ought to be tailored to local circumstances to support key areas. This strategy should facilitate the high-quality development of manufacturing industry and low-carbon development of cities.

Whole slide images as non-fungible tokens: A decentralized approach to secure, scalable data storage and access.

Background: Distributed ledger technology (DLT) enables the creation of tamper-resistant, decentralized, and secure digital ledgers. A non-fungible token (NFT) represents a record on-chain associated with a digital or physical asset, such as a whole-slide image (WSI). The InterPlanetary File System (IPFS) represents an off-chain network, hypermedia, and file sharing peer-to-peer protocol for storing and sharing data in a distributed file system. Today, we need cheaper, more efficient, highly scalable, and transparent solutions for WSI data storage and access of medical records and medical imaging data. Methods: WSIs were created from non-human tissues and H&E-stained sections were scanned on a Philips Ultrafast WSI scanner at 40× magnification objective lens (1 µm/pixel). TIFF images were stored on IPFS, while NFTs were minted on the Ethereum blockchain network in ERC-1155 standard. WSI-NFTs were stored on MetaMask and OpenSea was used to display the WSI-NFT collection. Filebase storage application programing interface (API) were used to create dedicated gateways and content delivery networks (CDN). Results: A total of 10 WSI-NFTs were minted on the Ethereum blockchain network, found on our collection "Whole Slide Images as Non-fungible Tokens Project" on Open Sea: https://opensea.io/collection/untitled-collection-126765644. WSI TIFF files ranged in size from 1.6 to 2.2 GB and were stored on IPFS and pinned on 3 separate nodes. Under optimal conditions, and using a dedicated CDN, WSI reached retrieved at speeds of over 10 mb/s, however, download speeds and WSI retrieval times varied significantly depending on the file and gateway used. Overall, the public IPFS gateway resulted in variably poorer WSI download retrieval performance compared to gateways provided by Filebase storage API. Conclusion: Whole-slide images, as the most complex and substantial data files in healthcare, demand innovative solutions. In this technical report, we identify pitfalls in IPFS, and demonstrate proof-of-concept using a 3-layer architecture for scalable, decentralized storage, and access. Optimized through dedicated gateways and CDNs, which can be effectively applied to all medical data and imaging modalities across the healthcare sector. DLT and off-chain network solutions present numerous opportunities for advancements in clinical care, education, and research. Such approaches uphold the principles of equitable healthcare data ownership, security, and democratization, and are poised to drive significant innovation.

Policy change to improve access to safe abortion care in federal Nepal.

In Nepal's constitution, safe abortion care is recognized as an essential component of a comprehensive approach to fulfill individuals' sexual and reproductive health and rights. In the current context of transition to a three-level governance (federal, provincial, and local), there are opportunities to accelerate decentralization and devolution of decision-making power, increase access to and coverage of safe abortion services, and improve health outcomes. This article documents the processes and results of the policy change undertaken by the Ministry of Health and Population in collaboration with development partners to decentralize the approval process of safe abortion sites and providers with the objective to increase access to and coverage of safe abortion services. With the decentralization of certification, the approval process for safe abortion service sites and providers has become simpler, less time consuming, and less expensive by reducing cost of traveling to Kathmandu or approaching authorities at the federal level. This has resulted in expanding safe abortion services across the country including remote areas with marginalized populations. Evidence-based advocacy enabled policy change for decentralization of the approval process. Collaboration among stakeholders has been vital for implementing the policy change, including issuing directives from the federal to provincial levels and capacity strengthening of provincial level officials in understanding the requirements for approval of sites and providers.