Dietary diversity, nutritional status and associated factors among lactating mothers visiting government health facilities at Dessie town, Amhara region, Ethiopia.

BACKGROUND: Maternal undernutrition is one of the most common causes of maternal morbidity and mortality in developing countries. Severe undernutrition among mothers leads to reduced lactation performance which further contributes to an increased risk of infant mortality. However, data regarding nutritional status of lactating mothers at Dessie town and its surrounding areas is lacking. This study assessed dietary diversity, nutritional status and associated factors of lactating mothers visiting health facilities at Dessie town, Amhara region, Ethiopia. METHODS: Institutional based cross-sectional study was conducted from March to April, 2017 among 408 lactating mothers. Systematic random sampling technique was employed to select the study participants. Data on socio-demographic and economic characteristics, health related characteristics, dietary diversity and food security status of participants were collected using interviewer administered questionnaire. Data were entered into EPI-INFO and analyzed using SPSS Version 22. Bivariate and multivariate analyses were performed to identify factors associated with dietary diversity and nutritional status of lactating mothers. RESULTS: More than half (55.6%) of lactating mothers had inadequate dietary diversity (DDS<5.3) and about 21% were undernourished (BMI<18.5 kg/m2). Household monthly income [AOR = 2.0, 95% CI (1.15, 3.65)], type of house [AOR = 1.8, 95% CI (1.15, 2.94)], nutrition information [AOR = 1.6, 95% CI (1.05, 2.61)] and household food insecurity [AOR = 1.8, 95% CI (1.05, 3.06)] were factors associated with dietary diversity of lactating mothers. Being young in age 15-19 years [AOR = 10.3, 95% CI (2.89, 36.39)] & 20-29 years [AOR = 3.4, 95% CI (1.57, 7.36)], being divorced/separated [AOR = 10.1, 95% CI (1.42, 72.06)], inadequate dietary diversity [AOR = 3.8, 95% CI (2.08, 7.03)] and household food insecurity [AOR = 3.1, 95% CI (1.81, 5.32)] were factors associated with maternal undernutrition. CONCLUSION: The dietary diversity of lactating mothers in the study area was sub optimal and the prevalence of undernutrition was relatively high. Public health nutrition interventions such as improving accessibility of affordable and diversified nutrient rich foods are important to improve the nutritional status of mothers and their children in the study area.

Charges, length of stay, and complication associations with trauma center ownership in adult patients with mild to moderate trauma.

BACKGROUND: For-profit (FP) trauma centers (TCs) charge more for trauma care than not-for-profit (NFP) centers. We sought to determine charges, length of stay (LOS), and complications associations with TC ownership status (FP, NFP, and government) for three diagnoses among patients with overall low injury severity. METHODS: Adult patients treated at TCs with an International Classification of Diseases-based injury severity score (ICISS) survival probability ≥ 0.85 were identified. Only those who with a principal diagnosis of femur, tibial or rib fractures were included. RESULTS: Total charges were significantly higher at FP centers than NFP and lower at government centers (89.6% and -12.8%, respectively). FP TCs had a 12.5% longer LOS and government TCs had a 20.4% longer LOS than NFP TCs. CONCLUSION: Patients presenting to FP TCs with mild/moderate femur, tibial, or rib fractures experienced higher charges and increased LOS compared with government or NFP centers. There was no difference in overall complication rates.

Tracking development assistance for health and for COVID-19: a review of development assistance, government, out-of-pocket, and other private spending on health for 204 countries and territories, 1990-2050.

BACKGROUND: The rapid spread of COVID-19 renewed the focus on how health systems across the globe are financed, especially during public health emergencies. Development assistance is an important source of health financing in many low-income countries, yet little is known about how much of this funding was disbursed for COVID-19. We aimed to put development assistance for health for COVID-19 in the context of broader trends in global health financing, and to estimate total health spending from 1995 to 2050 and development assistance for COVID-19 in 2020. METHODS: We estimated domestic health spending and development assistance for health to generate total health-sector spending estimates for 204 countries and territories. We leveraged data from the WHO Global Health Expenditure Database to produce estimates of domestic health spending. To generate estimates for development assistance for health, we relied on project-level disbursement data from the major international development agencies' online databases and annual financial statements and reports for information on income sources. To adjust our estimates for 2020 to include disbursements related to COVID-19, we extracted project data on commitments and disbursements from a broader set of databases (because not all of the data sources used to estimate the historical series extend to 2020), including the UN Office of Humanitarian Assistance Financial Tracking Service and the International Aid Transparency Initiative. We reported all the historic and future spending estimates in inflation-adjusted 2020 US$, 2020 US$ per capita, purchasing-power parity-adjusted US$ per capita, and as a proportion of gross domestic product. We used various models to generate future health spending to 2050. FINDINGS: In 2019, health spending globally reached $8·8 trillion (95% uncertainty interval [UI] 8·7-8·8) or $1132 (1119-1143) per person. Spending on health varied within and across income groups and geographical regions. Of this total, $40·4 billion (0·5%, 95% UI 0·5-0·5) was development assistance for health provided to low-income and middle-income countries, which made up 24·6% (UI 24·0-25·1) of total spending in low-income countries. We estimate that $54·8 billion in development assistance for health was disbursed in 2020. Of this, $13·7 billion was targeted toward the COVID-19 health response. $12·3 billion was newly committed and $1·4 billion was repurposed from existing health projects. $3·1 billion (22·4%) of the funds focused on country-level coordination and $2·4 billion (17·9%) was for supply chain and logistics. Only $714·4 million (7·7%) of COVID-19 development assistance for health went to Latin America, despite this region reporting 34·3% of total recorded COVID-19 deaths in low-income or middle-income countries in 2020. Spending on health is expected to rise to $1519 (1448-1591) per person in 2050, although spending across countries is expected to remain varied. INTERPRETATION: Global health spending is expected to continue to grow, but remain unequally distributed between countries. We estimate that development organisations substantially increased the amount of development assistance for health provided in 2020. Continued efforts are needed to raise sufficient resources to mitigate the pandemic for the most vulnerable, and to help curtail the pandemic for all. FUNDING: Bill & Melinda Gates Foundation.

Prevalence of winter migration to warmer destinations among Ontarians ("snowbirds") and patterns of their use of health care services: a population-based analysis.

BACKGROUND: Older Canadians frequently migrate to warmer destinations for the winter season (snowbirds). Our aim was to examine the prevalence of migration to warmer destinations among Ontarians, and to compare the characteristics and use of health care services of snowbirds to those of older Ontarians who did not migrate for the winter. METHODS: We conducted a population-based analysis using health administrative databases from Ontario. We compiled 10 seasonal cohorts (2009/10 to 2018/19) of adults aged 65 or more who filled a travel supply of medications under the Ontario Drug Benefits program (snowbirds) between September and January (snowbird season). We calculated the seasonal prevalence of snowbirds per 100 Ontarians aged 65 or more. We matched each snowbird in the 2018/19 season to 2 nonsnowbirds on age and sex, and compared their characteristics and patterns of use of government-funded health care services. RESULTS: Over the 10-year period, 53 431 to 70 863 Ontarians aged 65 or more were identified as snowbirds (seasonal prevalence 2.6%-3.3%). Compared to nonsnowbirds, snowbirds were more likely to be recent migrants, live in higher-income neighbourhoods, have fewer comorbidities and make more visits to primary care physicians. From January to March 2019, snowbirds accessed government-funded health care services for a median of 0 days (interquartile range [IQR] 0-1 d), compared to 4 days (IQR 2-8 d) among nonsnowbirds. INTERPRETATION: About 3% of older Ontarians migrate to warmer destinations for the winter each season. Since few access health care services in Ontario from January to March, researchers are encouraged to consider the snowbird population and the impact of their absence on evaluations that assume continuous observation.

Impact of Covid-19 pandemic on obstetric fistula repair program in Zimbabwe.

The advent of Covid-19 pandemic adversely affected many programs worldwide, public health, including programming for obstetric fistula were not spared. Obstetric fistula is an abnormal connection between the vagina and the bladder or the rectum resulting from obstetric causes, mainly prolonged obstructed labour. Zimbabwe has two obstetric fistula repair centers. Because the program uses specialist surgeons from outside the country, the repairs are organized in quarterly camps with a target to repair 90 women per quarter. This study aimed at assessing the impact of restrictions on movement and gathering of people brought about by the Cocid-19 pandemic and to characterize participants of the camp which was held in the midst of the Covid-19 pandemic at Mashoko Hospital. Specifically it looked at how Covid-19 pandemic affected programming for obstetric fistula repair and characterized participants of the fistula camp held in November to December 2020 at one of the repair centers. A review of the dataset and surgical log sheets for the camp and national obstetric fistula dataset was conducted. Variables of interest were extracted onto an excel spreadsheet and analyzed for frequencies and proportions. Data were presented in charts, tables and narratives. The study noted that Covid-19 pandemic negatively affected performance of fistula repairs greatly with only 25 women repaired in 2020 as compared to 313 in 2019. Ninety women were called to come for repairs but 52 did not manage to attend due to reasons related to the restriction of the Covid-19 pandemic lockdown. Two thirds of those women suffered from urinary incontinence while the other third had fecal incontinence. The successful repair rate was 92%. This study concluded that the pandemic greatly affected programming of fistula repair in the country and recommended the Ministry of Health and Child Care to institute measures to resume programming as soon as the situation allows.

Evidence of the effect of primary care expansion on hospitalizations: Panel analysis of 143 municipalities in the Brazilian Amazon.

BACKGROUND: The Family Health Strategy (FHS) became consolidated as a primary care model and gatekeeper for the Unified Health System (Sistema Único de Saúde, SUS) in the Brazil and it is considered one of the largest primary health care programmes in the world. Its rapid expansion allowed the SUS to meet the changing health care needs of the population remote localities of Brazilian municipalities. METHODS: In the present study, exploratory data analysis was performed using modelling to provide a general overview of the study and to delineate possible structural characteristics of the cross-sectional time-series data. Panel regression methods were used to assess the association between FHS coverage and ambulatory care-sensitive hospitalizations (ACSH rates) in the municipalities of Pará, in the Brazilian Amazon, from 2008 to 2017. RESULTS: The results showed strong evidence for the association between FHS coverage and ACSH rates, including reductions of 22% in preventable hospitalizations and 15% in hospital expenses that were directly linked to the 40% increase in FHS population coverage during the evaluated period. This expansion of primary care has mainly benefitted areas that are difficult to access and populations that were previously deprived of health care in the vast Amazon territory. CONCLUSIONS: The findings of this study show that the increase of the expansion of primary care reduces the preventable hospitalization and the hospital expenses. This reinforces the need for public protection of the health of populations at risk and the positive impacts of primary care in the Brazilian Amazon.

Realist evaluation to improve health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam: Study protocol.

BACKGROUND: Socio-economic growth in many low and middle-income countries has resulted in more available, though not equitably accessible, healthcare. Such growth has also increased demands from citizens for their health systems to be more responsive to their needs. This paper shares a protocol for the RESPONSE study which aims to understand, co-produce, implement and evaluate context-sensitive interventions to improve health systems responsiveness to health needs of vulnerable groups in Ghana and Vietnam. METHODS: We will use a realist mixed-methods theory-driven case study design, combining quantitative (household survey, secondary analysis of facility data) and qualitative (in-depth interviews, focus groups, observations and document and literature review) methods. Data will be analysed retroductively. The study will comprise three Phases. In Phase 1, we will understand actors' expectations of responsive health systems, identify key priorities for interventions, and using evidence from a realist synthesis we will develop an initial theory and generate a baseline data. In Phase 2, we will co-produce jointly with key actors, the context-sensitive interventions to improve health systems responsiveness. The interventions will seek to improve internal (i.e. intra-system) and external (i.e. people-systems) interactions through participatory workshops. In Phase 3, we will implement and evaluate the interventions by testing and refining our initial theory through comparing the intended design to the interventions' actual performance. DISCUSSION: The study's key outcomes will be: (1) improved health systems responsiveness, contributing to improved health services and ultimately health outcomes in Ghana and Vietnam and (2) an empirically-grounded and theoretically-informed model of complex contexts-mechanisms-outcomes relations, together with transferable best practices for scalability and generalisability. Decision-makers across different levels will be engaged throughout. Capacity strengthening will be underpinned by in-depth understanding of capacity needs and assets of each partner team, and will aim to strengthen individual, organisational and system level capacities.

Does the separating of hospital revenue from drug sales reduce the burden on patients? Evidence from China.

BACKGROUND: Since 2015, all pilot cities of public hospital reform in China have allowed the zero-markup drug policy and implemented the policy of Separating of Hospital Revenue from Drug Sales (SHRDS). The objective of this study is to evaluate whether SHRDS policy reduces the burden on patients, and to identify the mechanism through which SHRDS policy affects healthcare expenditure. METHODS: In this study, we use large sample data of urban employee's healthcare insurance in Chengdu, and adopt the difference in difference model (DID) to estimate the impact of the SHRDS policy on total healthcare expenditures and drug expenditure of patients, and to provide empirical evidence for deepening medical and health system reform in China. RESULTS: After the SHRDS policy's implementation, the total healthcare expenditure kept growing, but the growth rate slowed down between 2014 to 2015. The total healthcare expenditure of patients decreased by only 0.6%, the actual reimbursement expenditure of patients decreased by 4.1%, the reimbursement ratio decreased by 2.6%. and the drugs expenditure dropped by 14.4%. However, the examinations expenditure increased by 18.2%, material expenditure increased significantly by 38.5%, and nursing expenditure increased by 12.7%. CONCLUSIONS: After implementing the SHRDS policy, the significant reduction in drug expenditure led to more physicians inducing patients' healthcare service needs, and the increased social healthcare burden was partially transferred to the patients' personal economic burden through the decline in the reimbursement ratio. The SHRDS policy is not an effective way to control healthcare expenditure.

Comparison of out-of-pocket expenditure and catastrophic health expenditure for severe disease by the health security system: based on end-stage renal disease in South Korea.

BACKGROUND: Korea's health security system named the National Health Insurance and Medical Aid has revolutionized the nation's mandatory health insurance and continues to reduce excessive copayments. However, few studies have examined healthcare utilization and expenditure by the health security system for severe diseases. This study looked at reverse discrimination regarding end-stage renal disease by the National Health Insurance and Medical Aid. METHODS: A total of 305 subjects were diagnosed with end-stage renal disease in the Korea Health Panel from 2008 to 2013. Chi-square, t-test, and ANCOVA were conducted to identify the healthcare utilization rate, out-of-pocket expenditure, and the prevalence of catastrophic expenditure. Mixed effect panel analysis was used to evaluate total out-of-pocket expenditure by the National Health Insurance and Medical Aid over a 6-year period. RESULTS: There were no significant differences in the healthcare utilization rate for emergency room visits, admissions, or outpatient department visits between the National Health Insurance and Medical Aid because these healthcare services were essential for individuals with serious diseases, such as end-stage renal disease. Meanwhile, each out-of-pocket expenditure for an admission and the outpatient department by the National Health Insurance was 2.6 and 3.1 times higher than that of Medical Aid (P < 0.05). The total out-of-pocket expenditure, including that for emergency room visits, admission, outpatient department visits, and prescribed drugs, was 2.9 times higher for the National Health Insurance than Medical Aid (P < 0.001). Over a 6-year period, in terms of total of out-of-pocket expenditure, subjects with the National Health Insurance spent more than those with Medical Aid (P < 0.01). If the total household income decile was less than the median and subjects were covered by the National Health Insurance, the catastrophic health expenditure rate was 92.2%, but it was only 58.8% for Medical Aid (P < 0.001). CONCLUSION: Individuals with serious diseases, such as end-stage renal disease, can be faced with reverse discrimination depending on the type of insurance that is provided by the health security system. It is necessary to consider individuals who have National Health Insurance but are still poor.

Insulin Pump Therapy Improves Quality of Life of Young Patients With Type 1 Diabetes Enrolled in a Government-Funded Insulin Pump Program: A Qualitative Study.

BACKGROUND: The Nova Scotia Insulin Pump Program (NSIPP) subsidizes the cost of insulin pump therapy for young patients (≤25 years) with type 1 diabetes. The first NSIPP evaluation focused on clinical outcomes rather than quality of life. Existing research on insulin pumps and quality of life is mostly survey based, with limited first-voice experiences. In this qualitative study, we examined patient and parent perspectives on how insulin pumps affect quality of life in the context of a government-funded program. METHODS: In this investigation, we used a phenomenological approach, guided by a conceptual model. In-depth semistructured telephone interviews (median, 37 minutes) were completed with NSIPP enrollees and/or their parents. Saturation was reached after 23 interviews. Verbatim transcripts were coded independently by 2 researchers. Coding discrepancies were discussed and resolved using concept mapping to clarify relationships between codes and to identify main themes. RESULTS: There were 2 main themes: 1) NSIPP financial support was necessary for those without private insurance and 2) control over life and diabetes with subthemes of social experiences and worry. Participants expressed this theme differently depending on their stage of life. For example, some children experienced shame and even hid their pump, whereas teens were more self-confident with the discreetness of pumps and young adults wore their pump with pride. CONCLUSIONS: Insulin pump therapy, subsidized through the NSIPP, led to improved quality of life, which was experienced differently depending on stage of life.

Health system interventions for adults with type 2 diabetes in low- and middle-income countries: A systematic review and meta-analysis.

BACKGROUND: Effective health system interventions may help address the disproportionate burden of diabetes in low- and middle-income countries (LMICs). We assessed the impact of health system interventions to improve outcomes for adults with type 2 diabetes in LMICs. METHODS AND FINDINGS: We searched Ovid MEDLINE, Cochrane Library, EMBASE, African Index Medicus, LILACS, and Global Index Medicus from inception of each database through February 24, 2020. We included randomized controlled trials (RCTs) of health system interventions targeting adults with type 2 diabetes in LMICs. Eligible studies reported at least 1 of the following outcomes: glycemic change, mortality, quality of life, or cost-effectiveness. We conducted a meta-analysis for the glycemic outcome of hemoglobin A1c (HbA1c). GRADE and Cochrane Effective Practice and Organisation of Care methods were used to assess risk of bias for the glycemic outcome and to prepare a summary of findings table. Of the 12,921 references identified in searches, we included 39 studies in the narrative review of which 19 were cluster RCTs and 20 were individual RCTs. The greatest number of studies were conducted in the East Asia and Pacific region (n = 20) followed by South Asia (n = 7). There were 21,080 total participants enrolled across included studies and 10,060 total participants in the meta-analysis of HbA1c when accounting for the design effect of cluster RCTs. Non-glycemic outcomes of mortality, health-related quality of life, and cost-effectiveness had sparse data availability that precluded quantitative pooling. In the meta-analysis of HbA1c from 35 of the included studies, the mean difference was -0.46% (95% CI -0.60% to -0.31%, I2 87.8%, p < 0.001) overall, -0.37% (95% CI -0.64% to -0.10%, I2 60.0%, n = 7, p = 0.020) in multicomponent clinic-based interventions, -0.87% (-1.20% to -0.53%, I2 91.0%, n = 13, p < 0.001) in pharmacist task-sharing studies, and -0.27% (-0.50% to -0.04%, I2 64.1%, n = 7, p = 0.010) in trials of diabetes education or support alone. Other types of interventions had few included studies. Eight studies were at low risk of bias for the summary assessment of glycemic control, 15 studies were at unclear risk, and 16 studies were at high risk. The certainty of evidence for glycemic control by subgroup was moderate for multicomponent clinic-based interventions but was low or very low for other intervention types. Limitations include the lack of consensus definitions for health system interventions, differences in the quality of underlying studies, and sparse data availability for non-glycemic outcomes. CONCLUSIONS: In this meta-analysis, we found that health system interventions for type 2 diabetes may be effective in improving glycemic control in LMICs, but few studies are available from rural areas or low- or lower-middle-income countries. Multicomponent clinic-based interventions had the strongest evidence for glycemic benefit among intervention types. Further research is needed to assess non-glycemic outcomes and to study implementation in rural and low-income settings.

Baseline Characteristics of the 2015-2019 First Year Student Cohorts of the NIH Building Infrastructure Leading to Diversity (BUILD) Program.

Objective: The biomedical/behavioral sciences lag in the recruitment and advancement of students from historically underrepresented backgrounds. In 2014 the NIH created the Diversity Program Consortium (DPC), a prospective, multi-site study comprising 10 Building Infrastructure Leading to Diversity (BUILD) institutional grantees, the National Research Mentoring Network (NRMN) and a Coordination and Evaluation Center (CEC). This article describes baseline characteristics of four incoming, first-year student cohorts at the primary BUILD institutions who completed the Higher Education Research Institute, The Freshmen Survey between 2015-2019. These freshmen are the primary student cohorts for longitudinal analyses comparing outcomes of BUILD program participants and non-participants. Design: Baseline description of first-year students entering college at BUILD institutions during 2015-2019. Setting: Ten colleges/universities that each received <$7.5mil/yr in NIH Research Project Grants and have high proportions of low-income students. Participants: First-year undergraduate students who participated in BUILD-sponsored activities and a sample of non-BUILD students at the same BUILD institutions. A total of 32,963 first-year students were enrolled in the project; 64% were female, 18% Hispanic/Latinx, 19% African American/Black, 2% American Indian/Alaska Native and Native Hawaiian/Pacific Islander, 17% Asian, and 29% White. Twenty-seven percent were from families with an income <$30,000/yr and 25% were their family's first generation in college. Planned Outcomes: Primary student outcomes to be evaluated over time include undergraduate biomedical degree completion, entry into/completion of a graduate biomedical degree program, and evidence of excelling in biomedical research and scholarship. Conclusions: The DPC national evaluation has identified a large, longitudinal cohort of students with many from groups historically underrepresented in the biomedical sciences that will inform institutional/national policy level initiatives to help diversify the biomedical workforce.

Oferta de programas para el desarrollo integral de la primera infancia en Chile: revisión exploratoria / Program offer for the integral development of early childhood in Chile: scoping review

OBJETIVO: Describir la oferta programática en primera infancia destinada a favorecer el desarrollo infantil integral en Chile. MÉTODO: Se realizó una revisión exploratoria siguiendo el marco método lógico del Joanna Briggs Institute. La búsqueda fue realizada por un investigador y los criterios de inclusión fueron: programas gubernamentales destinados al desarrollo integral en menores de 5 años en Chile. Los datos fueron organizados y sintetizados para describir características del programa y de la o las prestaciones que entrega. RESULTADOS: La búsqueda identificó 2060 documentos y 72 cumplieron los criterios de inclusión. Se describen 59 programas vigentes que abarcan la primera infancia, es tando principalmente a cargo de los Ministerio de Justicia, Educación, Salud y Desarrollo Social. Los programas están destinados en su mayoría a la promoción e intervención, se encuentran focalizados en población vulnerable, son intersectoriales y utilizan diversas estrategias para su implementación. CONCLUSIÓN: La oferta programática en Chile para la primera infancia presenta características sugeridas como efectivas para favorecer el desarrollo infantil.

OBJECTIVE: To describe the program offering designed to promote comprehensive early childhood de velopment in Chile. METHOD: A scoping review was carried out following the Joanna Briggs Institute's methodological framework. A researcher conducted the review considering as inclusion criteria go vernment programs aimed at the comprehensive development of children under 5 years of age in Chile. The data were organized and synthesized to describe the characteristics of the program and the service(s) it provides. RESULTS: The search identified 2.060 documents and 72 met the inclusion crite ria. 59 current programs are covering early childhood, which are mainly managed by the Ministries of Justice, Education, Health, and Social Development. Most of the programs are aimed at promotion and intervention, focusing on vulnerable populations, are cross-sectoral, and use different strategies for their implementation. CONCLUSION: The program offering in Chile for early childhood has charac teristics suggested as effective to promote child development.

Prevalence of use and sources of antihypertensive medicine in Brazil: an analysis of the VIGITEL telephone survey. / Prevalência de uso e fontes de obtenção de medicamentos anti-hipertensivos no Brasil: análise do inquérito telefônico VIGITEL.

OBJECTIVE: The prevalence of hypertension in Brazil and worldwide has been increasing in recent decades, and drug therapy is one of the strategies used to control this condition. The objective of this study was to estimate the prevalence of use and identify the sources for obtaining antihypertensive drugs in Brazil, according to sociodemographic variables, comparing three periods: 2011, 2014 and 2017. METHODS: Data from individuals aged ≥20 years who reported a medical diagnosis of hypertension, interviewed by Vigitel in 2011, 2014 and 2017 were used. Frequency and prevalence of drug use in addition to the sources for obtaining medication were estimated by sociodemographic variables, with 95% confidence intervals. The differences between proportions were verified by Pearson's chi-square test (Rao-Scott), with a significance level of 5%. RESULTS: The prevalence of antihypertensive drug use remained stable (80%). Regarding the sources for obtaining these medicines, there was variation in the period, indicating a decrease in usage through the Brazilian Unified Health System (SUS) (44.2% in 2011; 30.5% in 2017). This decrease was accompanied with increase in PFPB (16.1% in 2011; 29.9% in 2017). The prevalence of other sources for obtaining medicine (private pharmacies/drugstores) showed stability in the period. CONCLUSIONS: The prevalence of medication use remained high and there was a change in the pattern of use according to sources, demonstrating migration between SUS pharmacies to the PFPB, and suggesting a reduction in the availability of medicines from public pharmacies universally, and for free.

Anti-corruption, transparency and accountability in health: concepts, frameworks, and approaches.

Background: As called for by the Sustainable Development Goals, governments, development partners and civil society are working on anti-corruption, transparency and accountability approaches to control corruption and advance Universal Health Coverage.Objectives: The objective of this review is to summarize concepts, frameworks, and approaches used to identify corruption risks and consequences of corruption on health systems and outcomes. We also inventory interventions to fight corruption and increase transparency and accountability.Methods: We performed a critical review based on a systematic search of literature in PubMed and Web of Science and reviewed background papers and presentations from two international technical meetings on the topic of anti-corruption and health. We identified concepts, frameworks and approaches and summarized updated evidence of types and causes corruption in the health sector.Results: Corruption, or the abuse of power for private gain, in health systems includes bribes and kickbacks, embezzlement, fraud, political influence/nepotism and informal payments, among other behaviors. Drivers of corruption include individual and systems level factors such as financial pressures, poorly managed conflicts of interest, and weak regulatory and enforcement systems. We identify six typologies and frameworks that model relationships influencing the scope and seriousness of corruption, and show how anti-corruption strategies such as transparency, accountability, and civic participation can affect corruption risk. Little research exists on the effectiveness of anti-corruption measures; however, interventions such as community monitoring and insurance fraud control programs show promise.Conclusions: Corruption undermines the capacity of health systems to contribute to better health, economic growth and development. Interventions and resources on prevention and control of corruption are essential components of health system strengthening for Universal Health Coverage.

The risk of corruption in public pharmaceutical procurement: how anti-corruption, transparency and accountability measures may reduce this risk.

Background: The goal of the public procurement of pharmaceuticals is to purchase sufficient quantities of high-quality pharmaceuticals at cost-effective prices for a given population. This goal can be undercut if corruption infiltrates the procurement process. Good procurement practices can help mitigate the risks of corruption and support equitable access to affordable and high-quality medicines.Objectives: This paper aims to 1) examine manifestations of corruption in the pharmaceutical procurement process and key factors behind them, and 2) identify how to design and implement effective anti-corruption, transparency and accountability mechanisms within this process.Methods: This paper was informed by a narrative literature review from 1996 to the present. The search focused on publications that addressed the issue of pharmaceutical procurement and governance and corruption issues. Our search included peer-reviewed literature, books, grey literature such as working papers, reports published by international organizations and donor agencies, and some media articles. Some documents used in this paper were already known to the authors.Results: Procurement is highly vulnerable to corruption particularly in the health sector. What is more, corruption in the procurement process does not appear to be limited to any one level of government or type of health system. The better integration of accountability, transparency and anti-corruption mechanisms in the procurement process is needed to reduce the risk of corruption.Conclusions: Lessons learned suggest that anti-corruption, transparency and accountability mechanisms in the pharmaceutical procurement process, such as open contracting and integrity pacts are helpful towards reducing the risk of corruption.

Frameworks for health systems performance assessment: how comprehensive is Ghana's holistic assessment tool?

Background: Measuring the performance of a health system is an essential requirement in creating systems that generate efficient, equitable, patient-focused, accessible and sustainable results. A fundamental requirement for a performance measurement system is the development of an assessment framework within which specific performance measures could be defined and applied regularly. This paper examines the comprehensiveness of Ghana's health system assessment framework called the Holistic Assessment Tool in relation to some of the internationally recognized frameworks. The paper also analyzes trends in the performance of the health system to understand whether or not an improvement has been recorded following the adoption and implementation of the Holistic Assessment Tool. Methods: Mainly secondary data were used in this analysis. Searches were conducted on Google Scholar, PubMed, Scopus and Science Direct between May and July, 2019 for published documents on health system performance assessment. We also obtained unpublished documents from Ghana's Ministry of Health, Ghana Health Service website, and Ghana Statistical Service database. Descriptive statistics were used to examine trends in the performance of the Ghanaian health system. Results: While the tool provides a national framework for evaluating the performance of the Ghana Health system in several domains, the Holistic Assessment Tool does not cover key health system domains such as information systems for health, access to essential medicines, and patient-centeredness. Also, the scope of the assessment program seems limited to the evaluation of the Ministry of Health's annual plans, programs and projects. However, the health system has recorded improvements in population health indicators, such as life expectancy at birth, infant mortality, under-5 mortality, HIV prevalence and disease burden (in terms of disability adjusted life years). Conclusions: The Holistic Assessment Tool is a useful framework, but needs further refinement, both in scope and in conceptual robustness. Future studies should consider exploring factors influencing performance of the Ghanaian health system. Such information will help in strategizing for better and more improvements.

Responding to aid volatility: government spending on district health care in Zambia 2006-2017.

Background: A corruption event in 2009 led to changes in how donors supported the Zambian health system. Donor funding was withdrawn from the district basket mechanism, originally designed to pool donor and government financing for primary care. The withdrawal of these funds from the pooled financing mechanism raised questions from Government and donors regarding the impact on primary care financing during this period of aid volatility.Objectives: To examine the budgets and actual expenditure allocated from central Government to the district level, for health, in Zambia from 2006 to 2017 and determine trends in funding for primary care.Methods: Financial data were extracted from Government documents and adjusted for inflation. Budget and expenditure for the district level over the period 2006 to 2017 were disaggregated by programmatic area for analysis.Results: Despite the withdrawal of donor funding from the district basket after 2009, funding for primary care allocated to the district level more than doubled from 2006 to 2017. However, human resources accounted for this increase. The operational grant, on the other hand, declined.Conclusion: The increase in the budget allocated to primary care could be an example of 'reverse fungibility', whereby Government accounted for the gap left by donors. However, the decline in the operational grant demonstrates that this period of aid volatility continued to have an impact on how primary care was planned and financed, with less flexible budget lines most affected during this period. Going forward, Government and donors must consider how funding is allocated to ensure that primary care is resilient to aid volatility; and that the principles of aid effectiveness are prioritised to continue to provide primary health care and progress towards achieving health for all.