The risk of losing health insurance in the United States is large, and remained so after the Affordable Care Act.

Health insurance coverage in the United States is highly uncertain. In the post-Affordable Care Act (ACA), pre-COVID United States, we estimate that while 12.5% of individuals under 65 are uninsured at a point in time, twice as many-one in four-are uninsured at some point over a 2-y period. Moreover, the risk of losing insurance remained virtually unchanged with the introduction of the landmark ACA. Risk of insurance loss is particularly high for those with health insurance through Medicaid or private exchanges; they have a 20% chance of losing coverage at some point over a 2-y period, compared to 8.5% for those with employer-provided coverage. Those who lose insurance can experience prolonged periods without coverage; about half are still uninsured 6 mo later, and almost one-quarter are uninsured for the subsequent 2 y. These facts suggest that research and policy attention should focus not only on the "headline number" of the share of the population uninsured at a point in time, but also on the stability and certainty (or lack thereof) of being insured.

A Retrospective Secondary Data Analysis of Telemedicine Service Utilization (2020-2023) Among Patients Covered By The Universal Coverage Scheme in Thailand.

Objective: The National Health Security Office in Thailand introduced a telemedicine program called "Telehealth/Telemedicine" in December 2020, which aimed to reimburse telemedicine services for patients with stable chronic diseases under the Universal Coverage Scheme (UCS). The current study investigated patient characteristics and trends in telemedicine service utilization under the UCS in Thailand and examined the impact of COVID-19 outbreaks on telemedicine services. Methods: A retrospective secondary data analysis using e-claim data from December 1, 2020, to April 18, 2023, was conducted. The analytical methods included descriptive analysis and an interrupted time series analysis. Results: During ∼29 months, 110,153 unique patients used telemedicine services, leading to a total of 259,047 visits. The average age was 54 years, and most of patients were female (57%). Hypertension was the most common diagnosis for patients receiving telemedicine services. Patients with mental health conditions often engaged in telemedicine consultation with drug delivery. During the Delta and Omicron outbreaks, telemedicine service utilization significantly increased compared with that in any nonpandemic periods within the 29-month timeframe (odds ratio [OR]: 3.85, p-value <0.01; OR: 2.55, p-value <0.01). Conclusions: The study findings highlight the initial trend of telemedicine services in Thailand from the start of the COVID-19 pandemic to the beginning of the post-COVID-19 period. As telemedicine will play a critical role in the future of health care, this information can support the scale-up of telemedicine, including monitoring and evaluation plans, to help improve the efficiency of the system.

Pattern of OPD utilisation during the COVID-19 pandemic under the Universal Coverage Scheme in Thailand: what can 850 million records tell us?

BACKGROUND: Out-patient department (OPD) is a crucial component of the healthcare systems in low- and middle-income countries including Thailand. A considerable impact of coronavirus disease 2019 (COVID-19) pandemic and its control measures, especially the lockdown, on utilisation of OPD services was expected. This study thus aims to estimate the pattern of OPD utilisation during the COVID-19 pandemic in Thailand including overall utilisation and within each sub-groups including diagnostic group, age group, and health region. METHODS: This study was a secondary data analysis of aggregated outpatient data from patients covered under the Universal Coverage Scheme (UCS) in Thailand over a 4-year period (2017-2020). Interrupted time series analyses and segmented Quasi-Poisson regression were used to examine the impact of COVID-19 on the overall OPD utilisation including the impact on each diagnostic group, age groups, health regions, and provinces. RESULTS: Analysis of 845,344,946 OPD visits in this study showed a seasonal pattern and increasing trend in monthly OPD visits before the COVID-19 pandemic. A 28% (rate ratio (RR) 0.718, 95% confidence interval (CI): 0.631-0.819) and 11% (RR 0.890, 95% CI: 0.811-0.977) reduction in OPD visits was observed during the lockdown and post-lockdown periods, respectively, when compared to the pre-lockdown period. Diseases of respiratory system were most affected with a RR of 0.411 (95% CI: 0.320-0.527), while the number of visits for non-communicable diseases (ICD-10: E00-E90, I00-I99) and elderly (> 60 years) dropped slightly. The post-lockdown trend in monthly OPD visits gradually increased to the pre-pandemic levels in most groups. CONCLUSIONS: Thailand's OPD utilisation rate during the COVID-19 lockdown decreased in some diseases, but the service for certain group of patients appeared to remain available. After the COVID-19 lockdown, the rate returned to the pre-pandemic level in a timely manner. Equipped with a knowledge of OPD utilisation pattern during COVID-19 based on a national real-world database could aid with a better preparation of healthcare system for future pandemics.

India's achievement towards sustainable Development Goal 6 (Ensure availability and sustainable management of water and sanitation for all) in the 2030 Agenda.

BACKGROUND: Clean water and sanitation are global public health issues. Safe drinking water and sanitation are essential, especially for children, to prevent acute and chronic illness death and sustain a healthy life. The UN General Assembly announced the 17 Sustainable Development Goals (SDGs) and 169 targets for the 2030 Agenda on 25 September 2015. SDG 6 is very important because it affects other SDG (1, 2,3,5,11,14 and 15). The present study deals with the national and state-wise analysis of the current status and to access deficiency of India's achievement towards SDG 6 (clean water and sanitation for all) for the 2030 agenda based on targets 6.1, 6.2,6.4,6.6 from 2012 to 2020. MATERIALS AND METHODS: Data of different indicators of SDG 6 are collected from different secondary sources-NSS 69th (2012) and 76th (2018) round; CGWB annual report 2016-2017 and 2018-2019; NARSS (2019-2020); SBM-Grameen (2020). To understand overall achievement towards SDG 6 in the 2030 agenda, the goal score (arithmetic mean of normalised value) has been calculated. MAJOR FINDINGS: According to NSS data, 88.7% of Indian households had enough drinking water from primary drinking water sources throughout the year, while 79.8% of households had access to toilet facilities in 2018. As per the 2019-2021 goal score for States and UTs in rural India based on SDG 6 indicator, SDG 6 achiever States and UTs (100%) are Sikkim, Himachal Pradesh, Andaman and Nicobar Islands. CONCLUSION: Drinking water and sanitation for all ensure a healthy life. It is a matter of concern for the government, policymakers, and people to improve the condition where the goal score and indicator value of SDG 6 are low.

Towards Universal Screening for Postpartum Depression in China: Lessons Learned from a Comprehensive Prevention Programme in Shenzhen.

PURPOSE: This study was conducted to assess the real-world efficacy of a universal programme for the prevention of postpartum depression (PPD) in Shenzhen. Given the lack of evidence on routine PPD screening and intervention in China, it sought to provide insights for programme planning and implementation, particularly in relation to achievement of the targets set by the first national guidelines for PPD prevention and treatment. METHODS: Using routine health information system data, the PPD screening, referral and intervention rates for 2015-2019 were calculated and compared to the programmes targets. Trends of variables were tested by using trend χ2. RESULTS: The programme screened 137,761 to 178,857 women for PPD every year with the coverage among all postpartum women increased steadily from 71.1% to 82. 5% (χ2 = 10145.251, p < 0.001). The PPD-positive rate maintained between 4.06% and 4.89%. However, although referral messages were given to an increased percentage of PPD-positive women (χ2 = 1090.908, p < 0.001), the intervention rate (i.e., referral uptake) were far lower than the programme target of 80%. CONCLUSIONS: This study demonstrated high efficacy of Shenzhen's comprehensive PPD prevention programme initiated in 2013. The resultant rise in the screening rate among all postpartum women, together with a high referral rate of those screened positive, have contributed to the city's relatively low PPD prevalence. PPD screening and intervention should be included as part of basic public health services to ensure universal coverage and specific strategies should be adopted to ensure referral uptake.

Effectiveness of a community-integrated intermediary care (CIIC) service model to enhance family-based long-term care for Thai older adults in Chiang Mai, Thailand: a cluster-randomized controlled trial TCTR20190412004.

BACKGROUND: Populations around the world are ageing faster, with the majority living in low- and middle-income countries where health and social care are yet to be universal and inclusive for the ageing population. This community-integrated intermediary care (CIIC) model is a novel prevention-based, long-term care model enhancing the family-based care system traditionally practised in Thailand and neighbouring Asian countries, and many low-and middle-income countries globally. This study assessed the effectiveness of the CIIC model in Chiang Mai, Thailand. METHODS: The two-arm parallel intervention study was designed as a cluster-randomized controlled trial. The study population at randomization and analysis was 2788 participants: 1509 in six intervention clusters and 1279 in six control clusters. The research protocol was approved by the WHO Research Ethics Review Committee (WHO/ERC ID; ERC.0003064). The CIIC service intervention model is a combination of formal care and informal care in a subdistrict setting consisting of three components: (1) care prevention delivered as community group exercise and home exercise; (2) care capacity-building of the family caregiver; and (3) community respite service. The primary outcome was family caregivers' burden at 6-month follow-up, and secondary outcome was activities of daily living. Analysis applied the intention-to-treat approach using cluster-level analysis via STATA 16 SE. RESULTS: Baseline characteristics did not differ between the two arms. Loss of follow up was 3.7%. Mean age of the participants was 69.53 years. Women constituted 60%. The COVID-19 pandemic caused delayed implementation. The proportion of families with reduced caregiver burden at 6-month follow-up was higher among the intervention clusters (mean 39.4%) than control clusters (mean 28.62%). The intervention clusters experienced less functional decline and fewer people with depression. CONCLUSIONS: When communities are integrated for preventing care, and families are empowered for giving care, it is possible to secure universal access to health and social care for the older persons, with basic resources mobilized from communities. This study had shown the CIIC model as an effective and potential step to the realization of universal health and long-term care coverage being inclusive of ageing populations in Thailand and globally. TRIAL REGISTRATION: This trial was registered at the Thailand Clinical Trial Registry-Trial registration number TCTR20190412004, https://www.thaiclinicaltrials.org/.

Willingness to pay for private health insurance among workers with mandatory social health insurance in Mongolia.

BACKGROUND: High out-of-pocket health expenditure is a common problem in developing countries. The employed population, rather than the general population, can be considered the main contributor to healthcare financing in many developing countries. We investigated the feasibility of a parallel private health insurance package for the working population in Ulaanbaatar as a means toward universal health coverage in Mongolia. METHODS: This cross-sectional study used a purposive sampling method to collect primary data from workers in public and primary sectors in Ulaanbaatar. Willingness to pay (WTP) was evaluated using a contingent valuation method and a double-bounded dichotomous choice elicitation questionnaire. A final sample of 1657 workers was analyzed. Perceptions of current social health insurance were evaluated. To analyze WTP, we performed a 2-part model and computed the full marginal effects using both intensive and extensive margins. Disparities in WTP stratified by industry and gender were analyzed. RESULTS: Only < 40% of the participants were satisfied with the current mandatory social health insurance in Mongolia. Low quality of service was a major source of dissatisfaction. The predicted WTP for the parallel private health insurance for men and women was Mongolian Tugrik (₮)16,369 (p < 0.001) and ₮16,661 (p < 0.001), respectively, accounting for approximately 2.4% of the median or 1.7% of the average salary in the country. The highest predicted WTP was found for workers from the education industry (₮22,675, SE = 3346). Income and past or current medical expenditures were significantly associated with WTP. CONCLUSION: To reduce out-of-pocket health expenditure among the working population in Ulaanbaatar, Mongolia, supplementary parallel health insurance is feasible given the predicted WTP. However, given high variations among different industries and sectors, different incentives may be required for participation.

A review of geospatial methods for population estimation and their use in constructing reproductive, maternal, newborn, child and adolescent health service indicators.

BACKGROUND: Household survey data are frequently used to measure reproductive, maternal, newborn, child and adolescent health (RMNCAH) service utilisation in low and middle income countries. However, these surveys are typically only undertaken every 5 years and tend to be representative of larger geographical administrative units. Investments in district health management information systems (DHMIS) have increased the capability of countries to collect continuous information on the provision of RMNCAH services at health facilities. However, reliable and recent data on population distributions and demographics at subnational levels necessary to construct RMNCAH coverage indicators are often missing. One solution is to use spatially disaggregated gridded datasets containing modelled estimates of population counts. Here, we provide an overview of various approaches to the production of gridded demographic datasets and outline their potential and their limitations. Further, we show how gridded population estimates can be used as alternative denominators to produce RMNCAH coverage metrics in combination with data from DHMIS, using childhood vaccination as examples. METHODS: We constructed indicators on the percentage of children one year old for diphtheria, pertussis and tetanus vaccine dose 3 (DTP3) and measles vaccine dose (MCV1) in Zambia and Nigeria at district levels. For the numerators, information on vaccines doses was obtained from each country's respective DHMIS. For the denominators, the number of children was obtained from 3 different sources including national population projections and aggregated gridded estimates derived using top-down and bottom-up geospatial methods. RESULTS: In Zambia, vaccination estimates utilising the bottom-up approach to population estimation substantially reduced the number of districts with > 100% coverage of DTP3 and MCV1 compared to estimates using population projection and the top-down method. In Nigeria, results were mixed with bottom-up estimates having a higher number of districts > 100% and estimates using population projections performing better particularly in the South. CONCLUSIONS: Gridded demographic data utilising traditional and novel data sources obtained from remote sensing offer new potential in the absence of up to date census information in the estimation of RMNCAH indicators. However, the usefulness of gridded demographic data is dependent on several factors including the availability and detail of input data.

Contribution of income and job strain to the association between education and cardiovascular disease in 1.6 million Danish employees.

AIMS: We examined the extent to which associations between education and cardiovascular disease (CVD) morbidity and mortality are attributable to income and work stress. METHODS AND RESULTS: We included all employed Danish residents aged 30-59 years in 2000. Cardiovascular disease morbidity analyses included 1 638 270 individuals, free of cardiometabolic disease (CVD or diabetes). Mortality analyses included 41 944 individuals with cardiometabolic disease. We assessed education and income annually from population registers and work stress, defined as job strain, with a job-exposure matrix. Outcomes were ascertained until 2014 from health registers and risk was estimated using Cox regression. During 10 957 399 (men) and 10 776 516 person-years (women), we identified 51 585 and 24 075 incident CVD cases, respectively. For men with low education, risk of CVD was 1.62 [95% confidence interval (CI) 1.58-1.66] before and 1.46 (95% CI 1.42-1.50) after adjustment for income and job strain (25% reduction). In women, estimates were 1.66 (95% CI 1.61-1.72) and 1.53 (95% CI 1.47-1.58) (21% reduction). Of individuals with cardiometabolic disease, 1736 men (362 234 person-years) and 341 women (179 402 person-years) died from CVD. Education predicted CVD mortality in both sexes. Estimates were reduced with 54% (men) and 33% (women) after adjustment for income and job strain. CONCLUSION: Low education predicted incident CVD in initially healthy individuals and CVD mortality in individuals with prevalent cardiometabolic disease. In men with cardiometabolic disease, income and job strain explained half of the higher CVD mortality in the low education group. In healthy men and in women regardless of cardiometabolic disease, these factors explained 21-33% of the higher CVD morbidity and mortality.

Autonomy, Coercion, and Public Healthcare Guarantees: The Uptake of Sofosbuvir in Germany.

Health insurance coverage for incarcerated citizens is generally acceptable by Western standards. However, it creates internal tensions with the prevailing justifications for public healthcare. In particular, a conceptualization of medical care as a source of autonomy enhancement does not align with the decreased autonomy of incarceration and the needs-based conceptualization of medical care in cases of imprisonment; and rejecting responsibility as a criterion for assigning medical care conflicts with the use of responsibility as a criterion for assigning punishment. The recent introduction of sofosbuvir in Germany provides a particularly instructive illustration of such tensions. It requires searching for a refined reflective equilibrium regarding the scope, limits, and justifications of publicly guaranteed care.

Refinement of the Affordable Care Act: A Progressive Perspective.

The Affordable Care Act (ACA) was the most significant expansion of health coverage since Medicare and Medicaid were enacted. The law resulted in approximately 13-20 million uninsured persons gaining coverage. Despite these gains, the ACA has numerous shortcomings. For progressives, the ACA was a unique opportunity to provide access to high-quality, comprehensive, equitable health coverage to all persons living in the United States. Using this perspective as our framework, in this review we highlight some of the limitations of the ACA and potential areas for refinement. We conclude that the ACA fell far short of the goal of achieving universal coverage and that the coverage made available through the ACA was not equitable. In addition, the ACA expanded coverage by building onto a highly fragmented, inefficient, and costly health system. Thus, it did little to control health costs. A more fiscally prudent approach would have been built upon more successful existing programs, such as a Medicare for All.

Costs of insecticide-treated bed net distribution systems in sub-Saharan Africa.

BACKGROUND: Insecticide-treated nets (ITNs) are one of the most cost-effective measures for preventing malaria. The World Health Organization recommends both large-scale mass distribution campaigns and continuous distributions (CD) as part of a multifaceted strategy to achieve and sustain universal access to ITNs. A combination of these strategies has been effective for scaling up ITN access. For policy makers to make informed decisions on how to efficiently implement CD or combined strategies, information on the costs and cost-effectiveness of these delivery systems is necessary, but relatively few published studies of the cost continuous distribution systems exist. METHODS: To address the gap in continuous distribution cost data, four types of delivery systems-CD through antenatal care services (ANC) and the expanded programme on immunization (EPI) (Ghana, Mali, and mainland Tanzania), CD through schools (Ghana and mainland Tanzania), and a combined community/health facility-based distribution (Zanzibar, Tanzania), as well as mass distributions (Mali)-were costed. Data on costs were collected retrospectively from financial and operational records, stakeholder interviews, and resource use surveys. RESULTS: Overall, from a full provider perspective, mass distributions and continuous systems delivered ITNs at overlapping economic costs per net distributed (mass distributions: 4.37-4.61 USD, CD channels: 3.56-9.90 USD), with two of the school-based systems and the mass distributions at the lower end of this range. From the perspective of international donors, the costs of the CD systems were, for the most part, less costly than the mass distributions (mass distributions: 4.34-4.55 USD, Ghana and Tanzania 2017 school-based: 3.30-3.69 USD, health facility-based: 3.90-4.55 USD, combined community/health facility 4.55 USD). The 2015 school-based distribution (7.30 USD) and 2016 health facility-based distribution (6.52 USD) programmes in Tanzania were an exception. Mass distributions were more heavily financed by donors, while CD relied more extensively on domestic resource contributions. CONCLUSIONS: These results suggest that CD strategies can continue to deliver nets at a comparable cost to mass distributions, especially from the perspective of the donor.

Coverage outcomes (effects), costs, cost-effectiveness, and equity of two combinations of long-lasting insecticidal net (LLIN) distribution channels in Kenya: a two-arm study under operational conditions.

BACKGROUND: Malaria-endemic countries distribute long-lasting insecticidal nets (LLINs) through combined channels with ambitious, universal coverage (UC) targets. Kenya has used eight channels with variable results. To inform national decision-makers, this two-arm study compares coverage (effects), costs, cost-effectiveness, and equity of two combinations of LLIN distribution channels in Kenya. METHODS: Two combinations of five delivery channels were compared as 'intervention' and 'control' arms. The intervention arm comprised four channels: community health volunteer (CHV), antenatal and child health clinics (ANCC), social marketing (SM) and commercial outlets (CO). The control arm consisted of the intervention arm channels except mass campaign (MC) replaced CHV. Primary analysis used random sample household survey data, service-provider costs, and voucher or LLIN distribution data to compare between-arm effects, costs, cost-effectiveness, and equity. Secondary analyses compared costs and equity by channel. RESULTS: The multiple distribution channels used in both arms of the study achieved high LLIN ownership and use. The intervention arm had significantly lower reported LLIN use the night before the survey (84·8% [95% CI 83·0-86·4%] versus 89·2% [95% CI 87·8-90·5%], p < 0·0001), higher unit costs ($10·56 versus $7·17), was less cost-effective ($86·44, 95% range $75·77-$102·77 versus $69·20, 95% range $63·66-$77·23) and more inequitable (Concentration index [C.Ind] = 0·076 [95% CI 0·057 to 0·095 versus C.Ind = 0.049 [95% CI 0·030 to 0·067]) than the control arm. Unit cost per LLIN distributed was lowest for MC ($3·10) followed by CHV ($10·81) with both channels being moderately inequitable in favour of least-poor households. CONCLUSION: In line with best practices, the multiple distribution channel model achieved high LLIN ownership and use in this Kenyan study setting. The control-arm combination, which included MC, was the most cost-effective way to increase UC at household level. Mass campaigns, combined with continuous distribution channels, are an effective and cost-effective way to achieve UC in Kenya. The findings are relevant to other countries and donors seeking to optimise LLIN distribution. TRIAL REGISTRATION: The assignment of the intervention was not at the discretion of the investigators; therefore, this study did not require registration.

Effect of two major health reforms on health care cost and utilization in Fars Province of Iran: family physician program and health transformation plan.

BACKGROUND: Family physician program (FPP) and health transformation plan (HTP) are two major reforms that have been implemented in Iran's health system in recent. The present study was aimed at evaluating the impact of these two reforms on the level of service utilization and cost of health care services. METHODS: This longitudinal study was conducted on people insured by social security organization in Fars province during 2009-2016. The data on the utilization of services and costs of general practitioner visits, specialist visits, medications, imaging, laboratory tests, and hospitalization were collected. Interrupted time series analysis was used to analyze the effect of the two mentioned reforms. RESULTS: FPP resulted in a significant reduction in the number of specialist visits, imaging, and laboratory tests in the short term, and in the number of radiology services, laboratory tests, and hospitalization in the long term. In contrast, HTP significantly increased the utilization of radiology services and laboratory tests both in the short term and long term. Concerning the costs, FPP resulted in a reduction in costs in short and long term except general practitioners' and specialist visit, and medication in long term. However, HTP resulted in an increase in health care costs in both of the studied time periods. CONCLUSIONS: FPP has been successful in rationalizing the utilization of services. On the other hand, HTP has improved people's access to services by increasing the utilization; but it has increased health care costs. Therefore, policymakers must adopt an agenda to revise and re-design the plan.

Determinants of long-lasting insecticidal net ownership and utilization in malaria transmission regions: evidence from Zimbabwe Demographic and Health Surveys.

BACKGROUND: Long-lasting insecticidal nets (LLINs) were first introduced in 2010 as a vector control intervention, to complement indoor residual spraying, to reduce malaria transmission in Zimbabwe. The objective of this study was to investigate factors that were associated with LLIN ownership and utilization among households in malaria transmission regions of Zimbabwe. METHODS: A secondary analysis of cross sectional data from the Zimbabwe demographic and health survey (ZDHS) conducted in 2010 and 2015 surveys round was conducted. The analysis used household-level datasets from across the country to generate evidence for the study. Univariate analysis was used to yield descriptive statistics. Principal component analysis (PCA) was used to calculate wealth quintiles. Binary logistic regression approach was used to identify determinants of LLIN ownership and utilization after controlling for other factors. Data analyses were conducted using STATA version 14 software. RESULTS: There were no major changes in demographic characteristics of households sampled between 2010 and 2015 survey cycles. LLIN ownership increased significantly by 42 percentage points from 2010 to 2015. There was a tremendous increase in universal coverage of LLINs between 2010 and 2015. The overall utilization levels of LLINs among children under-5 years decreased by 11 percentage points between 2010 and 2015. LLIN usage amongst households followed the same trend with that of the under-fives. Using logistic regression model for 2015 data, region/province, type of place of residence, availability of electricity, radio, roof type, gender of head of household, having telephone, type of cooking fuel, presence of mobile phone, owning a bank account, IRS spraying in the previous 12 months, wealth index, and satellite television decorder were independently associated with net ownership among households. Type of place of residence, age of household head, type of cooking fuel, IRS in previous 12 months, and pregnancy were associated with LLIN utilization. CONCLUSION: This study revealed increasing LLIN coverage and low usage in malaria-transmission regions of Zimbabwe. Strengthening of LLIN campaigns, social behaviour change communication (SBCC) interventions and programme routine monitoring are recommended.

Socioeconomic status, life expectancy and mortality in a universal healthcare setting: An individual-level analysis of >6 million Catalan residents.

We evaluated the association between individual-level socioeconomic status (SES), life expectancy, and mortality, in adult men and women from the general population living in Catalonia, a universal healthcare coverage setting. We used the Catalan Health Surveillance System database, which includes individual-level information on sociodemographic characteristics and mortality for all residents of Catalonia (Spain). We categorized individuals as high, medium, low or very low SES based on annual personal income and welfare receipt. We used 2016 mortality data to estimate life expectancy at age 18, and the probability of death by age, sex and SES categories. We followed a total of 6,027,424 Catalan residents in 2016. Men and women of very low SES had 12.0 and 9.4 years lower life expectancy compared to men and women of high SES, respectively. Low SES was also strongly associated with mortality in both men and women of any age. In the entire adult population of Catalonia, despite the availability of universal, high quality healthcare coverage, low SES is associated with lower life expectancy and higher mortality. Solutions to these large inequalities may combine tailored health promotion and management interventions, with solutions coming from outside of the health sector.

Antimalarial bednet protection of children disappears when shared by three or more people in a high transmission setting of western Kenya.

A sizeable proportion of households is forced to share single long-lasting insecticide treated net (LLIN). However, the relationship between increasing numbers of people sharing a net and the risk for Plasmodium infection is unclear. This study revealed whether risk for Plasmodium falciparum infection is associated with the number of people sharing a LLIN in a holoendemic area of Kenya. Children ⩽5 years of age were tested for P. falciparum infection using polymerase chain reaction. Of 558 children surveyed, 293 (52.5%) tested positive for parasitaemia. Four hundred and fifty-eight (82.1%) reported sleeping under a LLIN. Of those, the number of people sharing a net with the sampled child ranged from 1 to 5 (median = 2). Children using a net alone or with one other person were at lower risk than non-users (OR = 0.29, 95% CI 0.10-0.82 and OR = 0.47, 95% CI 0.22-0.97, respectively). On the other hand, there was no significant difference between non-users and children sharing a net with two (OR = 0.88, 95% CI 0.44-1.77) or more other persons (OR = 0.75, 95% CI 0.32-1.72). LLINs are effective in protecting against Plasmodium infection in children when used alone or with one other person compared with not using them. Public health professionals should inform caretakers of the risks of too many people sharing a net.

The feasibility of universal HPV vaccination program in Shenzhen of China: a health policy analysis.

BACKGROUND: HPV vaccination for the prioritized adolescent girls is well accepted and implemented in developed countries as an effective measure for cervical cancer prevention and control with increasing population-level effectiveness evidence accumulated. This study is to assess the feasibility of universal HPV vaccination among adolescent girls to inform strategies to manage political dimensions of policy-making process in Shenzhen, China, offering insights for other low- and middle-income countries undergoing HPV vaccine introduction. METHODS: Document review and in-depth interviews with identified stakeholders were conducted. The framework of Health Policy Triangle was adapted to guide data collection and analysis in terms of context, actors, process and content. Stakeholder analysis examining actors' position, power, role and interest and thematic analysis focusing on data coding and theme development were used. RESULTS: Shenzhen's contextual factors include legislative authority under a unitary political system, economic developments and cultural values on immunization and sexuality. Stakeholders' position and power could be explained by their role and interest in the Top-down health administration. Mothers could be potential bystanders if having little knowledge on HPV vaccination. Themes in policy-making process were problem definition, advocacy activities to promote HPV vaccination, HPV vaccine demand and access, the role of media and political attention on evidence-informed policy-making in Shenzhen. These stakeholders also discussed different aspects of program planning prospectively. CONCLUSIONS: Shenzhen witnesses a possibility of demonstration projects for local government's horizontal accountability but no potential advocates were identified at local level for fragmented organization of public health facilities and health professionals' lacking mobilization skills. A cervical cancer prevention expert could be a policy entrepreneur. Despite of these challenges, the recommendations to enhance the feasibility include multi-participation to engage non-governmental organizations, pharmaceuticals, target girls and their mothers, power enforcement along governing system, as well as better use of the media.

WhatsApp: a supplementary tool for improving bed nets universal coverage campaign in Mozambique.

BACKGROUND: WhatsApp (WA) is the most recent and attractive applicative among Smartphone users. The use of WA in healthcare environment has been shown of multiple benefices. Mozambique team involved in 2017 bed nets universal coverage campaign (UCC) implemented a distant mentoring strategy using WA. This study aims to perform a descriptive analysis of the use of WA as a supplementary tool for mentoring provincial and district health teams during bed nets universal coverage campaign in Mozambique. METHODS: Using WA, a qualitative study was carried out between March and July 2017. Seven WA groups were created. One group for central-level team, and six groups corresponding to each implementation province. The WA content was analyzed, grouped into separate themes, and subject to information triangulation among researchers and group participants. Saturation guided the quantity and quality of information. RESULTS: A total of 511 members were included in all WA groups. Of these, 96% were provincial WA groups. A total of 24,897 messages (text and images) were exchanged in all WA groups. The main communication form was text (22,660-91%), followed by images (2237-9%). Five themes emerged from content analyses: 1) administrative/financial, 2) logistic, 3) planning and implementation, 4) monitoring and evaluation, and 5) best practice. CONCLUSIONS: The use of WA during universal coverage bed nets campaign implementation in Mozambique fostered central-level coordination, providing implementation support to district and provincial teams, and promoting wider and timely information sharing among group members.

Fiscal space for Health in the Americas: is economic growth sufficient?

OBJECTIVE: In 2014, the member countries of the Pan American Health Organization signed the Strategy for Universal Access to Health and Universal Health Coverage. In it, they committed to increasing public expenditure on health until reaching the benchmark of 6% of gross domestic product (GDP). The objective of this paper is to determine, for each country in the Region, whether they can reach this target through economic growth alone and, if so, how long it would take. METHODS: Using World Bank and World Health Organization data, elasticity of public health expenditure (PHE) with respect to GDP was estimated for each country. Real economic growth and International Monetary Fund projections for 2016-2021 were used to project the expenditure series and determine the year each country would reach 6% of GDP. RESULTS: Six countries have already reached the 6% target. The Latin American and Caribbean countries that have achieved it are those that have single health systems, based on universal access and coverage. If current prioritization of PHE is maintained, three countries could reach the target in the next decade. Four more countries would reach it before mid-century, 10 in the second half of the century, and one would have to wait until the next century. Finally, 13 countries would never reach the proposed target. CONCLUSIONS: This analysis demonstrates the limitations of economic growth as a source of fiscal space. Other sources will need to be tapped, such as increased tax collection, specific health taxes, and greater efficiency in public spending, which will require social and political dialogue in the countries regarding their commitment to universal health principles.