Universal Coverage Research Articles

India Insured by 2047: The Role of Insurance Companies, Distribution Networks and Regulatory Frameworks

This research article discusses the role of three key pillars i.e., insurance companies, distribution network, and regulatory frameworks that contribute to the growth and stability of the Indian insurance sector. It presents the key drivers and challenges for India to achieve the target of ensuring universal insurance coverage by 2047. The study provides valuable insights for policymakers and other stakeholders by highlighting the role that insurance company can play to ensure greater accessibility of insurance products for all through underwriting and managing various insurance products to cater to the diverse needs of the Indian population. It emphasizes the importance of an efficient distribution network to have a wider reach and the significance of a regulatory framework in safeguarding the interests of both insurers and policyholders.

The National Health Insurance Scheme (NHIS) in Nigeria: current issues and implementation challenges

The National Health Insurance Scheme (NHIS) in Nigeria, despite its critical role in aiming for Universal Health Coverage, faces significant challenges. Initiated in 2005 with the goal of universal healthcare access by 2015, the scheme has struggled with low enrolment rates, fluctuating numbers of healthcare professionals, and substantial out-of-pocket expenditures for citizens. Current statistics indicate less than 5% of Nigerians are enrolled in NHIS, while 70% still finance their healthcare independently. Major issues include inefficient service delivery, inadequate healthcare infrastructure, and poor resource management, leading to substandard care quality. Recommendations for improvement focus on enhancing hospital efficiency, motivating and retaining healthcare workers, adopting appropriate technology, and clarifying prepayment mechanisms. Increased state contributions and robust evaluation metrics are also suggested to facilitate better adaptation to Nigeria’s diverse and growing population. Addressing these challenges is crucial for achieving the intended goals of the NHIS and moving closer to universal health coverage in Nigeria. Extensive discussions and strategic policy adjustments are essential to overcome these barriers, ensuring effective healthcare service delivery and financial protection for the Nigerian population.

The cost of providing care by family and friends (informal care) in the last year of life: A population observational study

Introduction: Little is known about replacement costs of care provided by informal carers during the last year of life for people dying of cancer and non-cancer diseases. Aim: To estimate informal caregiving costs and explore the relationship with carer and decedent characteristics. Design: National observational study of bereaved carers. Questions included informal end-of-life caregiving into the 2017 Health Survey for England including estimated recalled frequency, duration and intensity of care provision. We estimated replacement costs for a decedent’s last year of life valuing time at the price of a substitutable activity. Spearman rank correlations and multivariable linear regression were used to explore relationships with last year of life costs. Setting/participants: Adult national survey respondents – England. Results: A total of 7997 adults were interviewed from 5767/9612 (60%) of invited households. Estimated replacement costs of personal care and other help were £27,072 and £13,697 per carer and a national cost of £13.2 billion and £15.5 billion respectively. Longer care duration and intensity, older age, death at home (lived together), non-cancer cause of death and greater deprivation were associated with increased costs. Female sex, and not accessing ‘other care services’ were related to higher costs for other help only. Conclusion: We provide a first adult general population estimate for replacement informal care costs in the last year of life of £41,000 per carer per decedent and highlight characteristics associated with greater costs. This presents a major challenge for future universal care coverage as the pool of people providing informal care diminish with an ageing population.

Strengthening the family planning component of maternal health care: A new call to action to seize the opportunity provided by universal health coverage and primary healthcare frameworks.

SynopsisScaling up postpartum and postabortion family planning requires stronger health system stewardship, community and private sector engagement, measurement, and financing. Maternal health leadership is essential.

Impact of payment source, referral site, and place of residence on outcomes after allogeneic transplantation in Mexico.

The impact of social determinants of health in allogeneic transplant recipients in low- and middle-income countries is poorly described. This observational study analyzes the impact of place of residence, referring institution, and transplant cost coverage (out-of-pocket vs government-funded vs private insurance) on outcomes after allogeneic hematopoietic stem cell transplantation (alloHSCT) in two of Mexico's largest public and private institutions. To evaluate the impact of social determinants of health and their relationship with outcomes among allogeneic transplant recipients in Mexico. In this retrospective cohort study, we included adolescents and adults ≥ 16 years who received a matched sibling or haploidentical transplant from 2015-2022. Participants were selected without regard to their diagnosis and were sourced from both a private clinic and a public University Hospital in Mexico. Three payment groups were compared: Out-of-pocket (OOP), private insurance, and a federal Universal healthcare program "Seguro Popular". Outcomes were compared between referred and institution-diagnosed patients, and between residents of Nuevo Leon and out-of-state. Primary outcomes included overall survival (OS), categorized by residence, referral, and payment source. Secondary outcomes encompassed early mortality, event-free-survival, graft-versus-host-relapse-free survival, and non-relapse-mortality (NRM). Statistical analyses employed appropriate tests, Kaplan-Meier method, and Cox proportional hazard regression modeling. Statistical software included SPSS and R with tidycmprsk library. Our primary outcome was overall survival. We included 287 patients, n = 164 who lived out of state (57.1%), and n = 129 referred from another institution (44.9%). The most frequent payment source was OOP (n = 139, 48.4%), followed by private insurance (n = 75, 26.1%) and universal coverage (n = 73, 25.4%). No differences in OS, event-free-survival, NRM, or graft-versus-host-relapse-free survival were observed for patients diagnosed locally vs in another institution, nor patients who lived in-state vs out-of-state. Patients who covered transplant costs through private insurance had the best outcomes with improved OS (median not reached) and 2-year cumulative incidence of NRM of 14% than patients who covered costs OOP (Median OS and 2-year NRM of 32%) or through a universal healthcare program active during the study period (OS and 2-year NRM of 19%) (P = 0.024 and P = 0.002, respectively). In a multivariate analysis, payment source and disease risk index were the only factors associated with overall survival. In this Latin-American multicenter study, the site of residence or referral for alloHSCT did not impact outcomes. However, access to healthcare coverage for alloHSCT was associated with improved OS and reduced NRM.

Hospital accreditation in Mexico fails to improve the quality of healthcare: lessons from an impact evaluation.

Healthcare quality in low- and middle-income countries poses a significant challenge, contributing to heightened mortality rates from treatable conditions. The accreditation of health facilities was part of the former health reform in Mexico, proposed as a mechanism to enhance healthcare quality. This study assesses the performance of hospital accreditation in Mexico, utilizing indicators of effectiveness, efficiency, and safety. Employing a longitudinal approach with controlled interrupted time series analysis (C-ITSA) and fixed effects panel analysis, administrative data from general hospitals in Mexico is scrutinized. Results reveal that hospital accreditation in Mexico fails to enhance healthcare quality and, disconcertingly, indicates deteriorating performance associated with increased hospital mortality. Amidst underfunded health services, the implemented accreditation model proves inadequately designed to uplift care quality. A fundamental redesign of the public hospital accreditation model is imperative, emphasizing incentives for structural enhancement and standardized processes. Addressing the critical challenge of improving care quality is urgent for Mexico's healthcare system, necessitating swift action to achieve effective access as a benchmark for universal healthcare coverage.

Population-Based Study on the Implementation of Flash Glucose Monitoring and Severe Hypoglycemia in Adults With Type 1 Diabetes.

Objective: We analyzed the effect of implementing a flash glucose monitoring (FGM) technology in a public health care system with universal coverage on the rate of severe hypoglycemia requiring urgent care in adults with type 1 diabetes mellitus (T1DM). Methods: Using a comprehensive regional dataset, we extracted emergency care codes with hypoglycemia in individuals with T1DM who initiated the use of FGM in Andalucia, Spain, from January 1, 2020, to December 31, 2021. Severe hypoglycemia was defined as a confirmed blood glucose <70 mg/dL, which required the urgent dispatch of an emergency medical service (EMS) for onsite management. We compared hypoglycemic events reported in the 12 months before and after the initiation of FGM to determine the population incidence rates. Results: A total of 13,616 participants with a mean age of 43.7 ± 13.5 years were included. The follow-up periods were 23.4 and 24.8 months before and after FGM. There were 969 and 737 cases of hypoglycemia before and after the initiation of FGM. The baseline incidence rate was 358.58 episodes per 10,000 person-years, which decreased to 260.9 at the end of the follow-up (rate-ratio 0.72 [0.66; 0.80]). The reduction in hypoglycemia was significant in individuals aged ≥60 years (rate-ratio 0.40 [0.28; 0.55]) and males (0.64 [0.56; 0.72]). In addition, there was a reduction in the overall median HbA1c of -0.35% (95% CI [-0.38; -0.33], P < 0.001). Conclusion: The implementation of FGM systems in a public health care system as a provision for adults with T1DM was associated with significant reductions in the rate of severe hypoglycemic events that required urgent EMS care.

Cost Removed! Do Different Factors Influence Motivation for Vasectomy Reversal When Cost Is Not an Issue?

Vasectomy is a relatively common procedure performed for the purposes of sterilization; however, up to 6% of men that undergo vasectomy wish for its reversal at some point. Few studies have examined the motivation behind vasectomy reversal (VR), especially within special populations, such as the U.S. Military. The aim of this study was to examine the motivations of U.S. Military service members (SMs) who opted for VR surgery, considering their unique access to free health care. We conducted a retrospective record review of microsurgical VRs performed by a single surgeon (DJH) between January 2020 and May 2023. We evaluated patient's age at which vasectomy was performed, age at VR, reasons for seeking VR surgical care, number of children fathered before the vasectomy, and the age of the current partner. A total of 106 patients underwent VR during the study period, and 102 of them had their medical records available for review. The average age at the time of vasectomy was 31.3 years, while the average age at VR was 40.2 years. The average spousal age at the time of seeking VR was 34.8 years. Before undergoing vasectomy, the men had fathered an average of 2.7 children. Most men were enlisted members of the military (68) and of all service branches, Army represented the greatest number (50). The vast majority of men (76) cited having a new partner after divorce as the primary motivation for seeking VR. Within this group, 57 were remarried, 15 were in a new relationship, 3 were newly engaged, and 1 desired fertility for future relationships. Additionally, 21 sought VR to have more children with the same spouse. Among them, motivating factors included changes to financial status and improvement in partner's health condition. A minority of patients (2) desired VR due to post vasectomy pain syndrome or religious beliefs. Our study demonstrates that the primary driver for seeking VR surgical care among SMs was the desire for fertility with a new partner, which correlates with trends in the civilian sector. Approximately 20% of the men cited the wish to have more children with the same partner as their motivation. Non-fertility reasons, such as religious beliefs and post vasectomy pain syndrome, were also observed, albeit less frequently.

Characterization of the family-level Borreliaceae pan-genome and development of an episomal typing protocol.

The Borreliaceae family includes many obligate parasitic bacterial species which are etiologically associated with a myriad of zoonotic borrelioses including Lyme disease and vector-borne relapsing fevers. Infections by the Borreliaceae are difficult to detect by both direct and indirect methods, often leading to delayed and missed diagnoses. Efforts to improve diagnoses center around the development of molecular diagnostics (MDx), but due to deep tissue sequestration of the causative spirochaetes and the lack of persistent bacteremias, even MDx assays suffer from a lack of sensitivity. Additionally, the highly extensive genomic heterogeneity among isolates, even within the same species, contributes to the lack of assay sensitivity as single target assays cannot provide universal coverage. This within-species heterogeneity is partly due to differences in replicon repertoires and genomic structures that have likely arisen to support the complex Borreliaceae lifecycle in which these parasites have to survive in multiple hosts each with unique immune responses. We constructed a Borreliaceae family-level pangenome and characterized the phylogenetic relationships among the constituent taxa which supports the recent taxonomy of splitting the family into at least two genera. Gene content pro les were created for the majority of the Borreliaceae replicons, providing for the first time their unambiguous molecular typing. Our characterization of the Borreliaceae pan-genome supports the splitting of the former Borrelia genus into two genera and provides for the phylogenetic placement of several non-species designated isolates. Mining this family-level pangenome will enable precision diagnostics corresponding to gene content-driven clinical outcomes while also providing targets for interventions.

საპენსიო სისტემის რეფორმის აქტუალურობა საქართველოში

Georgia urgently needs pension reform. The disadvantage of the existing pension model was its pressure on the state budget. At the same time, the resent demographical changes, the increase in the life expectancy of pensioners, active aging in the demographic sector, the tendency of the labor force to decrease, the introduction of universal health insurance and other factors have had a significant impact on the country's economy and have highlighted new challenges that have put the sustainability of the state pension system at risk. The discussion of the need of the pension system reform in Georgia has become more and more active in recent years. It should be emphasized that within the expenditure allocation of the state budget, the largest proportion is attributed to social expenditures, with the state pension system claiming the most significant share. The pension scheme operating in Georgia does not guarantee a sufficient standard of living, it provides only a basic income, and that is why the government has prioritized the need of pension reform on the agenda so that the system responds more to the needs of aging populations and ensures their honorable old age as much as possible.

Predictors of failed same-day discharge in patients undergoing robot-assisted radical prostatectomy in a Canadian universal healthcare system.

Same-day discharge (SDD) after robot-assisted radical prostatectomy (RARP) has been shown to be feasible and safe. In order to improve uptake of this ambulatory model in Canada, we aimed to update our experience of SDD after RARP and identify reasons for SDD pathway non-initiation and failure in a universal healthcare system. A review of our prospectively collected database of patients undergoing RARP at a Canadian tertiary academic center from May 2021 to May 2023 was conducted. Binary logistic regression analysis determined predictors SDD pathway non-initiation and failure. We identified 387 patients, of which 198 were initiated on the SDD pathway. Of those initiated, 104 (52.5%) were successfully discharged home on the same day. Patients who travelled distances greater than 100 km, or who had non-CPAP (continuous positive airway pressure)-compliant obstructive sleep apnea were significantly less likely to be initiated on the SDD pathway (both p<0.05). Patients who were scheduled to be the second case or later had an estimated blood loss ≥300 mL, or had a postoperative abdominal drain, were predictive of failing SDD after initiation (all p<0.05). There were similar rates of readmissions, unscheduled office visits, and emergency department presentations, when compared to the traditional inpatient model (all p>0.05). SDD after RARP in a Canadian healthcare system remains feasible and safe for selected patients. Predictors of failed SDD identified in this study inform the development of future ambulatory protocols and highlight areas of need in infrastructure to increase uptake of these outpatient pathways.

Regional differences in heart failure risk in the United Kingdom are partially explained by biological aging.

Heart failure (HF) risk is greater in rural versus urban regions in the United States (US), potentially due to differences in healthcare coverage and access. Whether this excess risk applies to countries with universal healthcare is unclear and the underlying biological mechanisms are unknown. In the prospective United Kingdom (UK) Biobank, we investigated urban-rural regional differences in HF risk and the mechanistic role of biological aging. Multivariable Cox regression was used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of incident HF in relation to residential urban-rural region and a Biological Health Score (BHS) that reflects biological aging from environmental, social, or dietary stressors. We estimated the proportion of the total effect of urban-rural region on HF mediated through BHS. Among 417,441 European participants, 10,332 incident HF cases were diagnosed during the follow-up. Compared to participants in large urban regions of Scotland, those in England/Wales had significantly increased HF risk (smaller urban: HR = 1.83, 95%CI: 1.64-2.03; suburban: HR = 1.77, 95%CI: 1.56-2.01; very rural: HR = 1.61, 95%CI: 1.39-1.85). Additionally, we found a dose-response relationship between increased biological aging and HF risk (HRper 1 SD increase = 1.14 (95%CI: 1.12-1.17). Increased biological aging mediated a notable 6.6% (p < 0.001) of the total effect of urban-rural region on HF. Despite universal healthcare in the UK, disparities in HF risk by region were observed and may be partly explained by environmental, social, or dietary factors related to biological aging. Our study contributes to precision public health by informing potential biological targets for intervention.

Socioeconomic Status, Length of Stay, and Postoperative Complications in Oral Cavity Squamous Cell Carcinoma.

Background: Despite universal healthcare in Canada, low socioeconomic status (SES) has been associated with worse survival in oral cavity squamous cell carcinoma (OCSCC) patients. However, the relationship between SES and outcomes during the acute postoperative period is poorly defined. Hamilton, Ontario, presents a unique population with widely varying SES within the same geography. The objective of this study was to examine the relationship between SES, length of hospital stay (LOHS), and postoperative complications in OCSCC. Methods: Newly diagnosed OCSCC patients receiving primary surgical treatment from 2010 to 2014 were identified within a prospectively collected database. Inclusion criteria included age >18 years old, pathological diagnosis of oral cavity cancer, and primary surgical treatment with curative intent. Patients were excluded if they were undergoing palliative treatment or had previous head and neck surgery/radiotherapy. Postal codes were used to identify neighborhood-level socioeconomic variables via 2011 Canada Census data. Income quartiles were defined from groups of neighboring municipalities based on Canada Census definitions. Demographic, social, pathological, staging, and treatment data were collected through chart review. Results: One hundred and seventy-four patients were included in the final analysis. OCSCC patients with lower SES were more likely to be younger (P = .041), male (P = .040), have significant tobacco and alcohol use (P = .001), higher Charlson Comorbidity Index (CCI; P = .014), lower levels of education (P = .001), and have lower employment levels (P = .001). Lower SES patients had higher clinical tumor (P = .006) and clinical nodal (P = .004) staging and were more likely to receive adjuvant therapy (P = .001) and G-tubes (P = .001). Multivariable regression analysis showed that low SES was a statistically significant predictor of postoperative complications [β 2.50 (95% confidence interval (CI) 0.200, 3.17); P = .014] and LOHS [β 2.03 (95% CI 1.06, 2.99); P = .0001]. Tobacco and alcohol use, clinical tumor, and nodal stage, CCI, and planned adjuvant therapy were also statistically significant predictors of postoperative complications and LOHS (P < .05). Conclusion: Patients with lower SES have more advanced OCSCC disease with increased comorbidities that owes itself to more acute postoperative complications and LOHS within this study population. Patients with low SES should be identified as patients that require more support during their cancer treatment.

Nationwide Big Data Analysis of Statin Use and Intracerebral Hemorrhage Risk in Acute Ischemic Stroke Patients in Taiwan.

Background and Objectives: Although statins are recommended for secondary prevention of acute ischemic stroke, some population-based studies and clinical evidence suggest that they might be used with an increased risk of intracranial hemorrhage. In this nested case-control study, we used Taiwan's nationwide universal health insurance database to investigate the possible association between statin therapy prescribed to acute ischemic stroke patients and their risk of subsequent intracerebral hemorrhage and all-cause mortality in Taiwan. Materials and Methods: All data were retrospectively obtained from Taiwan's National Health Insurance Research Database. Acute ischemic stroke patients were divided into a cohort receiving statin pharmacotherapy and a control cohort not receiving statin pharmacotherapy. A 1:1 matching for age, gender, and index day, and propensity score matching was conducted, producing 39,366 cases and 39,366 controls. The primary outcomes were long-term subsequent intracerebral hemorrhage and all-cause mortality. The competing risk between subsequent intracerebral hemorrhage and all-cause mortality was estimated using the Fine and Gray regression hazards model. Results: Patients receiving statin pharmacotherapy after an acute ischemic stroke had a significantly lower risk of subsequent intracerebral hemorrhage (p < 0.0001) and lower all-cause mortality rates (p < 0.0001). Low, moderate, and high dosages of statin were associated with significantly decreased risks for subsequent intracerebral hemorrhage (adjusted sHRs 0.82, 0.74, 0.53) and all-cause mortality (adjusted sHRs 0.75, 0.74, 0.74), respectively. Conclusions: Statin pharmacotherapy was found to safely and effectively reduce the risk of subsequent intracerebral hemorrhage and all-cause mortality in acute ischemic stroke patients in Taiwan.

An examination of health care efficiency in Canada: a two-stage semi-parametric approach.

Using data envelopment analysis, we examine the efficiency of Canada's universal health care system by considering a set of labour (physicians) and capital (beds) inputs, which produce a level of care (measured in terms of health quality and quantity) in a given region. Data from 2013-2015 were collected from the Canadian Institute for Health Information regarding inputs and from the Canadian Community Health Survey and Statistics Canada regarding our output variables, health utility (quality) and life expectancy (quantity). We posit that variation in efficiency scores across Canada is the result of regional heterogeneity regarding socioeconomic and demographic disparities. Regressing efficiency scores on such covariates suggests that regional unemployment and an older population are quite impactful and associated with less efficient health care production. Moreover, regional variation indicates the Atlantic provinces (Newfoundland, Prince Edward Island, Nova Scotia, New Brunswick) are quite inefficient, have poorer economic prospects, and tend to have an older population than the rest of Canada. Oaxaca-Blinder decompositions suggest that the latter two factors explain about one-third of this efficiency gap. Based on our two-stage semi-parametric analysis, we recommend Canada adjust their transfer payments to reflect these disparities, thereby potentially reducing inequality in regional efficiency.

Enhancing Healthcare Decision-Making: Comparison Between Health Technology Assessments and Access to Medical Care in a High-income Country vs. Low/middle Income Countries

Background: Healthcare decision-making is a complex process that involves evaluating the value, efficacy, and accessibility of medical technologies and interventions. Health Technology Assessments (HTA) in high-income countries (HICs) have become a cornerstone of evidence-based healthcare decision-making. This systematic evaluation framework, exemplified by its robust, impartial examination of various medical technologies, plays a pivotal role in establishing the clinical effectiveness and cost-effectiveness of health technologies. In contrast, low and middle-income countries (LMICs) frequently contend with resource constraints and intricate healthcare systems characterized by fragmentation and limited access to advanced medical technologies. As formalized HTA processes may be less established, limiting comprehensive evaluations, decision-making may rely on regulatory approval, clinical guidelines, or international recommendations in LMICs. Similarly, access to medical care in high-income settings, such as the presence of universal healthcare coverage and well-developed health systems, contributes to equitable access to a wide range of medical services. In LMICs, challenges related to healthcare infrastructure, funding, and health workforce shortages hinder access to essential medical care, leading to inequities in health outcomes. This short review aims to compare the approaches to healthcare decision-making in high-income and low/middle-income countries, with a specific focus on HTAs and access to medical care.

Cancer care during a time of crisis: Israel’s experience during wartime.

e23030 Background: During the last decades, there have been many crises in the world, including COVID-19, the Ukraine-Russia war and major tsunamis and earthquakes. These situations create challenges for providing appropriate care for cancer patients. It remains an important research priority to understand how to improve care delivery for cancer patients under conditions of stress or emergency. Methods: Israel has one of the highest-quality healthcare systems in the world. Strengths of the health system include advanced technology, universal health insurance, and four strong health maintenance organizations. Israel’s health system recently performed relatively well during the COVID-19 pandemic. Here, we report on system efforts to continue providing care despite the massive terrorist attack by Hamas of October 7, 2023, the ongoing rocket fire, and the mobilization of young and middle-aged adults to the army, which led to staff shortages. Our report focuses in particular on efforts to maintain continuity and quality of care for cancer patients. Results: There have been three main pillars of Israel’s efforts to maintain care for cancer patients despite the challenges. 1) We activated strategies learned from previous events, including the COVID-19 pandemic and other wars. This enabled continuing treatment of cancer patients, including those who had been evacuated from border-adjacent areas, in oncology departments that are either missile-proof or adjacent to a protected area. 2) The existence of universal health insurance, together with strong health maintenance organizations, enabled us to fill in gaps in social needs and ensure that no patient is “left behind”. This, in turn, allowed patients and their care teams to continue their cancer care without reimbursement barriers or other interruptions, despite the challenges. 3) There was a massive groundswell of volunteerism and lay-led social service initiatives. Almost half (48.6%) of the Israeli population engaged in some volunteer activity during the first two weeks of the war. This included volunteers who provided transportation for patients to and from treatments, donation of medications aimed at helping evacuees from border areas, and volunteer medical staff, such as recent retirees. These civil initiatives played a critical role in providing the initial response to the urgent needs that were left unaddressed by the government. Conclusions: We identified three main pillars that enabled continuity and high quality of care for cancer patients to continue despite a major crisis. A rapid response due to having similar, previous experiences and ready plans. A high-performance and resilient health delivery system, and lay volunteerism in times of crisis. While Israel’s challenges in the present period are unique, nevertheless lessons can be learned by health systems that wish to become more resilient and able to provide adequate care in times of crisis.

TEMPORARY REMOVAL: Drivers of Anemia Reduction among Women of Reproductive Age in the Philippines: A Country Case Study

BackgroundAnemia prevalence among women of reproductive age (WRA) in the Philippines was 25% in 2000, decreasing to 13% in 2018. To date, an in-depth assessment of the determinants associated with this decline has not been conducted. ObjectiveTo conduct a systematic in-depth assessment of the quantitative and qualitative determinants of anemia among WRA in the Philippines between 2008 and 2018. MethodsEmploying standard Exemplars methodology, we conducted quantitative analyses using the Philippines’ National Nutrition Survey, the Expanded National Nutrition Survey, and the Philippines National Demographic and Health Surveys. Qualitative analyses included a comprehnsive literature review, program/policy analysis, and interviews with stakeholders to understand country-level enablers and barriers to WRA anemia decline in the Philippines. A final Oaxaca-Blinder decomposition analysis (OBDA) evaluated the relative contribution of direct and indirect factors. ResultsAmong non-pregnant women (NPW), mean hemoglobin (Hb) increased from 12.7 g/dL in 2008 to 13.1 g/dL in 2018 (p<0.01), corresponding to an 11%-point decline in anemia prevalence (23% to 12%). Inequities by geographical region, household wealth, and women’s educational attainment narrowed considerably during this time. Important direct and indirect nutrition programs were introduced during our study period, including universal healthcare and food fortification. Country experts interviewed credited programs focused on alleviating micronutrient deficiencies and poverty, and improvements in women’s health and well-being, for the country's extraordinary success. OBDA explained ∼50% of the observed change in mean Hb among NPW, with family planning (35%), household socio-demographics (29%), and improvement in women’s nutrition (23%) emerging as critical drivers of anemia decline, corroborating our qualitative and policy analyses. ConclusionsTo protect these gains, WRA anemia prevention efforts in the Philippines should continue to focus on universal healthcare access, women’s empowerment, and poverty alleviation.

Financial toxicity in the background of free health care: A cross-sectional survey in a tertiary care hospital in India.

e13685 Background: The financial toxicity of cancer treatment is a known fact in low to middle-income countries due to poverty, lack of health insurance and illiteracy. We tried to estimate the financial strain and its contributing factors in an Indian population with access to free cancer treatment. Methods: All government employees and their dependents are eligible to receive free treatment including inpatient management, investigations and medicines at our institute. All cancer patients ≥18 years were invited to participate in a survey. The survey included their demographic, cancer and therapy details, the COST-FACIT questionnaire, and information about increase in expenses since cancer diagnosis and source of additional finances. Results: 300 cancer patients completed the survey. 61.3% of the respondents were females and the mean patient age was 43.14 years. Breast cancer was the most common malignancy and stage IV was the most common stage. 44% were residents of a rural area. The average duration of treatment was 8.03 months. Prior to cancer diagnosis, 37.2% of the patients had average monthly expenses between INR 10-25,000 (USD 120 to 300). The approximate increase in monthly expenditures after cancer diagnosis was between INR 5-10,000 (USD 60 to 120) for 33.4% and between INR 10-25,000 (USD 120 to 300) for 31.4% of the population. The primary income source for 65.7% respondents was the salary of the government employee while 48% had two or more earning members in the family. Cancer treatment negatively affected the earning capacity of the patient alone in 40% of the population, while in 28% it affected the earning capacity of the patient and caregiver. 51% had to utilise their savings, 39% sold fixed assets, and 31% borrowed or took a loan to cope with the additional financial strain. Commonest expenses were travel, accommodation, and food (75.7%). 34.5% spent money on other therapy-related costs (second opinion or alternative therapy). The mean COST-FACIT score was 21.38,(20-24) demonstrating mild financial toxicity. Predictors of high financial toxicity were a single-earning member, familial discord and long duration of treatment (&gt; 6 months). Conclusions: Though all participants had access to free cancer treatment, all experienced mild financial toxicity due to non-therapeutic expenses. Despite desperate financial measures to complete treatment, most participants did not express severe financial toxicity. This may be attributed to the stigma of expected high expenditure associated with cancer treatment in India. COST-FACIT scoring may not have suitably assessed the financial strain experienced by patients with free healthcare. Additional financial information collected by the survey, (monthly expenses, earning members, source of additional funds), helped us to better understand financial impact of cancer treatment and identify gaps in our healthcare.

Integrating eye care into primary healthcare in Nigeria: Challenges of the primary healthcare workforce

AbstractVisual impairment and blindness pose a significant and growing public health threat in Nigeria. Over 1.6 million Nigerians are visually impaired or blind, with more than 80% of these cases being preventable and treatable. The risk for ocular morbidities is expected to increase due to rapid population growth, an aging population, and the rising burden of noncommunicable diseases. Despite efforts to improve eye health services, universal eye health remains elusive, with 35% of Nigerians unable to access eye care in primary healthcare (PHC) facilities. Many Nigerians instead turn to traditional and alternative medicine for primary eye care (PEC), which can worsen their outcomes. This article highlights the potential of the country's PHC system to address these challenges, emphasizing the importance of PEC as an integral part of PHC. The article discusses the various challenges faced by PHC workers in delivering eye care services in Nigeria, focusing on financing, training, leadership, and policies for eye care. It also provides a set of comprehensive recommendations aimed at overcoming these challenges, including improved leadership and policy implementation, optimized financing, strengthened collaborations and partnerships, enhanced education and training, and effective human resource management systems. We emphasize the importance of holistic and strategic efforts to bolster the PHC workforce's capacity to provide universal eye healthcare in Nigeria, ultimately improving access to high‐quality eye care services for all.