Health System Characteristics Research Articles

Human resources in dentistry geographical distribution in Brazil and Colombia: Comparative analysis from the perspective of historical institutionalism

The Human Resource in Health constitutes one of the six core components of health systems, playing a crucial role in realizing the right to health and ensuring access and service quality. Additionally, institutional frameworks within each country, encompassing laws, decrees, political systems, and health system characteristics, exert a significant influence on HRH and, specifically, in Human Resources in Dentistry (HRD). Both Brazil and Colombia experienced neoliberal reforms in the 1990s, introducing new institutions within the existing model and altering the social, political, and economic dynamics of each country. This study aims to examine the impact of institutional arrangements stemming from the 1990s neoliberal reforms in Brazil and Colombia on HRDs, focusing on geographic distribution. Employing a comparative analysis and adopting a historical institutionalism perspective, the research relies on a methodology involving multiple case studies with embedded units. Results reveal that the neoliberal reforms represented critical junctures reshaping the social and economic policies of both nations. In this context, the reforms influenced wealth distribution in both countries, subsequently impacting the unequal geographical distribution of HRD. These effects were closely tied to factors such as labor flexibility and the unregulated, unplanned expansion of dentistry courses. These elements initiated positive feedback loops, characterized by path dependence and increasing returns, which have contributed to the institutionalization and persistence of these phenomena within the state and have become entrenched in HRDs over time.

The effect of institutional characteristics and social norms on corruption in healthcare

AbstractCorruption in healthcare is widespread and consequential. Informal payments (IPs) are a common form of petty corruption, especially in low‐ and middle‐income countries. Using data from the Life in Transition Survey encompassing 33 countries across Europe and Central Asia, I analyze the prevalence and reasons behind IPs made to public health providers. In addition to individual‐ and system‐level factors often used in literature, I also introduce a latent measure of social norms related to high levels of corruption. These are associated with a significantly higher prevalence of paying informally. This paper also bridges a gap between the corruption literature and health‐related research by introducing a typology of IPs based on why they were made. I find that the association between health system characteristics and IPs prevalence differs based on the reason for payment. This difference is further exacerbated by the existence of corruption‐related social norms. The results of this analysis highlight the need to revisit existing anti‐corruption policies and align them to the underlying social norms.

Preferences and feasibility of long-acting technologies for treatment of hepatitis C virus in low- and middle-income countries: A survey of providers and policymakers.

Long-acting technologies (LATs) for hepatitis C virus (HCV) are under development as a strategy to improve linkage to care, treatment adherence and outcomes. We conducted a survey of HCV treatment prescribers and HCV policymakers in low- and middle-income countries (LMICs) regarding acceptability and feasibility of HCV LATs. We included one-time intramuscular injection, subdermal implant and transdermal patch as potential LAT options. We surveyed participants regarding optimal health system and patient characteristics, concerns, potential barriers, overall feasibility and preferences for HCV LAT as compared to daily oral medication. Overall, 122 providers and 50 policymakers from 42 LMICs completed the survey. Among providers, 93% (113/122) expressed willingness to prescribe LAT and 72% (88/120) of providers preferred LAT if provided at comparable efficacy, safety and cost as current oral treatments. Of providers preferring HCV LAT to daily oral medication, 67% (59/88) preferred injection, 24% (21/88) preferred patch and 9% (8/88) preferred implant. Only 20% (24/122) would prescribe LAT if it were more costly than oral treatment. In regression analysis, no provider characteristics were associated with preference for LAT over oral treatment. Policymakers reported high likelihood that LAT would be included in treatment guidelines (42/50; 84%) and national drug formularies (39/50; 78%) if efficacy, safety and cost were similar to oral treatment. HCV LATs could advance progress to HCV elimination in LMICs by diversifying treatment options to improve treatment coverage and outcomes. Provider preferences from LMICs are a critical consideration in the development of HCV LATs to ensure its early and equitable availability in LMICs.

Determinants of public health expenditure in the EU.

Public health expenditure is one of the fastest-growing spending items in EU member states. As the population ages and wealth increases, governments allocate more resources to their health systems. In view of this, the aim of this study is to identify the key determinants of public health expenditure in the EU member states. This study is based on macro-level EU panel data covering the period from 2000 to 2018. The association between explanatory variables and public health expenditure is analyzed by applying both static and dynamic econometric modeling. Although GDP and out-of-pocket health expenditure are identified as the key drivers of public health expenditure, there are other variables, such as health system characteristics, with a statistically significant association with expenditure. Other variables, such as election year and the level of public debt, result to exert only a modest influence on the level of public health expenditure. Results also indicate that the aging of the population, political ideologies of governments and citizens' expectations, appear to be statistically insignificant. Since increases in public health expenditure in EU member states are mainly triggered by GDP increases, it is expected that differences in PHE per capita across member states will persist and, consequently, making it more difficult to attain the health equity sustainable development goal. Thus, measures to reduce EU economic inequalities, will ultimately result in reducing disparities in public health expenditures across member states.

1965 US Voting Rights Act Impact on Black and Black Versus White Infant Death Rates in Jim Crow States, 1959-1980 and 2017-2021.

Objectives. To investigate the impact of the US Voting Rights Act (VRA) of 1965 on Black and Black versus White infant deaths in Jim Crow states. Methods. Using data from 1959 to 1980 and 2017 to 2021, we applied difference-in-differences methods to quantify differential pre-post VRA changes in infant deaths in VRA-exposed versus unexposed counties, controlling for population size and social, economic, and health system characteristics. VRA-exposed counties, identified by Section 4, were subject to government interventions to remove existing racist voter suppression policies. Results. Black infant deaths in VRA-exposed counties decreased by an average of 11.4 (95% confidence interval [CI] = 1.7, 21.0) additional deaths beyond the decrease experienced by unexposed counties between the pre-VRA period (1959-1965) and the post-VRA period (1966-1970). This translates to 6703 (95% CI = 999.6, 12 348) or 17.5% (95% CI = 3.1%, 28.1%) fewer deaths than would have been experienced in the absence of the VRA. The equivalent differential changes were not significant among the White or total population. Conclusions. Passage of the VRA led to pronounced reductions in Black infant deaths in Southern counties subject to government intervention because these counties had particularly egregious voter suppression practices. (Am J Public Health. 2024;114(3):300-308. https://doi.org/10.2105/AJPH.2023.307518).

Impact of Corticosteroid Therapy on ICU Patient Outcomes in Severe COVID-19 Cases: A Retrospective Cohort Study in Saudi Arabia.

The COVID-19 pandemic has presented significant challenges in clinical management, and intensive care units (ICUs) worldwide have become epicenters of high-stakes treatment decisions. Among these, corticosteroid therapy has risen as a pivotal, yet controversial, treatment modality. In Saudi Arabia, where unique demographic and health system characteristics intersect, understanding the specific effects of corticosteroids on ICU patient outcomes is not just critical but a pressing necessity in tailoring effective COVID-19 management strategies. This study aims to elucidate the effects of corticosteroid therapy on the outcomes of severe COVID-19 patients in Saudi Arabian ICUs, providing critical insights into treatment efficacy and guiding future clinical practices. In this cohort study, we meticulously reviewed the medical records of 1085 severe COVID-19 patients admitted to Saudi Arabian ICUs. Our analysis focused on demographic details, ICU outcomes, and the extent and implications of corticosteroid therapy. The study employed comprehensive methods for data collection, evaluation criteria, and statistical analysis, ensuring a thorough understanding of the impact of corticosteroids in this context. The study encompassed 1085 patients, predominantly male (74.5%, N=806), with an average age of 56 and a mean BMI of 30.07. A significant portion (72.3%, N=784) received corticosteroid therapy. These patients generally experienced longer ICU (mean 23 days) and hospital stays (mean 16 days), along with higher rates of microbiological cure (72.3%, N=648) and increased ICU discharge likelihood. Conversely, corticosteroid recipients showed higher mortality rates at ICU discharge. The statistical analysis confirmed the significance of these findings, reinforcing their importance in managing COVID-19 in ICUs. The research highlights the intricate dynamics of corticosteroid use in treating severe COVID-19 cases in ICUs. While associated with prolonged ICU stays and increased mortality, corticosteroids also correlate with higher microbiological cure rates and discharge likelihood. These insights call for careful deliberation in applying corticosteroid therapy, with implications for enhancing clinical protocols and guiding future research in severe COVID-19 treatment.

Family planning service disruptions in the first two years of the COVID-19 pandemic: Evidence from health facilities in seven low- and middle-income countries.

Many speculated that COVID-19 would severely restrict the delivery of essential health services, including family planning (FP), but evidence of this impact is limited, partly due to data limitations. We use cross-sectional data collected from regional and national samples of health facilities (n = 2,610) offering FP across seven low- and middle-income countries (LMICs) between 2019 and 2021, with longitudinal data from four geographies, to examine reported disruptions to the FP service environment during COVID-19, assess how these disruptions varied according to health system characteristics, and evaluate how disruptions evolved throughout the first two years of the pandemic, relative to a pre-pandemic period. Findings show significant variation in the impact of COVID-19 on facility-based FP services across LMICs, with the largest disruptions to services occurring in Rajasthan, India, where COVID-19 cases were highest among geographies sampled, while in most sub-Saharan African settings there were limited disruptions impacting FP service availability, method provision, and contraceptive supplies. Facility-reported disruptions to care were not reflected in observed changes to the number of FP clients or types of stockouts experienced in the first two years of the pandemic. Public and higher-level facilities were generally less likely to experience COVID-19-related disruptions to FP services, suggesting policy mitigation measures-particularly those implemented among government-operated health facilities-may have been critical to ensuring sustained delivery of reproductive healthcare during the pandemic.

Geospatial analysis and participant characteristics associated with colorectal cancer screening participation in Alberta, Canada: a population-based cross-sectional study

BackgroundColorectal cancer (CRC) is a leading cause of death in Canada and early detection can prevent deaths through screening. However, CRC screening in Alberta, Canada remains suboptimal and varies by sociodemographic and health system characteristics, as well as geographic location. This study aimed to further the understanding of these participant and health system characteristics associated with CRC screening in Alberta and identify clusters of regions with higher rates of overdue or unscreened individuals.MethodsWe included Albertans aged 52 to 74 as of December 31, 2019 (index date) and we used data from administrative health data sources and linked to the Alberta Colorectal Cancer Screening Program database to determine colorectal cancer screening rates. We used multivariable multinomial logistic regression analysis to investigate the relationship between sociodemographic, health system characteristics and participation in CRC screening. We used optimized Getis-Ord Gi* hot-spot analysis to identify hot and cold-spots in overdue for and no record of CRC screening.ResultsWe included 919,939 Albertans, of which 65% were currently up to date on their CRC screening, 21% were overdue, and 14% had no record of CRC screening. Compared to Albertans who were currently up to date, those who were in older age groups, those without a usual provider of care, those who were health system non-users, and those living in more deprived areas were more likely to have no record of screening. Areas with high number of Albertans with no record of screening were concentrated in the North and Central zones.ConclusionsOur study showed important variation in colorectal cancer screening participation across sociodemographic, health system and geographical characteristics and identified areas with higher proportions of individuals who have no record of screening or are under-screened in Alberta, Canada.

Exploring the association between primary care efficiency and health system characteristics across European countries: a two-stage data envelopment analysis

BackgroundPrimary care is widely seen as a core component of resilient and sustainable health systems, yet its efficiency is not well understood and there is a lack of evidence about how primary care efficiency is associated with health system characteristics. We examine this issue through the lens of diabetes care, which has a well-established evidence base for effective treatment and has previously been used as a tracer condition to measure health system performance.MethodsWe developed a conceptual framework to guide the analysis of primary care efficiency. Using data on 18 European countries during 2010–2016 from several international databases, we applied a two-stage data envelopment analysis to estimate (i) technical efficiency of primary care and (ii) the association between efficiency and health system characteristics.ResultsCountries varied widely in terms of primary care efficiency, with efficiency scores depending on the range of population characteristics adjusted for. Higher efficiency was associated with bonus payments for the prevention and management of chronic conditions, nurse-led follow-up, and a financial incentive or requirement for patients to obtain a referral to specialist care. Conversely, lower efficiency was associated with higher rates of curative care beds and financial incentives for patients to register with a primary care provider.ConclusionsOur results underline the importance of considering differences in population characteristics when comparing country performance on primary care efficiency. We highlight several policies that could enhance the efficiency of primary care. Improvements in data collection would enable more comprehensive assessments of primary care efficiency across countries, which in turn could more effectively inform policymaking.

Examining Characteristics of Local Public Health Systems With Exceptional Tribal Organization Participation.

To learn feasible ways to increase multisector community partnership with tribal organizations, meaning tribal health authorities or American Indian and Alaska Native (AI/AN)-serving organizations, by examining characteristics of local public health systems with exceptional tribal organization participation. In total, 728 local public health departments were surveyed in 2018 to generate a nationally representative sample of local public health systems in the United States. A positive deviance approach using logistic regression helped identify local public health systems that had tribal organization participation despite characteristics that make such participation statistically unlikely. Local public health systems with exceptional tribal organization participation were compared with systems with conventional participation, examining measures known to impact the formation of public health partnerships. This study used an exploratory logistic regression approach to identify unique characteristics of local public health systems with exceptional tribal organization participation. Of 728 health systems surveyed, 21 were identified as having exceptional tribal organization participation. Across varying thresholds to identify exceptional participation, having a higher network density and prioritizing equity in public health activities were found to consistently distinguish exceptional tribal organization participation in both nonrural and rural areas. Public health partnerships with tribal organizations are possible even in circumstances that make them unlikely. Efforts to build denser networks of collaborating organizations and prioritize equity may help public health systems achieve success with tribal organization partnerships.

5.D. Round table: Implementing Europe’s Beating Cancer Plan: Challenges and opportunities from European countries

Abstract Cancer is one of the most pressing issues in public health, one that places that carries a large burden on society, governments, and healthcare systems. Without strong action, cancer incidence in Europe is expected to increase by a fifth in 2040, translating into more than 5 million cancer cases (5,328,323) (IARC,2020) . While over 40 % of cases are preventable, 3.9 million people in the EU are diagnosed each year, and 1.9 million deaths are cancer-related. In an effort to tackle cancer, the European Commission (EC) launched two major initiatives: Europe's Beating Cancer Plan (EBCP), and the Mission on Cancer. The EBCP, launched in 2021, is a policy-driven initiative aimed at supporting Member States in addressing every stage of the disease: prevention, early detection, diagnosis, and treatment. The EBCP is supported by a research driven initiative which is the Mission on Cancer. The ambition of these initiative is to reduce the burden of cancer in Europe and save 3 million lives by 2030. Knowledge exchange and capacity building between member states are essential to create a common understanding of the challenges and opportunities in cancer prevention and control, as is facilitating exchange and collaboration between the plethora of actors within each national context. To guarantee the successful implementation of the EBCP and the Mission on Cancer, one must consider the diversity of national contexts. The aim of the workshop is to explore how countries evaluate their needs in the field, through engaging public health actors and community members, with a participatory approach, to implement the EBCP while taking into account the diversity of contexts within countries. In this workshop, we seek contextualise the EC's EBCP and explore implementation strategies from different Member States, with a particular focus on participatory approach to public health initiatives and policy design and implementation. More specifically, a panel will share experiences and discuss examples from Belgium and other European countries in supporting the national implementation of cancer initiatives. The panel will lay the foundation for a discussion with the audience on the opportunities and challenges in various EU countries on participatory public health policy design and implementation, using cancer policy related to prevention, diagnosis, treatment and research, as a case study. Key messages • Europe's Beating Cancer Plan should be contextualised taking into consideration Member States and their citizen's heterogeneity and needs, while also adapting to health systems characteristics. • Knowledge and capacity building between Member States is essential to create a common understanding of the challenges and opportunities in cancer prevention and control in Europe. Speakers/Panelists Jinane Ghattas EUPHAnxt Anabela Isidro Agência de Investigação Clínica e Inovação Biomédica, Lisbon, Portugal Linda Abboud Sciensano, Brussels, Belgium

Factors associated with vaccine coverage improvements in Senegal between 2005 and 2019: a quantitative retrospective analysis

ObjectiveSenegal has demonstrated catalytic improvements in national coverage rates for early childhood vaccination, despite lower development assistance for childhood vaccines in Senegal compared with other low-income and lower-middle income countries....

Factors Influencing the Referral of Patients with Prediabetes to a Diabetes Prevention Program in the Bronx, New York.

Disparate engagement in the Diabetes Prevention Program (DPP) may occur as early as the point of referral for certain subgroups, including Black and Hispanic men. We aimed to determine patient demographic and provider characteristics associated with referrals to a health system DPP in the Bronx, New York. Patient and health system characteristics for DPP-eligible patients seen in primary care between July 1, 2015, and December 31, 2017, were obtained through the electronic health record. Generalized mixed-effects modeling was used to test the association between referral rate and clinical and sociodemographic variables. Of 26,727 eligible patients, 66% were female, 46% were Hispanic, and 39% were non-Hispanic Black. Only 10% (n = 2,785) of eligible patients were referred to DPP. In the adjusted analyses, lower odds of referral were observed for men versus women (OR = 0.60; 95% CI, 0.52-0.66), for non-Hispanic White versus Hispanic patients (OR = 0.53; 95% CI, 0.40-0.71), and for uninsured patients versus Medicaid patients (OR = 0.66; 95% CI, 0.54-0.80). The odds were higher for patients in the highest versus lowest hemoglobin A1c (OR = 2.49; 95% CI, 2.27-2.72) category; for those in the highest versus lowest body mass index categories (OR = 1.61; 95% CI, 1.45-1.79); for middle-aged patients (aged 45-64 y) versus those aged 18-26 y (OR =1.63; 95% CI, 1.33-2.00); and for patients being seen by a family versus an internal medicine physician (OR = 1.65; 95% CI, 1.22-2.22). We identified under-referral for men and highlighted other patient and health system factors associated with referral rates. Interventions to address bias in referrals and increase referrals for men at high risk for diabetes, not typically represented in DPP, are recommended.

Financial risk protection in private health insurance: empirical evidence on catastrophic and impoverishing spending from Germany's dual insurance system.

Financial risk protection from high costs for care is a main goal of health systems. Health system characteristics typically associated with universal health coverage and financial risk protection, such as financial redistribution between insureds, are inherent to, e.g. social health insurance (SHI) but missing in private health insurance (PHI). This study provides evidence on financial protection in PHI for the case of Germany's dual insurance system of PHI and SHI, where PHI covers 11% of the population. Linked survey and claims data of PHI insureds (n = 3105) and population-wide household budget data (n = 42,226) are used to compute the prevalence of catastrophic health expenditures (CHE), i.e. the share of households whose out-of-pocket payments either exceed 40% of their capacity-to-pay or push them (further) into poverty. Despite comparatively high out-of-pocket payments, CHE is low in German PHI. It only affects the poor. Key to low financial burden seems to be the restriction of PHI to a small, overall wealthy group. Protection for the worse-off is provided through special mandatorily offered tariffs. In sum, Germany's dual health insurance system provides close-to-universal coverage. Future studies should further investigate the effect of premiums on financial burden, especially when linked to utilisation.

Reprocessing and reuse of dialyzers: A technological solution for balancing cost and quality in lower and middle-income countries.

Hemodialysis is the commonest kidney replacement therapy (KRT) globally and rapidly growing in developing countries, while in developed countries it is reaching a plateau. The penetration of hemodialysis (HD) varies widely among countries and is largely influenced by socioeconomics, healthcare financing, particularly by government, local infrastructure, healthcare workforce, health system characteristics, and affordability of the population. Biomedical equipment, consumables, disposables, and labor are major cost drivers of KRT. Implementing strategies to balance cost and quality of care is an arduous task for health care planning, delivery, and patient care in low- and middle-income countries. In this context, the cost of dialyzers which form a significant component of the recurring cost of HD can be reduced by reuse after appropriate reprocessing. But this practice is largely abandoned in developed countries because of concerns of safety. However, the evidence against the reuse of modern dialyzers is not robust and certainly not based on well-designed randomized trials. The industrialization of dialysis delivery, the interests of equipment manufacturers and the nature of dialysis delivery have propelled single use of dialyzers. In this context, developing countries needing to expand HD services access at low cost are caught at crossroads. Process improvements are needed to standardize reprocessing that prioritizes safety while maintaining effectiveness. Recent advances in mobile and internet technologies could make this an achievable reality. We propose such an approach that would ensure treatment effectiveness, patient and healthcare provider safety, efficient resource utilization, and cost control.

Sex differences in lifetime prevalence of low back pain: A multinational study of opposite-sex twin pairs.

Low back pain (LBP) is more likely to occur in people with a family history of this condition, highlighting the importance of accounting for familial factors when studying the individual risk of LBP. We conducted a study of opposite-sex twin pairs investigating sex differences in LBP while accounting for (genetic and shared environmental) familial factors. We applied a matched co-twin control design to study 795 adult opposite-sex pairs from Australia, Spain, and the United States (US). We used mixed-effects logistic regression to assess the within-pair association between female sex and lifetime prevalence of LBP in unadjusted and adjusted models for body-mass-index, and depression, as well as interactions between female sex and age (<median age vs. ≥median age) in this association. The mean age of the sample was 47.4 years (Standard Deviation = 16.5). The adjusted odds ratio (aOR) of the association between sex and LBP in the merged sample was 1.11 (95% Confidence Interval = 0.88-1.40), with 87.4% of the variance in the studied association explained by between-site heterogeneity (Q test; p = 0.001). Females had 2.37 (95% CI: 1.48-3.78) higher odds of LBP compared to their male co-twins in the Spanish sample (adjusted), but a sex association was not found in the Australian nor US samples. We found no evidence of the association between sex and LBP in our merged sample. Between-population differences (i.e. cultural background or health system characteristics) are likely to be major factors leading to variation in the sex association with LBP when familial factors are accounted for. Our study of adult opposite-sex twin pairs found no evidence of an association between female sex and lifetime prevalence of low back pain after controlling for familial factors in the merged sample from Australia, Spain and USA, contrary to findings from previous studies of unrelated individuals. Our findings indicate potentially relevant between-country genetic, cultural and environmental differences which may need to be considered for optimal and individualized strategies for the prevention and management of low back pain across the lifespan.

Validity evidence and psychometric evaluation of a socially accountable health index for health professions schools

There is an expectation that health professions schools respond to priority societal health needs. This expectation is largely based on the underlying assumption that schools are aware of the priority needs in their communities. This paper demonstrates how open-access, pan-national health data can be used to create a reliable health index to assist schools in identifying societal needs and advance social accountability in health professions education. Using open-access data, a psychometric evaluation was conducted to examine the reliability and validity of the Canadian Health Indicators Framework (CHIF) conceptual model. A non-linear confirmatory factor analysis (CFA) on 67 health indicators, at the health-region level (n = 97) was used to assess the model fit of the hypothesized 10-factor model. Reliability analysis using McDonald’s Omega were conducted, followed by Pearson’s correlation coefficients. Findings from the non-linear CFA rejected the original conceptual model structure of the CHIF. Exploratory post hoc analyses were conducted using modification indices and parameter constraints to improve model fit. A final 5-factor multidimensional model demonstrated superior fit, reducing the number of indicators from 67 to 32. The 5-factors included: Health Conditions (8-indicators); Health Functions (6-indicators); Deaths (5-indicators); Non-Medical Health Determinants (7-indicators); and Community & Health System Characteristics (6-indicators). All factor loadings were statistically significant (p < 0.001) and demonstrated excellent internal consistency (ω\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\upomega$$\\end{document} >0.95). Many schools struggle to identify and measure socially accountable outcomes. The process highlighted in this paper and the indices developed serve as starting points to allow schools to leverage open-access data as an initial step in identifying societal needs.

Exploring the intersection between country context and priority setting to prevent maternal mortality: A multi-methods study comparing expected vs observed priorities in five countries to validate the obstetric transition model.

The obstetric transition model suggests that, as countries economically develop, the primary causes of maternal mortality change. Countries are assigned to one of five stages based on their maternal mortality ratio to identify priorities for reducing maternal deaths based on predominant determinants of mortality at each stage. We aim to validate the obstetric transition model using data from six diverse low- and middle-income countries representing self-identified priorities for improving maternal health and measurement compiled in a multi-stakeholder process. We used multiple data sources from Bangladesh, Cote d'Ivoire, India, Mexico, Nigeria, and Pakistan, which included secondary data on country context and primary data derived from two sources: the content of multi-stakeholder meetings, called National Dialogues, which were organised around the 11 key themes identified in the World Health Organization's "Strategies toward ending preventable maternal mortality" (EPMM) and follow-up key informant interviews conducted in five of the seven countries. We conducted the analysis in four phases examining, the country's contextual profile, mapping the key themes and indicators to the model, exploring stakeholder prioritisation, and examining reasons for divergence from the model. Our results suggest that the stages of the obstetric transition generally align with the social, epidemiological, and health systems characteristics that the model predicts to be associated with countries at each stage, with some deviation related to health system deficiencies and barriers to access. Stakeholder priorities in maternal health generally align with those predicted by the model. Equity and women's rights emerged as a priority throughout all stages, not only within countries that are more advanced in the transition, as predicted by the model. Deviations between the model's predictions and country-level prioritisation were often explained by context-specific challenges. This study is one of the first to validate the obstetric transition model using real data. Our findings support the validity of the obstetric transition model as a useful guide to aid decisionmakers in prioritising attention towards addressing maternal mortality. Country context, including equity, remains important to further inform priority-setting.

Health System's Role in Facilitating Health Service Access among Persons with Spinal Cord Injury across 22 Countries.

(1) Background: Despite efforts to improve access to health services, between- and within-country access inequalities remain, especially for individuals with complex disabling conditions like spinal cord injury (SCI). Persons with SCI require regular multidisciplinary follow-up care yet experience more access barriers than the general population. This study examines health system characteristics associated with access among persons with SCI across 22 countries. (2) Methods: Study data are from the International Spinal Cord Injury Survey with 12,588 participants with SCI across 22 countries. Cluster analysis was used to identify service access clusters based on reported access restrictions. The association between service access and health system characteristics (health workforce, infrastructure density, health expenditure) was determined by means of classification and regression trees. (3) Results: Unmet needs were reported by 17% of participants: lowest (10%) in Japan, Spain, and Switzerland (cluster 1) and highest (62%) in Morocco (cluster 8). The country of residence was the most important factor in facilitating access. Those reporting access restrictions were more likely to live in Morocco, to be in the lowest income decile, with multiple comorbidities (Secondary Conditions Scale (SCI-SCS) score > 29) and low functioning status (Spinal Cord Independence Measure score < 53). Those less likely to report access restriction tended to reside in all other countries except Brazil, China, Malaysia, Morocco, Poland, South Africa, and South Korea and have fewer comorbidities (SCI-SCS < 23). (4) Conclusions: The country of residence was the most important factor in facilitating health service access. Following the country of residence, higher income and better health were the most important facilitators of service access. Health service availability and affordability were reported as the most frequent health access barriers.

A game theory data science-based mechanism for licensed pharmaceutical products concerning their deterioration: a case of a micro, small, and medium enterprise in Iran.

One of the main characteristics of health systems and pharmaceutical supply chains is their significant costs in the public sector, which has forced governments and companies active in this field to find ways to reduce costs. In this paper, the deterioration of imported pharmaceutical items is investigated as one of the challenges of the supply chain of pharmaceutical firms. Specifically, the micro, small medium enterprise (MSME), and a collaborative strategy to reduce its costs is presented. The technical solution of the cooperative strategy is the formation of a partnership alliance between the foreign patent holder of brand drugs and a domestic manufacturer through an exclusive license contract in the local country. This leads to a significant reduction of costs in the distribution network of the pharmaceutical supply chain. On the other hand, supply chain management techniques in the cooperative strategy provide the necessary motivation for its practical implementation by splitting fair profits between producers and other members, namely local government, distributors, and pharmacies. For these purposes, a cooperative game theory-based contract is utilized to set the parameters of the license agreement, and then a profit-sharing mechanism is introduced that splits the benefits of cooperation among the supply chain members based on their afforded costs. The most important contribution of the current research is to propose an integrated framework that combines the logistics network models, valuation methods, and profit split mechanisms that embody more facts from real-world problems than separate models in this regard in previous studies. Moreover, results of the proposed strategy in the supply chain of a drug for thalassemia patients in Iran indicate the effectiveness of the proposed strategy in reducing costs and deterioration. Further, it is shown that the higher the ordering costs of the imported drugs, the lower the market share of the patent holder, and the lower the financing expenses of the cooperative alliance, the more efficient is the proposed strategy.