Inequalities In Access Research Articles

An Assessment of Provider Payment Mechanisms (PPMs) in Ethiopia: Implications for Redesign of PPMs and Progress Toward Universal Health Coverage

ABSTRACT Ethiopia has made great strides in improving population health but sustaining health system and population health improvements in the current fiscal environment is challenging. Provider payment, as a function of purchasing, is a tool to use limited health resources better. This study describes the design and implementation of Ethiopia’s provider payment mechanisms (PPMs) and how they influence health system objectives and contribute to universal health coverage goals. The research team adapted the framework and analytical tools of the Joint Learning Network for Universal Health Coverage guide for assessing PPMs. Data were collected through literature review and key informant interviews with 11 purchasers and 17 health care providers. Content analysis was used to describe PPM design and implementation arrangements, and thematic analysis was used to distill effects on equity in resource distribution and access to care, efficiency, quality of care, and financial sustainability. The study revealed the PPMs had positive and negative consequences. Line-item budgets were perceived to be predictable and sustainable but had little effect on efficiency and provider performance. Fee-for-service was perceived to have negative effects on efficiency and financial sustainability but viewed positively on its ability to incentivize quality health services. Capitation and performance-based financing effects were viewed positively on equity in distribution of resources and quality respectively, but both were perceived negatively on their high administrative burden to providers. Ethiopia may consider a more nuanced approach to design blended provider payment to mitigate negative consequences while providing incentives for better quality of care and efficiency.

Process of development of decentralised clinical trial methodology for cancer clinical trials in Aotearoa New Zealand

aim: To develop processes for the development of decentralised clinical trial methodology for Aotearoa New Zealand, focussing on equity of access to cancer clinical trials for Māori, Pacific people, vulnerable communities and those in rural settings. methods: A national steering committee supported by Te Aho o Te Kahu – Cancer Control Agency was formed to: guide the adaptation and implementation of overseas decentralised clinical trial models to suit the needs of Aotearoa New Zealand with an equity focus; provide high-level oversight and expertise for direction and development of policies, procedures and infrastructure compliant with ICH GCP R2; and implement a national strategy. results: Twelve standard operating procedures were developed, as well as a supervision plan and a glossary. These were made freely available on the New Zealand Association of Clinical Research website. conclusion: Decentralised clinical trials offer a novel method of trial conduct that is patient- and whānau-centred. The model allows patients to remain in their local area with whānau and support networks, and their local treating team, increasing clinical trial accessibility and quality of care. This methodology has the potential to support improvement in research capabilities nationally and be utilised beyond oncology. It would benefit from significant investment in national clinical trial infrastructure.

New insights from a Malaysian real-world deep brain stimulation cohort

Background The availability of deep brain stimulation (DBS), a highly efficacious treatment for several movement disorders, remains low in developing countries, with scarce data available on utilization and outcomes. Objective We characterized the DBS cohort and outcomes at a Malaysian quaternary medical center. Methods A retrospective chart review was done on DBS-related surgery at the University of Malaya, including clinico-demographic, genetics, and outcomes data focusing on post-operative medication reduction and complications. Results 149 Parkinson's disease (PD) patients underwent DBS targeting the subthalamic nucleus. Six had globus pallidus internus DBS (primarily for dystonia). Only 16.1% of patients were government-funded. Of the 133 PD patients operated in the past decade (2013–2022), 25 (18.8%) had disease duration <5 years. At 6–12 months post-DBS, median levodopa-equivalent daily dose (LEDD) reduction was 440.5 [418.9] mg/day, corresponding to a reduction of ≥50% and ≥30% in 42.2% and 69.8% of patients, respectively. LEDD reductions were larger in the early-onset and short-duration subgroups. Three patients (1.9% of 155) had symptomatic intracranial hemorrhage, resulting in stroke in two. Pathogenic monogenic or GBA1 variants were detected in 12/76 (16%) of patients tested, mostly comprising the “severe” GBA1 variant p.L483P (12%). Conclusions This is the largest report on DBS from Southeast Asia. The procedures were effective, and complication rates on par with international norms. Our study found a high frequency of GBA1-PD; and included a substantial number of patients with short-duration PD, who had good outcomes. It also highlights regional inequities in access to device-aided therapy.

Tanker trucks in Chile: from the normalization of an emergency to the commodification of water

ABSTRACT This article examines the institutionalization and normalization of one mode of water access – water tanker trucks – in rural communities in Chile. Our findings reveal four explanations for community acceptance of this socio-technical device: challenges in measuring nationwide tanker truck usage, the tanker truck as a symbol of state presence in marginalized areas, its integration into existing practices that do not challenge water policies and its combination with local strategies. The institutionalization and normalization of this ‘solution’ allows for the commodification of water and the continuation and deepening of inequalities in water access for domestic consumption.

Gatekeeping or Provider Choice for Sustainable Health Systems? A Literature Review on Their Impact on Efficiency, Access, and Quality of Services

As early as 1978, the World Health Organization set primary healthcare as the basis on which health systems should be built worldwide. However, the health systems of the different countries show considerable variations in terms of the implementation of gatekeeping from primary to secondary healthcare and direct access to specialists and hospital care. This literature review attempts to present the gatekeeping system with references to the UK, Sweden, the Netherlands, and Germany compared to the situation in Greece, where no gatekeeping system exists. Particular emphasis is placed on the impact of gatekeeping on the healthcare system’s efficiency, equity of access, and the quality of the services provided. Evidence on the effects of gatekeeping is conflicting or limited by the low internal validity. Making the right gatekeeping implementation decisions is difficult in the absence of data. High-quality research studies on health outcomes, clinical efficacy, cost-effectiveness, quality of life, healthcare quality, utilisation of healthcare services, the burden in the healthcare system, and the opinions of patients, physicians, and policymakers are all necessary for developing policy.

The Effectiveness of Digital Learning Platforms in Enhancing Student Engagement and Academic Performance

This review explores the factors influencing the effectiveness of digital learning platforms (DLPs) in enhancing student engagement and academic performance. It identifies key factors such as technological infrastructure, the role of instructors, and student characteristics, which significantly impact the effectiveness of DLPs. Technological infrastructure, including platform availability, network connectivity, and device requirements, plays a crucial role in ensuring accessibility and usability. The instructor's role in adopting active teaching strategies and providing personalized support is also essential for maximizing student success in digital learning environments. Furthermore, student characteristics such as prior knowledge, learning preferences, and technological proficiency influence their ability to engage with and benefit from DLPs. The review presents evidence from empirical studies, case studies, and meta-analyses that demonstrate the positive impact of digital platforms on student engagement and academic outcomes, particularly in blended learning environments. The discussion emphasizes the importance of personalized learning and the need for further research in areas such as cross-cultural comparisons, long-term effectiveness, and equity in access to technology. Recommendations for higher education institutions to optimize the use of DLPs and ensure equitable access for all students are also provided.

Geospatial Assessment of Healthcare Accessibility and Equity in Qatar in Preparation for the 2022 FIFA World Cup

Accessibility to healthcare is one of the significant components of social determinants of public healthcare and is integral to societies’ overall well-being and economic prosperity. This study intends to assess changes in spatial distributions and accessibility of healthcare services within Qatar for 2010–2020, specifically concerning preparation for the 2022 FIFA World Cup. Assessment of the healthcare infrastructure is made using various techniques within a Geographic Information Systems (GIS) framework, like kernel density estimation, network analysis, and proximity analysis. The results show that access to healthcare has significantly improved, especially in urban centers such as Doha, besides a significant reduction in the length one travels to access healthcare facilities. However, despite improvements, many areas outside Doha still lag, requiring further investment in strategic planning. This study underscores how effective the health policies in Qatar and the Qatar National Master Plan (QNMP) have been in furthering principles of equity in access to healthcare services. The policy implications are that healthcare service planning should be integrated with urban development and transport networks for sustainable improvement in healthcare access. Thus, investment in infrastructure, strategic planning of locations, and addressing residual disparities are crucial for the long-term healthcare equity and system resilience of Qatar’s healthcare system.

Inequalities in health and health-care accessibility among older people in China

Abstract While health inequalities among older people have long been a research focus and are now high on policy agendas in developed societies, they have often been neglected in less developed ones, despite them experiencing rapid population ageing since the turn of the century. Using data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) cohort study (N = 63,578), this paper measures the health status of older people using the Quality of Well-Being scale, and estimates time trends in health inequality with concentration indices, followed by an investigation of their social determinants. Its specific focus is health care accessibility (HA) in the period 2005–2018, when China experienced an unprecedented advance in health-related social policy reform. The analysis reveals pro-rich inequalities in health among older people, but also shows that these have narrowed gradually over the past two decades, which is largely attributable to greater equity in access to health care. Within this general trend of inequality reduction, however, the role of HA has declined and social determinants such as education now have an increasing influence on health inequalities. These findings suggest that social policies targeting not only health improvements among older people but also health inequalities earlier in the life course are required if policy makers want to promote health equity in later life.

AI, Personalized Education, and Challenges

Artificial Intelligence (AI) is gaining traction in education, with potential applications that range from personalized learning to automated administrative tasks. However, the integration of AI into educational systems is not without its challenges. This paper explores both the opportunities and obstacles that AI presents in the field of education, particularly through the use of Intelligent Tutoring Systems (ITS) and Adaptive Learning Management Systems (ALMS). These technologies aim to tailor learning experiences to individual students by analyzing data and adjusting content to suit their needs. While this personalized approach could enhance student engagement and comprehension, it relies on vast amounts of data, raising concerns about privacy and the potential misuse of personal information. Moreover, AI’s impact on education extends to supporting educators by providing insights into student performance and automating routine tasks. However, the effectiveness of AI systems in this regard remains questionable, particularly when considering the limitations in current AI models and the challenges of integrating them into existing educational frameworks. The risk of algorithmic bias is also a critical issue, as AI systems can inadvertently reinforce inequalities present in the data they are trained on, leading to unfair or discriminatory outcomes. Additionally, while AI promises to streamline certain aspects of education, there are concerns that over-reliance on technology could depersonalize the learning process. Human educators play a crucial role in fostering not only intellectual growth but also emotional and social development—elements that AI systems are currently unable to replicate. This paper argues that while AI holds significant promise in education, its deployment must be carefully managed, with attention to ethical considerations, equity in access, and the preservation of the human elements essential to effective learning. Addressing these challenges is key to ensuring that AI contributes meaningfully to education rather than exacerbating existing issues.

Comprehensive Analysis of The Role of Nursing in Promoting Healthcare Equity

Nursing's contribution to healthcare equity is a component of the continual transformation of healthcare systems worldwide. Nurses, being in the most direct touch with the patient and responsibilities involved in multiple activities related to patient care, are well poised to perceive and respond to inequalities in healthcare access, provision, and utilization. Hence, the following paper describes the extent of nursing involvement and contribution to advancing healthcare equity, especially amongst vulnerable groups. Each strategy focuses on exploring the theories that enhance nursing approaches to social determinants of Health, cultural competency, and approaches to advocacy for effective health equity. Further, it examines how nursing education, workforce diversity, policy reform, and nursing can improve equity within a healthcare system. These insights support further and sustained reform of the system and nursing advocacy movements working toward the development of equal care for all.

Controversies in implementing the exemption policy for the elderly healthcare services in Tanzania: experiences from the priority setting process in two selected districts

BackgroundHealth financing system in Tanzania changed in the early 1990s as a result of the introduction of cost-sharing policies by the 1990s health sector reforms. The reforms brought about user fees which has led to inequity in access to health care services and catastrophic health expenditure among the elderly. In efforts to reduce the inequity gap among vulnerable groups, in 1994, the government introduced an exemption and waiver policy. More than three decades later, inequity in health care services access has persisted with the elderly population being more affected. The latter poses questions on the implementation efficiency of the exemption policy. We aimed to assess the implementation of the exemption policy on access to health services among the elderly in Tanzania by learning from the experiences of the priority setting process in two districts of western Tanzania.MethodsAn exploratory qualitative case study adopting Key informant interviews (KIIs) was used to collect data in Nzega and Igunga districts. The key informants involved the representatives of the planning team and decision makers from the community, health facility and district level. Information saturation was attained after the 24th interview and thus data collection ended. The content analysis approach was used to analyse the data.FindingsAlthough there is a designated office that deals with exemptions for the elderly in health facilities, there are challenges in accessing health services. The challenges include insufficient drugs, some laboratory tests not covered by the exemption, a lengthy process to access service, poor financial mechanisms for exempted services, inadequate information and clarity of the exemption categories, and limited to no involvement of different stakeholders in the exemption process.ConclusionThe exemption policy was introduced to help disadvantaged groups, including the elderly. However, its implementation encountered challenges which burden both the elderly and the health facilities. Its implementation has thus become a controversy to its initial aim that was to relieve the elderly from high healthcare costs. Revisiting the policy through a thorough stakeholders’ engagement and establishing alternative financing of the exemption policy are recommended.

Water and wastewater infrastructure inequity in unincorporated communities

Uneven access to water and wastewater infrastructure is shaped by local governance. A substantial number of U.S. households lack adequate access and the U.S. is one of the few countries with large populations living outside of city bounds, in unincorporated areas. Few studies address how infrastructure services and local governance are intertwined at a regional scale. We examine the connection between incorporation status and access to centralized infrastructure, using negative binomial regression. A novel dataset informs this analysis, comprised of 31,383 Census block groups located in nine states representing over 25% of the national population. We find evidence that inequities in access are associated with unincorporated status and poverty rates. Sewer coverage rates are significantly lower for unincorporated communities in close proximity to municipal boundaries. Infrastructure equity could be improved by targeting high-poverty unincorporated communities, addressing challenges with noncontiguous service areas, and strengthening regional water planning and participatory governance.

The emergence of citizen collectives for care: the role of social cohesion

BackgroundAgeing populations and the ability to cure an increasing number of ailments put pressure on the health care sector. Meanwhile, care institutions retreat from rural areas and some governments emphasizes the need for citizens to find informal care primarily in their own social network. In The Netherlands, citizens increasingly respond by coming together to organize (in)formal care among themselves in ‘care collectives’. However, little is known about the conditions that need to be met for such collective action to develop, and explanations that go beyond an individualist perspective are particularly lacking. In this study, we aim to fill this gap, and specifically argue for the potential role of social cohesion to facilitate collective action among citizens through fostering a social identity, and through the prevalence of social relations that facilitate reciprocity and mutual trust among citizens. We further test whether these relations vary between municipalities, and whether they depend on the necessity for care services.MethodsWe obtain data on the location of care collectives from an extensive Dutch inventory and match it to register data from Statistics Netherlands from 2020. We create measures for neighborhood attachment and contact using the ‘ecometric approach’. We test our hypotheses with multilevel logistic regression models and multilevel event history analysis for a subset of the data that can be analyzed longitudinally.ResultsWe find evidence for a positive association between neighborhood attachment and the emergence of a care collective, which is stronger if the necessity for care is higher. We do not find a relation between neighborhood contact and care collectives, nor do we find evidence that these relations vary between municipalities. We cannot replicate our positive associations in the longitudinal model, and thus remain reserved about their causal interpretation.ConclusionsThere is considerable variability in the extent to which neighborhoods organize care services collectively. Partly, this may be attributable to differences in the prevalence of neighborhood identity, which would imply that an increasing reliance on citizen collectives may increase inequality in access to healthcare. Further research should emphasize combining community-level information with data on individual participation in care collectives to delve deeper into the dynamics of invitation, representation and embeddedness than current data allows.

Inequalities in accessibility to daily opportunities in the metropolitan region of Belo Horizonte (Brazil)

Despite the historical core-periphery urbanization pattern marked by profound inequalities in Latin American cities, the emergence of new suburban structures may introduce more complex dynamics of accessibility. In this study, we conduct a novel investigation into inequalities in accessibility to non-work urban opportunities in the Metropolitan Region of Belo Horizonte (MRBH), utilizing a combined analysis of a cumulative opportunity accessibility indicator and population distribution to assess both social and spatial discrepancies. The findings reveal that low-income households experience significantly lower accessibility to urban opportunities, while the development of new suburban structures results in high accessibility levels in high-income neighborhoods. These results highlight two contrasting processes of segregation: low-income groups being displaced to distant peripheral areas with limited accessibility, while high-income groups settling in low-density residential developments with abundant motorized accessibility to nearby opportunities.

Geographic Variation in Prosthesis Prescription Disparities Between White and Black Veterans After Major Lower Limb Amputation: A Retrospective Cohort Analysis: Geographic Variation in Lower Limb Prosthesis Prescription Disparities.

To examine racial disparities in lower limb prosthesis (LLP) prescription practices between White and Black Veterans across different geographic levels within the United States Veterans Health Administration (VHA) and explore how racial disparities in LLP prescription practices differ by amputation level. Retrospective cohort study. VHA facilities across the United States. A total of 12,143 White and 4,711 Black Veterans who underwent major lower limb amputation between 2010 and 2022 in a VHA facility, including 4,885 with transfemoral amputations (TFA) and 11,969 with transtibial amputations (TTA). Not applicable. Age-standardized percentage point (pp) differences in LLP prescriptions between White and Black Veterans within 12 months post-amputation, analyzed at national, regional, and Veterans Integrated Service Network (VISN) levels. A positive pp difference indicates a racial disparity, meaning a higher proportion of White Veterans were prescribed LLPs compared to Black Veterans. Nationally, 54.5% of Veterans received an LLP prescription within 12 months post-amputation, with the age-standardized pp difference in LLP prescriptions favoring White Veterans by 5.06 pp (95% CI: 2.51, 7.61). Regional analysis revealed variations, with the Continental region showing the largest disparity (9.10 pp; 95% CI: 4.48, 13.71) and the Pacific region the smallest (3.27 pp; 95% CI: -3.87, 10.42). The VISN-level analysis uncovered greater variations, ranging from -9.26 to 14.54 pp. Disparities were more pronounced for Veterans with TFA (5.25 pp; 95% CI: 1.91, 8.59) compared to TTA (4.52 pp; 95% CI: 1.54, 7.50). Significant geographic variations exist in racial disparities for LLP prescriptions across the VHA, with most areas favoring White Veterans. Disparities were more pronounced for Veterans with transfemoral amputations, highlighting the need for targeted interventions to improve equity in access to prosthetic care, especially for Veterans with more proximal amputations and in regions and VISNs with the largest disparities.

Smart Response: Leveraging AI Analytics for Enhanced Disaster Resilience

The emergence of artificial intelligence and cloud computing has transformed modern disaster response capabilities, particularly by developing sophisticated real-time analytics systems for natural disaster management. This article examines the integration of AI-powered analytics platforms that synthesize data from multiple sources, including satellite imagery, meteorological stations, and social media streams, to enable rapid response during crises. This article demonstrates that cloud-based real-time analytics substantially enhance early warning systems and optimize resource allocation during disaster events while significantly improving response times compared to traditional methods. However, these technological advances raise important ethical considerations regarding data privacy and equity in access to digital resources. The findings suggest that AI-driven disaster response systems offer unprecedented capabilities in protecting communities. However, their implementation must be guided by robust frameworks that ensure equitable access and maintain privacy standards while maximizing public safety benefits.

Stigma and lack of access to quality healthcare in the transgender population.

More than 1.6 million US adults identify as transgender (that is, a gender different than the one traditionally associated with the biologic sex assigned to them at birth). These patients suffer from healthcare inequity and lack of access to healthcare, causing a public health crisis. This article seeks to raise awareness of this issue and encourage clinicians and healthcare systems to make meaningful changes to reduce healthcare stigma for transgender patients.

A review of health equity considerations in Cochrane reviews of lifestyle interventions for cardiovascular health in adults

ObjectiveCardiovascular disease (CVD) is the leading cause of global disease burden and rising healthcare costs. Systematic reviews (SRs) rigorously evaluate evidence on health interventions' effects and guide personal, clinical, and policy decision-making. Health equity is the absence of avoidable and unfair differences in health between groups within a population. Assessing equity in lifestyle interventions for cardiovascular health is important due to persisting health inequities in CVD burden and access to interventions. We aim to explore how health equity considerations are addressed in Cochrane SRs of lifestyle interventions for cardiovascular health. Study Design and SettingThis is a methodological review of Cochrane SRs of lifestyle interventions for cardiovascular health using the PROGRESS-Plus framework. PROGRESS-Plus stands for Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, and Social capital, while “Plus” stands for additional factors associated with discrimination and exclusion such as age, disability, and comorbidity. Using predefined selection criteria, two authors independently screened all Cochrane reviews published in the Cochrane Database of Systematic Reviews between August 2017 and December 2022. PROGRESS-Plus factors in the SRs were sought in the Summary of Findings (SoF) table, Methods/Inclusion criteria, Methods/Subgroup analyses, Results/Included studies, Results/Subgroup analyses, and Discussion/Overall completeness and applicability of evidence. ResultsWe included 36 SRs published by 10 Cochrane groups, addressing 11 health conditions with mostly dietary and exercise interventions. The most common PROGRESS-Plus factors assessed were gender/sex, age, and comorbidity. PROGRESS-Plus factors were most addressed in the inclusion criteria (64%), the discussion (75%), and the included studies (92%) sections of the SRs. Only 33% of SoF tables referenced PROGRESS-Plus. Sixty-nine percent of the included SRs planned for subgroup analyses across one or more PROGRESS-Plus factors, but only 43% of SRs conducted subgroup analyses, suggesting limited reporting of PROGRESS-Plus factors in primary studies. ConclusionsEquity factors are not sufficiently addressed in Cochrane reviews of lifestyle interventions for cardiovascular health. Low reporting of PROGRESS-Plus factors in implications for practice and research sections of Cochrane SRs limit equity focused guidance for current clinical practice, public health interventions and future research.

Creation of the Indigenous Support Line for health system navigation and culturally safe access to care: a quality improvement project

Indigenous Peoples face inequities in health and healthcare access due to colonial history and systems. To work towards the Truth and Reconciliation Commission of Canada’s Calls to Action and the...

Fishing or farming? Isotopic evidence of human subsistence strategies at the Dashuitian site during the middle Neolithic in the Three Gorges of the Yangtze River, China

The Three Gorges of the Yangtze River, with its deep canyons, abundant freshwater resources, and unique geographic location at the crossroads in the spread of rice-millet agriculture in the Middle Neolithic, is of great significance for understanding the interaction between fishing-hunting-gathering and farming in inland freshwater environments. However, few direct evidence for human subsistence strategies had been published in this region. This study presents results of carbon and nitrogen stable isotope analyses on human bones, animal and millet remains from the Dashuitian site (c. 6000–5500 BP) in the Three Gorges of the Yangtze River, China, to investigate the diet and subsistence and intrapopulation dietary variations in this region. The results indicate that the humans at the site consumed mostly freshwater fish foods and supplemented by terrestrial animals, with no discernable input from millets. They had consistently relied on a fishing, hunting, and gathering economy during the occupation of the site in the Middle Neolithic (c. 6000–5500 BP), differing from humans in other areas especially along the rivers and coasts of the lower Yangtze River valley for the roughly same period, further showing the extensive utilization of and adaptation to the available environmental resources. In addition, intrapopulation dietary variations based on burial style and sex provide evidence that differentiation and inequality, at least regarding to food consumption, existed at the Three Gorges region during the Middle Neolithic. Here, our findings provide isotopic evidence about the Middle Neolithic human subsistence strategies in the Three Gorges of the Yangtze River, providing a glimpse into the complexity related to inequality in food access among fisher-hunter-gatherers in inland areas, and new insights into understanding past human-environment interactions.