Dropout from the pentavalent vaccine series among children aged 12-23months in the Central African Republic: prevalence, associated factors, and caregiver-reported barriers.

The effects of EU accession process and firm investment dynamics on Western Balkans sustainable economic growth.

Existing evidence suggests that mortality remains disproportionately high across Africa, where gains in life expectancy continue to lag behind global progress. While health financing is central to health-system performance, its relationship with mortality in African settings remains insufficiently characterized, particularly when public spending, household out-of-pocket (OOP) payments, governance conditions, and demographic pressures are considered jointly. Our objective was to use a non-linear regression method to evaluate how health financing structures are associated with mortality and whether the association depends on the mode of financing. We use generalized additive mixed models (GAMMs) to allow for potential non-linear relationships between crude mortality rates and public health expenditure, out-of-pocket payments, political stability, and age dependency across 51 African countries from 2002 to 2022 (N = 1,071 country-year observations). A tensor-product interaction assessed whether financial protection modifies the effect of public health spending. Region-specific models were fitted for Central, East, West, Southern, and Northern Africa. Public health spending was associated with lower mortality across Africa, with the steepest reductions below approximately US$80 per capita and diminishing returns thereafter. Out-of-pocket (OOP) spending modified these returns: OOP burdens below 15% of total health expenditure strengthened the estimated mortality benefit of public investment by about 60%, whereas burdens above 40% substantially eroded it. Regionally, the spending-mortality association was strongest in Central, Eastern, and Western Africa, but weaker in Southern and Northern Africa, where age dependency and governance quality were more prominent predictors. The expenditure-OOP interaction was most pronounced in Eastern Africa (EDF = 9.45, F = 4.45, p < 0.001). The continent-wide model showed strong explanatory performance (adjusted R2 = 92.8%; deviance explained = 93.4%; N = 1,009). Increasing public health spending alone is unlikely to maximize mortality gains in Africa. Its impact depends on financial protection: reducing household out-of-pocket costs through pooled financing should be accompanied by expanded public investment. In Southern and Northern Africa, policy emphasis should also shift toward governance efficiency and demographic pressures. Subregion-specific strategies are therefore essential.

ABSTRACT The article examines the position of Yemenite Jews under Ottoman rule between 1872 and 1914 through three interconnected themes: relations, networks, and migration. Drawing primarily on underutilized Ottoman archival sources, the analysis examines changes in the social, legal and political conditions of the Jewish community following the re-establishment of Ottoman authority in Yemen. The present study places particular emphasis on the analysis of Ottoman correspondence, with a view to exploring interactions with Zaydi Muslim communities and provincial authorities, as well as contacts with European Jewish organizations. The text further explores the phenomenon of migration to Palestine, contextualizing it within the broader geopolitical landscape, marked by instances of political instability, economic hardship, and prevailing security concerns.

ABSTRACT Journalists’ safety and security are real concerns for many countries, specifically in developing countries, where political instability and internal conflicts have been pervasive. This article explores how journalists’ identities could be the cause of their repression in a conflict-prone country such as Ethiopia. The article used qualitative and quantitative approaches to collect data from 2020 to 2024, during which ethnically driven internal conflicts have been prevalent in the country. Questionnaires were distributed to 180 journalists working in private, public, and digital media, and interviews were carried out with 20 senior media practitioners. The results indicated that journalists in Ethiopia are facing severe harassment and intimidation coming from not only the government but also non-state actors. The results also indicated that journalists confirmed that reporting/framing the current internal conflict as ethnic conflicts, as well as their ethnic identities, are the main causes of their repression, which could have repercussions on the journalism profession and on ensuring freedom of expression.

The full-scale invasion of Ukraine by the Russian Federation in 2022 led to a significant reduction in the availability of medical services in Ukraine due to the disruption of healthcare facilities. It included the destruction of facilities restrictions on operations in life-threatening situations and a lack of electricity, water and heating. Staff shortages were also a factor, due to the death or forced migration of medical workers. The war has disrupted vital public health processes, including vaccination programmes, sanitation measures, and epidemiological surveillance. It has also negatively impacted the physical and mental health of the population, resulting in an increased premature and avoidable mortality. In the post-war period, Ukraine will inevitably face the consequences of damaged infrastructure and depleted resources. Drawing on the experience of other countries will therefore be essential for rebuilding the healthcare system and shaping effective demographic policies. Therefore, the experience of the countries of the former Yugoslavia, which underwent a series of armed conflicts between 1991 and 2001 is relevant for Ukraine. This article aims to summarise the conclusions of scientific publications on specific programmes and reforms implemented in the healthcare systems in countries of the former Yugoslavia were that affected by armed conflict at the end of the 20th century. It also aims to identify common reasons for the greater or lesser effectiveness of healthcare system reforms in these countries, and to seek and formulate applicable experiences for Ukraine. This study employed a systematic search of the PubMed and Web of Science bibliographic databases, as well as Google Scholar, to identify academic publications based on criteria relating to the study’s objectives and the comprehensiveness of the reform analysis. A content analysis of the legal frameworks of countries in the former Yugoslavia was also conducted. It has been found that successful healthcare reforms shared several features: compulsory health insurance, a focus on primary healthcare strengthening, and targeted national programmes for preventing and treating non-communicable diseases. Slovenia’s experience has demonstrated that transitioning to social insurance, improving primary care, and implementing consistent policies on non-communicable diseases can reduce mortality long-term. It has been shown that in countries where reforms have not yielded the expected results, they were characterised by chronic underfunding, inefficient resource allocation, a lack of substantial organisational change, the persistence of informal payments, and the emigration and displacement of medical staff. High mortality rates from avoidable causes suggest a combination of inadequate investment and poor communication with the population regarding prevention and timely access to care. Frequent changes in leadership in the healthcare sector, alongside political instability, have created additional obstacles to strategic development. Based on an analysis of the experience of post-war healthcare reforms in the countries of the former Yugoslavia, the following recommendations can be proposed for Ukraine: the fastest possible restoration of universal healthcare coverage with an emphasis on primary care; effective cooperation between the central government, local authorities and domestic professional associations in the process of rebuilding the healthcare system; timely and reasoned initiation of requests for assistance from international donors, and the rational use of this assistance; organisation of effective physical and psychological rehabilitation measures; development and implementation of public awareness campaigns on health issues and personal responsibility for own health.

Aim and background: Despite the cultural importance and unifying role of football, the sport faces significant obstacles, including political instability, inadequate infrastructure, and financial constraints. This study aims to identify the main challenges limiting the growth of football in Iraq. Methodology: This study used a qualitative approach, involving semi-structured interviews with 20 football-related individuals. That means the number of participants was 20 people involved in Iraqi football. The minimum duration of the interview was 23 minutes, and the maximum was one hour and seven minutes. The research group included Iraqi Football Association officials, parliament members, sporting directors, coaches, administrators, referees, and former national team players. Objective analysis is used to analyse data through the use of targeted modelling, which uses a six-step objective analysis method (Braun and Clarke 2006). resulting in the identification of 35 codes grouped into seven main themes derived from the data. Results: The findings reveal political interference in sports governance, unstable management practices, insufficient budgets, poor organizational structures, underdeveloped infrastructure, and fundamentally weak participation. These challenges are interconnected, worsening governance weaknesses that, in turn, intensify financial and developmental issues. Conclusion: The study concludes that Iraqi sport faces complex, systemic obstacles. Iraqi football suffers from issues related to governance and resource management. Reforms should prioritize transparent leadership, diversified funding, infrastructure investment, and fundamental development to achieve sustainable growth and competitive success. To improve these efforts, challenges should be assessed using the SPLISS model and reformulated accordingly.

ABSTRACT Fish farming is a part of the agricultural sector that provides economic, social, and ecosystem functions that are important for reducing food and nutrition insecurity for the poorest and most marginalized groups around the world and particularly crucial for poverty reduction in African countries. While many studies are preoccupied with developed countries, there is less research focusing on Sub‐Saharan Africa. In Ethiopia, research on the governance of fishing management is relatively scarce. Therefore, this study aimed to analyze the implications of environmental governance for fishing management. Purposive and convenience sampling were used to select respondents. Survey data were collected from 180 fishers, with three key informants. Principal component analysis (PCA) and factor analysis (FA) were used to analyze the quantitative data. The results show a low level of environmental governance practices in the two study areas, a lack of attention to the fishing sector, political instability being the major challenge in one of the study areas, top‐down governance approach, and fishing as a characteristic of poverty. We argue that strong political drive, capacity, and stability are crucial for effective environmental and governance. Interactive governance of natural resource systems, adaptive and collaborative environmental governance are needed to promote sustainable fishery management across Africa. Insights from this study can contribute to the implementation of a new framework for future sustainable fishing management. The proposed framework critically engages with the challenges and interventions that are needed to positively influence fishing management and can fill current geographical and topical research gaps.

The post-2000 period in South America presents a striking divergence in malaria epidemiology: Ecuador achieved a >99% reduction in malaria incidence approaching elimination, while Venezuela experienced one of the most severe resurgences in modern public health history. We examined the association between governance factors, health policies, intersectoral coordination, and malaria control outcomes by comparing the national experiences of Ecuador and Venezuela. We conducted a comparative ecological study using epidemiological data from WHO World Malaria Reports and PAHO updates (2000-2023), integrated with political stability indices, health expenditure data, GDP per capita, poverty rates, and crude-oil price series from World Bank and CFR databases. A joinpoint (segmented) regression model was applied to each country's log-transformed malaria incidence time series to identify statistically significant inflection points and estimate annual percentage change (APC) per segment. A multi-dimensional framework assessed governance, health-system capacity, surveillance infrastructure, intersectoral coordination, and community engagement. We also examined systemic fragility through concurrent infectious disease trends (diphtheria, measles, tuberculosis) in Venezuela. Use of AI language models is declared in the Methods. Ecuador reduced cases from 106,641 (2001) to 757 (2023), a 99.3% reduction. The joinpoint model identified two significant inflection points (2008, 2014) delineating three phases of declining trend (APC: , , ). Venezuela experienced a 1,217% increase from 35,500 (2000) to a peak of 527,627 (2018); a single joinpoint at 2014 marked a shift from non-significant endemic transmission (APC: , ) to explosive resurgence (APC: , ), temporally coinciding with the global crude-oil price collapse and ensuing fiscal contraction. Post-2018 case declines in Venezuela are accompanied by concurrent surveillance collapse, mass emigration, and reduced care-seeking, suggesting underreporting rather than epidemiological improvement. Pearson correlations with malaria incidence were observed for political stability index (), health expenditure (% GDP, ), poverty rate (), and crude-oil price () in Venezuela. These correlations should be interpreted with caution given potential confounding and collinearity among indicators. Comparison across five governance-resilience domains using PAHO/WHO operational criteria shows systematic differences between countries. Resurgence of diphtheria (>1,600 cases), measles (>7,300 cases), and tuberculosis (near-doubling of incidence) in Venezuela occurred concurrently with the malaria resurgence. Health-system resilience and governance quality appear to be associated with the relationship between macroeconomic shocks and epidemiological outcomes. The strong collinearity between political stability and commodity-price cycles in Venezuela precludes definitive attribution to either factor independently. Technical interventions may be insufficient without stable governance, protected financing, and institutional continuity. Recommendations aligned with the PAHO malaria elimination framework are provided.

Timor-Leste's immunization journey: progress, challenges, and the road to IA2030 a viewpoint on leaving no child behind.

Achieving universal health coverage is a key component of the Sustainable Development Goals, focusing on equitable access to quality health services and minimising financial hardship. While strategies often target the demand-side, supply-side barriers such as travel time and facility-level constraints are often overlooked. Accurately quantifying who is affected by these barriers and identifying their locations and specific barriers is critical to improving service delivery. This study examines these barriers in Mali, a country with significant health system challenges exacerbated by high fertility rates and political instability. Using the WHO’s Health Resources and Services Availability Monitoring System, we conduct an analysis of the geographic accessibility of antiretroviral therapy (ART) services. Our aim is to estimate the number of people affected by supply-side barriers by using a geographic accessibility model that calculates travel time to facilities with ART services. The analysis applies a least-cost path algorithm to assess accessibility, where ART services are defined as accessible within 2 hours travel time. People within this range with available services have access while those outside are geographically constrained. For those within 2 hours but without ART access, we identified and quantified facility-specific barriers. The results show that nearly 2.7 million Malians do not have timely access to ART within 2 hours. For about 70%, distance is the main barrier, while the rest face facility-level issues such as the fact that the service is not being planned in the facility, lack of medical supplies and lack of training. This study offers important insights for targeted interventions to scale up ART provision and provides a scalable model for other health services and contexts.

Yemen's health system has faced prolonged shocks, including war, epidemics, and COVID-19, challenging both governance and resilience. This study examines how formal governance structures and institutional capacities shaped the system's ability to anticipate, absorb, adapt, learn, and transform across a decade of crisis (2014-2025). We conducted a longitudinal qualitative analysis based on interviews with health system leaders and technical actors. Using a resilience-capacity framework, we analyzed governance functions across four phases: pre-conflict period (pre-2014), conflict escalation (2015-2019), COVID-19, and the post-pandemic period. Data were thematically coded and interpreted through the sequential resilience lens of preparedness, absorption, adaptation, learning, and transformation. Participants consistently described a health system with intact formal governance structures but fragile functional capacity. Pre-2014 governance was administratively stable yet centralized and poorly prepared for shocks. During the conflict, preparedness collapsed amid fragmented authorities, and absorptive capacity relied heavily on donor-driven service delivery. COVID-19 triggered temporary improvements in coordination and emergency response, but these were largely ad hoc and poorly institutionalized. Post-pandemic, preparedness remained procedural, absorptive capacity weakened as external funding declined, adaptive measures persisted in localized and reversible forms, and transformative governance remained constrained by political instability and weak enforcement. Digital "workaround governance," including WhatsApp-based coordination, facilitated rapid decision-making but highlighted gaps in formal systems and accountability. Across phases, learning was fragmented, donor-driven, and rarely institutionalized, limiting system-wide reform. Yemen's experience demonstrates that maintaining formal governance structures does not guarantee health system resilience. Sustainable resilience requires institutionalized preparedness, domestic contingency financing, integration of adaptive innovations, and embedding learning into routine governance. Efforts to strengthen health systems in fragile and conflict-affected settings must address governance, capacity, and political economy simultaneously to move beyond reactive crisis management toward transformative change.

Constitutional design plays a major role in the accommodation of diversity in plural and divided societies. This article examines the measures taken to accommodate diversity in the Independence Constitution of Mauritius and discusses their implications towards nation-building in postcolonial Mauritius. Mauritius has a plural society composed of the descendants of migrants and the population is divided along ethnic, linguistic, religious, caste and class lines. During the decolonisation process, the main challenge was to balance identity with political interest in order to avoid conflict. The Independence Constitution crafted by the British was the result of negotiations between different political, ethnic and religious groups, with the main point of contention being identity and representation in independent Mauritius. Yet, postcolonial Mauritius became one of Africa’s success stories in terms of sustained democracy, political stability and economic growth. The article argues that while the measures taken to accommodate the diversity of the Mauritian population into the Constitution have contributed to state-building, they have frozen identities in a changing society and thereby not promoted nation-building in the postcolonial era.

This article analyzes the current situation, characteristics, and emerging issues of religious life in Vietnam’s land border areas. The analysis is based on statistical data and field surveys conducted in several border provinces, with representative case studies from Điện Biên, Gia Lai, and An Giang. The findings indicate that religious life in these regions has undergone notable transformations in the context of economic reforms, international integration, and the increasing expansion of inter- and trans-border relations. Major religions such as Buddhism, Catholicism, Protestantism, Hòa Hảo Buddhism, and Caodaism, together with several religions associated with ethnic minority communities \- such as Khmer Theravada Buddhism and Islam \- form a diverse yet unevenly distributed religious landscape across different regions. The article also devotes significant attention to identifying emerging challenges and pressing issues in contemporary religious life, particularly those related to religious security, the exploitation of religion for political purposes, and certain limitations in the implementation of religious policies and laws. On this basis, the author proposes several policy recommendations to strengthen capacity to ensure religious security and to reinforce political and security stability in border areas, thereby contributing to social stability and the sustainable development of Vietnam’s border regions

Deaf people experience significant barriers to education, healthcare, employment, and information access, resulting in inequities across a myriad of contexts. To better understand these disparities, our all-deaf research team conducted semi-structured interviews with deaf and hearing (parents, caregivers, and educators) adults across Ecuador, exploring how structural, institutional, and social factors influence daily life and well-being. Participants (n = 36) described systemic exclusion from education and employment, limited access to interpreters and assistive technologies, and constrained autonomy due to insufficient family support and institutional resources. These barriers compound health risks by restricting access to care, information, and social participation. Participants' narratives highlighted how political and economic instability, institutional neglect, and discrimination create structural vulnerabilities that extend beyond individual-level factors. Findings underscore the importance of public health interventions that address structural and communicative inequities, including inclusive education, accessible health services, and community-based support, to improve health equity and quality of life for deaf populations in Ecuador.

ABSTRACT This article uncovers a convention on foreign judgments, negotiated between Britain and Italy in 1887. The Prime Minister, Lord Salisbury, saw it as ‘the most practical first step towards the attainment of complete uniformity’: proof that the civil and common law worlds could agree on common private international law rules. It was Britain’s first such agreement with a civil law country, half a century before much narrower agreements with France and Belgium. It remained unratified amid Italian political instability and perceived German influence (similar concerns scuppered negotiations in the 1930s). The convention was the high-water mark of British attempts to take a leading role in pan-European codification. By the 1890s, under Dicey’s influence, Britain had abandoned its grand ambitions for a truly global regime. The common law was left to its own devices for another generation, with Britain standing aloof from the codification projects it had once sought to lead.

Stroke is the second leading cause of global disability with the majority of stroke-related disabilities occurring in low- and middle-income countries. In Myanmar, ongoing political instability and healthcare disruption have further limited access to stroke rehabilitation services. This study evaluated a contextually tailored continuing professional development program designed to strengthen evidence-based stroke rehabilitation knowledge, skills, and clinical implementation among physiotherapists in Myanmar. This mixed methods, quasi-experimental study used convenience sampling to recruit rehabilitation professionals participating in a blended learning stroke rehabilitation program in Myanmar. The program combined online coursework, synchronous mentoring, and in-person clinical skills training. Training effectiveness was evaluated using the Kirkpatrick Model across the domains of reaction, learning, behavior, and results. Participants completed pre-training, post-online, post-in-person, and six-month follow-up surveys assessing self-perceived knowledge, skills, and implementation of evidence-based stroke rehabilitation techniques. Quantitative data were analyzed using Kruskal-Wallis and Mann-Whitney U tests with Bonferroni correction. Focus group interviews were conducted six months following training and analyzed using thematic analysis. Quantitative and qualitative findings were integrated during interpretation to better understand implementation within the Myanmar context. Ethical approval was obtained from the Johns Hopkins Bloomberg School of Public Health Institutional Review Board. Seventeen rehabilitation professionals participated in the online training and 16 physiotherapists completed the in-person clinical skills component. Seven participants participated in focus group interviews six months later. Participants demonstrated significant improvements in self-perceived knowledge and skills related to evidence-based stroke rehabilitation, particularly for interventions requiring minimal equipment. Follow-up surveys indicated integration of evidence-based assessment and treatment approaches into clinical practice. Qualitative findings contextualized these changes and identified four themes: challenges in rehabilitation perception, need for enhanced training in fine motor skills, resourceful adaptation of techniques for low-resource settings, and the importance of a learning community. Integrated findings demonstrated that participants adapted evidence-based rehabilitation concepts using locally available resources and peer support networks. Contextualized training approaches emphasizing adaptability, peer learning, and resource-conscious implementation may support the application of evidence-based stroke rehabilitation practices in LMICs affected by workforce and health system constraints.

Population ageing in Myanmar is occurring amid prolonged political instability and civil war, exacerbating social isolation and vulnerabilities among older adults, particularly in rural areas. While digital technologies have the potential to support social cohesion, little is known about how older adults in conflict-affected rural Myanmar access and use these tools, the barriers they face, and the strategies they adopt to cope with digital exclusion. This qualitative study was conducted in rural communities in Kayin State, southeastern Myanmar. Semi-structured in-depth interviews were conducted with 30 older adults aged 60years and above in rural Kayin State, Myanmar. Due to security concerns in the conflict setting, all interviews were conducted online via Zoom. Guided by the Socioecological Model and Stress and Coping Theory, data were thematically analyzed to explore patterns of digital technology use, multi-level barriers, and coping strategies related to social connection during the ongoing civil war. Older adults primarily used mobile phones and social media platforms especially Facebook to maintain contact with family members, access information, and support emotional well-being during periods of conflict. These technologies facilitated intergenerational communication, reduced feelings of isolation, and enabled access to timely information related to security and daily living. However, their contribution to social cohesion was often limited by significant barriers, including low digital literacy, financial constraints, unstable electricity and internet connectivity, age-related physical limitations, and concerns about surveillance and phone signal and internet restrictions following the 2021 military coup. Despite these challenges, participants adopted adaptive coping strategies such as relying on family support, sharing devices, and selectively using familiar or low-cost platforms, relocating to access the signals, and adjusting communication practices to avoid surveillance risks. Digital technologies provide a limited but meaningful contribution to sustaining social cohesion among older adults in rural, conflict-affected Myanmar by supporting communication, emotional connection, and access to information. However, their contribution remains uneven, as structural inequalities, political constraints, and infrastructural limitations continue to restrict equitable access. Addressing these challenges requires context-sensitive, age-appropriate digital inclusion strategies, alongside sustained investments in rural connectivity and community-based support, to strengthen social connectedness and well-being among older adults in protracted crisis settings.

The Tigris and Euphrates rivers and their tributaries are the lifeline of Iraq and parts of Syria, and they are significant water resources in Türkiye and Iran. Iraq is known in historical texts as the land between two rivers, or Mesopotamia, which illustrates the importance of the rivers to this country. Recent hydraulic structures in upstream states, along with climate change factors, have caused interruptions to the flow of the rivers and reduced their waters, thereby creating a huge water deficit in downstream Iraq. This paper reviews the profound significance of the rivers for Iraq. It argues that state sovereignty, political instability, and increasing fluctuations in precipitation because of climate change pose considerable challenges to the natural flow of the rivers, making short-term bilateral solutions more practical.

Colonialism has left an enduring and profoundly detrimental legacy on the socioeconomic and health landscape of formerly enslaved nations across Africa, Asia, the Americas, and the Caribbean. The repercussions of colonial rule continue to manifest in persistent economic disparities, political instability, and inadequate healthcare infrastructures. Despite the profound and lasting effects of colonial exploitation, discussions on reparations remain limited in both scope and urgency. Addressing historical injustices is not merely a matter of historical reflection but an ethical and moral obligation. Among the various forms of reparations, such as financial restitution, debt relief, and public apologies, investment in public health systems stands out as a sustainable and impactful approach. Targeted public health investment can serve as a powerful mechanism for redressing colonial injustices and bridging the development gap between former colonial powers and their once-subjugated nations.