In South-East Asia, government implementation of policies recommended for addressing unhealthy diets has generally been slow and fragmented, largely due to food industry opposition and a lack of effective cross-sectoral coordination and policy action. To help government policy-makers and other interest-holders address these issues, this study aimed to identify key arguments that undermine implementation of policies for addressing unhealthy diets in the region, and to propose a set of counter-strategies. We conducted semi-structured interviews with 15 interest-holders based in India, Indonesia, Sri Lanka, and Thailand, and performed a scoping review of diverse literature. Data analysis was guided by the 'Policy Dystopia Model', initially used to study the corporate political activity of the tobacco industry. Identified arguments were categorised into six themes: i) questioning the policy design and development process; ii) misrepresenting or distorting the supporting evidence, and/or presenting counter evidence; iii) exaggerating and/or fabricating unintended consequences on health and equity; iv) raising concerns about effects on the economy; v) querying the policy's compatibility with trade and investment agreements and national laws; and vi) raising concerns about restrictions on personal 'freedom'. To help counter these arguments, along with key material and structural factors that may increase their salience, we proposed the following set of counter-strategies: i) develop a communication strategy to counter opposing arguments; ii) implement governance measures to mitigate corporate influence on public health policy, research, and practice; iii) implement governance measures to enable effective health-promoting intersectoral and interdepartmental coordination; and iv) strengthen research, advocacy, and capacity building on the determinants of health. Successful implementation of these counter-strategies will require extensive organising and collaborating among diverse interest-holders in South-East Asia and beyond.

Out-of-pocket health expenditures (OOPE) represent a financial strain that can increase the risk of impoverishment, especially in older people. Universal health coverage is the primary strategy to ensure financial protection. The Mexican health system is based on social security. Therefore, the objective of this research is to analyze the relationship between out-of-pocket health expenditures and social security status over time among Mexican adults aged 50 and older. A secondary analysis using data from the 2012, 2015, 2018, and 2021 waves of the Mexican Health and Aging Study. Multivariable linear regression models were performed to identify the relation between social security and OOPE. Individuals without social security reported the lowest mean expenditures. In contrast, older people with social security stability showed a steady increase in spending throughout the period, reporting the highest mean expenditures on total OOPE. Other variables, such as education, work, economic situation, multimorbidity, disability, and self-rated health status, show a greater relation with OOPE in contrast with social security. Our findings indicate that older adults with stable social security coverage reported the highest OOPE. This finding contrasts with international evidence on the protective role of health insurance. These findings may be attributed to four factors: 1) the challenging epidemiological profile of older adults characterized by chronic diseases and disability, 2) the structural and organizational changes in the Mexican health system following the political transition in 2018, 3) a decline in healthcare access among older adults during the COVID-19 outbreak; and 4) the longstanding oversaturation and low health resources in the health system.

In recent years, low- and middle-income countries (LMICs) have received substantial amounts of Official Development Assistance for Health (DAH) to address domestic health funding gaps and improve access to universal healthcare. However, the effectiveness of DAH in improving health outcomes remains contested, with varying findings across studies due to differences in methodologies, data sources, and target populations. This systematic review synthesises the existing evidence on the impact of DAH on health outcomes in LMICs, highlighting both the positive and negative effects, and identifying key mechanisms through which aid influences health. A total of 61 studies were included in the review, with a primary focus on maternal and child health outcomes. Despite methodological differences, the weight of evidence indicates a generally positive impact of DAH, particularly in countries with higher governance standards and better economic conditions. Our findings underscore the importance of contextual factors, such as governance and proximity to aid-funded projects, in shaping the effectiveness of health aid. To maximise the impact of DAH, policymakers need to strengthen donor coordination, align aid with national health priorities, and reinforce domestic health systems. Future research should focus on refining causal inference methods and exploring innovative aid-delivery mechanisms to sustain long-term health improvements.

Universal health coverage (UHC) provides a platform for attaining 'Health for All'. Attaining UHC requires substantial investment and resources in the health sector. This can be challenging for many sub-Saharan African (SSA) countries. Public-private partnerships (PPPs) could be a potential solution. The implementation of healthcare PPPs for developing health system capacities for UHC presents both significant opportunities and notable challenges. This scoping review, part of a broader review on PPPs, examines the facilitators and barriers of healthcare PPPs and their impact on UHC. The review was guided by Arksey and O'Malley's guidelines for conducting a scoping review. PubMed, Medline (Ovid), Global Health (Ovid), Web of Science, Scopus, and EconLit were searched for peer-reviewed English language publications from January 2013 to December 2023. Nineteen studies were eligible for the final analysis following screening of 944 studies. Identified key facilitators of PPPs for UHC included well-established institutional structures, robust accreditation systems, accountability mechanisms, and political will and support. These factors contributed to improving primary healthcare delivery which is a critical dimension for UHC. Key barriers identified were limited capacity of implementing partners, regulatory inadequacies, and insufficient funds. These barriers negatively affected the performance of healthcare PPPs, which translates into systemic inequities in access to essential health services, impeding progress towards achieving UHC. Considering contract management capacity of implementers, sources and flow of funds, and regulatory frameworks are highly recommended for UHC to be realised using PPPs.

Despite efforts to promote HPV vaccination, coverage remains suboptimal in China. Following Guangzhou's 2022 free HPV vaccination program for girls aged 9-15, a cross-sectional survey was conducted from May to August 2024 among 411 parents of eligible girls in Guangzhou. The questionnaire was developed based on the supply-demand alignment theory. Vaccine Hesitancy Scale and Family Health Scale-Short Form were administered. Generalized linear regression identified factors associated with hesitancy. Overall, 10.7% of parents exhibited high hesitancy. Key determinants included occupation [farmers: β=-3.61, 95% CI=(-6.88, -0.34)], preference for imported over domestic vaccines [β=-1.65, 95% CI= -3.10, -0.12)]. Higher family health scores [β=0.25, 95% CI=(0.16, 0.33)], moderate child health status [β=1.24, 95% CI=(0.10, 2.38)], and satisfaction with community healthcare centers (CHCs) [β=0.05, 95% CI=(0.02, 0.07)] were less hesitant. Paradoxically, longer CHC wait times (>1 hour) [β=2.29, 95% CI=(0.27, 4.31)], and difficulty accessing information [β=2.80, 95% CI=(0.33, 5.27)] correlated with lower hesitancy. The results suggest potential policy-driven tolerance. Besides, this emphasizes the critical need for enhanced service quality in CHCs, targeted health education, and confidence-building in national vaccines. These insights offer potential guidance for implementing complementary strategies to achieve equitable HPV vaccine coverage.

Since children's participation in social health insurance (SHI) in China is voluntary, fluctuations in enrollment or dropout are inevitable. Using data from the two waves of the China Family Panel Study in 2020 and 2022, this study aims to examine these participation dynamics and their impact on children's health service utilization and medical expenses. Specifically, a balanced panel of 1,958 children under the age of 15 was constructed, first-difference and difference-in-difference models were employed to assess the factors influencing children's SHI enrollment or dropout, as well as the impact of these changes on health service utilization and medical expenses. Robustness checks were conducted after excluding new enrollees and dropouts separately. Our analysis showed that between 2020 and 2022, 263 children (13.4%) were newly enrolled in SHI, while 135 (6.9%) dropped out. Maternal SHI enrollment increased the likelihood of children's enrollment and reduced the probability of dropout. Children with commercial insurance were 34% less likely to enroll and 58% more likely to dropout. Compared to children with unchanged participation status, newly enrolled children were about 8% more likely to use outpatient services and had 77% higher medical expenses in the past year, whereas no significant changes were observed among those who dropped out. These findings highlight the dynamic nature of children's SHI participation in China and suggest that passive enrollment policies and parental participation could help promote universal coverage. Improving the reimbursement system, particularly for children's outpatient care, is also recommended.

Developing pediatric intensive care units (PICU) in resource-limited regions presents several challenges, including significant resource constraints, a shortage of trained personnel, and a lack of standardized care protocols. Prioritizing skills and knowledge development for healthcare professionals, selecting effective yet affordable equipment, and strong leadership have been identified as essential for establishing sustainable pediatric critical care services in low middle-income countries (LMICs). In this article, we describe the practical, phased approach undertaken in a charitable hospital setting in northeast India to establish a pediatric intensive care unit, highlighting adaptability, institutional commitment, patient team building and systematic record-keeping in overcoming these challenges. The lessons drawn from this experience can offer valuable insights for similar healthcare settings in LMICs, demonstrating that high-quality pediatric critical care can be achieved even in resource-constrained environments.

India has made good progress in the use of modern contraceptives in recent decades, however identifying women who are left behind is important to policy makers for further improving availability, accessibility, and coverage of family planning services to the marginalized population and hence achieving the international and national development agenda. Using five rounds of the National Family Health Survey data conducted between 1992-93 to 2019-21, this study examined the trends and patterns in inequality-by household wealth quintile and women's education-in modern contraceptive prevalence rates (mCPR) and demand for family planning satisfied with modern methods in urban and rural areas. The findings showed a secular trend of increasing rates in the use of modern contraceptives across socioeconomic sub-groups within urban (mCPR among the poorest quintile increased from 32% to 49%, and among the richest quintile from 51% to 60% in 1992-93 to 2019-21, respectively) and rural (mCPR among the poorest quintile increased from 27% to 49%, and among the richest quintile from 49% to 59% in 1992-93 to 2019-21, respectively) areas. Similarly, the inequality over time-measured by the concentration index-in mCPR has declined from 0.311 to 0.158 in urban areas and from 0.247 to 0.143 in rural areas between 1992-93 to 2019-21. Despite the overall decline in inequality, the pro-rich situation persists in contraceptive use in the country, and the extent of the inequality was high for modern reversible methods, both in urban and rural areas. Our findings underscore the increasing availability and accessibility of modern reversible methods, particularly among marginalized populations, along with improved information provided on the range of choices. This will help in achieving the global commitment of universal access to reproductive health, including family planning, and balance the method-mix in a country that is currently dominated by female sterilization.

Mobile health (mHealth) technologies are increasingly being used in innovative ways to overcome traditional barriers to the provision of, and access to, sexual and reproductive health (SRH) services among young people in rural low-and-middle income countries (LMICs). In rural Ghana, mHealth platforms are now being implemented by health care providers (HCPs) to improve access to SRH information for young people. However, the actual use of these platforms from the perspective of HCPs has not yet been explored. This study investigated HCPs' perspectives on the availability of mHealth platforms in rural Ghana and the perceived benefits of using such platforms to provide SRH information and services to rural dwelling young people. A qualitative exploratory study using semi-structured interviews was conducted with a convenience sample of 20 HCPs across three rural regions of Ghana. Participants were recruited using the snowballing method between May and August 2021. Interviews were audio recorded via Zoom with participants' consent. The data were transcribed verbatim and thematically analysed. All participants had experience providing mHealth-based SRH information and services to young people in rural Ghana. The mobile platforms used included phone calls, text messages, voice messages, Facebook, WhatsApp, and Twitter. These platforms facilitated SRH education on contraception,Human immunodeficiency Virus (HIV), sexually transmissible infections, hygiene, and menstruation. HCPs reported several benefits of using mHealth, including ease and convenience, low cost, anonymity, privacy and confidentiality (especially in light of socio-cultural norms and religious beliefs), reduced healthcare delivery workload, and reduced pressure on limited health infrastructure. The findings suggest that innovative mHealth platforms have the potential to improve young people's access to conventional SRH information and services in rural Ghana. Furthermore, the findings demonstrate the preferred and acceptable use of these platforms among users. The results highlight the acceptability and utility of mHealth, as well as the need for its wider adoption and integration. While the provision of SRH information and services through mHealth is promising, further research is needed to understand the barriers that affect access and delivery for young people in rural communities.

Distributed leadership has been proposed to offer value for health systems - by enabling people to work towards collective goals within settings such as hospitals. Yet, there is still limited empirical exploration of its dynamics in practice, especially in low- and middle-income contexts. To address this knowledge gap, this case study draws on conceptual work in empirically examining leadership in one district hospital in the Western Cape province, South Africa, seeking to identify evidence of distributed leadership and the factors influencing its emergence. Data were extracted from 28 academic theses, policies and strategic documents relating to health leadership, management and governance in the provincial health system (Phase 1) and 12 semi-structured, in-person interviews were conducted with hospital personnel (Phase 2). Phase 1 data provided the context of the case and guided the collection of data in Phase 2. All data were thematically analysed. The analysis reveals that there were pockets of distributed leadership within the hospital, as characterised by chains of multiple leaders working together to co-create shared meaning, take collective decisions and achieve common goals, enabled by relational leadership practices. These pockets supported both routine service delivery and bottom-up service improvement action. However, the unequal distribution of decision-making power, in the context of bureaucratic and professional hierarchies, limited the widespread emergence of distributed leadership. The case study suggests that distributed leadership can emerge in district hospitals with positive consequences for health service delivery, but that efforts to nurture its emergence should both bolster the leadership capabilities of individual leaders and address the bureaucratic and professional hierarchies that characterise the context within which hospital leadership unfolds. To aid the future practice of, and research about, distributed leadership the paper proposes a comprehensive definition of the concept, derived from the combination of wider literature and this study's empirical findings.

Financial protection is a core pillar of universal health coverage (UHC), yet current monitoring approaches in low- and middle-income countries (LMICs) largely focus on direct medical costs, neglecting direct transport costs and indirect time costs lost when seeking care. This commentary highlights the importance of fully accounting for these often-excluded costs, which disproportionately affect poorer and rural populations and can significantly hinder access to essential health services and lead to foregone care. We outline five priority areas for action, including improved measurement of transport and time costs through household surveys, methodological advancements in valuing time, increased investment in primary health care to reduce physical access barriers, adaptation of financing schemes and social protection programs to cover non-medical costs, and a multisectoral approach to address structural determinants. Fully integrating these dimensions into financial protection metrics and policies is critical for ensuring more equitable progress toward UHC in LMICs.

Intervention evaluation is critical for determining the value of health interventions; however, real-world implementation frequently falls short of achieving anticipated large-scale impacts. This evidence-to-practice gap often arises from challenges in capturing the complexity inherent in intervention implementation. This complexity may stem from the intervention itself, the dynamic and interrelated processes of dissemination, implementation, and sustainment, or the constraints of real-world settings characterized by interconnected systems. Integrating implementation science, which employs theories, models, and frameworks to understand the adoption and integration of evidence-based interventions, with systems science, which provides tools to model and analyze complex systems, offers a promising pathway for addressing these challenges. However, practical guidance on combining these approaches to evaluate dynamic interactions between interventions and implementation contexts, while simultaneously capturing system-level learnings, remains limited. In this methodological musing, we reflect on our experience integrating systems and implementation science to develop a conceptual and quantitative model for scenario evaluation of a maternal health service delivery redesign initiative in Kakamega, Kenya. We use four research objectives as a touchstone for organizing our reflections, explicated by three steps of an evaluation process: (1) developing a qualitative systems model using implementation frameworks and causal loop diagrams; (2) constructing and parameterizing a quantitative computational model; and (3) conducting scenario analyses to explore "what-if" strategies and inform adaptive planning. These reflections highlight the potential strengths of an integrated approach and offer practical considerations for researchers and practitioners evaluating complex health interventions through quantitative modelling and scenario development.

Raising taxes on tobacco is considered the most effective measure for reducing tobacco consumption. Although Uganda ratified WHO's Framework Convention on Tobacco control which recommends levying taxes on tobacco products by up to 75% of their retail price, in Uganda taxes on tobacco stagnated at 35% between 2017 and 2024. There is little in-depth research interrogating the political economy underpinning tobacco tax policy in Uganda. The aim of this study is to apply political economy analysis in exploring barriers to implementing WHO's recommended tobacco tax rates in Uganda. Our qualitative study entailed key informant and in-depth interviews with 34 purposively selected participants. Data were analyzed by thematic approach. Tobacco industry narratives are dominant among policy elite with a strongly entrenched notion that raising taxes will bring economic harm such as 'killing off' the tobacco industry and by implication diminish government tax revenue. Participants identified tobacco industry interference in tobacco tax policy in Uganda through both 'soft' tactics such as sustained lobbying of policy elite in the executive and legislative arms of government and 'hard' tactics through litigation. Contrary to recommendations of having a 'single spine' or uniform tax on tobacco, Uganda continues to implement a differential tax structure for tobacco products. The paucity of non-industry-funded - research on effects of raising tobacco taxes was observed while the attrition of civil society champions in advocacy campaigns for raising taxes ensured that there was no sustained counterbalance to the tobacco industry in Uganda which the later exploited to promote the narrative that taxes needed to be maintained at a low level where they would not cause 'economic harm'. Our findings highlight the need for strengthening civil society advocacy in order to sustain the momentum on raising tobacco taxes in Uganda.

This article revisits the argument that in the absence of good governance, remittance inflows cause the government to renege on the provision of social services and crowd out public finance where private substitutes exist. Using a quantile approach on a sample of African countries for the period 1990-2022, and after controlling for the endogeneity of remittances, the results show a positive contribution of remittances to public health expenditure, which tis annihilated into a non-linear crowd-out of public health expenditure across quantiles in the presence of varied political regimes. This relationship does not change even in the presence of a health shock. The crowd-out of public health expenditure points to an indirect effect of remittances through household consumption, private investment and tax revenue.

Integrated care effectively addresses challenges like high costs and low efficiency in healthcare. This paper investigates the impact of integrated care models in urban China on inpatient costs and health services efficiency, and explores variations by age category, chronic disease status and healthcare institutions. Data is sourced from the insurance claims database in Guangzhou (2012-2015). Seven integrated care models are introduced at different times during the study period. The propensity score matching with staggered difference-in-differences approach is employed to examine the effects of integrated care models on inpatient costs (total inpatient costs and out-of-pocket (OOP) spending) and health services efficiency (length of stay (LOS)). After matching, 147 healthcare institutions are included, with 44 in the intervention group and 103 in the control group. There are 1,721 institution-month-level observations in the intervention group and 3,746 observations in the control group. Integrated care models reduce total inpatient costs (6.6%), OOP spending (17.3%), and LOS (3.3%) across all healthcare institutions. For patients aged 60 and above receiving care in primary/secondary care institutions, there are notable decreases in total inpatient costs, OOP spending, and LOS. However, for patients aged 60 and above in tertiary care institutions, integrated care models did not significantly affect these three outcomes. Additionally, patients with chronic diseases in primary/secondary care institutions also experience reductions in total inpatient costs, OOP spending, and LOS. Integrated care models in urban China contribute to lower inpatient costs and higher health services efficiency, particularly for older adults and patients with chronic diseases who are receiving care in primary/secondary care institutions. These findings have important policy implications for the implementation of integrated care models in urban China.

Universal Health Coverage (UHC) remains a critical goal in sub-Saharan Africa, where healthcare systems face significant challenges. State-Church Partnership has emerged as an innovative strategy to address gaps in healthcare delivery, leveraging the extensive networks of Faith-Based Organizations to provide essential services, particularly in remote areas. A scoping review followed Arksey and O'Malley's framework and the PRISMA-ScR guidelines. We systematically searched peer-reviewed databases, including PubMed, Web of Science, Scopus, and CINAHL, for relevant studies published from inception until December 2024. Data were extracted and thematically analyzed using NVivo 11 to identify key themes related to state-church partnership models, their impact on UHC, implementation challenges, and emerging best practices. The review included eight studies covering various state-church partnership models in sub-Saharan Africa (SSA). Findings highlight that FBOs contribute between 30% and 70% of healthcare services in some regions, improving access, affordability, and equity. They play a critical role in maternal and child health, HIV/AIDS prevention, and health workforce training. However, challenges such as funding constraints, service quality variability, and limited policy integration hinder their effectiveness. Emerging best practices include enhanced government collaboration, community engagement, and capacity-building initiatives. In conclusion, State-Church Partnerships are vital in strengthening healthcare systems and achieving UHC in SSA. To maximize their impact, formalized policy frameworks, sustainable financing mechanisms, and quality assurance measures are essential. Strengthening state-FBO collaboration can bridge healthcare gaps and ensure equitable healthcare access.

Limited research has been conducted on strategies to improve the efficiency of HIV services for key populations (KPs). This study investigates ways to enhance healthcare delivery efficiency, focusing on HIV services for KPs. We explore two strategies: expanding service volume and offering multiple HIV services within a single health facility. Using data from the Linkages Across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) program in Kenya and Malawi, we exploit the variation in services provided to assess correlations between different service delivery configurations and their costs. We apply log-log fixed-effects regression models to analyze relationships between the total costs of four HIV services and the volume and range of services delivered. We find that service volume increases correlate with higher total costs, albeit less than proportionally, consistent with possible economies of scale. Negative correlations between service integration and total costs suggest that integrating HIV services for KPs could lead to reduced total costs for some service combinations. These results indicate potential strategies to increase the efficiency of HIV services for KPs, which can inform strategic planning and program execution in Kenya, Malawi, and similar countries.

The accessibility to the prevention and management of perinatal depression can be improved by using community health workers. This review was aimed at determining the effectiveness of interventions led by community health workers (CHWs) in reducing depressive symptoms and the prevalence of depression during the perinatal period. We conducted a search in PubMed, CINAHL, SCOPUS and ProQuest Databases of Dissertation and Thesis (PQDT) to locate studies conducted in sub-Saharan Africa. We appraised the quality of eligible studies using standardized critical appraisal instruments from the Joanna Briggs Institute (JBI). We extracted data from the included studies using an a-priori prepared data extraction tool. We pooled the findings of the studies using meta-analysis. The initial search yielded 199 studies, out of which we included 16 articles in this review. During the first three months after birth, CHW-led preventive psycho-social interventions reduced the risk of depressed mood by 35% [RR=0.65(0.46,092)] [Low-quality evidence]. The interventions reduced the risk of depressed mood by 32% six-months post birth [RR=0.68(0.52, 0.87)] [Very low-quality evidence]. The effect of the interventions is sustained through 9-12 months after birth resulting in a reduction in the risk of depressed mood by 38% (RR=0.72(0.54,0.96) [Low-quality evidence]. Among women with moderate depressive symptoms, compared to usual care, CHW-led therapeutic psycho-social interventions reduced the symptoms by an average of 0.71 [SMD=-0.71 (-0.84, -0.59) units during the first three months after birth. The effect lasts 9-12 months after birth (SMD=-0.28 (-0.41, -0.15) [Moderate-quality evidence]. In conclusion, the work of CHWs may be integrated into the prevention and management of perinatal depression after careful analysis of the feasibility, applicability and meaningfulness of the interventions to local context. High-quality randomized trials may help to inform further optimization of the role of CHWs in reducing the risk of depressed mood and depressive symptoms during perinatal period.

Within the global health landscape exists a complex interplay between global health security (GHS) and universal health coverage (UHC) - two influential agendas with profound influence on health system strengthening initiatives. There is a need to understand why and how coherence between GHS and UHC is being pursued in health policy and planning, particularly in the wake of the COVID-19 pandemic, which profoundly reshaped the field of global health. This paper presents one of the first detailed analyses of contemporary efforts to conceptualize and operationalize GHS-UHC coherence - through the perspectives of key actors responsible for its implementation. The study employed thirty-one interviews with senior officials across four major types of global health actors: multilateral and global health organizations, country governments, donors and international finance institutions, and civil society organizations. It reveals important insights in the way specific actor and geopolitical groups varied in terms of shifting perceptions of GHS and UHC, as well as major factors influencing GHS-UHC coherence (e.g., strategic considerations including motivations and concerns, and structural considerations including enablers and barriers). The analysis suggests that an emerging 'hybrid norm' linking GHS and UHC appears well-underway. It further contends that strengthening coherence between GHS and UHC not only depends on, but also enhances, three key imperatives: 1) overcoming geopolitical power asymmetries, 2) leveraging strategic collaboration across actor types, and 3) pursuing integrative health diplomacy amid polycrisis. While this study centers on GHS-UHC alignment, its broader objective is to foster a more equitable and resilient global health architecture by tackling the interconnected causes of fragmentation through hybrid normative frameworks. By focusing on the politics of norms underpinning GHS and UHC integration, this work contributes to rethinking how global health institutions collaborate, ultimately helping to build more sustainable global health governance fit to withstand future political, economic, and social challenges.