Health systems and reform最新文献

Diabetes mellitus is seventh-leading cause of death in the United States, and has a substantial economic burden, contributing $237 billion in direct medical costs. The incidence rate of type 2 diabetes (T2DM) is expected to continue to increase, disproportionally impacting vulnerable groups. The increasing prevalence and disproportionate burden emphasize the need for health systems to effectively integrate and implement large- and small-scale, culturally tailored nurse-led diabetes prevention programs (DPP) and diabetes self-management education programs (DSME). This two-stage analysis uses a health system approach to provide a synopsis of evidence-based nurse-led DPP and DSME implementation across various health system settings. Using the results from an integrative review, a health system focused framework was developed and applied to two case studies highlighting specific aspects of how successful large- and small-scale nurse-led interventions are integrated into health systems across varying vulnerable populations specifically Veterans, Asian Americans and Haitians. Case study results use examples to show large-scale implementation of DSME across the federal Veterans Health Administration (VHA) improves diabetes self-management and access for Veterans and smaller-scale DPP and DSME programs within community health centers targeting vulnerable populations impact health literacy and diabetes self-management. These examples demonstrate key steps toward improving access and outcomes for diabetes management and the critical role of nurse-led diabetes interventions as a priority across the health system and the importance of financial and organizational support for DPP and DSME programs to overcome access barriers to improve diabetes interventions and management.

The Venezuelan humanitarian crisis has led to the displacement of over 7.7 million migrants, with Colombia hosting around one-third. Colombia has been praised for its progressive policies for Venezuelan migrant integration, and the government's Estatuto Temporal de Protección para Migrantes Venezolanos (ETPMV), introduced in February 2021, provides one of the region's most comprehensive regularization policies, permitting 10 years of residency and access to social protection services, including health insurance. We assessed the impact of the ETPMV on self-reported health insurance enrollment and formal healthcare utilization using two telephone surveys with 4,423 female Venezuelan migrants in 2020 and 2023. We used a difference-in-differences methodological approach, accounting for differences in levels of migrant health system integration across municipalities measured by a municipal enrollment index derived from secondary data. We find that the ETPMV significantly increases health insurance enrollment for female Venezuelan migrants and that while uninsured individuals experience a significant decline in healthcare utilization from 2020 to 2023, insured individuals experience no significant change. Additionally, the effect of insurance varies by municipal enrollment index, with greater impacts of insurance in areas with lower levels of regularization and health insurance enrollment. These results highlight the success of ETPMV in enhancing access to healthcare for Venezuelan migrants, with insurance enrollment providing a protective effect against declines in healthcare utilization compared to uninsured individuals. These findings underscore the importance of comprehensive regularization policies to address migrant health needs, while emphasizing the importance of continued efforts toward integration.

Ethnic inequities in the receipt of medicines are influenced by a range of factors including inequities in the social determinants of health, barriers to accessing health care, and differences in quality of care. Policy decisions about medicines funding and eligibility play an important role in contributing to equity in access and equity in outcomes. This policy report analyzes the 2021 policy decision in Aotearoa New Zealand to use ethnicity as an explicit eligibility criterion for access to publicly funded sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide-1 receptor agonists for type 2 diabetes. Advocacy for this policy decision was driven by Indigenous health experts, based on strong evidence of persisting ethnic inequities in diabetes prevalence, access to treatment, and outcomes. The impact this policy has had so far on inequities in receipt of diabetes treatment indicates that using explicit ethnicity-based eligibility criteria may help overcome some barriers to access to diabetes care, even in universal health care systems.

The related overweight, obesity and diabetes epidemics are more than five decades old and have progressed inexorably. A billion people in the world are now obese, and nearly a billion are diabetic. The belief that diabetes is caused by overweight and obesity has led to public health advice focused on lifestyle change as the main preventive approach. This advice has shifted over time, and some parts of the public health community have started to switch from a lifestyle to an environmental perspective. There is a growing but not yet conclusive evidence base that rather than diabetes being caused by overweight and obesity, the three conditions have a common third cause, and difficulties in controlling weight and blood glucose emerge in tandem. New classes of medications, including semaglutides and tirzepatides, effectively address these processes. They are in the early stages of development but have accumulated a safety record over the last decade. They are largely currently available only to those who can afford their relatively high cost, but new generations of related medications are capable of becoming lower cost, and wider access to them could transform the overweight, obesity and diabetes pandemics. There is a marked absence of enthusiasm for their potential role in the public health community. This appears to reflect stigmatized attitudes to overweight and obesity, which contrast with attitudes to diabetes. A successful medical treatment may be the key to resolving that stigma and reversing the three pandemics.

Health systems research as a field has increased its attention to political factors that shape health system development. However, there has been a lack of consensus about which conceptual frameworks and models from the academic discipline of political science are most relevant to the study of health systems. The COVID-19 pandemic underlined the centrality of politics to health, but it also demonstrated the limitations of existing frameworks used to analyze the politics of health. This article reviews the political science literature on the politics of COVID-19, identifies several gaps in the theoretical frameworks used in this work, and draws some conclusions for future work on the politics of pandemics and the politics of health system development writ large.

Health systems worldwide face challenges in managing resource scarcity, necessitating systematic and fair approaches to prioritize essential health services. Practical guidance on structuring transparent and inclusive priority setting processes remains limited. This paper presents a 10-step method for designing fair priority-setting processes, demonstrated through the revision of the Zanzibar Essential Health Care Package (2019-2022). The 10-step method provides pragmatic and context-specific guidance, bridging the gap between global frameworks and local implementation in resource-limited settings. These 10 steps build upon recognized and accepted conditions and principles for health priorities and include: (1) development of a roadmap, (2) establishment of management, (3) selection of criteria for priority setting, (4) identification of candidate interventions, (5) formulation of financing strategies, (6) evidence generation, (7) employment of analytics, (8) setting priorities, (9) implementation arrangement, and (10) monitoring and evaluation to track implementation. The core team guided each step based on three fundamental principles-stakeholder involvement, transparency, and structured deliberation. In Zanzibar, consensus-building workshops were held to determine the criteria for setting priorities: cost-effectiveness, budget impact, disease burden, and equity. Political/public acceptability emerged as an additional criterion due to the challenges associated with including abortion services. Financial risk protection was deemed significant but was instead incorporated into the implementation and health financing plans. The core team offered preliminary training sessions on health priorities to stakeholders. This structured 10-step method encourages participation and inclusivity of marginalized groups usually excluded from such discussions, trust, and legitimacy in Essential Health Care Package processes, thereby providing policymakers with a tool for improvement.

This commentary traces the origins of Japan's special education system and explores the need to equip preschool teachers with the specific knowledge and skills necessary to care for children under the age of six with disabilities during disasters in Japan. Japan's slow implementation of inclusive education, in which children with and without disabilities are educated together, was noted by the UN Committee on the Rights of Persons with Disabilities in 2022. The Committee also recommended improved care for persons with disabilities in disaster situations and humanitarian emergencies. Historically, Japan has promoted policies that segregate children with disabilities from children without disabilities. Integrated childcare began in the 1970s, but there continues to be a lack of suitable systems and practical guidelines for disaster management in inclusive childcare. The curricula of institutions that train childcare professionals were reviewed. As of April 1, 2023, there were 666 designated childcare teacher training institutions in Japan. Of these, 498 training institutions offered courses to obtain both kindergarten and nursery teaching licenses. Thirty-seven of the institutions were national and public schools, of which the present study included 36 schools whose syllabus was available online and whose course content could be confirmed. Only one school (2.8%) was found to include "disaster and childcare" in its curriculum, and three schools (8.3%) included "safety of children with disabilities" in their curriculum. Specialist disaster preparedness training to enable teachers to care for preschool children with disabilities in the event of a disaster is critical in the context of inclusive childcare.

The Universal Health Care (UHC) Act in the Philippines aims to provide equitable access to quality and affordable health care. However, its implementation is hampered by significant financing and resource constraints. This study explores these challenges from the perspectives of various stakeholders, aiming to inform policy and improve the execution of the UHC Act. In this qualitative study, we conducted 17 focus group discussions and 19 key informant interviews between September 2023 and May 2024. Participants included national and local policymakers, public and private healthcare providers, and patients. The data were analyzed using the WHO's health system financing framework, focusing on revenue raising, pooling, and purchasing. The findings reveal critical issues across all financing functions. Revenue-raising is undermined by a lack of funding for local government units and challenges in PhilHealth premium collection from the informal sector. In terms of pooling, the Special Health Fund is hindered by the absence of clear guidelines and delays in fund transfers. Purchasing is plagued by bureaucratic procurement processes, shortages of suppliers, and significant delays and issues in PhilHealth reimbursements. The optimal implementation of the UHC Act in the Philippines is impeded by interrelated financing and resource challenges. Addressing these challenges requires comprehensive reforms, including strengthening local health system integration, finalizing guidelines for local governments, and reforming procurement and PhilHealth's payment systems.

Sri Lanka has one of the highest prevalence rates of diabetes, and improving diabetes control is a national priority. The care cascade framework, a tool for evaluating diabetes control and identifying system gaps, has not been assessed nationally in Sri Lanka. This study addresses this gap using data from a nationally representative longitudinal cohort. Using 2018-2019 data from the Sri Lanka Health and Ageing Study (SLHAS), we evaluated the diabetes care cascade, estimating levels of (i) prevalence, (ii) testing, (iii) diagnosis, (iv) awareness, (v) treatment, (vi) medication adherence, and (vii) control. Logistic regression assessed factors associated with step performance, and concentration indices quantified socioeconomic inequalities. Performance was benchmarked against other countries. In 4,827 participants the weighted diabetes prevalence was 23.2%. Of those with diabetes, 86.0% had been tested, 62.3% diagnosed, 58.6% aware, 44.7% treated, and 20.6% (hemoglobin A1c, HbA1c < 8.0%) and 12.4% (HbA1c < 7.0%) controlled. Older adults and those with hypertension achieved higher rates at all steps, while disparities by gender, education, location, and body mass index were minimal. Concentration indices confirmed pro-rich inequity from testing to treatment but revealed no significant inequity in control. Sri Lanka outperforms most low- and middle-income countries (LMICs) in testing, diagnosis, treatment, and disparities in coverage, reflecting underlying system strengths. But only one in five Sri Lankans with diabetes achieve control, with significant losses post-treatment. High diagnosis and treatment rates alone are insufficient; strategy must shift toward understanding the reasons for poor control. and improving treatment outcomes, a lesson with wider relevance.