Social isolation and its relationship to multidimensional poverty

Survival Time Disparities after Palliative Care Use Among Low-Income Patients on Social Welfare Programs: A Retrospective Cohort Study

Background

Relieving the total pain of patients with cancer and supporting their well-being throughout their lives are important roles of palliative and supportive care. Poverty may inhibit patients from receiving dignified end-of-life care; however, using social welfare services may reduce its impact on patients' end-of-life experiences. Nevertheless, no study has investigated which social welfare service could lead to favorable end-of-life experiences for patients living in poverty.

Objective

This study aimed to describe the characteristics of users of palliative care among low-income patients and examine the difference in survival time among patients with cancer on social welfare services in a single center in Kyoto, Japan.

Design

We conducted a retrospective cohort study.

Setting/Subjects

We included 220 patients using Public Assistance (PA: aid minimum income and medical/long-term care), Free/Low-Cost Medical Care (FLCMC: aid only medical care), and nonwelfare-users who newly received palliative care in 2021.

Measurements

We calculated patients' survival time from the initiation of palliative care to death. In addition, we identified patients who experienced home death.

Results

Compared with nonusers, FLCMC beneficiaries had shorter survival times (adjusted hazard ratio [aHR] 2.05, 95% confidence interval [CI] 0.80-5.22). No difference was observed among PA beneficiaries (aHR 1.19, 95% CI 0.49-2.87). No home death was observed among welfare service recipients.

Conclusions

Social welfare benefits only for medical expenses may not sufficiently support dignified end-of-life care for low-income patients. Further studies are required to examine the robustness of this study considering various bio-psycho-social factors that can influence these findings, to support low-income patients with cancer on social welfare services.

Beyond Purchasing Power: The Association Between Sense of Community Belongingness and Food Insecurity Among Older Adults in Canada

Food is a basic human need, yet a significant proportion of older Canadian adults are vulnerable to food insecurity. The health risks associated with aging make food insecurity among this subgroup a critical policy issue. In Canada, policy solutions to food insecurity are however skewed toward the provision of income support to vulnerable groups. While these income support programs are timely, little emphasis is placed on social factors such as sense of community belongingness. This is despite evidence that food insecurity is a socially mediated experience that goes beyond the ability to purchase food. Drawing data from the Canadian Community Health Survey (n = 24,546) and using negative log-log regression, we examined the association between sense of community belongingness and food insecurity among older adults. Findings show that older adults with a "very weak" (odds ratio [OR] = 1.40, p < .001) and "somewhat weak" (OR = 1.23, p < .01) sense of community belongingness were significantly more likely to be food insecure compared to those with a "very strong" sense of belongingness. This study contributes to a growing body of the literature that demonstrates the need for an integrated approach to addressing food insecurity - one that goes beyond income support to include consideration of social factors like sense of community belonging.

Are livelihoods of slum dwellers sustainable and secure in developing economies? Evidences from Lucknow, Uttar Pradesh in India

Objectives

We adopted the Sustainable Livelihood Security (SLS) approach to assess the living conditions of slum dwellers in Lucknow, Uttar Pradesh, India. Keeping the urban poor at the centre, we attempted to bring out the multidimensional nature of poverty and explored various aspects of the livelihood of slum dwellers.

Methods

We surveyed 900 households from both notified and non-notified slums of Lucknow city to construct the SLS index, keeping the social, economic, infrastructural, health, and micro-environmental aspects of slum dwellers in the background. We collected data based on the household approach of the UN and the neighbourhood approach of the Government of India and aggregated the weighted index values under various sub-components to construct a composite index.

Results

The results suggested that the index values were low for both types of slum dwellers in Lucknow city specifically in the economic, infrastructural, and micro-environmental aspects. The results also showed that 'non-notified slum dwellers' were much more deficient in all the dimensions compared to their 'notified' counterparts. The livelihood condition of the marginalized households (backward castes and minorities) was especially precarious and vulnerable.

Conclusion

The findings reveal the existence of a high level of informality of livelihood of the urban poor in terms of housing, employment, health, and other basic amenities, and demonstrate that their livelihood condition is characterized by a low assets base, and poor strategies to overcome exigencies and risks.

Recommendations

This paper recommends enactment of an urban employment guarantee act, conducting of sabhas (meetings) at the ward level on a regular basis to promote awareness, and notification of non-notified slums to notified slums on regular basis for the overall development of slum dwellers.

"Please, Mr. Postman:" Exploring the Use of Letter Writing to Address Loneliness

PURPOSE

Informed by prior research and influenced by concerns that the COVID-19 pandemic heightened social isolation, this project examined the impact of a 12-month long letter writing project on levels of loneliness.

METHOD

Through partnerships with local anti-poverty agencies, pen pals were paired between MSW students and community members who utilize services at these organizations. Participants completed the UCLA Loneliness Scale before and after the intervention.

RESULTS

We found a mean decrease in loneliness at the end of the intervention.

DISCUSSION

Letter writing was a successful way to attend to loneliness due to its accessibility to the participants. Our letter writing intervention is different in many ways from e-mail and texting. Participants noted that the waiting process between letter gave them time to think more deeply about their response as well as event to look forward to (e.g. getting mail). We found that the low-tech aspects of the project might have been helpful to some participants.

CONCLUSION

Letter writing is an easily replicable, low-cost, low-tech activity for use by practitioners, which may be useful in a variety of social work settings to reduce loneliness.

Health literacy, financial insecurity and health outcomes among people living with HIV in Australia

It is well documented that lower socio-economic status is associated with poorer health outcomes, while health literacy is considered important for improving health. What is less clear, is the extent to which greater health literacy can improve health outcomes among people for whom poverty or financial insecurity are important barriers to health. The paper presents findings from an Australian survey of people living with HIV (PLHIV) (N = 835) in which we explored the relationship between financial insecurity and health outcomes, looking at the extent to which health literacy mediates this relationship. The study drew on a comprehensive definition of health literacy, measuring participant’s confidence to communicate with healthcare providers, navigate the health system and take an active stance in relation to their health. Findings showed that financial insecurity was associated with lower health literacy and poorer self-reported physical and mental health. Health literacy mediated 16.2% of the effect of financial insecurity on physical health scores and 16.6% of the effect of financial insecurity on mental health scores. This suggests that programmes which seek to build health literacy among PLHIV may improve health outcomes among PLHIV who are struggling financially. Health literacy programmes are likely to be effective if they build confidence and resourcefulness among people to engage with health information, decision-making and care.

Changes in health-related quality of life scores among low-income patients on social welfare programs in Japan during the COVID-19 pandemic: a single-center repeated cross-sectional study

BACKGROUND

Low-income is one of the well-established determinants of people's health and health-related behavior, including susceptibility to the coronavirus disease 2019 (COVID-19) infection. Two social welfare services are available in Japan to support financial and medical care among low-income patients: Public Assistance (PA), which provide both minimum income and medical costs; and Free/Low-Cost Medical Care (FLCMC), wherein only medical costs were covered. In this study, changes in Health-Related Quality of Life (HRQOL) scores of low-income patients on PA and FLCMC, before and after COVID-19 pandemic, were described and compared against those that are not utilizing the said services (comparison group) to evaluate the contribution of social welfare services in protecting the HRQOL of the beneficiaries during the pandemic.

METHODS

We used repeated cross-sectional data of adult beneficiaries of FLCMC and PA, as well as those without social welfare services, who regularly visit the Kamigyo clinic in Kyoto, Japan. We collected the data from 2018 and 2021 using a questionnaire on patients' socioeconomic attributes and the Japanese version of Medical Outcomes Study 12-Item Short Form Health Survey (SF-12). The Japanese version of SF-12 can calculate the three components scores: physical health component summary (PCS), the mental health component summary (MCS), and the role-social component summary (RCS), which can be transformed to a 0-100 range scale with a mean of 50 and standard deviation of 10.

RESULTS

Data of 200 and 174 beneficiaries in 2018 and 2021, respectively, were analyzed. Low-income patients on social welfare services had lower PCS, and RCS than the comparison group in both years. Multiple linear regression analyses with cluster-adjusted standard error estimator showed that the decline in MCS was significantly higher among FLCMC beneficiaries than in those without welfare services (Beta: -4.71, 95% Confidence Interval [CI]: -5.79 to -3.63, p < 0.01), and a decline in MCS among PA recipients was also observed (Beta: -4.27, 95% CI: -6.67 to -1.87 p = 0.02).

CONCLUSIONS

Low-income beneficiaries of social welfare may have experienced mental health deterioration during the COVID-19 pandemic. To maintain healthy lives during the pandemic, additional support on mental health for low-income recipients of social welfare services may be required.

External resilience in the context of drug use and socio-structural vulnerabilities: a qualitative exploration among women who use drugs and sell sex in Baltimore, Maryland

Background

Resilience is a commonly used construct in substance use and mental health research. Yet it is often narrowly defined by only its internal qualities (e.g., adaptability, hardiness) and overlooks its external qualities (e.g., supportive relationships, navigating one’s environment). Further, substance use is often viewed as antithetical to resilience despite populations like women who use drugs and sell sex (WWUD-SS) surviving significant hardships. This study aims to fill a gap in the literature by characterizing external resilience among WWUD-SS and understanding the ways that socio-structural vulnerabilities (e.g., poverty, stigma) and substance use shape external resilience.

Methods

WWUD-SS (N = 18) enrolled in an ongoing cohort study were purposively sampled for age, race, and recruitment location and participated in semi-structured, in-depth interviews aimed to elucidate external resilience (i.e., social support and resource utilization). WWUD-SS were queried about recent difficult experiences with a focus on how they did or did not use social support or formal resources (e.g., clinic, crisis hotline) in response.

Results

Participants were a median age of 37 years, 50% identified as Black, and 50% reported currently injecting drugs. Participants described reluctance to ask for support and often felt resigned to address problems alone. Participants also distinguished between transactional relationships (help is contingent upon receiving something in return) versus genuine (non-transactional or altruistic) support, including the role of family members who do and do not use drugs. Resource utilization was rare, and “self-medication” through substance use was common absent other perceived options for help.

Conclusions

External resilience appears limited among WWUD-SS and shaped by the social and economic contexts of a street-involved life. WWUD-SS’ ability to exercise external resilience may be undercut by experiencing structural vulnerabilities and competition for material resources that create transactional relationships and diminish the perceived value of social support. Internalized stigma, reflecting the larger society’s stigmatized views of drug use, sex work, and poverty, left WWUD-SS eschewing help from outside sources. Focus on internal resilience alone offers an incomplete picture of the construct in drug-using populations. Improving connections to community resources may be a targeted way to strengthen external resilience, as are policies addressing structural vulnerabilities for marginalized communities.

The multidimensional relative poverty of rural older adults in China and the effect of the health poverty alleviation policy

Introduction

Although, especially in the past decade, poverty measurement approaches have been duly developed in two paths (from unidimensional to multidimensional poverty and from absolute to relative poverty), merely a few studies have focused on the combination of both perspectives. However, with global aging, poverty among older adults simultaneously presents multidimensionality and relativity characteristics. This paper explores a multidimensional relative poverty index (MRPI) relative to the aged group in four dimensions, namely, health, social, mental, and material, and then empirically evaluates the specific effects on the MRPI of one of the key targeted anti-poverty policies, that is, the health poverty alleviation policy (HPAP), which includes public health service, medical expense reimbursement, rewarding assistance, basic medical insurance, and so on.

Methods

Using pooled cross-sectional data of poverty alleviation from 2014 to 2020 with a total of 83,521 observations aged 60+ in County J, Shaanxi Province in China, we calculate the MRPI for the older adults via a fuzzy set approach. Statistical difference testing is used to analyze the characteristics and trends of the MRPI. In policy evaluation, to address endogenous problems, the treatment effect model based on Heckman's two-stage regression and finite distributed lag model are used with a controlled township cluster structure.

Results

From 2014 to 2020, the MRPI shows a significant upward trend for older adults in rural China, and the health component takes the dominant MRPI position. Empirically, we find that the HPAP can significantly alleviate the MRPI of older adults. Furthermore, among the health poverty alleviation measures, basic medical insurance is the most effective anti-poverty policy to support older adults. Specifically, empirical evidence shows that there is a more statistically significant reduction in the MRPI with the HPAP for the sub-group of older adults with chronic diseases or disabilities.

Conclusion

Both relativity and multidimensionality should be emphasized when analyzing poverty vis-à-vis the aging society, and for this, the MRPI is one of the effective tools. Comparing the relativity with the aged group engenders a more accurate understanding of their poverty situation. Moreover, the importance of the health component among all the four dimensions is more conducive to the detailed analysis of their poverty. The empirical analysis results show that regarding poverty reduction approaches in China, developing integrated health promotion systems is necessary and imminent, especially in the long run, such as long-term care insurance that covers typical disabled older adults with chronic diseases.

Loneliness and Emancipation: A Multilevel Analysis of the Connection between Gender Inequality, Loneliness, and Social Isolation in the ISSP 2017

The present article analyzes the connection between, on the one hand, gender equality and, on the other hand, loneliness and social isolation. It hypothesizes that modern relational institutions that support gender equality, such as no-fault divorce laws, reduce loneliness in close relationships. This hypothesis is put to the test through a multilevel analysis of the International Social Survey Program (ISSP) 2017. The analysis reveals that the data agree, to a large extent, with the theoretical arguments. The prevalence of loneliness is higher in countries with higher levels of gender inequality (as measured by the Gender Inequality Index (GII)). This can be attributed to a moderation effect; at lower levels of gender inequality, partnerships provide better protection from loneliness. These results are robust to controls for demographic composition, level of health, educational attainment, income poverty, and interview mode. Last, the analyses show that the threat of emotional isolation is more widespread in countries with low gender inequality. These findings, however, are only significant before controlling for demographic composition, level of health, educational attainment, income poverty, and interview mode, and they require further analysis. The concluding section relates these findings to the popular tendency to argue that modern society has created a “loneliness epidemic” and discusses policy implications.

Financial distress and suicidal behaviour during COVID-19: Family identification attenuates the negative relationship between COVID-related financial distress and mental Ill-health

COVID-19 provides a 'perfect storm' of social and economic suicide risk-factors. Recent research has evidenced an initial impact of the pandemic upon suicide rates, but has yet to understand how elevated financial threat and social isolation may predict suicide ideation/behaviour, or which social factors promote resilience. This study addressed these shortcomings. An online longitudinal survey study (N = 370) which took place from May to September 2020 showed COVID-related financial distress predicts suicidal thoughts and behaviour via increased depression and loneliness. Family identification attenuates these relationships. Our findings reaffirm the importance of social factors in reducing mental ill-health outcomes of economic crises.

Competing challenges for immigrant seniors: Social isolation and the pandemic

The pandemic has exposed and amplified complex and complicated health and societal challenges while offering immense opportunities to transform societies to improve health for all. Social isolation is a challenging and persistent issue experienced by many older adults, especially among immigrant and refugee seniors. Unique risk factors such as racism, discrimination, language barriers, weak social networks, and separation from friends and family predispose immigrant and refugee seniors to a higher risk of social isolation. The pandemic has magnified the unique risks and has highlighted the differential health and economic impacts. This article examines social isolation among immigrant and refugee seniors in Canada by focusing on the policy context, available programs and services to reduce social isolation, and the conceptualization and measurement considerations for advancing research to address social isolation among this growing population. Drawing on specific examples, we discuss immigration, aging, and social isolation within the context of Canada. While our article focuses on Canada as a case study, our discussion has relevancy and implications for other high-income countries with aging immigrant and refugee populations. In moving forward, we argue that a more complete and targeted understanding of social isolation is essential to informing program and policy development to support immigrant and refugee seniors in Canada and beyond. The transformation needed in our societies to create health for all requires strong equity and determinants of health perspective and a systems approach beyond health to ensure lasting change.

Non-financial social determinants of diabetes among public assistance recipients in Japan: A cohort study

AIMS/INTRODUCTION

Poverty is an important social determinant of diabetes. Poverty is a multidimensional concept including non-financial difficulties, such as social isolation and exclusion from communities. Many countries provide financial social assistance programs for those in need. This study aimed to explore non-financial social determinants of diabetes among public assistance recipients in Japan, by using linkage data of two municipal public assistance databases and medical assistance claim data.

MATERIALS AND METHODS

We carried out a retrospective cohort study. Public assistance is provided to households below the poverty line to ensure their income security. We extracted recipients' sociodemographic factors of January 2016 (household number and employment status as non-financial social determinants of diabetes) and identified the incidence of diabetes diagnosis until December 2016 as the outcome.

RESULTS

We included the data of 2,698 younger individuals (aged <65 years) and 3,019 older individuals (aged >65 years). A multivariable Poisson regression, with a robust standard error estimator, showed that among 2,144 younger recipients at risk, unemployment and living alone were slightly associated with 1-year cumulative incidence of diabetes diagnosis (adjusted incidence ratio 1.20, 95% confidence interval 0.93-1.54 and adjusted incidence ratio 1.15, 95% confidence interval 0.89-1.48, respectively). Among 2,181 older recipients at risk, there was no strong association between their sociodemographic factors and incidence of diabetes diagnosis.

CONCLUSIONS

Unemployment and living alone might be additional risk factors for diabetes among younger public assistance recipients. Multidimensional supports assuring financial and non-financial securities are required to prevent diabetes among people living in poverty.

Changes in health-related quality of life among impoverished persons in the Free/Low-Cost Medical Care Program in Japan: Evidence from a prospective cohort study

BACKGROUND

The Free/Low-Cost Medical Care Program (FLCMC) can subsidize the payment (exempt/lower) in designated institutions in Japan. Given that poverty is a multidimensional concept including social isolation, the FLCMC applicants may need social support over and above financial aid to improve their quality of life. However, there was no data to discuss what services should be provided and to whom. Hence, we aimed to describe the changes in health-related quality of life scores among users of the FLCMC, with respect to their socioeconomic backgrounds.

METHODS

This cohort study included patients who newly used FLCMC from July 2018 to April 2019. We used patients' social work records, obtained at baseline, and self-report questionnaires on the Medical Outcomes Study 8 Items Short Form Health Survey (SF-8), measured both at baseline and six-month-after the application. We used the change in physical and mental health component summary score (PCS-8 and MCS-8) as outcome variables.

RESULTS

Multiple linear regression analyses, adjusting for age, sex, healthcare institute, and baseline PCS-8 and MCS-8, showed that lower income was associated with an increase in PCS-8 (coef. -0.09; 95% CI, -0.15 to, -0.03) and MCS-8 (coef. -0.04; 95% CI, -0.11, to 0.03). Living alone (versus. living with someone) was potentially associated with a decrease in both PCS-8 (coef. -1.58; 95% CI, -7.26 to 4.09) and MCS-8 (coef. -3.62; 95% CI, -9.19 to 1.95).

CONCLUSIONS

Among patients using FLCMC, those who live alone may need additional support. Further study testing the generalizability of the findings is required.

Understanding and improving the experience of claiming social security for mental health problems in the west of Scotland: A participatory social welfare study

A growing body of literature links claimant interactions with the UK social security system and negative psychological consequences. Psychologists for social change developed a framework to outline proposed mechanisms of psychological impact from austerity. This codesigned study aimed to make an informed comment on areas of dis(agreement) between the Austerity Ailments framework and how people claiming for mental health problems describe their own experiences. In line with the participatory social welfare design of the study, qualitative analysis was performed by both claimants and academics. The overall findings indicate that existing framework mostly captured claimant experiences. However, some aspects of the claimant experience (particularly social aspects) were not well captured. Claimants were keen to utilise this study as an opportunity to gather claimant ideas on how to improve the system. Therefore, we report their suggestions that may be useful for those designing and improving social welfare systems.

Are You Getting Enough to Eat? Addressing Food Insecurity in Rehabilitation Clients

Food insecurity is a well-known risk factor for poor health and quality-of-life outcomes. Recent explorations of census data have concluded that it is experienced disproportionately by individuals with disabilities, making it an important area of focus for rehabilitation counseling and research. The purpose of this study is to explore the relationship between food insecurity and work barriers and intrapersonal characteristics that are often the focus of rehabilitation counseling. Findings from a national sample of adults with disabilities ( N = 435) reveal that individuals with less than a bachelor’s degree or in a household earning less than $40,000 per year were more likely to report high food insecurity. In addition, food insecurity correlated with unfavorable outcomes in measures of self-reported health, depression, social support, acceptance of chronic illness and disability (CID), and vocational self-efficacy. Implications are presented for increasing attention to the issue of food insecurity within the context of rehabilitation counseling practice and research, including strategies for augmenting services to include food assistance in a way that is sensitive to the experience of individuals with significant resource gaps.

Subjective Social Status as a Predictor of Loneliness: The Moderating Effect of the Type of Long-Term Care Setting

Much has been written about the important role that subjective social status plays in older adults' well-being and subjective health. Less is known, however, about the potential role played by subjective social status in people's sense of loneliness. In the present study, the author examined the role of subjective social status as a predictor of loneliness in adult day care centers (ADCCs) and continuing care retirement communities (CCRCs) over a 1-year period. The main analyses consist of data from 245 respondents (141 ADCC participants and 104 CCRC residents) who completed the interviews in Waves 1 and 2. A significant interaction between subjective social status and type of long-term care setting was found. Higher levels of subjective social status were associated with lower levels of loneliness in CCRCs, but no such association was evident in ADCCs. These findings are interpreted in view of the characteristics of the CCRC as a total institution versus the ADCC as a setting that provides support for only several hours per day, several days per week.

An Adapted Model of Cost-Related Nonadherence to Medications Among People With Disabilities

Despite emerging evidence on cost-related nonadherence (CRNA) to prescription medications, there is little conceptualization and exploration of this phenomenon with respect to disability. Specifically, there is a gap in the literature that explores factors influencing medication cost–adherence relationship among individuals living with a disability. To advance research on and policy for CRNA to medications among people with disabilities, we need a framework that can contribute towards guiding solutions to this problem. We examined the applicability of Piette and colleagues’ existing model for CRNA to the context of people with disabilities and suggested an adapted model (CRNA to medications for persons with disability [CRNA-d]) that can provide a more specific conceptualization of CRNA with respect to disability. The adapted CRNA-d model depicts that CRNA to prescription medications with respect to disability is a dynamic and multifaceted phenomenon, determined by various socioeconomic, disability-related, medication-related, prescriber-related, and system-related factors. We discuss how higher susceptibility to health complications, barriers to income and employment, additional health care costs, the complexity of medical regimens, limited access to physician services, and other policy-related factors increase the risk of persons with disabilities to face cost-related barriers to fulfill their necessary medications.

Social isolation: development and validation of measures

Purpose

The purpose of this paper is to develop and empirically validate items on social isolation. The comprehensive literature review of existing studies on the measures of social isolation, loneliness and the related construct was conducted. The paper seeks to conceptualize, validate and present items to measure social isolation.

Design/methodology/approach

The paper is based on theoretical and empirical investigation of the measures of social isolation, loneliness and related constructs such as social others, social loneliness and feeling of sociability. The items were generated through theoretical exploration of previous literature and later modified. The author examined the items through exploratory factor analysis, confirmatory factor analysis and further checked for external criterion validity. Data collected from 128 individuals, in India, were examined to design and validate the scale.

Findings

The finding of the paper is a ten-item social isolation scale. Using structural equation modeling, we have found extraversion and well-being significantly associated with final items in the present study, confirming the external quality of the scale.

Practical implications

Organizations may benefit by close examination of the presence of social isolation in employees along with providing support and assistance to employees so as to reduce negative consequences of social isolation and can address the well-being of the employee.

Originality/value

There is a dearth of developed and validated measures of social isolation in the literature. The study reveals the conceptualization and empirical validation of measures of social isolation in the Indian context so that researchers can move forward to develop theories on social isolation.

Disparities of health service for the poor in the coastal area: does Universal health coverage reduce disparities?

Background & Objective: Poor people, in general, get poor quality of health services. The situation is very much worsening for the poor who live in the remote areas in the coastal belt of Bangladesh as health care facilities and services are often less complete, farther away, and therefore most costly to reach than in urban hospitals and physician. Ensure of better health service for the poor, it is essential to examine the effectiveness of Universal Health Coverage (UHC). This study sets its objectives to evaluate the health service for the poor in the coastal area of Bangladesh and develop an approach of management strategy. Methods: This study followed a two-stage cluster sampling technique and carried out a household survey through the open-ended questionnaire. In addition, the study applied the logistic regression model to generate empirically supported assessments. Results: Result from the disparity rate ratio (DRR) revealed that there is a big health care disparity of different income groups like poor and rich. Furthermore, results from the model demonstrated that Medicaid, Medicare, Social Health Insurance, Telemedicine and Capitation under the provision Universal Health Coverage (UHC) are statistically significant compared to reduce the health care disparity. Conclusion: UHC becomes a critical issue for improved and quality health care system for all the groups especially, the poor in coastal Bangladesh. This study showed that Medicaid, Medicare and Social Health Insurance and Capitation perform well to provide better health care facilities for all.