The promise and peril of universal health care

Pregnant women with chronic hepatitis B virus infection at the assessment of tenofovir disoproxil fumarate prescription: Baseline characteristics of a prospective cohort study in Vietnam

Objectives

We aimed to determine epidemiological characteristics and serologic markers among chronically hepatitis B virus (HBV)-infected pregnant women during the assessment of tenofovir disoproxil fumarate (TDF) prescription in Vietnam.

Methods

We consecutively recruited 375 pregnant women with chronic HBV (cHBV) infection at week 25±2 of pregnancy, at which time they were assessed for TDF use as pre-prophylaxis and/or pre-treatment at the Hospital for Tropical Diseases in southern Vietnam during December 2019-April 2021. Demographic characteristics, serological biomarkers, and prenatal liver ultrasounds were obtained through interviews and reviews of medical records.

Results

The median age of pregnant women was 29 years (interquartile range: 26-32). More than half of pregnant women (208/375; 55.5%) started TDF for prevention of mother-to-child transmission of HBV and/or treatment of chronic hepatitis B (CHB). Among the pregnant women initiating TDF, 96.1% (198/206) tested positive for hepatitis B e antigen, and 21.6% (45/208) had quantitative hepatitis B surface antigen (qHBsAg) ≤104 IU/mL. A relatively strong correlation between qHBsAg and HBV deoxyribonucleic acid (DNA) (r = 0.81; 95% CI: 0.76-0.85) was observed in pregnant women starting TDF.

Conclusions

Our results demonstrate the high need for TDF prescription for prevention and/or treatment purposes in pregnant women with cHBV infection. Pregnant women with qHBsAg levels ≤104 IU/mL may prioritize HBV DNA testing over qHBsAg to decide on TDF prescription.

Beyond Healing: Embracing the Triple Bottom Line Approach in Post-pandemic Healthcare

A triple bottom line (TBL) encompasses economic, social, and environmental dimensions, which provides a strategy for transforming contemporary healthcare systems. This study contextualized current TBL developments in healthcare under the spotlight of COVID-19 pandemic-related challenges and opportunities. The paper has five sections, including an introductory section that outlines the TBL concept and its relevance to healthcare. Following this, we provide an overview of the three pillars of the TBL, including its economic, social, and environmental dimensions as they relate to healthcare. This section also includes several case studies to illustrate TBL-based practices in diverse healthcare settings, focusing on how these were implemented and the outcomes and barriers to adopting such practices. In addition to showcasing current TBL practices, we review three significant challenges to TBL and highlight potential areas for future research, such as innovative practices, educational reform, and the need for the development of robust TBL metrics. The overarching conclusion is that the TBL provides a profound approach to conceptualizing contemporary healthcare to meet the urgent requirements for a more resilient, equitable, and environmentally responsible healthcare system.

Geospatial analysis of spatial distribution, patterns, and relationships of health status in the belt and road initiative

The Health Silk Road plays a crucial role in the Belt and Road Initiative, and comprehending the health status within the participating countries is fundamental for fostering cooperation in public health. This paper collected five health indicators to represent the health status of the Belt and Road countries. Employing spatial statistics, the spatial patterns of health indicators and the associations with influencing factors were investigated. The utilized spatial statistics encompass spatial autocorrelation methods, geographical detector and spatial lag model. The results revealed obvious disparities and significant positive spatial autocorrelation of health indicators within the Belt and Road countries. Specifically, countries in Sub-Saharan Africa exhibited significant clustering of limited health indicators, while countries in Europe and Central Asia demonstrated significant clustering of robust health indicators. Furthermore, the health indicators exhibited significant spatial heterogeneity and association with the influencing factors. Universal health coverage, household air pollution, and the prevalence of undernourishment emerge as influential factors affecting health indicators. Overall, our findings highlighted complex influencing factors that contributed to the profound health inequalities across the Belt and Road countries. These factors should be duly considered in public health collaborations within the Belt and Road Initiative.

Assessment of needs and gaps in public health cadre in India - a situational analysis

BACKGROUND

A structured and organized public health set up with systematically trained personnel to manage and deliver public health services from grassroot levels to higher administrative levels with separate public health directorate is the need of the hour. The objective of this study was to conduct a situational analysis of public health cadre in select states in India to gain an in-depth understanding of the progress and explore the gaps and challenges in its implementation.

METHODS

Four states from the country were selected based on stages of implementation of the cadre. The WHO health systems framework was the basis of assessment. In-depth interviews of 78 stakeholders from public health system across various categories and levels were conducted.

RESULTS

Every state has a dedicated cadre for public health in the form of a separate hierarchical structure and Directorate. There are deficits in human resources skilled enough to manage and implement public health across all levels. Its penetration below districts level is limited. There are limited opportunities available for contractual staffs in terms of remuneration and job progression. The respondents strongly emphasized on having personnel with training in public health, especially at leadership positions. Funding was not reported to be a problem although some challenges in the timeliness of release of funds were reported. Under the existing Health Management Information System, duplication of data exists and there is underutilization of data for policy making.

CONCLUSION

A dedicated public health cadre is under evolution in India. The main challenge is inadequate workforce skilled in public health management. States are committed to finding solutions to overcome these barriers.

Preferences on Policy Options for Ensuring the Financial Sustainability of Healthcare Services in the Kingdom of Saudi Arabia

Background

Escalating global health expenditures pose a threat to healthcare financing sustainability, requiring the exploration of alternative financing policies and resource allocation strategies to curb their adverse effects. The aim of this study was to gather insight into the preferences of healthcare workers, including physicians, nurses, allied healthcare professionals, and healthcare administrators, as well as academics in the field of healthcare management and health sciences in Saudi universities, regarding policy options that can secure the financial sustainability of healthcare services in Saudi Arabia.

Methods

A cross-sectional research design was employed, and data were collected through an online self-administered survey from August 2022 to December 2022 in Saudi Arabia. The survey garnered responses from 513 participants hailing from all 13 administrative regions in Saudi Arabia. Analyses were performed using non-parametric statistical tests, specifically the two-sample Mann-Whitney U-test and Kruskal-Wallis test, to determine the statistical significance of differences in the policy ranking and policy feasibility options.

Results

The study findings reveal a consensus among stakeholders on the most and least preferred policies. All stakeholders expressed opposition to financing healthcare by diverting resources from defence, social protection, and education, while they favoured policies that entail imposing penalties on health-related issues such as waste management and pollution. Nevertheless, variations among stakeholders were evident in regard to the rankings for specific policies, particularly between healthcare workers and academics. Moreover, the results highlight that tax-based policies are the most feasible approach to generating healthcare funds, despite ranking lower in terms of preferred policies.

Conclusion

This study provides a framework for understanding stakeholder preferences on healthcare financing sustainability by ranking 26 policy options according to stakeholder groups. The appropriate mixture of financing mechanisms should be informed by evidence-based and data-driven approaches that consider relevant stakeholder preferences.

Review on distribution, fate, and management of potentially toxic elements in incinerated medical wastes

Medical wastes include all solid and liquid wastes that are produced during the treatment, diagnosis, and immunisation of animals and humans. A significant proportion of medical waste is infectious, hazardous, radioactive, and contains potentially toxic elements (PTEs) (i.e., heavy metal (loids)). PTEs, including arsenic (As), cadmium (Cd), lead (Pb) and mercury (Hg), are mostly present in plastic, syringes, rubber, adhesive plaster, battery wastes of medical facilities in elemental form, as well as oxides, chlorides, and sulfates. Incineration and sterilisation are the most common technologies adopted for the safe management and disposal of medical wastes, which are primarily aimed at eliminating deadly pathogens. The ash materials derived from the incineration of hazardous medical wastes are generally disposed of in landfills after the solidification/stabilisation (S/S) process. In contrast, the ash materials derived from nonhazardous wastes are applied to the soil as a source of nutrients and soil amendment. The release of PTEs from medical waste ash material from landfill sites and soil application can result in ecotoxicity. The present study is a review paper that aims to critically review the dynamisms of PTEs in various environmental media after medical waste disposal, the environmental and health implications of their poor management, and the common misconceptions regarding medical waste.

COVID-19 Spotlights Connections between Disease and Multiple Lifestyle Factors

The SARS-CoV-2 virus (severe acute respiratory syndrome coronavirus 2), and the disease it causes (COVID-19), have had a profound impact on global human society and threaten to continue to have such an impact with newly emerging variants. Because of the widespread effects of SARS-CoV-2, understanding how lifestyle choices impact the severity of disease is imperative. This review summarizes evidence for an involvement of chronic, non-resolving inflammation, gut microbiome disruption (dysbiosis with loss of beneficial microorganisms), and impaired viral defenses, all of which are associated with an imbalanced lifestyle, in severe disease manifestations and post-acute sequelae of SARS-CoV-2 (PASC). Humans' physiological propensity for uncontrolled inflammation and severe COVID-19 are briefly contrasted with bats' low propensity for inflammation and their resistance to viral disease. This insight is used to identify positive lifestyle factors with the potential to act in synergy for restoring balance to the immune response and gut microbiome, and thereby protect individuals against severe COVID-19 and PASC. It is proposed that clinicians should consider recommending lifestyle factors, such as stress management, balanced nutrition and physical activity, as preventative measures against severe viral disease and PASC.

Polyurethane-polypyrrole hybrid structural color films for dual-signal mechanics sensing

The monitoring of mechanical indexes involved in body movement has attracted immense interest in the diagnosis of neurodegenerative diseases. Here, we present a hybrid flexible conductive structural color (SC) film with the capability of dual-signal mechanics screening. The film is constructed by oxidatively polymerizing pyrrole on the surface of an inverse opal polyurethane (IPU) membrane, which can be utilized to measure the mechanical indexes through resistance change. Owing to the inverse opal structure, the film shows visual structural color change when stretched and released according to the body movement. Additionally, the highly uniform ordered porous structure endows the conductive film with a lower coefficient of variance on relative resistance change. Benefiting from these features, we have demonstrated that such a flexible conductive SC film could monitor Parkinson's disease (PD) by detecting mechanical indexes simultaneously via dual signals. These features indicate the great value of the stretchable conductive SC films in mechanics sensing applications.

Current Applications of Machine Learning in Spine: From Clinical View

STUDY DESIGN

Narrative review.

OBJECTIVES

This review aims to present current applications of machine learning (ML) in spine domain to clinicians.

METHODS

We conducted a comprehensive PubMed search of peer-reviewed articles that were published between 2006 and 2020 using terms (spine, spinal, lumbar, cervical, thoracic, machine learning) to examine ML in spine. Then exclude research of other domain, case report, review or meta-analysis, and which without available abstract or full text.

RESULTS

Total 1738 articles were retrieved from database, and 292 studies were finally included. Key findings of current applications were compiled and summarized in this review. Main clinical applications of those techniques including image processing, diagnosis, decision supporting, operative assistance, rehabilitation, surgery outcomes, complications, hospitalization and cost.

CONCLUSIONS

ML had achieved excellent performance and hold immense potential in spine. ML could help clinical staff to improve medical level, enhance work efficiency, and reduce adverse events. However more randomized controlled trials and improvement of interpretability are essential to clinicians accepting models' assistance in real work.

The value of vaccines

Optimizing vaccine spending depends on recognizing the full value of vaccination (VoV). Existing taxonomies of such value are not comprehensive because they are not guided by general theories. I rely on two such theories: subjective-value theory claims that what has value is determined by what people actually or ideally want in life. A welfarist theory of government states that a fundamental objective of government is to promote social value (or social welfare). These jointly imply that any aspect of life that individuals actually or ideally value and that could be negatively affected by vaccine-preventable diseases (and therefore positively affected by preventive vaccines) is an element of VoV. I build a more comprehensive-value taxonomy than currently exists based on this implication.

Prevention of COVID-19 pandemic through technological innovation: ensuring global innovative capability, absorptive capacity, and adaptive healthcare competency

The study examines the role of technology transfer in preventing communicable diseases, including COVID-19, in a heterogeneous panel of selected 65 countries. The study employed robust least square regression and innovation accounting matrixes to get robust inferences. The results found that overall technological innovation, including innovative capability, absorptive capacity, and healthcare competency, helps reduce infectious diseases, including the COVID-19 pandemic. Patent applications, scientific and technical journal articles, trade openness, hospital beds, and physicians are the main factors supporting the reduction of infectious diseases, including the COVID-19 pandemic. Due to inadequate research and development, healthcare infrastructure expenditures have caused many communicable diseases. The increasing number of mobile phone subscribers and healthcare expenditures cannot minimize the coronavirus pandemic globally. The impulse response function shows an increasing number of patent applications, mobile penetration, and hospital beds that will likely decrease infectious diseases, including COVID-19. In contrast, insufficient resource spending would likely increase death rates from contagious diseases over a time horizon. It is high time to digitalize healthcare policies to control coronavirus worldwide.

How equitable is health spending on curative services and institutional delivery in Malawi? Evidence from a quasi-longitudinal benefit incidence analysis

Background

Malawi is one of a handful of countries that had resisted the implementation of user fees, showing a commitment to providing free healthcare to its population even before the concept of Universal Health Coverage (UHC) acquired global popularity. Several evaluations have investigated the effects of key policies, such as the essential health package or performance-based financing, in sustaining and expanding access to quality health services in the country. Understanding the distributional impact of health spending over time due to these policies has received limited attention. Our study fills this knowledge gap by assessing the distributional incidence of public and overall health spending between 2004 and 2016.

Methods

We relied on a Benefit Incidence Analysis (BIA) to measure the socioeconomic inequality of public and overall health spending on curative services and institutional delivery across different health facility typologies. We used data from household surveys and National Health Accounts. We used a concentration index (CI) to determine the health benefits accrued by each socioeconomic group.

Results

Socioeconomic inequality in both public and overall health spending substantially decreased over time, with higher inequality observed in overall spending, non-public health facilities, curative health services, and at higher levels of care. Between 2004 and 2016, the inequality in public spending on curative services decreased from a CI of 0.037 (SE 0.013) to a CI of 0.004 (SE 0.011). Whiles, it decreased from a CI of 0.084 (SE 0.014) to a CI of 0.068 (SE 0.015) for overall spending in the same period. For institutional delivery, inequality in public and overall spending decreased between 2004 and 2016 from a CI of 0.032 (SE 0.028) to a CI of -0.057 (SE 0.014) and from a CI of 0.036 (SE 0.022) to a CI of 0.028 (SE 0.018), respectively.

Conclusions

Through its free healthcare policy, Malawi has reduced socioeconomic inequality in health spending over time, but some challenges still need to be addressed to achieve a truly egalitarian health system. Our findings indicate a need to increase public funding for the health sector to ensure access to care and financial protection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01624-5.

International models of neuropalliative care

Can equitable Neuropalliative care (NpC) be delivered globally? This chapter surveys existing services and ground realities in different parts of the world. In many countries, universal healthcare (UHC) seems to have been a precondition for the establishment of palliative care (PC). PC has been recognized as a basic human right as a part of UHC. Quality of Death and PC surveys provide an overview of the existing situation. Currently, PC is largely focused on the needs of cancer patients and this is a legacy issue for professionals and systems. Communities however recognize suffering and do not distinguish between medical diagnoses. The development of NpC as a subspecialty of neurology allows neurologists everywhere to become primary palliative care providers for their own patients. It is also necessary to integrate neurology with existing palliative care services. There is much that can be done to improve NpC provision even within the limits that bound every jurisdiction and trial evidence is emerging to inform this practice. This chapter is a survey of the challenges and the potential.

Variations in Quality of Care by Sex and Social Determinants of Health Among Younger Adults With Acute Myocardial Infarction in the US and Canada

IMPORTANCE

Quality of care of young adults with acute myocardial infarction (AMI) may depend on health care systems in addition to individual-level factors such as biological sex and social determinants of health (SDOH).

OBJECTIVE

To examine whether the quality of in-hospital and postacute care among young adults with AMI differs between the US and Canada and whether female sex and adverse SDOH are associated with a low quality of care.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort analysis used data from 2 large cohorts of young adults (aged ≤55 years) receiving in-hospital and outpatient care for AMI at 127 centers in the US and Canada. Data were collected from August 21, 2008, to April 30, 2013, and analyzed from July 12, 2019, to March 10, 2021.

EXPOSURES

Sex, SDOH, and health care system.

MAIN OUTCOMES AND MEASURES

Opportunity-based quality-of-care score (QCS), determined by dividing the total number of quality indicators of care received by the total number for which the patient was eligible, with low quality of care defined as the lowest tertile of the QCS.

RESULTS

A total of 4048 adults with AMI (2345 women [57.9%]; median age, 49 [interquartile range, 44-52] years; 3004 [74.2%] in the US) were included in the analysis. Of 3416 patients with in-hospital QCS available, 1061 (31.1%) received a low QCS, including more women compared with men (725 of 2007 [36.1%] vs 336 of 1409 [23.8%]; P < .001) and more patients treated in the US vs Canada (962 of 2646 [36.4%] vs 99 of 770 [12.9%]; P < .001). Conversely, low quality of post-AMI care (748 of 2938 [25.5%]) was similarly observed for both sexes, with a higher prevalence in the US (678 of 2346 [28.9%] vs 70 of 592 [11.8%]). In adjusted analyses, female sex was not associated with low QCS for in-hospital (odds ratio [OR], 1.05; 95% CI, 0.87-1.28) and post-AMI (OR, 1.07; 95% CI, 0.88-1.30) care. Conversely, being treated in the US was associated with low in-hospital (OR, 2.93; 95% CI, 2.16-3.99) and post-AMI (OR, 2.67; 95% CI, 1.97-3.63) QCS, regardless of sex. Of all SDOH, only employment was associated with higher quality of in-hospital care (OR, 0.72; 95% CI, 0.59-0.88). Finally, only in the US, low quality of in-hospital care was associated with a higher 1-year cardiac readmissions rate (234 of 962 [24.3%]).

CONCLUSIONS AND RELEVANCE

These findings suggest that beyond sex, health care systems and SDOH that depict social vulnerability are associated with quality of AMI care. Taking into account SDOH among young adults with AMI may improve quality of care and reduce readmissions, especially in the US.

Sociodemographic Inequalities in Health Insurance Ownership among Women in Selected Francophone Countries in Sub-Saharan Africa

In sub-Saharan Africa, improving equitable access to healthcare remains a major challenge for public health systems. Health policymakers encourage the adoption of health insurance schemes to promote universal healthcare. Nonetheless, progress towards this goal remains suboptimal due to inequalities health insurance ownership especially among women. In this study, we aimed to explore the sociodemographic factors contributing to health insurance ownership among women in selected francophone countries in sub-Saharan Africa. Methods. This study is based on cross-sectional data obtained from Demographic and Health Surveys on five countries including Benin (n = 13,407), Madagascar (n = 12,448), Mali (n = 10,326), Niger (n = 12,558), and Togo (n = 6,979). The explanatory factors included participant age, marital status, type of residency, education, household wealth quantile, employment stats, and access to electronic media. Associations between health insurance ownership and the explanatory factors were analyzed using multivariate regression analysis, and effect sizes were reported in terms in average marginal effects (AMEs). Results. The highest percentage of insurance ownership was observed for Togo (3.31%), followed by Madagascar (2.23%) and Mali (2.2%). After stratifying by place of residency, the percentages were found to be significantly lower in the rural areas for all countries, with the most noticeable difference observed for Niger (7.73% in urban vs. 0.54% in rural women). Higher levels of education and wealth quantile were positively associated with insurance ownership in all five countries. In the pooled sample, women in the higher education category had higher likelihood of having an insurance: Benin (AME = 1.18; 95% CI = 1.10, 1.27), Madagascar (AME = 1.10; 95% CI = 1.05, 1.15), Mali (AME = 1.14; 95% CI = 1.04, 1.24), Niger (AME = 1.13; 95% CI = 1.07, 1.21), and Togo (AME = 1.17; 95% CI = 1.09, 1.26). Regarding wealth status, women from the households in the highest wealth quantile had 4% higher likelihood of having insurance in Benin and Mali and 6% higher likelihood in Madagascar and Togo. Conclusions. Percentage of women who reported having health insurance was noticeably low in all five countries. As indicated by the multivariate analyses, the actual situation is likely to be even worse due to significant socioeconomic inequalities in the distribution of women having an insurance plan. Increasing women's access to healthcare is an urgent priority for population health promotion in these countries, and therefore, addressing the entrenched sociodemographic disparities should be given urgent policy attention in an effort to strengthen universal healthcare-related goals.

Modified scoping review of the enablers and barriers to implementing primary health care in the COVID-19 context

Since the Alma Ata Declaration of 1978, countries have varied in their progress towards establishing and sustaining comprehensive primary health care (PHC) and realizing its associated vision of 'Health for All'. International health emergencies such as the coronavirus-19 (COVID-19) pandemic underscore the importance of PHC in underpinning health equity, including via access to routine essential services and emergency responsiveness. This review synthesizes the current state of knowledge about PHC impacts, implementation enablers and barriers, and knowledge gaps across the three main PHC components as conceptualized in the 2018 Astana Framework. A scoping review design was adopted to summarize evidence from a diverse body of literature with a modification to accommodate four discrete phases of searching, screening and eligibility assessment: a database search in PubMed for PHC-related literature reviews and multi-country analyses (Phase 1); a website search for key global PHC synthesis reports (Phase 2); targeted searches for peer-reviewed literature relating to specific components of PHC (Phase 3) and searches for emerging insights relating to PHC in the COVID-19 context (Phase 4). Evidence from 96 included papers were analysed across deductive themes corresponding to the three main components of PHC. Findings affirm that investments in PHC improve equity and access, healthcare performance, accountability of health systems and health outcomes. Key enablers of PHC implementation include equity-informed financing models, health system and governance frameworks that differentiate multi-sectoral PHC from more discrete service-focussed primary care, and governance mechanisms that strengthen linkages between policymakers, civil society, non-governmental organizations, community-based organizations and private sector entities. Although knowledge about, and experience in, PHC implementation continues to grow, critical knowledge gaps are evident, particularly relating to country-level, context-specific governance, financing, workforce, accountability and service coordination mechanisms. An agenda to guide future country-specific PHC research is outlined.

Reinforcing locally led solutions for universal health coverage: a logic model with applications in Benin, Namibia and Uganda

Development assistance for health programmes is often characterised as donor-led models with minimal country ownership and limited sustainability. This article presents new ways for low-income and middle-income countries to gain more control of their development assistance programming as they move towards universal health coverage (UHC). We base our findings on the experience of the African Collaborative for Health Financing Solutions (ACS), an innovative US Agency for International Development-funded project. The ACS project stems from the premise that the global health community can more effectively support UHC processes in countries if development partners change three long-standing paradigms: (1) time-limited projects to enhancing long-lasting processes, (2) fly-in/fly-out development support to leveraging and strengthening local and regional expertise and (3) static knowledge creation to supporting practical and co-developed resources that enhance learning and capture implementation experience. We assume that development partners can facilitate progress towards UHC if interventions follow five action steps, including (1) align to country demand, (2) provide evidence-based and tailored health financing technical support, (3) respond to knowledge and learnings throughout activity design and implementation, (4) foster multi-stakeholder collaboration and ownership and (5) strengthen accountability mechanisms. Since 2017, the ACS project has applied these five action steps in its implementing countries, including Benin, Namibia and Uganda. This article shares with the global health community preliminary achievements of implementing a unique, challenging but promising experience.

The Societal Value of Vaccination in the Age of COVID-19

In recent years, academics and policymakers have increasingly recognized that the full societal value of vaccination encompasses broad health, economic, and social benefits beyond avoided morbidity and mortality due to infection by the targeted pathogen and limited health care costs. Nevertheless, standard economic evaluations of vaccines continue to focus on a relatively narrow set of health-centric benefits, with consequences for vaccination policies and public investments.The COVID-19 pandemic illustrates in stark terms the multiplicity and magnitude of harms that infectious diseases may inflict on society. COVID-19 has overtaxed health systems, disrupted routine immunization programs, forced school and workplace closures, impeded the operation of international supply chains, suppressed aggregate demand, and exacerbated existing social inequities.The obvious nature of the pandemic's broad effects could conceivably convince more policymakers to identify and account for the full societal impacts of infectious disease when evaluating the potential benefits of vaccination. Such a shift could make a big difference in how we allocate societal resources in the service of population health and in how much we stand to gain from that spending.

Significant inefficiency in running community health systems: The case of health posts in Southwest Ethiopia

Background

Although much has been documented about the performance of the health extension program, there is a lack of information on how efficiently the program is running. Furthermore, the rising cost of health services and the absence of competition among publicly owned health facilities demands strong follow up of efficiency. Therefore, this study aimed to assess the technical efficiency of the health posts and determinants in Southwestern Ethiopia.

Methods and materials

We used data for one Ethiopian fiscal year (from July 2016 to June 2017) to estimate the technical efficiency of health posts. A total of 66 health posts were included in the analysis. We employed a two-stage data envelopment analysis to estimate technical efficiency. At the first stage, technical efficiency scores were calculated using data envelopment analysis program version 2.1. Predictors of technical efficiency were then identified at the second stage using Tobit regression, with STATA version 14.

Results

The findings revealed that 21.2% were technically efficient with a mean technical efficiency score of 0.6 (± 0.3), indicating that health posts could increase their service volume by 36% with no change made to the inputs they received. On the other hand, health posts had an average scale efficiency score of 0.8 (± 0.2) implying that the facilities have the potential to increase service volume by 16% with the existing resources. The regression model has indicated average waiting time for service has negatively affected technical efficiency.

Conclusion

More than three-quarters of health posts were found inefficient. The technical efficiency score of more than one-third of the health posts is even less than 50%. Community mobilization to enhance the uptake of health services at the health posts coupled with a possible reallocation of resources in less efficient health posts is a possible approach to improve the efficiency of the program.

Individual awareness and treatment effectiveness of hypertension among older adults in Ghana: evidence from the World Health Organization study of global ageing and adult health wave 2

INTRODUCTION

the aim of this study was to report the prevalence of hypertension, its awareness and treatment effectiveness among older adults (aged 50 years and above) in Ghana.

METHODS

the Ghana World Health Organization´s (WHO) Study on Global Aging and Adult Health (SAGE) wave 2 dataset was used in this study. The study adopted a cross-sectional study design. Information on self-reported hypertension as well as measured hypertension was analyzed. The level of awareness regarding hypertension and the effectiveness of treatment was determined using descriptive statistics. Factors associated with an individual´s awareness of their hypertensive status were determined using Rao-Scott Chi square test statistic and the predictors of unawareness of hypertension were determined using adjusted logistic regression analysis. A p-value of ≤0.05 was deemed significant.

RESULTS

information on 3,575 adults in Ghana aged 50 years or older was included in this analysis. The mean age of study participants was 65.1 ± 10.7 years with 59% being female. The prevalence of measured hypertension was 50.7% [95%CI=48.3-53.2]. The overall prevalence of hypertension among older adults in Ghana who were hypertensive but were not aware of it was 35.0% [95%CI=31.6-38.5]. Of the 332 individuals who self-reported being hypertensive, only 74 (22.2%) were on any form of treatment, with only 17 (5.1%) having their blood pressures well controlled.

CONCLUSION

approximately half of all older adults in Ghana have elevated blood pressures. Most of these are not aware of their elevated blood pressure and for those who are aware, very few are on treatment and even fewer have their blood pressure well controlled. Structured national population level screening and health promotion for elevated blood pressure by Ministry of Health/ Ghana Health Service is worthy of consideration.

Are family medicine centres achieving their target in Turkey: Impact on health care utilization of mothers and infants

The family medicine (FM) system was introduced as the main source of primary care in Turkey as a component of the Health Transformation Program reforms. During a gradual implementation process, provinces switched to the FM system at different points in time between 2005 and 2010. In this paper, we use a micro-level data set to test whether the health care utilization of mothers during pregnancy, childbirth and the postnatal period is affected by the program. Using a difference-in-differences method for estimation, we find that the program is only effective for pregnant women who lived in provinces with a limited availability of specialist doctors. As a result of the FM program, women are likely to have their first prenatal consultancy earlier and their probability of seeing a doctor during their prenatal visit and receiving an ultrasound and blood and urine sample checks increases if they live in a province with a low number of specialists per 10,000 people. We find that the impact of the FM program decreases as the rate of specialists in a province increases, which negates any positive effect of the program on health care use.

Fraud and Abuse in the Saudi Healthcare System: A Triangulation Analysis

In the insurance industry, the majority of fraud and abuse cases fall into a limited number of patterns, yet false claims normally lead to negative national, local, and organizational effects. Through monitoring the exploitative and abusive behavior commonly found in healthcare services, this paper aims to analyze initiatives implemented by governmental and related healthcare insurance agencies in Saudi Arabia to reduce moral offenses. To accomplish this objective, major governmental health insurance policy documents were analyzed at the macro-level. At the meso-level, semi-structured interviews were conducted with five health insurance professionals on measures undertaken to prevent such incidents. At the micro-level, the critical factors of fraudulent behaviors were analyzed using a retrospective analysis. Data were retrieved from anti-fraud records of ten leading health insurance companies and the focus was mainly on individuals involved in unethical practices between 2014 and 2019. After a full audit was completed, the results concluded that the Saudi healthcare system is composed of twenty-six cooperative health insurance agencies and over 5,202 health services providers. The official documents contain the details of various moral hazard measures. On annual average, more than 196 fraudulent cases were reported with a claim rejection rate of approximately 15%. The majority of fraud cases were reported in dental services with invalid card usage, followed by obstetrics-gynecology services (47 and 113 cases, respectively). Females tended to make up most deceit cases in obstetrics-gynecology with a high level of abuse (95% confidence interval: −83.398 to −24.202; P < .003 and −28 > 638 to −7.362; P < .005, respectively). This study ultimately identifies basic measures employed at the macro-level to reduce moral hazards. However, such measures are not intended to be coherently implemented at the micro-level, especially by health insurance companies and healthcare providers.

Prevention of mother-to-child transmission of hepatitis B virus: protocol for a one-arm, open-label intervention study to estimate the optimal timing of tenofovir in pregnancy

INTRODUCTION

Hepatitis B virus (HBV) remains a public health threat and the main route of transmission is from mother to child (MTCT). Tenofovir disoproxil fumarate (TDF) treatment can reduce MTCT of HBV although the optimal timing to attain undetectable HBV DNA concentrations at delivery is unknown. This protocol describes the procedures following early initiation of maternal TDF prior to 20 weeks gestation to determine efficacy, safety and feasibility of this approach in a limited-resource setting.

METHODS AND ANALYSES

One hundred and seventy pregnant women from the Thailand-Myanmar border between 12 and <20 weeks gestational age will be enrolled into a one-arm, open-label, TDF treatment study with cessation of TDF 1 month after delivery. Sampling occurs monthly prenatal, at birth and at 1, 2, 4 and 6 months post partum. Measurement of tenofovir concentrations in maternal and cord plasma is anticipated in 10-15 women who have detectable HBV DNA at delivery and matched to 20-30 women with no detectable HBV DNA. Infant HBsAg status will be determined at 2 months of age and HBV DNA confirmed in HBsAg positive cases. Adverse events including risk of flare and adherence, based on pill count and questionnaire, will be monitored. Infants will receive HBV vaccinations at birth, 2, 4 and 6 months and hepatitis B immunoglobulin at birth if the mother is hepatitis B e antigen positive. Infant growth and neurodevelopment at 6 months will be compared with established local norms.

ETHICS AND DISSEMINATION

This study has ethical approval by the Ethics Committee of the Faculty of Tropical Medicine, Mahidol University (FTM ECF-019-06), Johns Hopkins University (IRB no: 00007432), Chiang Mai University (FAM-2559-04227), Oxford Tropical Research Ethics Committee (OxTREC Reference: 49-16) and by the local Tak Community Advisory Board (TCAB-02/REV/2016). The article will be published as an open-access publication.

TRIAL REGISTRATION NUMBER

NCT02995005, Pre-results.

Tenofovir for prevention of mother to child transmission of hepatitis B in migrant women in a resource-limited setting on the Thailand-Myanmar border: a commentary on challenges of implementation

BACKGROUND

The aim of this manuscript is to highlight challenges in the implementation of maternal tenofovir disoproxil fumarate (tenofovir) for prevention of mother to child transmission (PMTCT) of hepatitis B virus (HBV) in resource limited setting. Current preventive strategies in resource-limited settings fail mainly due to prohibitive costs of hepatitis B immunoglobulin (HBIG) and a high proportion of homebirths, meaning both HBIG and hepatitis B birth dose vaccine are not given. A new strategy for PMTCT without the necessity of HBIG, could be daily tenofovir commenced early in gestation. Implementation challenges to early tenofovir for PMTCT can provide insight to elimination strategies of HBV as the burden of disease is high in resource-limited settings.

METHODS

Challenges encountered during implementation of a study of tenofovir for PMTCT before 20 weeks gestation in rural and resource-limited areas on the Thailand-Myanmar border were identified informally from trial study logbooks and formally from comments from patients and staff at monthly visits. ClinicalTrials.gov Identifier: NCT02995005.

MAIN BODY

During implementation 171 pregnant women were hepatitis B surface antigen (HBsAg) positive by point of-care test over 19 months (May-2018 until Dec-2019). In this resource-limited setting where historically no clinic has provided tenofovir for PMTCT of HBV, information provided by staff resulted in a high uptake of study screening (95.5% (84/88) when offered to pregnant women. False positive point-of-care rapid tests hinder a test and treat policy for HBV and development of improved rapid tests that include HBeAg and/or HBV DNA would increase efficiency. Integrated care of HBV to antenatal care, transport assistance and local agreements to facilitate access, could increase healthcare at this critical stage of the life course. As safe storage of medication in households in resource-limited setting may not be ideal, interactive counseling about this must be a routine part of care.

CONCLUSION

Despite challenges, results from the study to date suggest tenofovir can be offered to HBV-infected women in resource-limited settings before 20 weeks gestation with a high uptake of screening, high drug accountability and follow-up, with provision of transportation support. This commentary has highlighted practical implementation issues with suggestions for strategies that support the objective of PMTCT and the World Health Organization goal of HBV elimination by 2030.

Artificial intelligence: opportunities and implications for the health workforce

Healthcare involves cyclic data processing to derive meaningful, actionable decisions. Rapid increases in clinical data have added to the occupational stress of healthcare workers, affecting their ability to provide quality and effective services. Health systems have to radically rethink strategies to ensure that staff are satisfied and actively supported in their jobs. Artificial intelligence (AI) has the potential to augment provider performance. This article reviews the available literature to identify AI opportunities that can potentially transform the role of healthcare providers. To leverage AI's full potential, policymakers, industry, healthcare providers and patients have to address a new set of challenges. Optimizing the benefits of AI will require a balanced approach that enhances accountability and transparency while facilitating innovation.

A Call for Better Integrated Policies to Accelerate the Fertility Decline in Sub-Saharan Africa

To accelerate their demographic transition, sub-Saharan African (SSA) countries must trigger significant and rapid fertility declines. These fertility declines will open a demographic window of opportunity and enable countries to capture a first demographic dividend. Despite some successes, many programs aimed at decreasing fertility in SSA have yielded disappointing results. This commentary argues that better integrated policies will help to accelerate fertility declines in SSA. Such an approach should harness the synergies between a set of four key policy levers: women's empowerment; female education; family planning, reproductive health services, and universal health coverage; and legal reforms. These policy levers should be coupled with renewed commitment from leaders on the continent and increased investments in both family planning and population institutions. By concomitantly investing in these priorities and harnessing the synergies of these policy levers, countries in SSA have a critical opportunity to accelerate their demographic transition, which could help them reach emerging economy status.

Investing in the health of girls and women: a best buy for sustainable development

Human rights, theory, evidence, and common sense all suggest that greater investment in women’s health could be among the “best buys” for broader economic development and societal wellbeing, say Michelle Remme and colleagues

Primary Care 2030: Creating an Enabling Ecosystem for Disruptive Primary Care Models to Achieve Universal Health Coverage in Low- and Middle-Income Countries

Background:

Forty years after Alma Ata, there is renewed commitment to strengthen primary health care as a foundation for achieving universal health coverage, but there is limited consensus on how to build strong primary health care systems to achieve these goals.

Methods:

We convened a diverse group of global stakeholders for a high-level dialogue on how to create an enabling ecosystem for disruptive primary care innovation. We focused our discussion on four themes: workforce innovation and strengthening; impactful use of data and technology; private sector engagement; and innovative financing mechanisms.

Findings:

Here, we present a summary of our convening’s proceedings, with specific recommendations for strengthening primary health care systems within each of these four domains.

Conclusions:

In the wake of the Astana Declaration, there is global consensus that high-quality primary health care must be the foundation for universal health coverage. Significant disruptive innovation will be required to realize this goal. We offer our recommendations to the global community to catalyze further discourse and inform policy-making and program development on the path to Health for All by 2030.

An integrated intervention for chronic care management in rural Nepal: protocol of a type 2 hybrid effectiveness-implementation study

BACKGROUND

In Nepal, the burden of noncommunicable, chronic diseases is rapidly rising, and disproportionately affecting low and middle-income countries. Integrated interventions are essential in strengthening primary care systems and addressing the burden of multiple comorbidities. A growing body of literature supports the involvement of frontline providers, namely mid-level practitioners and community health workers, in chronic care management. Important operational questions remain, however, around the digital, training, and supervisory structures to support the implementation of effective, affordable, and equitable chronic care management programs.

METHODS

A 12-month, population-level, type 2 hybrid effectiveness-implementation study will be conducted in rural Nepal to evaluate an integrated noncommunicable disease care management intervention within Nepal's new municipal governance structure. The intervention will leverage the government's planned roll-out of the World Health Organization's Package of Essential Noncommunicable Disease Interventions (WHO-PEN) program in four municipalities in Nepal, with a study population of 80,000. The intervention will leverage both the WHO-PEN and its cardiovascular disease-specific technical guidelines (HEARTS), and will include three evidence-based components: noncommunicable disease care provision using mid-level practitioners and community health workers; digital clinical decision support tools to ensure delivery of evidence-based care; and training and digitally supported supervision of mid-level practitioners to provide motivational interviewing for modifiable risk factor optimization, with a focus on medication adherence, and tobacco and alcohol use. The study will evaluate effectiveness using a pre-post design with stepped implementation. The primary outcomes will be disease-specific, "at-goal" metrics of chronic care management; secondary outcomes will include alcohol and tobacco consumption levels.

DISCUSSION

This is the first population-level, hybrid effectiveness-implementation study of an integrated chronic care management intervention in Nepal. As low and middle-income countries plan for the Sustainable Development Goals and universal health coverage, the results of this pragmatic study will offer insights into policy and programmatic design for noncommunicable disease care management in the future.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04087369. Registered on 12 September 2019.

AMAFRICA, a patient-navigator program for accompanying lymphoma patients during chemotherapy in Ivory Coast: a prospective randomized study

Background

Previous studies have indicated that accompanying socially underserved cancer patients through Patient Navigator (PN) or PN-derived procedures improves therapy management and reassurance. At the Cancer Institute of Toulouse-Oncopole (France), we have implemented AMA (Ambulatory Medical Assistance), a PN-based procedure adapted for malignant lymphoma (ML) patients under therapy. We found that AMA improves adherence to chemotherapy and safety. In low-middle income countries (LMIC), refusal and abandonment were documented as major adverse factors for cancer therapy. We reasoned that AMA could improve clinical management of ML patients in LMIC.

Methods

This study was set up in the Abidjan University Medical Center (Ivory Coast) in collaboration with Toulouse. One hundred African patients were randomly assigned to either an AMA or control group. Main criteria of judgment were refusal and abandonment of CHOP or ABVD chemotherapy.

Results

We found that AMA was feasible and had significant impact on refusal and abandonment. However, only one third of patients completed their therapy in both groups. No differences were noted in terms of complete response rate (CR) (16% based on intent-to-treat) and median overall survival (OS) (6 months). The main reason for refusal and abandonment was limitation of financial resources.

Conclusion

Altogether, this study showed that PN may reduce refusal and abandonment of treatment. However, due to insufficient health care coverage, its ultimate impact on OS remains limited.

21st-century capitalism: structural challenges for universal health care

The structural perspective outlined here sheds light on some of the fundamental challenges involved in achieving Universal Health Care (UHC) in this twenty-first-century era of trade and financialized capitalism. This commentary explores connections between the structure of twenty-first-century capitalism and challenges to achieving UHC, discussing three features of today’s capitalism: financialized capitalism; trade, intangibles and global value chains; and inequality (as exacerbated by the first two features). The final section discusses the various opportunities for reform to facilitate UHC—from tinkering with the status quo, to deeper regulatory reform and fundamental structural change.

How Can Digital Health Technologies Contribute to Sustainable Attainment of Universal Health Coverage in Africa? A Perspective

Background: Innovative strategies such as digital health are needed to ensure attainment of the ambitious universal health coverage in Africa. However, their successful deployment on a wider scale faces several challenges on the continent. This article reviews the key benefits and challenges associated with the application of digital health for universal health coverage and propose a conceptual framework for its wide scale deployment in Africa. Discussion: Digital health has several benefits. These include; improving access to health care services especially for those in hard-to-reach areas, improvements in safety and quality of healthcare services and products, improved knowledge and access of health workers and communities to health information; cost savings and efficiencies in health services delivery; and improvements in access to the social, economic and environmental determinants of health, all of which could contribute to the attainment of universal health coverage. However, digital health deployment in Africa is constrained by challenges such as poor coordination of mushrooming pilot projects, weak health systems, lack of awareness and knowledge about digital health, poor infrastructure such as unstable power supply, poor internet connectivity and lack of interoperability of the numerous digital health systems. Contribution of digital health to attainment of universal health coverage requires the presence of elements such as resilient health system, communities and access to the social and economic determinants of health. Conclusion: Further evidence and a conceptual framework are needed for successful and sustainable deployment of digital health for universal health coverage in Africa.

The status of Ghanaian community health workers' supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey

Introduction: Community-based services are a critical component of high-quality primary healthcare. Ghana formally launched the National Community Health Worker (CHW) program in 2014, to augment the pre-existing Community-based Health Planning and Services (CHPS). To date, however, there is scant data about the program's implementation. We describe the current supervision and service delivery status of CHWs throughout the country. Methods: Data were collected regarding CHW supervision and service delivery during the 2017 round of the Performance Monitoring and Accountability 2020 survey. Descriptive analyses were performed by facility type, supervisor type, service delivery type, and regional distribution. Results: Over 80% of CHWs had at least monthly supervision interactions, but there was variability in the frequency of interactions. Frequency of supervision interactions did not vary by facility or supervisor type. The types of services delivered by CHWs varied greatly by facility type and region. Community mobilization, health education, and outreach for loss-to-follow-up were delivered by over three quarters of CHWs, while mental health counseling and postnatal care are provided by fewer than one third of CHWs. The Western region and Greater Accra had especially low rates of CHW service provision. Non-communicable disease treatment, which is not included in the national guidelines, was reportedly provided by some CHWs in nine out of ten regions. Conclusions: Overall, this study demonstrates variability in supervision frequency and CHW activities. A high proportion of CHWs already meet the expected frequency of supervision. Meanwhile, there are substantial differences by region of CHW service provision, which requires further research, particularly on novel CHW services such as non-communicable disease treatment. While there are important limitations to these data, these findings can be instructive for Ghanaian policymakers and implementers to target improvement initiatives for community-based services.

The status of Ghanaian community health workers' supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey

Introduction: Community-based services are a critical component of high-quality primary healthcare. Ghana formally launched the National Community Health Worker (CHW) program in 2014, to augment the pre-existing Community-based Health Planning and Services (CHPS). To date, however, there is scant data about the program’s implementation. We describe the current supervision and service delivery status of CHWs throughout the country.

Methods: Data were collected regarding CHW supervision and service delivery during the 2017 round of the Performance Monitoring and Accountability 2020 survey. Descriptive analyses were performed by facility type, supervisor type, service delivery type, and regional distribution.

Results: Over 80% of CHWs had at least monthly supervision interactions, but there was variability in the frequency of interactions. Frequency of supervision interactions did not vary by facility or supervisor type. The types of services delivered by CHWs varied greatly by facility type and region. Community mobilization, health education, and outreach for loss-to-follow-up were delivered by over three quarters of CHWs, while mental health counseling and postnatal care are provided by fewer than one third of CHWs. The Western region and Greater Accra had especially low rates of CHW service provision. Non-communicable disease treatment, which is not included in the national guidelines, was reportedly provided by some CHWs in nine out of ten regions.

Conclusions: Overall, this study demonstrates variability in supervision frequency and CHW activities. A high proportion of CHWs already meet the expected frequency of supervision. Meanwhile, there are substantial differences by region of CHW service provision, which requires further research, particularly on novel CHW services such as non-communicable disease treatment. While there are important limitations to these data, these findings can be instructive for Ghanaian policymakers and implementers to target improvement initiatives for community-based services.

The status of Ghanaian community health workers’ supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey

Introduction: Community-based services are a critical component of high-quality primary healthcare. Ghana formally launched the National Community Health Worker (CHW) program in 2014, to augment the pre-existing Community-based Health Planning and Services (CHPS). To date, however, there is scant data about the program’s implementation. We describe the current supervision and service delivery status of CHWs throughout the country. Methods: Data were collected regarding CHW supervision and service delivery during the 2017 round of the Performance Monitoring and Accountability 2020 survey. Descriptive analyses were performed by facility type, supervisor type, service delivery type, and regional distribution. Results: Over 80% of CHWs had at least monthly supervision interactions, but there was variability in the frequency of interactions. Frequency of supervision interactions did not vary by facility or supervisor type. The types of services delivered by CHWs varied greatly by facility type and region. Community mobilization, health education, and outreach for loss-to-follow-up were delivered by over three quarters of CHWs, while mental health counseling and postnatal care are provided by fewer than one third of CHWs. The Western region and Greater Accra had especially low rates of CHW service provision. Non-communicable disease treatment, which is not included in the national guidelines, was reportedly provided by some CHWs in nine out of ten regions. Conclusions: Overall, this study demonstrates variability in supervision frequency and CHW activities. A high proportion of CHWs already meet the expected frequency of supervision. Meanwhile, there are substantial differences by region of CHW service provision, which requires further research, particularly on novel CHW services such as non-communicable disease treatment. While there are important limitations to these data, these findings can be instructive for Ghanaian policymakers and implementers to target improvement initiatives for community-based services.

Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal

Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care-first-contact access, care coordination, comprehensiveness and continuity-offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular 'at-goal' metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. 'At-goal' status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions.

Science and health for all children with cancer

Each year ~429,000 children and adolescents aged 0 to 19 years are expected to develop cancer. Five-year survival rates exceed 80% for the 45,000 children with cancer in high-income countries (HICs) but are less than 30% for the 384,000 children in lower-middle-income countries (LMICs). Improved survival rates in HICs have been achieved through multidisciplinary care and research, with treatment regimens using mostly generic medicines and optimized risk stratification. Children’s outcomes in LMICs can be improved through global collaborative partnerships that help local leaders adapt effective treatments to local resources and clinical needs, as well as address common problems such as delayed diagnosis and treatment abandonment. Together, these approaches may bring within reach the global survival target recently set by the World Health Organization: 60% survival for all children with cancer by 2030.

Breath Sensors for Health Monitoring

Breath sensors can revolutionize medical diagnostics by on-demand detection and monitoring of health parameters in a noninvasive and personalized fashion. Despite extensive research for more than two decades, however, only a few breath sensors have been translated into clinical practice. Actually, most never even left the scientific laboratories. Here, we describe key challenges that currently impede realization of breath sensors and highlight strategies to overcome them. Specifically, we start with breath marker selection (with emphasis on metabolic and inflammatory markers) and breath sampling. Next, the sensitivity, stability, and selectivity requirements for breath sensors are described. Concepts are elaborated to systematically address these requirements by material design (focusing on chemoresistive metal oxides), orthogonal arrays, and filters. Finally, aspects of portable device integration, user communication, and clinical applicability are discussed.

The macroeconomic burden of noncommunicable diseases in the United States: Estimates and projections

We develop and calibrate a dynamic production function model to assess how noncommunicable diseases (NCDs) will affect U.S. productive capacity in 2015-2050. In this framework, aggregate output is produced according to a human capital-augmented production function that accounts for the effects of projected disease prevalence. NCDs influence the economy through the following pathways: 1) when working-age individuals die of a disease, aggregate output undergoes a direct loss because physical capital can only partially substitute for the loss of human capital in the production process. 2) If working-age individuals suffer from a disease but do not die from it, then, depending on the condition's severity, they tend to be less productive, might work less, or might retire earlier. 3) Current NCD interventions such as medical treatments and prevention require substantial resources. Part of these resources could otherwise be used for productive investments in infrastructure, education, or research and development. This implies a loss of savings across the population and hampers economy-wide physical capital accumulation. Our results indicate a total loss of USD94.9 trillion (in constant 2010 USD) due to all NCDs. Mental health conditions and cardiovascular diseases impose the highest burdens, followed by cancer, diabetes, and chronic respiratory diseases. In per capita terms, the economic burden of all NCDs in 2015-2050 is USD265,000. The total NCD burden roughly corresponds to an annual tax rate of 10.8% on aggregate income.