In rural Bangladesh, many households continue to rely on private and informal providers even when public healthcare options are available at low or zero monetary cost. This paper studies whether the barrier is mainly misinformation, access frictions, or trust and uncertainty about public care. A cluster-randomized field experiment was conducted with 2,320 households across 580 neighborhoods and three sequential treatment arms. Information provision sharply increases awareness of public care options but has limited effects on actual utilization. In contrast, encouraging a one-time experience with public care produces significant increases in public uptake, substitution away from informal providers, and meaningful reductions in out-of-pocket spending, especially on medicines. Households induced to use public care reduced total health spending by approximately 601 Bangladeshi taka (USD 5.46 at 2023 exchange rate; 32% of the control group mean) relative to non-users (95% CI 373-829 taka; p<0.001), with most of the reduction driven by lower medicine expenditure. The findings suggest that improving beliefs alone is insufficient and that lowering uncertainty through a first successful experience is a key lever for shifting healthcare demand toward public options.
Health policies inevitably produce unintended consequences when introduced into a health system. These consequences can be linked to factors occurring before and throughout a policy's development and implementation. Understanding unintended consequences in relation to these factors can help mitigate its unintended health system impact. Current literature reveals a paucity of information exploring this interaction. Examining the 2007 Occupation-Specific Dispensation (OSD) strategy for nurses in South Africa can help fill this gap. We conducted a health policy analysis exploring the relationship between unintended consequences and the factors which occur in a policy process using a qualitative systematic review and applying a longitudinal lens. We included literature relating to the 2007 OSD in nursing and human resources for health (HRH) from 1994 onwards. In data analysis, we applied the Walt and Gilson (1994) Health Policy Analysis (HPA) Triangle to 1) give an overall description of the OSD policy process in the nursing sector; 2) identify the main unintended health system consequences of the policy for nurses and 3) investigate the relationship between the unintended consequences of the 2007 OSD and its relevant contributing factors occurring before, during and after the OSD's development and implementation. Three main unintended consequences were identified: nursing demoralization; nursing division and a breakdown in the relationship between nursing managers and frontline staff. Our findings suggest that the relationship between unintended consequences and its relevant contributing factors are rooted in the historical and socio-political realities of the health system. Frontline-level actors can help mitigate potential unintended consequences through sharing their historical and socio-political insight. We therefore urge policymakers to include these actors in policy development and implementation processes. Future research should explore the inclusion of frontline knowledge in policy processes as a method to reduce the potential severity and/or number of unintended consequences experienced.
At the 2026 World Economic Forum (WEF) Annual Meeting in Davos, health was positioned as central to economic resilience, productivity, and geopolitical stability. Four themes dominated the global health agenda: artificial intelligence (AI)-enabled health systems, investible health system resilience, women's health as an economic investment opportunity, and mental health as a macroeconomic priority. While these agendas reflect important global concerns, they are being advanced during a period characterised by shrinking development assistance, fiscal stress, debt pressures, and uneven institutional capacity across many low-income countries (LICs). This commentary argues that the central question is not only whether these agendas can be implemented in LICs, but also whether they represent relevant and efficient priorities within resource-constrained health systems. Drawing on literature from health policy and systems research, health financing, implementation science, and political economy, the paper examines how current global health agendas frequently assume levels of data readiness, financing stability, administrative capability, workforce availability, and governance capacity that are not consistently present in constrained settings. On this basis, neither technological innovation nor investment mobilisation can be treated as inherently valuable or as a substitute for contextualised priority setting. Proposed investments should be assessed against domestic disease burdens, societal preferences, system-wide effects, and feasible alternative uses of scarce resources. Durable progress in LICs will depend on strengthening countries' capacity not only to implement reforms, but also to determine which reforms warrant priority, allocate resources efficiently, and sustain foundational health system functions, including public financing, workforce development, information systems, regulatory capability, and accountable governance. The commentary concludes by calling for a context-sensitive and system-wide approach to global health agenda-setting.
Antimicrobial resistance (AMR) is a health threat globally and particularly in low- and middle-income countries. Senegal, like many other African countries, faces significant challenges in addressing the AMR crisis. This article aims to investigate the policy-making process that supports efforts to combat AMR in Senegal since the adoption of the country's 2017 National Multisectoral Action Plan Against Antimicrobial Resistance. A survey was conducted between January and August 2023 with key organizations involved in the policy-making process related to AMR at the national level. We collected both quantitative data describing the policy networks and qualitative data characterizing the beliefs of organizations. These mixed data were analysed using a dual approach, employing the policy network analysis and the advocacy coalition framework, to investigate the complexity of the national policy-making process. This article provides empirical evidence that the policy network has a centre-periphery structure, with a coalition of three organizations at its heart. Additionally, this article highlights the importance of technical and financial partners in the process of making policies to combat AMR in Senegal.
Global health diplomacy is central to shaping the international response to health challenges, yet what counts as "success" or "failure" remains contested. This study explores how gender and geopolitical identity influence perceptions of success and failure among global health diplomacy practitioners. Drawing on qualitative analysis of free-text responses from 136 professionals worldwide, we identify distinct narrative patterns. Women and Global South respondents emphasized normative goals: equity, justice, and structural reform, framing success in terms of inclusion, voice, and redistribution. In contrast, men and Global North respondents often framed success through processes: institutional innovation, efficiency, and procedural legitimacy. Failures were similarly divergent, seen as systemic exclusion and dependency by some, and as governance breakdowns or missed diplomatic opportunities by others. Our findings highlight the plurality of diplomatic worldviews and call for a more reflexive, inclusive approach to evaluating and practicing global health diplomacy that recognizes diverse epistemologies and power dynamics shaping the field.
In many low- and middle-income countries (LMICs), inequities in maternal health outcomes are linked to disparities in spatial access to essential health services. In Zambia, significant portions of the rural population reside beyond 5 kilometers from the nearest health facility. This contributes to the "three delays" of maternal mortality: delay to seek care, delay to reach a health facility, and delay to receive care from a skilled health provider. Consequently, at 187 per 100,000 live births, Zambia's maternal mortality ratio is above the global target of fewer than 70. This paper describes the application of a geospatial prioritization approach used by the Ministry of Health to guide investments in new maternal health infrastructure (mothers' waiting homes and maternity annexes) and upgrades to existing facilities. Using cross-sectional data from 692 public health facilities in Eastern and Southern Provinces, the approach integrates routine service and maternal mortality data from the national Health Management Information System (HMIS), with facility infrastructure assessments and geospatial analysis. Facilities were screened using binary eligibility criteria based on recorded maternal deaths and then ranked using a weighted scoring model reflecting infrastructure readiness gaps for continuity of maternal care. Findings indicate widespread facility coverage for labor and delivery services, contrasted against inadequate capacity for the recommended 48-hour postnatal observation care. Maternal deaths were concentrated in 28% of facilities in Eastern and 19% in Southern Province. Applying the prioritization framework reduced the potential scope of infrastructure investment from 606 facilities to 27 high-priority sites, lowering projected investment costs from US$41.8 million to approximately US$2 million. The approach demonstrates how targeted infrastructure investments, informed by geospatial and routine health system data, can improve equity, continuity of care, and optimize impact from limited resources. This applied framework offers a practical and scalable model for evidence-informed infrastructure planning in resource-constrained settings.
Community-led distribution of HIV self-test (HIVST) kits has potential to combine the benefits of community-based HIV testing with the strengths of community-led interventions. We report the process evaluation from the community-led arm of a cluster-randomized trial in rural Zimbabwe comparing community-led versus community-based HIVST distribution where distributors were paid. Twenty communities were supported to design HIVST distribution models that suited their context. We conducted community meetings where we introduced community-led HIVST, including messages on the benefits of viral load suppression (Undetectable=Untransmissible; "U=U"). Communities determined how, and by whom, distribution would be done. Communities implemented their distribution model over 4-6 weeks. We conducted in-depth interviews with community members (n=20), distributors (n=20) and health workers (n=20) as well as 12 focus group discussions (n=91) with community members. We triangulated findings with participant observations during community meetings and implementation and descriptively analysed program data on HIVST distribution. Qualitative data were analysed thematically. Participant observations found communities collaboratively developed and embraced HIVST distribution, demonstrating strong enthusiasm for participation. Messaging on U=U was met with interest and surprise, as many community members were unaware of this information, and became a key motivator for HIVST implementation and uptake. Across communities, 348 distributors distributed 27,812 kits door-to-door and/or from their homes or other community venues. Communities where model development was led by local leaders - rather than collective processes- expressed lower level of satisfaction and had slow implementation. Health workers supported HIVST distribution well, with opportunities for improvement noted. While distributors felt proud to deliver HIVST, many experienced logistical burdens, and need for material support from the programme and community. Communities designed HIVST delivery models that were acceptable and feasible, however efforts to make community-led models sustainable are critical. Delivering messages on U=U should continue to be prioritized and embedded within community-based HIVST distribution models.
Although evidence-informed health policymaking is widely promoted, evidence use in vaccine policymaking and the institutional and actor dynamics shaping it remain poorly understood. This study investigates what types of evidence were used and how they were used in vaccine policymaking in Kenya. Using a qualitative case study design, we focused on the introduction and roll-out of HPV and malaria vaccines. Data collection included 34 in-depth interviews with national Ministry of Health officials, Kenya National Immunization Technical Advisory Group members, County Expanded Programme of Immunization logisticians, international partners, and local civil society organizations; 417 hours of observation of vaccine-related policy and planning meetings; and a review of relevant policy and planning documents. Framework analysis was used to analyse the data, guided by two analytical frameworks: (1) a spectrum approach for categorizing evidence along two dimensions - scientific to tacit and global to local - and (2) Weiss's models of research use, which interpret patterns of evidence utilization in policymaking. The findings show that international actors, through their financial and technical authority, substantially influenced national policymakers' adoption of global guidance and scientific evidence. Local programmatic expertise played a crucial role in validation and contextualization of global guidance and scientific evidence to fit local contexts. The dominance of medical and public health professionals in decision-making spaces led to the prioritisation of evidence on vaccines' public health benefits over socio-political considerations. Local civil society's influence in vaccine policymaking was limited, with their community-based experiential knowledge primarily informing advocacy, communication, and social mobilization, rather than vaccine prioritisation and policy decisions. We conclude that strengthening evidence-informed policymaking requires more inclusive approaches that value diverse evidence types. Addressing power imbalances that shape what counts as credible evidence and integrating local civil society perspectives throughout the policymaking process can enhance the legitimacy, acceptability, and effectiveness of policy decisions.
In fragile and shock-prone settings, where political instability, economic crises, and institutional fragmentation weaken central authorities, strengthening local health governance has become critical for health system resilience. Lebanon represents an example, having faced compounded shocks including economic collapse, the COVID-19 pandemic, and armed conflict, all of which have strained an already fragmented health system. Despite increasing recognition of the importance of sub-national governance, limited empirical evidence exists on how municipal-level health governance structures function in practice under such conditions. This article evaluates the establishment and functioning of a Municipal Health Committee (MHC) as a pilot model of local health governance, analysing factors influencing good governance practices. Using participatory action research and an implementation research design, qualitative data were collected through process documentation and field observations, six critical reflective meetings, and nine key informant interviews. Data were analysed using the TAPIC framework to examine transparency, accountability, participation, integrity, and capacity in the MHC's operations. Findings indicate that the MHC enhanced inclusive participation thereby strengthening local legitimacy and trust. The committee progressively embedded transparency and evidence-informed decision-making, including efforts to generate local health data. However, compliance by formulated ideal and institutional integrity was persistently challenged by political interference, patronage networks, weak enforceability of accountability mechanisms, and financial precarity. Sustained mentorship by the research team strengthened governance practices and enhanced the MHC's ability to implement its mandate effectively. Municipal committees can strengthen equity and resilience in settings through inclusive, evidence-informed processes; however, sustainability depends on local ownership, functional autonomy from political capture, and capacity development.
Thailand's healthcare system faces challenges in delivering effective community-based care for dependent patients in rural areas; while access has expanded over more than four decades, services remain fragmented and effective coverage from community to higher-level care is still lacking. The Ubolratana Hospital model in Khon Kaen Province represents an innovation, combining a full-time 24-hour community caregiver cadre integrated within a hospital-led local healthcare team with five adaptive diversified funding streams. This qualitative implementation research, guided by the Consolidated Framework for Implementation Research (CFIR), examined the determinants of adoption and sustainment of the model over its six-year operation. CFIR informed interview guide was used as the key data collection and analytical framework across its five domains (innovation, outer setting, inner setting, individuals (roles & characteristics), and implementation process). We conducted semi-structured interviews with key informants spanning hospital administrators, physicians, nurses, community caregivers, sub-district primary care unit personnel, local government officials, community leaders and family members between March and May 2025. Data were analysed using framework analysis combining deductive CFIR coding with inductive sub-coding. Adoption was facilitated by a hospital-initiated caregiver role, sustained inner setting leadership embodied in a long-tenured 'social engineer' hospital director and his successor team, a three-stage community-led caregiver selection process, and Buddhist-integrated spiritual care; sustainment relied on a coordinated multi-level care process and the continuity of care centre's reflective evaluation. Outer setting barriers included fragmented public health financing, the 2022 decentralisation of sub-district primary care units to provincial administrative organisations, and donor-funding uncertainty. Since 2020 the model has been progressively scaled under Ramathibodi Faculty of Medicine sponsorship to 22 districts across 15 provinces (53 villages, cumulative investment >10 million baht). The Ubolratana experience therefore offers a practical, rather than directly replicable, framework whose diffusion depends on cultivating local leadership, building trust, and adapting innovation components to local conditions.
The economic burden of disease remains a significant global public health challenge. In China, the Critical Illness Insurance scheme is a pivotal policy designed to protect households from catastrophic health expenditure. However, evidence on residents' preferences for this insurance is limited. Identifying these preferences is essential for advancing resident-centered policy reform. To address this gap, we conducted a discrete choice experiment to quantify public preferences for Critical Illness Insurance attributes among residents in Shandong Province, China. Through literature review, qualitative interviews, and expert consultation, we designed a discrete choice experiment with six policy attributes: cost, reimbursement ratio, deductible, annual reimbursement limit, scope of reimbursable expenses, and restriction to designated hospitals. An orthogonal design generated choice sets. Data were collected from 360 residents across three cities in Shandong Province and analyzed using mixed logit and latent class models. Latent class analysis identified preference heterogeneity across subgroups. Based on model results, we calculated relative importance scores and simulated selection probabilities. A total of 334 valid questionnaires were collected (46.4% male; 53.6% female). Mixed logit analysis identified the reimbursement ratio (32.73%) as the most important attribute, followed by the annual reimbursement limit (23.81%) and scope of reimbursable expenses (23.10%). Latent class analysis revealed two subgroups: a "Coverage-Intensity Sensitive" group (Class 1, n=125) and a "Reimbursement-Focused Group" group (Class 2, n=209). Class 1 prioritized high reimbursement limits (68.3% relative importance), preferring no annual limit. Class 2 emphasized optimizing the reimbursement ratio (45.6%) and hospital flexibility, while accepting higher deductibles. Policymakers should prioritize increasing reimbursement rates and expanding coverage scope, with appropriate premium adjustments. Aligning critical illness insurance design with residents' heterogeneous preferences contributes to more targeted and efficient policy arrangement.
Hand hygiene an effective public health measure for preventing infectious diseases. Sustained hand hygiene practice requires an enabling environment that constitutes access to hand hygiene products and services, clear and effective policy provisions, financing, monitoring and coordination mechanisms. This paper analyses Kenya's national hand hygiene policy landscape and identifies the underlying governance barriers and systemic opportunities for strengthening hand hygiene policy and practice in Kenya. Guided by the Health Policy Triangle (HPT) framework, this study systematically examined the context, content, process, and actors shaping Kenya's hand hygiene policy landscape. Primary data was collected through Key Informant Interviews (KIIs) with 11 strategic stakeholders involved in policy development, implementation, regulation and program delivery. Secondary data was through a comprehensive review of 20 policy instruments, including national policies, strategies, protocols, roadmaps, and binding legal documents. In Kenya, policies are formulated at the national level and devolved to the County level for implementation, with support from state and non-state actors. The analysis showed that Kenya lacks a standalone, hand hygiene policy document. However, hand hygiene provisions are present in policy documents which cover hand hygiene in several settings such as rural areas, schools and health facilities. This reflects fragmented policy presence rather than complete absence. Barriers hindering effective implementation include weak inter-sectoral coordinating mechanisms, inadequate financing, and a lack of data. These gaps create governance and operational fragmentation, undermining the sustainability of hand hygiene interventions.To transition to an enabling environment, Kenya should establish explicit national hand hygiene standards with clear definitions and minimum requirements, secure dedicated and sustainable financing mechanisms, ensure national-County coordination, and integrate standardized hand hygiene indicators into the national and sub-national health information systems. These reforms will support a more coherent governance, evidence informed planning and accountability for hand hygiene implementation.
Timely linkage from HIV diagnosis to care is critical for effective treatment and epidemic control. We evaluated the effectiveness of conditional micro-incentives on linkage to HIV care in the Home-Based Intervention to Test and Start (HITS) trial, a real-world implementation trial in rural South Africa. Of 45 communities in uMkhanyakude, KwaZulu-Natal, 16 were randomized to micro-incentive arms offering food vouchers (R50 [US$3]) conditional on completing home-based HIV counseling and testing (HBHCT) and linkage to care within 6 weeks, and 29 to non-incentive arms. All individuals were eligible for HBHCT, enrolled between February and December 2018, and followed for 1 year. The primary outcome was linkage to care at 1 year among men; secondary outcomes included linkage within the 6-week voucher eligibility among men and women, and at 1 year among women. Intention-to-treat analyses were performed using Poisson regression adjusted for study arms. Among 13,894 men and 19,884 women eligible for the study (aged ≥15 years), home-based testing uptake was 21% (n=2,867) and 29% (n=5,795), yielding 122 (4.3%) and 375 (6.5%) new diagnoses, respectively. Overall, micro-incentives nearly doubled HIV-positive diagnoses. Among men, micro-incentives did not increase linkage to care within 6 weeks (risk ratio [RR]=0.78, 95% CI: 0.51-1.21) or at 1 year (RR=1.08, 95% CI: 0.86-1.35). Among women, micro-incentives increased linkage to care within 6 weeks by 51% (RR=1.51; 95% CI: 1.03-2.21), with no residual impact at 1 year (RR=1.07, 95% CI: 0.91-1.26). In a hyper-endemic rural African setting, once-off micro-incentives can substantially increase early linkage to HIV care among women during the incentive eligibility period but are inadequate to significantly improve care engagement among men.
TB preventive therapy (TPT) is one of three key interventions for reducing TB in South Africa, but uptake and completion rates remain low. In South Africa, the current TPT options include isoniazid and rifapentine or isoniazid and rifampicin. Evidence and lessons learned from programmatic uses of isoniazid preventative therapy (IPT) could provide operational advice to enhance the implementation of new TPT regimens. We conducted 28 in-depth provider interviews (IDIs) to elicit experiences of and preferences for the different TPT regimens between 04/2022 and 12/2022 in the City of Johannesburg, Gauteng and Greater Tzaneen sub-district, Mopani district, Limpopo Provinces. We used purposive sampling to recruit doctors (n=7), pharmacists (n=8) and nurses (n=13) in high and low volume TB and/or HIV facilities. IDIs were recorded for quality, transcription, and translation purposes. Data analysis was conducted using a thematic approach in NVivo 11. We present provider preferences and perspectives for TPT uptake. The most important attributes relating to preferences for TPT regimens attributes among healthcare providers included medication safety, efficacy and low pill burden. Despite valid preferences for different regimens, healthcare service providers had varied experiences around factors that influence the uptake of the different TPT regimens they offered at their facilities. Many providers indicated that patient booking errors, missing patient records, staff shortages, long queues, medication side effects and limited understanding of the benefits of TPT were reasons for poor patient TPT uptake and adherence. Limited knowledge was attributed to a lack of educational materials and insufficient staff-patient engagement time. Providers noted that increased clinician awareness and patient counselling contribute to a higher rate of TPT prescriptions, as well as improved patient uptake and adherence. Thus counselling, staff training, side-effects management, and improved file documentation are key factors for TPT uptake.
The Immunization Agenda 2030 calls for reaching all people with immunization services, including "zero-dose" children-children who have not received any routine vaccines. To plan and finance efforts to fully vaccinate these children and improve coverage and equity, decision-makers need reliable cost estimates. However, primary data on the costs of reaching zero-dose children, typically part of disadvantaged and hard-to-reach populations, are scarce. This study approximates these costs using standardized, country-level estimates of vaccine delivery unit costs for outreach delivery in low- and middle-income countries (LMICs). We extracted outreach delivery cost per dose estimates for childhood immunization services from the 2024 update of the Immunization Delivery Cost Catalogue. Using these data, we developed a meta-regression model to estimate standardized outreach vaccine delivery unit costs. The generalized linear model assumed a Gamma-distributed outcome with a log link and included both country-level and study-level predictors: study year, economic or financial cost basis, routine or campaign delivery, and full or incremental costing approach. The fitted model was used to estimate 2024 outreach delivery costs per dose for 129 LMICs. The model was estimated using 48 observations from 19 countries focused on outreach or mobile vaccine delivery. The best-fitting specification included diphtheria-tetanus-pertussis coverage, per capita gross domestic product, and under-five population size as predictors. For 2024, the predicted mean economic cost per dose was $8.65 (95% credible interval $2.33-23.71), averaged across all 129 LMICs. To fully immunize a zero-dose child with 13 recommended vaccinations, the equivalent cost estimate was $112.45 ($30.29-308.23). Reaching zero-dose children is crucial for improving equity in global health, and estimates of the costs of doing so are needed to inform budgeting for immunization programs. These meta-regression-based cost estimates can help countries to improve budgeting, planning, and resource allocation for efforts to reach zero-dose children.
The relationship between social health insurance reforms and income inequality has not been thoroughly examined with the domain of social policy research. This study employs data from the China Family Panel Studies spanning 2014-20 and employs a staggered difference-in-difference model to examine the association between China's Urban-rural Residents' Medical Insurance Integration reform and the urban-rural income disparity, as well as related changes in household health and income. Our findings indicate that the reform has significantly reduced the income gap, a result that is consistent across multiple robustness checks. Notably, the improvement in the health status and economic conditions of rural households is consistent with the reduction in urban-rural income inequality, while no comparable changes were observed among urban households, which were not directly affected by the reform. Furthermore, the reform's effectiveness was most pronounced among households with lower dependency ratios and those with lower incomes. The impact of the policy was particularly significant in regions characterized by advanced healthcare infrastructure and higher levels of economic development. This study contributes to the literature by providing empirical evidence on the relationship between social health insurance reform and income inequality, while offering suggestive insights into how changes in health and economic conditions may be associated with this relationship.
This study presents a prospective policy analysis of healthcare workforce (human resources for health, HRH) reforms in Meghalaya, India, a state facing dual challenges of a rising burden of non-communicable diseases (NCDs) and persistent inequities in access to medical and public health specialists. Grounded in a health systems and social justice perspective, this study examines current HRH needs and proposed reforms, evaluating their potential to address the evolving health demands of the population, particularly among poor and marginalized groups vulnerable to NCDs. Using secondary evidence, including national surveys, epidemiological data, and government reports, the study maps workforce gaps, especially in rural and tribal regions, and highlights the physician-centric nature of HRH governance in India. The Walt and Gilson policy triangle, combined with adapted HRH evaluation frameworks, guided the analysis of policy context, content, processes, and actors. This approach identified key gaps in recruitment, rural retention, cadre structures, and specialist training for effective NCD prevention and management. A scenario analysis, using the Intuitive Logic method, developed a best-case trajectory of reform achievable through equity-oriented design, strong political will, and institutional capacity, while recognizing risks of policy stagnation. Findings indicate that achieving a socially accountable HRH system characterized by equitable distribution, transparent governance, and meaningful community engagement is critical for improving NCD outcomes and reducing health inequities, particularly by preventing financial distress among the poor. The study contributes to health policy and systems research by linking institutional design to future health system resilience, underscoring the need to embed justice, participation, and adaptability within HRH governance to effectively address present and future health challenges in low-resource contexts such as Meghalaya.
Prolonged economic sanctions-often framed as non-military tools-have increasingly harmed health systems, especially where institutional and policy capacities are fragmented. Despite the growing debate on sanctions, documented analyses of health system responses remain scarce. This study examines Iran to assess how prolonged sanctions shaped its health policy architecture and resilience capacity, with attention to compounded crises such as COVID-19.Phase one synthesized seven empirical studies conducted by the authors-including document reviews, interviews, Delphi, and policy analyses-to assess how resilience principles were embedded across the four stages of the health policy cycle: agenda-setting, policy formulation, implementation, and evaluation. These findings formed the foundation for Phase two, which applied an expanded Theory of Change (ToC) framework to reconstruct policy logics, surface implicit assumptions, and identify institutional breakpoints. After modelling the ToC, a panel of experts reviewed and validated the findings, ensuring methodological rigour and contextual accuracy in mapping resilience under sanctions.The findings indicate that while Iranian health authorities implemented adaptive measures, responses were shaped by fragmented coordination, untested assumptions, and limited structured learning systems. Resilience limitations emerged during implementation and were embedded in early design phases, not fully anticipated or addressed, given the complex and uncertain policy environment.This study offers an analytical framework for mapping resilience in policy systems under long-term constraints. Building on identified governance and design weaknesses, we recommend strengthening international legal safeguards; establishing protected humanitarian corridors; institutionalizing risk-informed planning; routine scenario-based resilience testing; and feedback-driven learning mechanisms within national policy systems. These capacities are essential to absorb shocks and enable adaptive, inclusive, sustainable responses. By clarifying structural domains where resilience can be embedded in advance, the analysis offers guidance for countries under comparable pressures to target strategies in governance, planning, and resource protection. This provides a transferable blueprint for strengthening justice-oriented health systems under long-term constraints.
Understanding the population's preferences for health insurance plays an important role in optimizing insurance scheme design and improving enrollment rate. This study aims to quantitatively investigate preference for supplementary voluntary health insurance (SVHI) from a multi-site survey and examine its heterogeneity in China. A discrete choice experiment was conducted in Shandong, Henan, and Sichuan provinces using multi-stage stratified sampling method. Five SVHI attributes were identified: premium, benefit package, deductible, reimbursement rate, and reimbursement for preexisting conditions. Choice sets were generated using a D-efficient design, grouped into two blocks randomly assigned to respondents, with each set comprising two SVHI options and an opt-out. Data were collected via face-to-face computer-assisted interviews. Mixed logit models were used to estimate preference weights, willingness-to-pay (WTP), and attribute importance scores. Preference heterogeneity was analyzed by disease-related financial risk awareness, numeracy, and health insurance knowledge, demographic, socioeconomic, and health characteristics. Of the 1326 respondents who completed the questionnaire, 1254 were included in the analysis. Reimbursement rate was the most important attribute (34.26%), followed by premium (25.06%), benefit package (17.60%), deductible (17.50%), and reimbursement for preexisting conditions (5.58%). Overall, respondents expressed the highest WTP (USD 48.50) for improving the reimbursement rate from 50% to 90%, while they showed lowest WTP (USD 8.60) for decreasing deductible from USD 2777.78 to 1388.89. Heterogeneity analysis revealed stronger enrollment preferences among respondents with risk awareness, higher health insurance knowledge, higher numeracy, higher educational attainment, higher income, and those living in urban areas. In addition, higher levels of risk awareness, insurance knowledge, numeracy, income, and education were associated with increased WTP for SVHI attributes. Preference heterogeneity by risk awareness and insurance knowledge suggests need for targeted risk information communication and education campaign to promote SVHI uptake and diverse insurance design tailored to socioeconomic differences in preferences for attributes.
