Background Metabolic syndrome is a growing global health challenge, affecting one in four adults worldwide, with prevalence in sub-Saharan Africa estimated at 20–30%. In Botswana, urban prevalence is 27%, reflecting a high burden of NCDs. Prisoners are particularly vulnerable due to overcrowding, poor nutrition, sedentary confinement, and limited access to health services. Objectives To evaluate the systemic capacity, effectiveness, and readiness of Botswana's prison health care delivery mechanisms in managing metabolic syndrome, focusing on diagnostic, treatment, and continuity-of-care protocols. Methods A descriptive cross-sectional study was conducted across all 20 prison health facilities in Botswana. A structured questionnaire adapted from the WHO Service Availability and Readiness Assessment (SARA) tool was administered to healthcare providers. Composite scores were generated to produce a Facility Readiness Index (FRI). Results Service delivery and health information systems demonstrated moderate readiness, with most facilities maintaining chronic disease registers and reporting NCD statistics. Workforce shortages were pronounced, particularly in health posts, which relied heavily on single nurses. Medicines and equipment were moderately available, but frequent stock-outs of insulin, oral hypoglycemics, and inhalers undermined continuity of care. Governance and financing emerged as the weakest domains, with half of facilities lacking standard operating procedures and only 20% reporting dedicated budgets for NCD care. The overall FRI was 58%, indicating low-to-moderate systemic readiness. Conclusion Botswana's prison health system demonstrates significant gaps in readiness for metabolic syndrome care. Strengthening diagnostic capacity, workforce training, medicine supply chains, and integration with national health systems is essential to safeguard prisoner health and broader public health outcomes.
Objective The Executive Order (EO) reintroducing the Most Favored Nation (MFN) policy sets out measures to lower prices of branded medicines in the United States (US) and increase them elsewhere. Methods To understand the impact of the policy on prices and on pharmaceutical innovation, this paper reviews empirical literature on historic price trends in the US and other high-income countries, the impact of international reference pricing (IRP), and the impact of regulation and market conditions on Research and Development (R&D). Results 49 studies were included. List prices are greater in the US than other high-income countries, and the difference in net prices has widened in the last two decades. The IRP literature indicates that for some drugs, MFN might be able to reduce prices in the US and increase them in reference countries, particularly for drugs where Medicare and Medicaid have a high global market share. In other cases, firms may strategically delay or cancel launch in other countries to avoid price comparisons. It is likely that MFN will provoke a reduction in global pharma revenues and aggregate investment in R&D. Conclusion A few countries are increasing prices as part of trade deals with the US. If countries do not wish to increase prices, then they should expect, and prepare for, slower pharma innovation. From a public health perspective, it is not just aggregate R&D that matters, but whether R&D investment is directed to projects which are likely to promote the greatest health gain.
Introduction Estonian households faced persistent financial hardship due to high out-of-pocket payments for outpatient prescription medicines. An “additional medicine benefit” was therefore introduced in 2003, which lowers co-payments once a person's spending for outpatient prescription medicine has reached a threshold. However uptake remained low due to administrative hurdles and lack of awareness. In response, Estonia reformed this benefit in 2018, including leveraging digital technologies to automate eligibility checks and benefit provision at the point of sale. This paper explores how Estonia developed, designed and implemented these digital technologies and analyses the reform's observed changes. Methods This study employed a qualitative-dominant mixed-methods approach, including document reviews, key informant interviews, and analysis of administrative data from the Estonian Health Insurance Fund (EHIF). The WHO framework for assessing digital technologies in health financing guided data collection and thematic analysis. Results Built on Estonia's e-prescription system, the reform included lowering co-payment thresholds coupled with automating a member's benefit and enabling related real-time data exchange. The share of patients benefitting rose from 0.4% in 2017 to 15.6% in 2018, which is assumed to have contributed to decreasing the incidence of catastrophic health spending during the same time. Automation has significantly reduced the administrative burdens for EHIF, pharmacists and patients. Conclusion Estonia's experience demonstrates how digital technologies support health financing reforms, contributing to increased efficiency, improved financial protection and utilization aligned with need. Yet, there is further potential to use existing data and digital technologies to better target benefits to those most in need.
Background:In Japan, the "Regional Healthcare Plan" aims to optimize the allocation of hospital beds based on projected healthcare demand. However, many regions fail to achieve the recommended bed attainment rates, suggesting that factors beyond demand, particularly healthcare workforce supply, may influence regional disparities. This study examined the association between hospital bed attainment rates and the density of multidisciplinary healthcare professionals across Japan. Methods:We conducted a nationwide cross-sectional ecological study using publicly available data from the 2023 Community Health Care Visions and 2023 Medical Facility Survey. The unit of analysis was the secondary medical field. Hospital bed attainment rates were calculated as the ratio of actual to required beds and were categorized into three groups (<90%, 90-110%, and > 110%) for each bed function (intensive care, acute care, inpatient rehabilitation, and chronic care). The healthcare workforce density (per 100,000 people) was calculated for multiple professions. Group comparisons were performed using the Kruskal-Wallis test with Bonferroni correction, and associations were assessed using Spearman's rank correlation coefficients. Results:Bed attainment rates varied widely across regions, with only a minority meeting the recommended range, particularly for intensive and acute care beds. The association between bed attainment rates and workforce density differed according to bed function. High total bed attainment rates were associated with a high density of nonphysician professionals, including nurses and rehabilitation staff. Intensive care bed attainment rates were positively associated with physicians and pharmacists. By contrast, acute care bed attainment rates were negatively correlated with physician and pharmacist densities. Inpatient rehabilitation and chronic care bed attainment rates were positively associated with the density of multiple nonphysician professionals, such as therapists, dietitians, and care workers. Conclusion:The relation between hospital bed attainment rates and healthcare workforce density varies substantially according to bed function. These findings suggest that effective regional healthcare planning should incorporate not only projected demand but also the composition and distribution of the healthcare workforce to avoid mismatches between bed capacity and service delivery.
Antimicrobial resistance is a significant public health challenge. Antibiotic development pipelines are insufficient to tackle this threat, with unfavourable pricing and reimbursement a key factor deterring the development of novel compounds. New antibiotics are priced against generic comparators, and practical and ethical constraints make it challenging to demonstrate superiority in clinical trials. New antibiotics are often classified as reserve antibiotics for a very select group of closely monitored patients with multidrug-resistant infections. The broader value of antibiotics is not routinely considered. 'Pull' incentives have been implemented to encourage development, but are not universally available, and some companies may not qualify.While it may seem counterintuitive at first, many parallels can be drawn between novel antibiotics and orphan/ultra-orphan drugs. Like orphan drugs, novel antibiotics often target small, high-unmet need patient groups, with potential for considerable clinical benefit. Several countries have established specific reimbursement pathways for orphan drugs, allowing higher prices and flexibility for clinical data uncertainty; thus, potentially addressing some of the challenges faced by antibiotics in the absence of dedicated reimbursement pathways.A multidisciplinary advisory board was convened to explore the feasibility of this further and provide recommendations to companies on leveraging orphan drug pathways for antibiotics. This paper presents its recommendations on evidence-generation activities to demonstrate added clinical value and economic savings, along with effective advocacy and collaboration to raise awareness. Key recommendations include conducting additional single-arm trials in last-line patients, generating a natural history control arm, and strengthening collaboration to build advocacy around the threat of AMR.
Despite commune health stations serving as the backbone of Vietnam's primary healthcare, severe physician maldistribution persists. To explore factors influencing the recruitment and retention of family physicians in rural areas, we conducted a discrete choice experiment among 315 family physicians in Vietnam. Mixed logit regression was used to estimate the relative importance of individual characteristics and key job attributes, which included income change, career promotion, living condition, and government support for private clinics. Our findings indicate that a 50% increase in salary has the most significant influence on rural job uptake for key subgroups, including those under 50, assistant doctors, and those with prior rural exposure. However, the marginal utility of financial incentives diminishes rapidly beyond a specific threshold. Subgroup analysis further reveals heterogeneous preferences: physicians who transitioned from commune health stations to higher-level facilities, and those working in primary health care areas, respond more strongly to non-financial incentives such as career promotion and private practice support than to additional income increases. Physicians would forgo 48.36% of their salary to secure an urban posting, yet would accept a rural position if offered expedited promotion or private practice support, each valued at approximately 38% of monthly income. Achieving sustainable rural deployment therefore requires differentiated rather than uniform intervention: moderate salary increases for younger and rural-exposed physicians, combined with accelerated promotion pathways and private practice facilitation for those in primary health care and higher-level facilities. Translating stated preferences into actual rural uptake ultimately hinges on government credibility in delivering promised benefits.
Background:Successive Australian healthcare policies promoting privatisation have increased demand for independent speech-language pathology (SLP) services. This growth has intensified pressure on healthcare funding mechanisms and highlighted confusion in the literature between health financing systems and healthcare funding provisions at the funding model level. In response, public funding arrangements have increasingly supported access to private SLP services for Australian children and young people. This scoping review aimed to identify and describe current public funding models (PFMs) used to access standard paediatric SLP funding through Australian independent SLP providers. Method:Scoping review methodology was undertaken and incorporated search terms synonymous with funding mechanisms, population-based, block and individualised funding. Result:Iterative searching and screening of three health and two scholarly business databases unveiled eighty-six (n = 86) articles, revealing six genres of PFMs and nine associated typologies. The review identified that seven (n = 7) contemporary PFMs were used to access Australian independent SLP services. Conclusion:Health funding and health financing serve different functions within healthcare systems. Compared with the extensive literature on health financing, research on health funding remains limited. A key contribution of this scoping review was the identification of themes and the systematic classification of PFMs by genre and typology, providing a blueprint for understanding past, current, and future PFMs. Furthermore, mapping Australian independent SLP services across funding models and typologies highlighted the diversity of public funding provisions within Australia. Future research should examine how policy architects can balance increasing demand, integration of the latest scientific evidence-base, and equitable access to SLP services.
With increasingly limited funding availability for global health programmes including the elimination of motherto-child transmission of HIV, syphilis, and hepatitis B, cost-effective and cost-saving service delivery options such as service integration strategies are vital. The introduction of dual HIV/syphilis rapid diagnostic tests (RDTs) has helped bridge testing gaps by enabling immediate integration of testing for HIV and syphilis. First prequalified by WHO in 2013, widescale adoption of the dual RDTs required extensive global and national advocacy and coordination, including evidence generation, guideline development, engagement across key countries, and shifts in policies, priorities and market dynamics. Price reductions of these commodities -driven by negotiations with manufacturers-accelerated scale-up and led to broader adoption. Global Fund data indicates a rapid increase in dual RDT procurements, while country-level data shows that nations incorporating dual RDTs into antenatal care have significantly improved syphilis testing coverage which is key to eliminating congenital syphilis. Understanding the key enablers that facilitated widescale adoption of dual RDTs as well as ongoing challenges can inform rapid rollout of future multiplex testing products, which may support continued progress toward testing goals through integrated service delivery during funding decreases and shifting priorities.
The study analyses the extent, evolution and impoverishing effects of catastrophic health expenditures (CHE) in Portugal from 2005 to 2022. The analysis also identifies factors associated with the occurrence of CHE. The results show a progressive reduction in financial burden with increased access to healthcare services. CHE incidence decreased from 9.42% (2005) to 5.04% (2022). Reduced access to the Portuguese NHS was associated to increased reliance on private services and out-of-pocket costs. Barriers, unmet needs and challenges regarding the protection of vulnerable groups remain, including the elderly and individuals incapacitated to work. Households with at least one senior show a particular vulnerability to CHE. Regional disparities are reinforced by underdeveloped healthcare infrastructure, limited access and financial barriers.
The study analyses the extent, evolution and impoverishing effects of catastrophic health expenditures (CHE) in Portugal from 2005 to 2022. The analysis also identifies factors associated with the occurrence of CHE. The results show a progressive reduction in financial burden with increased access to healthcare services. CHE incidence decreased from 9.42% (2005) to 5.04% (2022). Reduced access to the Portuguese NHS was associated to increased reliance on private services and out-of-pocket costs.Barriers, unmet needs and challenges regarding the protection of vulnerable groups remain, including the elderly and individuals incapacitated to work. Households with at least one senior show a particular vulnerability to CHE. Regional disparities are reinforced by underdeveloped healthcare infrastructure, limited access and financial barriers.
The effective use of Health Management Information Systems (HMIS) is critical for strengthening decision-making and resource allocation in healthcare, particularly in low and middle-income countries such as Malawi. Yet, district level data use remains constrained by institutional challenges that undermine the potential of HMIS. This study proposes a framework to enhance data use in health management at the district level, drawing on institutional theory and the dynamics of coercive, normative and mimetic pressures. A qualitative approach was employed, including semi-structured interviews, participant observations, and documents analysis, to examine how these pressures shape data practices within Malawi’s health sector. Findings reveal that improved data use depends on key activities such as regulating practices, building human capacity, sustaining efforts, integrating data tools and platforms, coordinating processes and partnerships, motivating contributions, and sharing best practices. By addressing these institutional concerns, the proposed framework offers actionable recommendations for policymakers and practitioners to foster a culture of data use, strengthen health management decision-making, and advance ICT4D scholarship on HMIS effectiveness and health outcomes in low and middle-income settings.
Background Finding new therapeutic indications for established medicines continues to have important impact. Although drug repurposing (DR) offers the potential for a faster and more affordable complement to de novo development, barriers to successful DR remain pervasive. Objective To prioritize barriers identified earlier in a systematic literature review by the REMEDi4ALL Horizon Europe project, involving multiple stakeholder groups, to create a shortlist of the most important barriers and to examine differences in stakeholders’ perceptions. Methods A policy survey was conducted among stakeholder groups involved in DR. Participants rated the barriers based on their impact and actionability, using 5-point categorical scales. A weighted scoring method was used to create the shortlist by combining scores across domains, while ensuring that each stakeholder group’s preferences were retained in the final shortlist. Results 60 individual responses were collected. The final shortlist contained 22 barriers, including 4 barriers related to exclusivity rights for repurposed medicines (RMs), 2 to pricing of RMs, 5 to market authorization of RMs, 2 to perception off-patent RMs, 2 to business case for off-patent RMs, 2 to non-industry funded DR, 2 to health technology assessment of RMs, 2 to ecosystem for non-profit or small-medium sized enterprises-driven DR, and 1 to business case for repurposing on-patent compounds. Conclusion Prioritizing barriers helps identify solutions by addressing the critical challenges first. Acknowledging that different stakeholder groups may perceive the impact and actionability of these barriers differently is crucial for building a shared, multi-stakeholder perspective when formulating policy recommendations to address the barriers.
Background: Authority over healthcare professional regulation in the United States rests with individual states, resulting in varied timelines and approaches to granting nurse practitioners (NPs) full practice authority (FPA). The impact of these policy changes on healthcare utilization and patient outcomes remains unclear. Objective: To evaluate the effect of NP full practice authority on healthcare access and patient outcomes across U. S. states. Methods: We applied a staggered difference-in-differences model using data from state legal statutes and the Medical Expenditure Panel Survey (1997-2018). Analyses included all 50 states and the District of Columbia to assess changes in healthcare utilization-specifically, NP-provided primary care visits, physician visits, and emergency department (ED) use-before and after FPA enactment. Results: States adopting NP full practice authority experienced a modest but significant increase in NP primary care visits without a corresponding decline in physician visits. Additionally, non-urgent ED utilization decreased in states with FPA, suggesting improved access to primary care. Patient-reported activities of daily living improved modestly, indicating potential health benefits associated with expanded NP authority. Conclusions: Granting full practice authority to nurse practitioners enhances access to care, optimizes healthcare utilization, and may yield modest improvements in patient outcomes. These findings support the role of FPA policies in strengthening the primary care workforce while maintaining quality of care. Future research should explore long-term impacts and broader health system effects as additional states implement or modify FPA legislation.
Introduction:Access to pharmaceuticals is a key area of health systems performance. Previous analyses showed medicines to be the largest contributor to catastrophic spending in Lithuania, particularly for people with lowest incomes. This paper examines changes to household spending on health following 2017-2020 pharmaceutical policies to improve access to outpatient medicines. Methods:Household spending and catastrophic health spending were calculated using household budget survey data for 2016 and 2021. Pharmaceutical policies were obtained from the review of legislation and regulation, and publications by the relevant health authorities. Results:Catastrophic spending in Lithuania reduced from 11.5% in 2016 to 9.4% in 2021, driven by reductions in out-of-pocket spending for medicines and with significant decrease in the poorest income quintile and among people aged 75 + . The measures introduced in 2017-2020 included eliminating percentage co-payments for nearly all covered medicines, as well as exempting people aged 75 + and some other groups on low income from co-payments for medicines. Conclusions:In 2017-2020 measures were implemented reduce the burden of household spending on medicines, resulting in reduction of catastrophic spending in the most vulnerable groups. Challenges remain, as still 9% of households experience catastrophic spending. Next steps could involve broadening exemptions, addressing gaps in the positive list, and understanding accessibility barriers in other health care services.
This analysis examines trends in health spending in Tajikistan from 2000 to 2022 and situates them within the country’s key health financing reforms, with the aim of informing progress toward Universal Health Coverage (UHC) and identifying persistent gaps. By applying data from the WHO Global Health Expenditure Database (GHED), which is structured according to the System of Health Accounts (SHA 2011), and contextualizing results with national policy documents and relevant literature, the paper assesses both expenditure patterns and reform dynamics.While government health spending has increased in absolute terms, it remains modest as a share of GDP and general government expenditure. Out of pocket payments have declined slightly as a share of current health spending, yet they still account for nearly two-thirds, posing barriers to equitable access and financial protection. Recent reform initiatives, such as pooling and strategic purchasing pilots, show potential to improve equity and efficiency; however, their long-term impact will depend on sustained implementation and systematic tracking of expenditures.The findings underscore the importance of tracking expenditure in a systematic way to guide health reform. Institutionalizing the routine production of health accounts using SHA 2011 would improve transparency, strengthen allocative efficiency, and support more strategic resource allocation and informed policy dialogue. Ultimately, tracking health spending is not just a technical exercise, but a strategic tool to align financing with policy priorities and advance UHC.
Strengthening the health workforce is a central policy challenge in fragile and low-income settings, yet governments often lack basic information on what it costs to train health professionals. This study provides the first institutional level evidence on the structure and magnitude of medical education costs in Afghanistan using detailed administrative and financial records from Kabul Medical University. A retrospective costing approach combined with a step-down cost accounting framework is used to allocate all direct and shared expenditures across faculties and across years of study. The results reveal large differences in per student costs across programs, with Curative Medicine requiring substantially more resources than Stomatology, Nursing, and Public Health. Support services account for a large share of total expenditure, and resource use rises sharply in clinically intensive years. A sensitivity analysis that varies personnel costs, allocation rules, and price adjustments shows that these patterns remain stable. The findings indicate that fiscal pressures, gender imbalances in enrollment, and inefficient allocation of support costs limit the effectiveness of current training investments. The study provides a quantitative foundation for policies that seek to improve the financial sustainability of medical universities, align training capacity with national health needs, and strengthen resource tracking systems in fragile and low-income contexts.
Background:Price transparency has been cited as a tool to reduce out-of-pocket (OOP) payments to patients. These tools for prescription drugs often focus on the price to patients for the drug alone. However, costs associated with drug delivery (i.e. infusion center fees, labs, etc) are often unknown and could impact the effectiveness of price transparency tools. Objective: To examine total OOP payments on day of drug receipt ("full day", i.e. drug + drug administration fees) out-of-pocket (OOP) payments associated with six first-line treatments for metastatic castrate resistant prostate cancer and compare these with payments for drug alone and by insurance type. Methods:Using the IBM Marketscan databases, we identify male patients who initiated treatment with one of six focus drugs (docetaxel, abiraterone, enzalutamide, sipuleucel-T, cabazitaxel, and radium-223) used to treat mCRPC from 07/01/2013-06/30/2019. We calculated total OOP payments on day of drug receipt (full day OOP payments) by drug type for six first line treatments. We then used a two-part model to assess the association of first-line therapy with OOP payments for the four most frequently prescribed during the study time period. Results:We find that there is variation in the proportion of payments for drug alone relative to full day payments across first-line treatments. However, regression-adjusted mean full day OOP payments are not statistically different across first-line treatments for mCRPC for the four most frequently prescribed drugs. There are differences in the likelihood that an individual will incur any OOP payment by first-line treatment type and by health plan type. Conclusion:These analyses suggest that when accounting for additional services required on the day of drug receipt, the amount a patient pays to receive a medication for mCRPC can be very different from the OOP payment for the drug alone; these payments also vary by drug and health plan type. Therefore, price transparency for drug alone may not lead to reduced OOP payments for patients.
Evidence from studies conducted in high-income countries suggests that lifestyle factors, such as leisure-time physical activity, sedentary habits, and obesity, are associated with a significant socioeconomic burden of disease and the attribution of direct costs to healthcare systems. In Brazil, the occurrence of primary care-sensitive hospitalizations is responsible for a relevant socioeconomic burden. However, there is a scarcity of evidence regarding the association of lifestyle factors on the direct costs of the Brazilian healthcare system. In this context, the present study aims to analyze the association between leisure-time physical activity, sedentary habits, and obesity with hospitalization costs in São Paulo city, Brazil. A quantitative analysis of microdata from the São Paulo Health Survey (ISA-Capital), which is representative for the urban population of São Paulo City, and was conducted in 2003, 2008, and 2015, was employed. Multiple two-part regression models (logit and GLM) and marginal effects (ME) were estimated. The study's findings suggest that meeting the weekly frequency of leisure-time physical activity recommended by the World Health Organization is associated with lower hospitalization costs in the public (logit β = -0.475, p < 0.05; ME = -31.03, p < 0.05) and private sector (logit β = -0.494, p < 0.01; ME = -37.89, p < 0.01). Sedentary habits (logit β = 0.442, p < 0.05; ME = 40.92, p < 0.01), and obesity (GLM β = 0.385, p < 0.05) were associated with higher costs in the private sector. No associations were observed between sedentary habits and obesity for hospitalization costs in the public sector. The evidence from the present study suggests that policies encouraging the adoption of healthy active lifestyles, such as practicing leisure-time physical activity and reducing sedentary habits, as well as policies for obesity prevention, may be important strategies for minimizing hospitalization costs in urban population contexts in the two-tier of the Brazilian healthcare system. Yet, associations identified in the study should be interpreted with caution due to the impossibility of establishment of causal links between lifestyle factors and healthcare expenditures.
Background:There has been global concern about nursing shortages and nurse migration, as nurses move in search of better working conditions. Ireland is one of the countries facing nursing shortages. Ireland, like many other countries, has begun to rely heavily on migrant nurses. This study examines the recent trends in the nursing workforce and possible contributing factors to Ireland's dependence on international nurse recruitment, drawing insights from existing data and literature. Methodology:This paper integrates and analyses secondary data obtained from the Nursing and Midwifery Board of Ireland (NMBI) 2003-2022 and data from the Faculty of Nursing and Midwifery, RCSI, registration register (2015-2022). The population data of Ireland was obtained from the Central Statistics Office (CSO). Result:The data available indicates a heavy reliance on migrant nurses due to a shortage of Irish-trained nurses relative to increased demand for nurses in the period (2003-2022). More than 50% of the Nurses registered in that period were migrant nurses (EU and Non-EU). Conclusion:There is an urgent need for Ireland to increase the domestic training of nurses and midwives, as well as, a need to develop a robust nurse workforce planning system to improve retention and ensure nursing workforce self-sufficiency.
Background:Risk adjustment models in Medicare Advantage determine annual payments of over $300 billion in public funds to private companies. Policymakers want risk adjustment models that are both accurate and interpretable to ensure appropriate use of public funds. Methods:The trade-off between accuracy and interpretability from using standard machine learning (ML) models for risk adjustment was evaluated. A cross-sectional analysis was conducted using 2018-2019 Medicare claims with 3,602,618 beneficiaries. Multiple risk adjustment models were estimated, including traditional and ML-based approaches. Performance was assessed using out-of-sample mean absolute and squared error (MAE and MSE). Interpretability was measured using coefficient count and log-transformed coefficient count of models. Results:ML models, especially gradient-boosted trees, significantly improved prediction accuracy relative to recent Medicare models, with MAE reductions of - 1,352 (95 % CI: -1,392, -1,316) and MSE reductions of - 5 (95 % CI: -9, -1). However, these improvements increased model complexity by more than 1000x and provided less than 0.1 % of the accuracy improvement per additional coefficient of a previous major model change. Notably, the predictions from gradient-boosted trees responded less to strategic diagnosis coding, reducing incentives to upcode. Conclusions:Standard ML models can modestly improve predictive accuracy but substantially worsen model interpretability in risk adjustment. Future research is needed to improve accuracy in these models while maintaining the interpretability essential for oversight of public spending.
