Despite the existence of the smoke-free regulations, smoking prevalence and exposure to secondhand smoke in Vietnam remain high, particularly in hospitality venues. Using data from the Provincial Global Adult Tobacco Survey (PGATS) 2024 in Vietnam, this study aimed to assess adherence with smoke-free regulations in public places, analyze the association between the presence of no-smoking signage and tobacco sales/advertising with smoking evidence status. This was a cross-sectional observational study conducted in Vietnam from July 2024 to December 2024. Compliance with smoke-free regulations is understood as the complete absence of any smoking evidence in public places, regardless of the source. A total of 3,028 observations were conducted across public places and workplaces in 37 provinces and cities in Vietnam, using the PGATS 2024 Observation Checklist. This was a cross-sectional observational study conducted in Vietnam from July 2024 to December 2024. Compliance with smoke-free regulations is understood as the complete absence of any smoking evidence in public places, regardless of the source. A total of 3,028 observations were conducted across public places and workplaces in 37 provinces and cities in Vietnam, using the PGATS 2024 Observation Checklist. Compliance with smoke-free regulations was low in restaurants (36.3

A harmonious relationship between the medical profession and the society it serves is essential for any country's health system to fulfill its mandate. Society offers trust, respect, authority, and professional autonomy to doctors, and in return, expects doctors to provide good care and prioritize people's welfare. However, in many parts of the world, we observe growing dissatisfaction, increasingly expressed violently, with the medical profession. Understanding what explains this growing dissatisfaction is necessary to initiate measures to maintain and improve this important social relationship and social contract. Using India as a case, and drawing on insights from qualitative, in-depth interviews with purposively selected doctors, journalists, legal experts, police, patients and patients' rights activists, and social commentators, we demonstrate how a range of mismatched expectations-regarding the organization of the medical profession, the structure of healthcare provision, the status and identity of doctors in society, and fair compensation for care provides-are contributing to the disruption of this critical social relationship. We argue that these dynamics can be meaningfully examined through the lens of the 'social contract' between the medical profession and the society it serves. Our analysis also shows how these mismatched expectations are highly contentious and how they are rooted in the increasingly market-logic-based organization of healthcare. For researchers across the world, our study offers a novel approach to researching the relationship between the medical profession and society, and, for policy makers and health system leaders in India, our findings offer practical entry points to develop policy interventions to help restore, recalibrate, and secure this important social contract.

Background: Since 2009, China has implemented a chronic disease management program within primary healthcare (PHC) institutions in response to challenges posed by an aging population. However, the effectiveness of the program has been reported as mixed, likely due to variations in PHC physicians' efforts and the support they received from the health system and community. This multi-sector engagement was conceptualized as management intensity in this study, and its impact on the program's effectiveness was evaluated. Methods: This study analyzed 60 885 patients under the chronic disease management program in Yuhuan, Zhejiang province, as of 2023. Management intensity, the primary predictor, was quantified by township-level residual measured based on patients' length of follow-up after eliminating patient demographics. This approach removed the portion of follow-up length attributable to individual characteristics, leaving the residual serving as a purified exposure variable for management intensity. The outcome measures included outpatient visits, inpatient admissions, outpatient and inpatient expenses, and glycemic and blood pressure (BP) control status. Data sources included chronic disease management registration records, service records of follow-up, and electronic medical records. A two-level mixed-effects regression model was then used to examine how management intensity affected the outcomes. Results: Each unit increase in management intensity corresponded to 0.21 more PHC outpatient visits and 0.15 fewer hospital outpatient visits. Meanwhile, higher management intensity was also associated with increased utilization of PHC inpatient services (odds ratio [OR]: 0.98, 95% CI: 0.97-0.98) and decreased utilization of hospital inpatient services (OR: 1.24, 95% CI: 1.18-1.29). Conclusion: Greater management intensity correlated with better health outcomes and higher utilization of PHC services. Since multi-sector engagement strongly affected how intensively chronic diseases were managed, it was imperative for health systems and communities to actively participate in and strengthen the program by supporting physicians.

The pursuit of Universal Health Coverage (UHC) in India is particularly challenging given the country’s vast population and pronounced socioeconomic disparities. Although extensive research addresses specific healthcare areas, contemporary data on citizens’ healthcare access, quality, and preferences to inform UHC design are lacking. To bridge this gap, the Lancet Commission on a Citizen-Centred Health System for India conducted a Citizens Survey from November 2022 to April 2023, interviewing respondents in person in 50,000 randomly selected households across 125 districts in 29 Indian states and Union Territories. The survey comprised 141 questions covering healthcare utilization, experiences, costs, satisfaction, delivery preferences, insurance coverage, willingness to pay, health information behaviors, technology use, aspirational health norms, and electoral attitudes towards health. The survey had a high participation rate (98%) and a low non-response rate (9.5%), 70% of households were rural, 56% of respondents were male, 79% were Hindu, and 39% identified as Scheduled Caste or Tribes. The data aim to inform citizen-centric reforms, advancing a UHC responsive to India’s diverse population needs.

Prevalence of common perinatal mental disorders (CPMDs) in Vietnam ranges from 16.9

BACKGROUND:Health system responsiveness (HSR) is a core health system goal yet remains underexamined for older adults with functional limitations and socio-economic vulnerability in India. OBJECTIVE:To present a novel assessment of HSR among older adults aged 60+ with functional limitations and socio-economic vulnerability in India across six domains: prompt attention, dignity, communication, confidentiality, choice of providers, and quality of amenities. METHODS:We analysed data from the nationally representative Longitudinal Ageing Study in India Wave 1 (2017-2018), including 16,659 older adults for outpatient care and 2,358 for inpatient care. Multivariable linear regressions assessed the association between HSR and functional limitations, multimorbidity, and socio-economic factors. Functional limitations were defined as one or more limitations in Activities of Daily Living and/or Instrumental Activities of Daily Living. Overall HSR score was calculated by summing across domains. RESULTS:Median HSR score was 24 (range 6-30), equivalent to approximately 75 on a 0-100 scale, for outpatient and inpatient care. Older adults with functional limitations experienced poorer responsiveness in outpatient (β = -0.62; 95%CI: -0.84, -0.41) and inpatient care (β = -0.62; 95%CI: -1.14, -0.09). Negative associations were observed in public facilities, while in private facilities this was significant only for outpatient care. Among those with functional limitations, lower castes and lower economic status reported poorer responsiveness. CONCLUSIONS:Older adults with functional limitations in India experience poorer HSR, with worse care among lower castes and poorer groups. These findings suggest the presence of ableism within the Indian health system that needs to be systematically identified and tackled to ensure equitable and responsive healthcare.

Background:Tribal women in India face inequitable access to health care and are at high risk of cervical cancer. However, no disaggregated data on cervical cancer survival for such populations are currently available, to support the need for focused health policies and programmes.Methods:We compared the survival experience of women diagnosed with cervical cancer between 2014 and 2022, from defined rural (population 116,000) and tribal areas (population 63,822) in Vellore and Tiruvannamalai districts in Tamil Nadu, South India. Cases were identified through patient registries at healthcare facilities and ongoing population-based surveillance based on reporting by community health workers. The outcome was time to death due to cervical cancer recorded in the routine demographic surveillance system. Analysis was conducted using Kaplan-Meier curves and Cox proportional hazards regression.Results:Among the 77 women (30 tribal, 47 rural) identified with cervical cancer, the mean age at diagnosis was 46 years among tribal women, compared to 54 years among rural women (t test P value 0.002). Tribal women experienced 2.02 (95% confidence interval: 1.03-3.96) times higher mortality within five years, after adjusting for age and stage at diagnosis.Conclusions:The higher mortality in tribal women, even after adjusting for age and the stage of diagnosis, indicates inequities in access to health care for the treatment of cervical cancer. India needs to improve access to affordable, culturally appropriate cancer treatment and cervical screening, to ensure equitable survival outcomes for all affected women.

Pregnancy and postpartum-related mental health problems present serious public health threat to the society; however, this is not prioritized in sub-Saharan Africa (SSA). We aimed to determine the prevalence and analyze perceptions and experiences of maternal mental health (MMH) distress and health systems responsiveness to mental well-being of pregnant and postpartum clients and their relatives, and frontline health workers in two districts of Southern Ghana. The study used a cross-sectional mixed methods design and purposively selected study sites to provide insights from rural and urban settings. A structured survey involving antenatal (n = 827), postnatal (n = 618), and delivery (n = 58) maternal health clients was conducted in primary healthcare facilities using a modified World Health Organization health systems responsiveness questionnaire and the 21-item screening tool for depression, anxiety, and stress scale (DASS21). Eighteen focus group discussions (FGDs) were conducted, fourteen involving antenatal and postnatal clients with/without mental health conditions (n = 104), and four with frontline healthcare providers (n = 24). We also conducted six in-depth interviews, four (n = 4) involved postnatal clients with mental health conditions and two (n = 2) involved clients’ relatives. Quantitative data were analyzed using Stata 15 and employing descriptive analysis and generalized linear models. Thematic analysis was done on the qualitative data, with some further analysis of themes using the text sort function in Microsoft Excel. Mild, moderate, and severe MMH distress were experienced in pregnancy and post-partum, but were not addressed as part of routine formal care. The DASS21 showed 19

To deliver palliative care, it is important to understand what a “good death” means to the relevant people. Such studies have mostly occurred in high-income settings that usually live by Western ideals. What matters to people is likely to vary across different regions of the world, influenced by multiple factors. Although there is a great need for palliative care in South Asia, there is a lack of comprehensive understanding of what a good death means in this setting. This study aimed to increase understanding of what is considered a good death in South Asia. Systematic review and narrative synthesis. A systematic search was conducted across eight databases, an Advanced Google search, and a bibliography search of selected articles. A data-based convergent synthesis was performed, along with quality appraisal. Twenty-five empirical studies were selected for analysis from India, Pakistan, Bangladesh, Sri Lanka, and Bhutan. Four themes emerged. Mutual care and connection support a continued sense of self : contributing to others, while receiving connection through relationships and spiritual practices, was important for patients and supported by families and healthcare workers. Freedom to choose—privilege or burden ?: the choice to participate in care was necessary for some patients but a burden for others, who preferred the family to lead their care. Severe uncontrolled pain and financial distress precluded choice for some patients, who felt death was the only option. Decisions regarding artificial prolongation of life were complex for patients and healthcare workers. Opportunities in the last days : when actively dying, there was general agreement on the importance of being pain-free, feeling safe, and having family present. Home was not always the preferred place of death. For family, it was critical to perform last rites. After death matters : What happens after death—influenced by leaving a legacy and religious beliefs—affected all parties before, during, and post-death. To our knowledge, this is the first review of what a good death means in South Asia. There is a dearth of research from most South Asian countries. Although the South Asian perspective has similarities with the Western perspective, we note important nuances around decision-making, prolongation of life, prognostic awareness, and wanting to end one's life, moderated by culture, religion, and poverty. We support policies that account for these variations. Ongoing work is required to provide good symptom management, thus increasing opportunities for patient participation in care. Further research is needed in areas of ethics and religion at the end of life in South Asia.

BACKGROUND:As a frontrunner in introducing cervical screening in India, the state of Tamil Nadu urgently needs to consider how to improve screening rates and switch to Human Papillomavirus (HPV) detection tests. METHODS:We used a mixed methods design to assess the readiness of the state health system for delivering the current cervical screening program, as well as for future HPV self-collection. Following a desk review, we surveyed 14 government health facilities in three districts of Tamil Nadu and calculated overall and domain-specific (service utilization, service availability, general service, cervical screening) readiness scores as percentages. We conducted four interviews and five focus group discussions with 37 participants [managers, primary care nurses, community health workers (CHWs)] to clarify findings and obtain suggestions regarding the introduction of HPV self-collection in tribal, rural, and urban low-resource settings. RESULTS:Scores for general services and readiness to offer visual inspection with acetic acid (VIA) and follow-up were more than 70% in the surveyed facilities. Despite the availability of trained nurses, infrastructure and resources, utilisation was primarily limited to symptomatic women attending health facilities due to poor acceptability of screening that would require facility visits. Most participants felt that self-collection could reduce women's fear and embarrassment and could be delivered through CHWs in the community or by nurses at facilities. However, motivation for screening may remain low as most asymptomatic women do not perceive a need for screening, and/or fear implications of a positive test. Tertiary laboratories appear ready for HPV testing, given availability of high-throughput PCR equipment, computerised laboratory information management systems, and a planned hub and spoke model of improving access to laboratory tests. CONCLUSIONS:Despite relatively good infrastructure and staffing for VIA screening in public healthcare facilities, service utilisation was primarily by symptomatic women, contributing to low screening rates. HPV self-collection was highly acceptable to administrative and field staff. Widespread educational approaches to motivate asymptomatic women to screen using self-collection, with decentralised sample collection and treatment, could potentially improve cervical screening rates. CLINICAL TRIAL NUMBER:Not applicable.

We critically interrogate the current conceptualisation of health systems responsiveness in light of ongoing political, economic, and health system transitions occurring in many low- and middle-income countries (LMICs), and call for a nuanced, contemporaneous, and expanded understanding of the concept. Drawing on key work on health economics and healthcare markets, we unpack the economic and health systems transitions that LMICs have experienced in the last two decades, specifically the shift towards neoliberalism. We discuss the impact of these transitions, particularly, the rapid growth in for-profit care and the covert or outright privatisation of public health services, on health care provision. We critically review the literature on health systems responsiveness to then demonstrate how current analytical frameworks do not yet sufficiently reflect the role of the market in responsive care provision. In light of this, we make a case for explicitly recognising the role of the market logic in both shaping peoples' expectations of their health systems and the health system's response to these expectations.

In countries without a gatekeeping system, including China, promoting primary healthcare (PHC) utilization can improve system efficiency and reduce healthcare burden. However, evidence on diabetes patients’ PHC utilization and its impact on health outcomes remains limited. This study employs continuity of care (COC) to examine care-seeking behavior at PHC institutions in China and assess its association with clinical outcomes and healthcare costs. We conducted a retrospective cohort study in Yuhuan, Zhejiang Province, China, including 3,672 patients newly diagnosed with diabetes between 2016 and 2019. Data from chronic disease management records, follow-up service records, and electronic medical records from 2020 to 2023 were linked. COC was assessed from 2020 to 2022 using standard measures including the Continuity of Care Index (COCI), Usual Provider of Care (UPC), and Sequential Continuity (SECON), as well as PHC-specific measures: the Primary Healthcare Index (PHCI) and a binary indicator for having the primary healthcare institution as the usual provider of care (PHC-UPC). We evaluated clinical outcomes (hospitalization, glycemic control) and healthcare costs in 2023. Logistic and linear regression models were used to assess association, adjusting for patient demographics and clinical characteristics. The mean PHCI was 0.73. Higher PHCI was significantly associated with decreased outpatient costs (P < 0.001), decreased inpatient costs (P < 0.001), and a lower likelihood of hospitalization (OR = 0.503, P < 0.001). Similarly, having used a PHC-UPC was associated with reduced outpatient and inpatient costs (P < 0.001) and a lower likelihood of hospitalization (OR = 0.708, P < 0.001). However, among patients with poorly controlled diabetes, neither PHCI nor having used a PHC-UPC showed a positive association with glycemic control (OR = 0.496, P = 0.003; OR = 0.629, P = 0.002). Continuity at PHC significantly lowers hospitalization and healthcare costs in China’s non-gatekeeping system. However, no significant improvement in glycemic control among poorly controlled diabetes was observed. Strengthening PHC capacity for personalized diabetes management and timely hospital referrals is essential to optimize outcomes.

In low- and middle-income countries, maternal mental health needs remain neglected, and common mental disorders during pregnancy and after birth are routinely associated with hormonal changes. The psycho-social and spiritual components of childbirth are often downplayed. A qualitative study was conducted as part of a wider realist evaluation on health systems responsiveness to examine the interrelationships between pregnant and postnatal women, their families, and their environment, and how these influence women's interactions with healthcare providers in Ghana. Data collection methods combined six qualitative interviews (n = 6) and 18 focus group discussions (n = 121) with pregnant and postnatal women, their relatives, and healthcare providers (midwives, community mental health nurses) at the primary healthcare level. Data analysis was based on the context-mechanism-outcome heuristic of realist evaluation methodology. A programme theory was developed and iteratively refined, drawing on Crowther's ecology of birth theory to unpack how context shapes women's interactions with public and alternative healthcare providers. We found that context interacts dynamically with embodiment, relationality, temporality, spatiality, and mystery of childbirth experiences, which in turn influence women's wellbeing in three primary areas. There is an intricate intersection of pregnancy with mental health impacting women's expectations of temporality, which does not always coincide with the timings provided by formal healthcare services. Societal deficiencies in social support structures for women facing economic challenges become particularly evident during the pregnancy and postnatal period, where women need heightened assistance. Socio-cultural beliefs associated with the mystery of childbirth, the supportive role of private providers and faith healing practices offered women a feeling of protection from uncertainty. Co-production of context-specific interventions, including the integration of maternal and mental health policies, with relevant stakeholders can help formal healthcare providers accommodate women's perspectives on spirituality and mental health, which can subsequently help to make health systems responsive to maternal mental health conditions.

Despite efforts to advance universal health coverage (UHC) in different contexts, evidence gaps remain, and implementation science has been underused to address these gaps and determine ‘what works’. The study aimed to establish a research agenda that could guide future research by identifying implementation science research priorities to advance UHC. A three-round modified Delphi study design with a multi-country panel was employed. Initial implementation science research gaps were identified from two scoping reviews conducted by our team, supplemented by 10 papers that we identified through a search of Medline and CINAHL databases. We generated 64 research gaps that were shared with 272 participants in Round I. Round I responses were analysed using descriptive statistics and a cut-off of 75% to move to Round II. Round I qualitative analysis resulted in an additional 15 research gaps and one new topic area. Based on Round I findings, an improved set of research gaps was shared in Round II. Quantitative data in Round II were analysed using the same approach as Round I, using an 85% cut-off point. Open-ended responses were analysed thematically. Round II research gaps were then presented in a virtual workshop. Results from the workshop were analysed using weighted ranking analysis. Round I response rate was 34.9% with 43 research gaps across 12 topic areas. Round II response rate was 77.9% with 42 gaps across 13 topic areas that passed to the virtual workshop. The workshop response rate was 39%. Through this process, the top 10 ranked implementation science research gaps were identified. Identified research gaps are focused on assessing equity in the delivery of health services and financial risk protection interventions. Future research will further contextualise this research agenda with country-level actors.

Low- and middle-income countries (LMICs) are rapidly urbanizing, and in response to this, there is an expansion in the body of scholarship and significant policy interest in urban healthcare provision. The idea and the reality of 'urban advantage' have meant that health research in LMICs has disproportionately focused on health and healthcare provision in rural contexts and is yet to sufficiently engage with urban health as actively. We contend that this research and practice can benefit from a more explicit engagement with the rich conceptual understandings that have emerged in other disciplines around the urban condition. Our critical review included publications from four databases (MEDLINE, EMBASE, CINAHL, and Social Sciences Citation Index) and two Community Health Worker (CHW) resource hubs. We draw upon scholarship anchored in sociology to unpack the nature and features of the urban condition; we use these theoretical insights to critically review the literature on urban community health worker programs as a case to reflect on community health practice and urban health research in LMIC contexts. Through this analysis, we delineate key features of the urban, such as heterogeneity, secondary spaces and ties, size and density, visibility and anonymity, precarious work and living conditions, crime, and insecurity, and specifically the social location of the urban CHWs and present their implications for community health practice. We propose a conceptual framework for a distinct imagination of the urban to guide health research and practice in urban health and community health programs in the LMIC context. The framework will enable researchers and practitioners to better engage with what entails a 'community' and a 'community health program' in urban contexts.

How people experience their interactions with their health system are central to the notion of health systems responsiveness. These experiences may be ‘personal’, but they are also shaped by the broader historical, political, cultural, social, and economic contexts within which they occur. Yet, few studies on people’s experiences of care, particularly those focused on health systems responsiveness, explicitly take this into account. In this study, and drawing on in-depth interviews with 28 pregnant and postpartum women in a rural province of Vietnam, we use a novel approach that draws on the work of Archer and Chalari to uncover and analyse women’s ‘internal conversations’, in which they reflect upon and make sense of their maternity care-related experiences. Women’s ‘internal conversations’ reflected their need for short waiting times and high-quality ultrasonography, concerns regarding privacy and confidentiality, expectations of receiving dignified care, and their experiences of decision-making relating to caesarean section. Our findings reveal how women’s preferences, demands, and expectations have likely evolved in response to the Doi Moi-related shifts that have changed the organisation and structure of Vietnam’s economy, society, and health system. We make the case for health systems researchers and actors to consciously take into account the society and health system-level evolutions and changes when researching or developing interventions for improving responsive health systems.

Introduction Task-shifting and task-sharing strategies show promise for managing chronic diseases especially in low-income and middle-income countries (LMICs), though their effectiveness in multimorbidity management remains unclear. This study synthesised evidence on task-shifting and task-sharing strategies globally and assessed the impact on core health outcomes in multimorbidity management.Methods We conducted a systematic review and meta-analysis of global studies evaluating task-shifting and sharing interventions for individuals with multimorbidity. Six databases, including PubMed, Embase, Web of Science, Ovid (Medline), CINAHL and Cochrane Library, were searched for studies reporting the core outcomes of multimorbidity management in quality of life, mortality, hospitalisation, emergency department visits and symptoms of depression and anxiety. Random-effects models were used to calculate pooled effect sizes with heterogeneity assessed through subgroup and meta-regression analyses.Results From 8471 records, 36 studies from 14 countries were included, with only 5 conducted in LMICs. Twenty-one studies, encompassing 20 989 participants, were eligible for meta-analysis. More than half of the studies involved nurses as delegates, with some sharing the tasks with health professionals and about 10% of studies involved non-health professionals, including community healthcare workers as delegates to share the responsibility in caring for individuals with multimorbidity. Most studies were multicomponent, with 16.7% addressing all guideline-recommended aspects of multimorbidity management. By pooling the findings, task-shifting and task-sharing interventions were associated with a 27% reduction in mortality (OR: 0.73, 95% CI: 0.55 to 0.97, I²=0%), a modest improvement in quality of life (standardised mean difference (SMD): 0.1, 95% CI: 0.03 to 0.17, I²=47%) and reduced symptoms of depression (SMD: 0.27, 95% CI: −0.52 to –0.02, I²=90%), but showed no significant effect on hospitalisation, emergency visits or anxiety-related symptoms.Conclusions Some evidence, although limited in existing research, indicates the great potential of task-shifting and task-sharing strategies in supporting management of multimorbidity. Further research is needed to optimise and adopt these interventions, particularly in LMICs where evidence remains scarce.PROSPERO registration number CRD42024526845.

In 2024, Australia achieved the WHO’s 2030 target of 70

INTRODUCTION:To deliver palliative care, it is important to understand what a "good death" means to the relevant people. Such studies have mostly occurred in high-income settings that usually live by Western ideals. What matters to people is likely to vary across different regions of the world, influenced by multiple factors. Although there is a great need for palliative care in South Asia, there is a lack of comprehensive understanding of what a good death means in this setting. This study aimed to increase understanding of what is considered a good death in South Asia. DESIGN:Systematic review and narrative synthesis. METHOD:A systematic search was conducted across eight databases, an Advanced Google search, and a bibliography search of selected articles. A data-based convergent synthesis was performed, along with quality appraisal. RESULTS:Twenty-five empirical studies were selected for analysis from India, Pakistan, Bangladesh, Sri Lanka, and Bhutan. Four themes emerged. Mutual care and connection support a continued sense of self: contributing to others, while receiving connection through relationships and spiritual practices, was important for patients and supported by families and healthcare workers. Freedom to choose-privilege or burden?: the choice to participate in care was necessary for some patients but a burden for others, who preferred the family to lead their care. Severe uncontrolled pain and financial distress precluded choice for some patients, who felt death was the only option. Decisions regarding artificial prolongation of life were complex for patients and healthcare workers. Opportunities in the last days: when actively dying, there was general agreement on the importance of being pain-free, feeling safe, and having family present. Home was not always the preferred place of death. For family, it was critical to perform last rites. After death matters: What happens after death-influenced by leaving a legacy and religious beliefs-affected all parties before, during, and post-death. CONCLUSIONS:To our knowledge, this is the first review of what a good death means in South Asia. There is a dearth of research from most South Asian countries. Although the South Asian perspective has similarities with the Western perspective, we note important nuances around decision-making, prolongation of life, prognostic awareness, and wanting to end one's life, moderated by culture, religion, and poverty. We support policies that account for these variations. Ongoing work is required to provide good symptom management, thus increasing opportunities for patient participation in care. Further research is needed in areas of ethics and religion at the end of life in South Asia.