Monitoring Intervention Coverage in the Context of Universal Health Coverage

Monitoring universal health coverage (UHC) focuses on information on health intervention coverage and financial protection. This paper addresses monitoring intervention coverage, related to the full spectrum of UHC, including health promotion and disease prevention, treatment, rehabilitation, and palliation. A comprehensive core set of indicators most relevant to the country situation should be monitored on a regular basis as part of health progress and systems performance assessment for all countries. UHC monitoring should be embedded in a broad results framework for the country health system, but focus on indicators related to the coverage of interventions that most directly reflect the results of UHC investments and strategies in each country. A set of tracer coverage indicators can be selected, divided into two groups—promotion/prevention, and treatment/care—as illustrated in this paper. Disaggregation of the indicators by the main equity stratifiers is critical to monitor progress in all population groups. Targets need to be set in accordance with baselines, historical rate of progress, and measurement considerations. Critical measurement gaps also exist, especially for treatment indicators, covering issues such as mental health, injuries, chronic conditions, surgical interventions, rehabilitation, and palliation. Consequently, further research and proxy indicators need to be used in the interim. Ideally, indicators should include a quality of intervention dimension. For some interventions, use of a single indicator is feasible, such as management of hypertension; but in many areas additional indicators are needed to capture quality of service provision. The monitoring of UHC has significant implications for health information systems. Major data gaps will need to be filled. At a minimum, countries will need to administer regular household health surveys with biological and clinical data collection. Countries will also need to improve the production of reliable, comprehensive, and timely health facility data. Please see later in the article for the Editors'' Summary

Summary Points

• Monitoring universal health coverage (UHC) should be integral to overall tracking of health progress and performance, which requires regular assessment of health system inputs (finances, health workforce, and medicines), outputs (service provision), coverage of interventions, and health impacts, as well as the social determinants of health.
• Within this overall context, we propose that UHC monitoring focus on financial protection and intervention coverage indicators, with a strong equity focus. This paper focuses on intervention coverage.
• Progress towards UHC should be tracked using tracer intervention coverage indicators selected on the basis of objective considerations and designed to keep the numbers of indicators small and manageable while covering a range of health interventions to capture the essence of the UHC goal.
• Since UHC is about progressive realization and countries differ in epidemiology, health systems, socioeconomic development, and people''s expectations, the indicator sets will not be the same everywhere.
• Coverage indicators should cover promotion and prevention, as well as treatment, rehabilitation, and palliation. While there are several suitable indicators for the first two, there are major gaps for coverage indicators of treatment, as population need for treatment is difficult to measure.
• A small set of well-established international intervention tracer coverage indicators can be identified for monitoring UHC. Where no good indicators are currently available, proxy indicators and equity analysis of service utilization can provide some insights.
• Special attention needs to be paid to quality of services, either through the tracer indicator itself (referred to as effective coverage) or through additional indicators on quality of services or health impact of the intervention.
• Targets should be set in accordance with baseline, historical rate of progress, and measurement considerations.
• The main data sources of intervention coverage indicators are household surveys and health facility reports. Investments in both are needed to improve the ability of countries to monitor progress towards UHC.
• It is essential to find effective ways of communicating progress towards UHC in ways that are meaningful to the general public and that capture the attention of policy makers.

This paper is part of the PLOS Universal Health Coverage Collection.

     

Monitoring Progress towards Universal Health Coverage at Country and Global Levels

Universal health coverage (UHC) has been defined as the desired outcome of health system performance whereby all people who need health services (promotion, prevention, treatment, rehabilitation, and palliation) receive them, without undue financial hardship. UHC has two interrelated components: the full spectrum of good-quality, essential health services according to need, and protection from financial hardship, including possible impoverishment, due to out-of-pocket payments for health services. Both components should benefit the entire population.This paper summarizes the findings from 13 country case studies and five technical reviews, which were conducted as part of the development of a global framework for monitoring progress towards UHC.The case studies show the relevance and feasibility of focusing UHC monitoring on two discrete components of health system performance: levels of coverage with health services and financial protection, with a focus on equity. These components link directly to the definition of UHC and measure the direct results of strategies and policies for UHC. The studies also show how UHC monitoring can be fully embedded in often existing, regular overall monitoring of health sector progress and performance. Several methodological and practical issues related to the monitoring of coverage of essential health services, financial protection, and equity, are highlighted. Addressing the gaps in the availability and quality of data required for monitoring progress towards UHC is critical in most countries.

Summary Points

• The overall goal of universal health coverage (UHC) is that all people obtain the good-quality essential health services, including promotion, prevention, treatment, rehabilitation, and palliation, that they need without enduring financial hardship.
• A global UHC monitoring framework, developed by WHO and the World Bank Group in interaction with the process that led to this PLOS Collection, was used in 13 country case studies, underpinned by five technical reviews.
• The UHC monitoring framework focuses on the simultaneous monitoring of coverage of the population with essential health services and with financial protection against catastrophic out-of-pocket health payments, stratified by wealth quintile, place of residence, and sex.
• Most countries focus on regular monitoring of a set of tracer indicators for priority health services, as well as the occurrence of financial hardship and impoverishment due to out-of-pocket health expenses. The indicators generally follow international standards of measurement and can be used for global comparisons.
• Most countries do not have an explicit framework for UHC monitoring. The monitoring of UHC is, however, partially embedded in regular overall health sector progress and performance reviews which include health system inputs, service delivery, and health status indicators.
• There are major gaps in the availability and quality of data required for monitoring progress towards UHC. Countries mostly rely on international survey programs or national surveys to obtain disaggregated data on coverage and financial protection indicators, complemented by health facility data, but often the frequency and contents of these surveys are not sufficient to meet the country''s information needs.
• Monitoring progress towards the two components of UHC will be complementary and critical to achieving desirable health outcome goals, such as ending preventable deaths and promoting healthy life expectancy, and also reducing poverty and protecting household incomes.

     

Beyond UHC: Monitoring Health and Social Protection Coverage in the Context of Tuberculosis Care and Prevention

Tuberculosis (TB) remains a major global public health problem. In all societies, the disease affects the poorest individuals the worst. A new post-2015 global TB strategy has been developed by WHO, which explicitly highlights the key role of universal health coverage (UHC) and social protection. One of the proposed targets is that “No TB affected families experience catastrophic costs due to TB.” High direct and indirect costs of care hamper access, increase the risk of poor TB treatment outcomes, exacerbate poverty, and contribute to sustaining TB transmission. UHC, conventionally defined as access to health care without risk of financial hardship due to out-of-pocket health care expenditures, is essential but not sufficient for effective and equitable TB care and prevention. Social protection interventions that prevent or mitigate other financial risks associated with TB, including income losses and non-medical expenditures such as on transport and food, are also important. We propose a framework for monitoring both health and social protection coverage, and their impact on TB epidemiology. We describe key indicators and review methodological considerations. We show that while monitoring of general health care access will be important to track the health system environment within which TB services are delivered, specific indicators on TB access, quality, and financial risk protection can also serve as equity-sensitive tracers for progress towards and achievement of overall access and social protection.

This paper is part of the PLOS Universal Health Coverage Collection.

Summary Points

1. The WHO has developed a post-2015 Global TB Strategy emphasizing that significant improvement to TB care and prevention will be impossible without the progressive realization of both universal health coverage and social protection. This paper discusses indicators and measurement approaches for both.
2. While access to high-quality TB diagnosis and treatment has improved dramatically in recent decades, there is still insufficient coverage, especially for correct diagnosis and treatment of multi-drug resistant TB.
3. Continued and expanded monitoring of effective coverage of TB diagnosis and treatment is needed, for which further improvements to existing surveillance systems are required.
4. Many households face severe financial hardship due to TB. Out-of-pocket costs for medical care, transport, and food are often high. However, income loss is the largest financial threat for TB-affected households.
5. Consequently, the financial risk protection target in the post-2015 Global TB Strategy—“No TB affected families experience catastrophic costs due to TB”—concerns all direct costs as well as income loss. This definition is more inclusive than the one conventionally used for “catastrophic health expenditure,” which concerns only direct medical costs.

     

Equity-Oriented Monitoring in the Context of Universal Health Coverage

Monitoring inequalities in health is fundamental to the equitable and progressive realization of universal health coverage (UHC). A successful approach to global inequality monitoring must be intuitive enough for widespread adoption, yet maintain technical credibility. This article discusses methodological considerations for equity-oriented monitoring of UHC, and proposes recommendations for monitoring and target setting. Inequality is multidimensional, such that the extent of inequality may vary considerably across different dimensions such as economic status, education, sex, and urban/rural residence. Hence, global monitoring should include complementary dimensions of inequality (such as economic status and urban/rural residence) as well as sex. For a given dimension of inequality, subgroups for monitoring must be formulated taking into consideration applicability of the criteria across countries and subgroup heterogeneity. For economic-related inequality, we recommend forming subgroups as quintiles, and for urban/rural inequality we recommend a binary categorization. Inequality spans populations, thus appropriate approaches to monitoring should be based on comparisons between two subgroups (gap approach) or across multiple subgroups (whole spectrum approach). When measuring inequality absolute and relative measures should be reported together, along with disaggregated data; inequality should be reported alongside the national average. We recommend targets based on proportional reductions in absolute inequality across populations. Building capacity for health inequality monitoring is timely, relevant, and important. The development of high-quality health information systems, including data collection, analysis, interpretation, and reporting practices that are linked to review and evaluation cycles across health systems, will enable effective global and national health inequality monitoring. These actions will support equity-oriented progressive realization of UHC.

This paper is part of the PLOS Universal Health Coverage Collection.

Summary Points

• The equitable realization of universal health coverage requires an equity-oriented approach to monitoring; equity advocates should be unified in proposing a technically sound platform for monitoring that is easy to understand and communicate.
• Global monitoring should include complementary dimensions of inequality (such as economic status and urban/rural residence, in addition to sex), adopt a gap or whole spectrum approach, and conceptualize economic-related measures using quintiles.
• Both absolute and relative measures of inequality as well as disaggregated data should be reported, and national averages should be presented alongside inequality monitoring.
• Targets for global monitoring of health inequalities should be based on proportional reduction of absolute inequality.
• Countries can develop capacity for health inequality monitoring by strengthening health information systems for data collection, analysis, reporting, and dissemination.

     

Achieving global mortality reduction targets and universal health coverage: The impact of COVID-19

Wenhui Mao and coauthors discuss possible implications of the COVID-19 pandemic for health aspirations in low- and middle-income countries.

Summary points

• The Coronavirus Disease 2019 (COVID-19) pandemic threatens progress toward a “grand convergence” in global health—universal reduction in deaths from infections and maternal and child health conditions to low levels—and toward achieving universal health coverage (UHC).
• Our analysis suggests that COVID-19 will exacerbate the difficulty of achieving grand convergence targets for tuberculosis (TB), maternal mortality, and, probably, for under-5 mortality. HIV targets are likely to be met.
• By 2035, our analysis suggests that the public sectors of low-income countries (LICs) would only be able to finance about a third of the costs of a package of 120 essential non-COVID-19 health interventions through domestic sources, unless the country increases significantly the priority assigned to the health sector; lower middle-income countries (LMICs) would likewise only be able to finance a little less than half.
• The likelihood of getting back on track for reaching grand convergence and UHC will depend on (i) how quickly COVID-19 vaccines can be deployed in LICs and LMICs; (ii) how much additional public sector health financing can be mobilized from external and domestic sources; and (iii) whether countries can rapidly strengthen and focus their health delivery systems.

     

Financial Risk Protection and Universal Health Coverage: Evidence and Measurement Challenges

Financial risk protection is a key component of universal health coverage (UHC), which is defined as access to all needed quality health services without financial hardship. As part of the PLOS Medicine Collection on measurement of UHC, the aim of this paper is to examine and to compare and contrast existing measures of financial risk protection. The paper presents the rationale behind the methodologies for measuring financial risk protection and how this relates to UHC as well as some empirical examples of the types of measures. Additionally, the specific challenges related to monitoring inequalities in financial risk protection are discussed. The paper then goes on to examine and document the practical challenges associated with measurement of financial risk protection. This paper summarizes current thinking on the area of financial risk protection, provides novel insights, and suggests future developments that could be valuable in the context of monitoring progress towards UHC.

This paper is part of the PLOS Universal Health Coverage Collection.

Key Summary Points

• Health payments are a heavy financial burden for millions around the world. Financial risk protection is concerned with safeguarding people against the financial hardship associated with paying for health services.
• Two commonly applied concepts capture the lack of financial risk protection. The first, catastrophic health expenditure, occurs when a household''s out-of-pocket (OOP) payments are so high relative to its available resources that the household foregoes the consumption of other necessary goods and services. The second concept, impoverishment, occurs when OOP payments push households below or further below the poverty line, a threshold under which even the most basic standard of living is not ensured.
• Headcount indicators, which measure the number of people affected, alone do not give the full picture of the problem. Additional measures of the intensity of financial hardship provide useful insights into the nature of OOP payments in different settings.
• Robust monitoring of financial risk protection requires reliable household expenditure surveys ideally conducted every 2 to 5 years.

     

Evidence-based policymaking when evidence is incomplete: The case of HIV programme integration

Jan Hontelez and co-authors discuss the use of different types of evidence to inform HIV program integration.

Summary points

• Sustainable Development Goal 3 aims to “ensure healthy lives and promote well-being for all at all ages” and has set a target of achieving global universal health coverage, representing a major policy shift away from mostly disease-specific “vertical programmes”.
• While health service integration can be a promising strategy to improve healthcare coverage, health outcomes, and efficiency, the exact impact of integration in different settings is hard to predict, and policy makers need to choose from a large variety of integration strategies and opportunities with varying levels of scientific evidence.
• Using the case of health service integration for HIV in low- and middle-income countries, we outline implementation strategies for integration opportunities with lacking or scarce high-level causal evidence, based on existing frameworks and methodologies from within and beyond healthcare and implementation science.
• Proper use of scientific evidence in other contexts requires adequate and systematic assessments of the transportability of an intervention. Several methods exist that allow for judging transferability and comprehensively identifying key context-specific indicators across studies that can affect the reported impact of interventions.
• When (transferable) evidence is absent, we propose that by drawing on well-established design and implementation methodologies—underpinned by ongoing learning and iterative improvement of local service delivery strategies—countries could substantially improve decision-making even in the absence of scientific evidence.
• Reaching the goal of making the HIV response an integral part of a larger, universal, people-centred health system that meets the needs and requirements of citizens can be facilitated by applying lessons learned from implementation science and novel design methodologies.

     

Evaluation of progress toward universal health coverage in Myanmar: A national and subnational analysis

BackgroundUniversal health coverage (UHC) encompasses 2 main components: access to essential healthcare services and protection from financial hardship when using healthcare. This study examines Myanmar’s efforts to achieve UHC on a national and subnational level. It is a primer of studying the concept of UHC on a subnational level, and it also establishes a baseline for assessing future progress toward reaching UHC in Myanmar.Methods and findingsThe study uses the Demographic and Health Survey (2015) and the Myanmar Living Conditions Survey (MLCS; 2017) and adapts a previously developed UHC index to provide insights into the main barriers preventing the country’s progress toward UHC. We find a negative correlation between the UHC index and the state/region poverty levels. The equity of access analysis reveals significant pro-rich inequity in access to all essential healthcare services. Socioeconomic status and limited availability of healthcare infrastructure are the main driving forces behind the unequal access to interventions that are crucial to achieving UHC by 2030. Finally, financial risk protection analysis shows that the poor are less likely to use healthcare services, and, once they do, they are at a greater risk of suffering financial catastrophe. Limitations of this study revolve around its correlational, rather than causal, nature.ConclusionsWe suggest a 2-pronged approach to help Myanmar achieve UHC: Government and state authorities should reduce the financial burden of seeking healthcare, and, coupled with this, significant investment in and expansion of health infrastructure and the health workforce should be made, particularly in the poorer and more remote states.

Zlatko Nikoloski and colleagues provide analytical insight into Myanmar’s efforts to achieve universal health coverage on a national and sub-national level.     

Effective Coverage for Antiretroviral Therapy in a Ugandan District with a Decentralized Model of Care

Introduction

While increasing access to antiretroviral therapy (ART) is reported from many African countries, data on effective coverage particular from settings without external support or research remains scarce. We examined and report effective coverage data from a public ART program in rural Uganda.

Methods

We conducted a retrospective cohort study at all ART-providing governmental health facilities in Iganga District, Eastern Uganda. Based on all HIV patients registered between April 2004 and September 2009 (n = 4775), we assessed indicators of program performance and determined rates of retention and Cox proportional hazards for attrition. Effective ART coverage was calculated using projections (SPECTRUM software) adapted to the district demographic structure and number of people receiving ART.

Results

By September 2009, district public sector effective ART coverage was 10.3% for adults and 1.9% for children. After a median follow-up of 26.9 months, overall ART retention was 54.7%. The probability of retention was 0.72 (95% confidence interval (CI) 0.69–0.75) at 12 and 0.58 (CI 0.54–0.62) at 36 months after ART initiation. Individual health facilities differed considerably regarding performance indicators and retention. Overall, 198 (16.9%) individual files of 1171 registered ART patients were lost. Young adult age (15–24 years) had a higher risk of attrition (HR 2.1, CI 1.4–3.2) as well as WHO stage I (HR 4.8, CI 1.9–11.8) and WHO stage IV (HR 2.5, CI 1.3–4.7). An interval ≥6 weeks between HIV testing and ART initiation was associated with a reduced risk (HR 0.6, CI 0.47–0.78).

Conclusion

Compared to reported national data effective ART coverage in Iganga District was low. Intensified efforts to improve access, retention in care, and quality of documentation are urgently needed. Children and young adults require special attention in the program.     

Health Insurance Coverage and Its Impact on Medical Cost: Observations from the Floating Population in China

Background

China has the world''s largest floating (migrant) population, which has characteristics largely different from the rest of the population. Our goal is to study health insurance coverage and its impact on medical cost for this population.

Methods

A telephone survey was conducted in 2012. 644 subjects were surveyed. Univariate and multivariate analysis were conducted on insurance coverage and medical cost.

Results

82.2% of the surveyed subjects were covered by basic insurance at hometowns with hukou or at residences. Subjects'' characteristics including age, education, occupation, and presence of chronic diseases were associated with insurance coverage. After controlling for confounders, insurance coverage was not significantly associated with gross or out-of-pocket medical cost.

Conclusion

For the floating population, health insurance coverage needs to be improved. Policy interventions are needed so that health insurance can have a more effective protective effect on cost.     

The global burden of Plasmodium vivax malaria is obscure and insidious

J. Kevin Baird and colleagues, examine and discuss the estimated global burden of vivax malaria and it’s biological, clinical, and public health complexity.

Summary points

• Estimates of the global burdens of morbidity attributable to acute attacks of Plasmodium falciparum malaria typically dwarf those of Plasmodium vivax, i.e., hundreds of millions versus tens of millions of cases.
• Global burden estimates take no account of latent and subpatent reservoirs of infections carrying more subtle burdens of illness and death in impoverished settings of malnutrition, coendemic infections, and limited access to quality healthcare. Impacts of chronic malaria on human health may be substantial and are excluded from estimates of burdens of acute malaria.
• Compartments of human infection by P. vivax beyond vascular patency—vascular subpatency, extravascular subpatency, sexual latency, and hepatic latency—obscure endemic transmission and burdens of infection and illness.
• Long thought to be absent from most of sub-Saharan Africa due to the high prevalence of the Duffy-negative phenotype among residents, recent investigations suggest that widespread reservoirs of transmission may occur across that region.
• Human glucose-6-phosphate dehydrogenase (G6PD) deficiency may also affect susceptibility to infection and directly impact access to effective antirelapse therapy of P. vivax using 8-aminoquinolines that are dangerous to those patients. Natural polymorphisms of the human cytochrome P-450 2D6 gene impact parasite susceptibility to primaquine antirelapse therapy at population levels.
• All these factors impose great complexity in considering estimates of burdens of P. vivax and access to effective mitigation of the harm caused. The conventional diagnostics underpinning epidemiological and clinical understanding of vivax malaria may be inadequate to the biology of this parasite.

     

Closing the health equity gap: A role for implementation science?

Beryne Odeny discusses strategies to improve equity in health care and health research.

WHO defines health equity as “the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically, or geographically or by other means of stratification” [1]. Yet, contrary to this fundamental aspiration and the international mandate on universal health coverage (UHC), almost 50% of the world’s population does not receive needed health services, and progress toward health equity remains elusive [2].     

Regional Differences in Intervention Coverage and Health System Strength in Tanzania

Background

Assessments of subnational progress and performance coverage within countries should be an integral part of health sector reviews, using recent data from multiple sources on health system strength and coverage.

Method

As part of the midterm review of the national health sector strategic plan of Tanzania mainland, summary measures of health system strength and coverage of interventions were developed for all 21 regions, focusing on the priority indicators of the national plan. Household surveys, health facility data and administrative databases were used to compute the regional scores.

Findings

Regional Millennium Development Goal (MDG) intervention coverage, based on 19 indicators, ranged from 47% in Shinyanga in the northwest to 71% in Dar es Salaam region. Regions in the eastern half of the country have higher coverage than in the western half of mainland. The MDG coverage score is strongly positively correlated with health systems strength (r = 0.84). Controlling for socioeconomic status in a multivariate analysis has no impact on the association between the MDG coverage score and health system strength. During 1991–2010 intervention coverage improved considerably in all regions, but the absolute gap between the regions did not change during the past two decades, with a gap of 22% between the top and bottom three regions.

Interpretation

The assessment of regional progress and performance in 21 regions of mainland Tanzania showed considerable inequalities in coverage and health system strength and allowed the identification of high and low-performing regions. Using summary measures derived from administrative, health facility and survey data, a subnational picture of progress and performance can be obtained for use in regular health sector reviews.     

Universal healthcare coverage and health service delivery before and during the COVID-19 pandemic: A difference-in-difference study of childhood immunization coverage from 195 countries

BackgroundSeveral studies have indicated that universal health coverage (UHC) improves health service utilization and outcomes in countries. These studies, however, have primarily assessed UHC’s peacetime impact, limiting our understanding of UHC’s potential protective effects during public health crises such as the Coronavirus Disease 2019 (COVID-19) pandemic. We empirically explored whether countries’ progress toward UHC is associated with differential COVID-19 impacts on childhood immunization coverage.Methods and findingsUsing a quasi-experimental difference-in-difference (DiD) methodology, we quantified the relationship between UHC and childhood immunization coverage before and during the COVID-19 pandemic. The analysis considered 195 World Health Organization (WHO) member states and their ability to provision 12 out of 14 childhood vaccines between 2010 and 2020 as an outcome. We used the 2019 UHC Service Coverage Index (UHC SCI) to divide countries into a “high UHC index” group (UHC SCI ≥80) and the rest. All analyses included potential confounders including the calendar year, countries’ income group per the World Bank classification, countries’ geographical region as defined by WHO, and countries’ preparedness for an epidemic/pandemic as represented by the Global Health Security Index 2019. For robustness, we replicated the analysis using a lower cutoff value of 50 for the UHC index. A total of 20,230 country-year observations were included in the study. The DiD estimators indicated that countries with a high UHC index (UHC SCI ≥80, n = 35) had a 2.70% smaller reduction in childhood immunization coverage during the pandemic year of 2020 as compared to the countries with UHC index less than 80 (DiD coefficient 2.70; 95% CI: 0.75, 4.65; p-value = 0.007). This relationship, however, became statistically nonsignificant at the lower cutoff value of UHC SCI <50 (n = 60). The study’s primary limitation was scarce data availability, which restricted our ability to account for confounders and to test our hypothesis for other relevant outcomes.ConclusionsWe observed that countries with greater progress toward UHC were associated with significantly smaller declines in childhood immunization coverage during the pandemic. This identified association may potentially provide support for the importance of UHC in building health system resilience. Our findings strongly suggest that policymakers should continue to advocate for achieving UHC in coming years.

In a difference-in-difference study, Sooyoung Kim and colleagues study associations between progress toward universal healthcare coverage and childhood immunizations before and during the COVID-19 pandemic.     

Did Equity of Reproductive and Maternal Health Service Coverage Increase during the MDG Era? An Analysis of Trends and Determinants across 74 Low- and Middle-Income Countries

Introduction

Despite widespread gains toward the 5^th Millennium Development Goal (MDG), pro-rich inequalities in reproductive health (RH) and maternal health (MH) are pervasive throughout the world. As countries enter the post-MDG era and strive toward UHC, it will be important to monitor the extent to which countries are achieving equity of RH and MH service coverage. This study explores how equity of service coverage differs across countries, and explores what policy factors are associated with a country’s progress, or lack thereof, toward more equitable RH and MH service coverage.

Methods

We used RH and MH service coverage data from Demographic and Health Surveys (DHS) for 74 countries to examine trends in equity between countries and over time from 1990 to 2014. We examined trends in both relative and absolute equity, and measured relative equity using a concentration index of coverage data grouped by wealth quintile. Through multivariate analysis we examined the relative importance of policy factors, such as political commitment to health, governance, and the level of prepayment, in determining countries’ progress toward greater equity in RH and MH service coverage.

Results

Relative equity for the coverage of RH and MH services has continually increased across all countries over the past quarter century; however, inequities in coverage persist, in some countries more than others. Multivariate analysis shows that higher education and greater political commitment (measured as the share of government spending allocated to health) were significantly associated with higher equity of service coverage. Neither country income, i.e., GDP per capita, nor better governance were significantly associated with equity.

Conclusion

Equity in RH and MH service coverage has improved but varies considerably across countries and over time. Even among the subset of countries that are close to achieving the MDGs, progress made on equity varies considerably across countries. Enduring disparities in access and outcomes underpin mounting support for targeted reforms within the broader context of universal health coverage (UHC).     

Evidence-informed policy for tackling adverse climate change effects on health: Linking regional and global assessments of science to catalyse action

Robin Fears and co-authors discuss evidence-informed regional and global policy responses to health impacts of climate change.

Summary points

• Effective policy making depends on synthesising and improving the use of existing robust scientific evidence, tackling misinformation, and identifying knowledge gaps to be filled by new research.
• A global project organised by the InterAcademy Partnership (IAP) is bringing together evidence from Africa, Asia, the Americas, and Europe to evaluate climate change effects on health and to assess policy priorities for adaptation and mitigation solutions. Project design encouraged inclusivity in assessing research from across disciplines and from diverse geographical and socioeconomic contexts encompassing issues for vulnerable groups (including Indigenous Peoples) and integrating outputs at national, regional, and global levels.
• Coordinated policy development approaches across sectors and regions and integration at national–regional–global levels are essential to understand trade-offs, avoid inadvertent consequences, and capitalise on potential synergies for multiple benefits for health, equity, and environment.
• National priorities must include integrating health actions into national climate adaptation plans and Nationally Determined Contributions (NDCs) under the Paris Agreement. Regional policy action is important to address cross-boundary issues and to build critical mass for quantifying and implementing solutions.
• A focus on human health can catalyse the strengthening of international coherence and commitment to tackling shared climate change challenges. Health must be prioritised in current global policy initiatives, including the United Nations Framework Convention on Climate Change (UNFCC) Conference of the Parties 26 (COP26), UN Convention on Biological Diversity (CBD) Conference of the Parties 15 (COP15), and the UN Food Systems Summit. The scientific and health communities have a key role to help lead efforts by engaging at the science–policy interfaces to address barriers to action.

     

Near-Real-Time Feature-Selective Modulations in Human Cortex

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Highlights? Understanding cognition requires knowledge of temporal dynamics of neural behavior ? SSVEP may be used to reconstruct orientation response profiles at a subsecond scale ? Provides a metric that can rapidly track information processing in human cortex     

Chasing Tails: Cathepsin-L Improves Structural Analysis of Histones by HX-MS,

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Highlights

• •Cathepsin-L is introduced as a novel protease for HX-MS studies.
• •Cathepsin-L improves resolution of traditionally challenging histone tails.
• •Cathepsin-L can be readily combined with pepsin for improved protein coverage.
• •In-solution dynamics of the H3.1 and H4 monomers reveal extensive EX1 kinetics.

     

FlashPack: Fast and Simple Preparation of Ultrahigh-performance Capillary Columns for LC-MS*

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Highlights

• •Fast and simple capillary column packing protocol.
• •Low-pressure packing at <100 bars from ultrahigh sorbent suspension concentration.
• •Sorbent particle aggregation leading to blocking of the column entrance is avoided.
• •Effective for long capillary UHPLC column packing with a wide range of sorbents.

     

Cancer systems epidemiology: Overcoming misconceptions and integrating systems approaches into cancer research

Patricia Mabry and coauthors discuss application of systems approaches in cancer research.

Summary points

• While traditional epidemiological approaches have helped generate important insights about cancer prevention and treatment, they have important limitations and alone cannot bridge the gaps that continue to exist in cancer research and knowledge.
• One shortcoming is the failure to fully account for and characterize the complexity of various systems (e.g., biological, behavioral, social, environmental, and economic) that can lead to cancer and are affected by cancer.
• Systems approaches can help researchers, clinicians, and other decision makers better understand complex systems and address these systems at many levels, ranging from the cellular to the societal scale.
• Systems mapping can shed light on otherwise hidden mental models, and dynamic modeling can enable virtual experimentation—the systematic exploration of counterfactual scenarios not observable in the real world.
• We present and discuss 14 common misconceptions that will need to be overcome in order for systems epidemiology to realize its potential role in cancer prevention and control.
• Examples of systems approaches applied to cancer-related research topics are given to illustrate the utility of systems approaches to transform cancer epidemiology to cancer systems epidemiology.