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.

     

Comparison of structural changes in skin and amnion tissue grafts for transplantation induced by gamma and electron beam irradiation for sterilization

Sterilization is an important step in the preparation of biological material for transplantation. The aim of the study is to compare morphological changes in three types of biological tissues induced by different doses of gamma and electron beam radiation. Frozen biological tissues (porcine skin xenografts, human skin allografts and human amnion) were irradiated with different doses of gamma rays (12.5, 25, 35, 50 kGy) and electron beam (15, 25, 50 kGy). Not irradiated specimens served as controls. The tissue samples were then thawn and fixed in 10 % formalin, processed by routine paraffin technique and stained with hematoxylin and eosin, alcian blue at pH 2.5, orcein, periodic acid Schiff reaction, phosphotungstic acid hematoxylin, Sirius red and silver impregnation. The staining with hematoxylin and eosin showed vacuolar cytoplasmic changes of epidermal cells mainly in the samples of xenografts irradiated by the lowest doses of gamma and electron beam radiation. The staining with orcein revealed damage of fine elastic fibers in the xenograft dermis at the dose of 25 kGy of both radiation types. Disintegration of epithelial basement membrane, especially in the xenografts, was induced by the dose of 15 kGy of electron beam radiation. The silver impregnation disclosed nuclear chromatin condensation mainly in human amnion at the lowest doses of both radiation types and disintegration of the fine collagen fibers in the papillary dermis induced by the lowest dose of electron beam and by the higher doses of gamma radiation. Irradiation by both, gamma rays and the electron beam, causes similar changes on cells and extracellular matrix, with significant damage of the basement membrane and of the fine and elastic and collagen fibers in the papillary dermis, the last caused already by low dose electron beam radiation.     

Tight Coupling Between Shoot Level Foliar N and P,Leaf Area,and Shoot Growth in Arctic Dwarf Shrubs Under Simulated Climate Change

Nutrient availability limits productivity of arctic ecosystems, and this constraint means that the amount of nitrogen (N) in plant canopies is an exceptionally strong predictor of vegetation productivity. However, climate change is predicted to increase nutrient availability leading to increases in carbon sequestration and shifts in community structure to more productive species. Despite tight coupling of productivity with canopy nutrients at the vegetation scale, it remains unknown how species/shoot level foliar nutrients couple to growth, or how climate change may influence foliar nutrients–productivity relationships to drive changes in ecosystem carbon gain and community structure. We investigated the influence of climate change on arctic plant growth relationships to shoot level foliar N and phosphorus (P) in three dominant subarctic dwarf shrubs using an 18-year warming and nutrient addition experiment. We found a tight coupling between total leaf N and P per shoot, leaf area and shoot extension. Furthermore, a steeper shoot length-leaf N relationship in deciduous species (Vaccinium myrtillus and Vaccinium uliginosum) under warming manipulations suggests a greater capacity for nitrogen to stimulate growth under warmer conditions in these species. This mechanism may help drive the considerable increases in deciduous shrub cover observed already in some arctic regions. Overall, our work provides the first evidence at the shoot level of tight coupling between foliar N and P, leaf area and growth i.e. consistent across species, and provides mechanistic insight into how interspecific differences in alleviation of nutrient limitation will alter community structure and primary productivity in a warmer Arctic.     

COX-2-derived prostacyclin protects against bleomycin-induced pulmonary fibrosis

Prostacyclin is one of a number of lipid mediators elaborated from the metabolism of arachidonic acid by the cyclooxygenase (COX) enzymes. This prostanoid is a potent inhibitor of platelet aggregation, and its production by endothelial cells and protective role in the vasculature are well established. In contrast, much less is known regarding the function of this prostanoid in other disease processes. We show here that COX-2-dependent production of prostacyclin plays an important role in the development of fibrotic lung disease, limiting both the development of fibrosis and the consequential alterations in lung mechanics. In stark contrast, loss of prostaglandin E(2) synthesis and signaling through the G(s)-coupled EP2 and EP4 receptors had no effect on the development of disease. These findings suggest that prostacyclin analogs will protect against bleomycin-induced pulmonary fibrosis in COX-2(-/-) mice. If such protection is observed, investigation of these agents as a novel therapeutic approach to pulmonary fibrosis in humans may be warranted.     

Dynamic aspects of the response of the pulvinus in the leaf of bean plants(Phaseolus vulgaris L.) to photoexcitation

The pulvinus of bean (Phaseolus vulgaris L) responds to unilateral photo-excitation by phototropic curvature. Osmotically active solutes and water are transported from its exposed to the opposite sector of its motor tissue, resulting in differential changes in turgor pressure in these sectors and generation of a trans-pulvinar torque. A null-point approach was used to non-invasively study these dynamic changes in the terminal leaflet of bean. A variable torque was applied perpendicular to the midrib, to restrain laminar movement by precisely and continuously counteracting the generated torque. This equilibrium prevented curvature of the pulvinus and the associated opposite axial changes in volume in the opposite sectors of its motor tissue. The laminar torques measured were used to estimate stresses (changes in turgor pressure) generated within the motor tissue. These stress values were used to derive the corresponding changes in osmotic pressures and in solute concentration. Skotonastically downfolded leaflets were excited with white light to study their combined dynamic response to photonastic and phototropic excitation. Photonastically unfolded (horizontal) leaflets were excited with blue and red light, alone and in combination, to determine the spectral dependence of the dynamic pulvinar responses tophototropic excitation by itself.     

Modification of postsynaptic dopaminergic sensitivity by female sex hormones

Stereotyped behavior in response to d-amphetamine or apomorphine was significantly reduced in female guinea pigs following cophorectamy. Responsiveness to either dopamine agonist was significantly increased by the subsequent chronic administration of either estradiol valerate or progesterone. Modification of postsynatpic dopaminergic sensitivity by female sex hormones may underly the clinical association of hyperkinetic movement disorders, psychosis or depression seen with alterations in female sex hormones in man.     

Experimentally induced Fasciola hepatica infections in black-tailed deer.

The susceptibility of black-tailed deer (Odocoileus hemionus columbianus) to the common liver fluke (F. hepatica) was studied. Two deer and one sheep comprised each of three experimental groups. Animals in each group were inoculated individually with 250, 500, or 1000 F. hepatica metacercariae. One deer and one sheep given 1000 metacercariae died with lesions consistent with black disease 7 weeks after inoculation. At necropsy 6 or 15 weeks postinoculation, the mean percentage recovery of the inoculum was 38.9% from the deer and 51.9% from the sheep. Fluke eggs recovered from the deer were viable and metacercariae cultured from the eggs were fully infective for sheep. Pathologic changes associated with F. hepatica infection were more severe in the infected deer; consequently, the deer were less resistant to the lethal effects of the parasite than sheep. Considering the experimental results and the fact that naturally acquired common liver fluke infection has been reported infrequently from black-tailed deer, it was concluded that black-tailed deer do not constitute a significant reservoir for F. hepatica in domestic livestock.