BACKGROUND: India launched a national health insurance scheme named Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in 2018 as a key policy for universal health coverage. The ambitious scheme covers 100 million poor households. None of the studies have examined its impact on the quality of care. The existing studies on the impact of AB-PMJAY on financial protection have been limited to early experiences of its implementation. Since then, the government has improved the scheme\'s design. The current study was aimed at evaluating the impact of AB-PMJAY on improving utilisation, quality, and financial protection for inpatient care after four years of its implementation.
METHODS: Two annual waves of household surveys were conducted for years 2021 and 2022 in Chhattisgarh state. The surveys had a sample representative of the state\'s population, covering around 15,000 individuals. Quality was measured in terms of patient satisfaction and length of stay. Financial protection was measured through indicators of catastrophic health expenditure at different thresholds. Multivariate adjusted models and propensity score matching were applied to examine the impacts of AB-PMJAY. In addition, the instrumental variable method was used to address the selection problem.
RESULTS: Enrollment under AB-PMJAY was not associated with increased utilisation of inpatient care. Among individuals enrolled under AB-PMJAY who utilised private hospitals, the proportion incurring catastrophic health expenditure at the threshold of 10% of annual consumption expenditure was 78.1% and 70.9% in 2021 and 2022, respectively. The utilisation of private hospitals was associated with greater catastrophic expenditure irrespective of AB-PMJAY coverage. Enrollment under AB-PMJAY was not associated with reduced out-of-pocket expenditure or catastrophic health expenditure.
CONCLUSIONS: AB-PMJAY has achieved a large coverage of the population but after four years of implementation and an evidence-based increase in reimbursement prices for hospitals, it has not made an impact on improving utilisation, quality, or financial protection. The private hospitals contracted under the scheme continued to overcharge patients, and purchasing was ineffective in regulating provider behaviour. Further research is recommended to assess the impact of publicly funded health insurance schemes on financial protection in other low- and middle-income countries.

BACKGROUND: Pakistan developed its first national Essential Package of Health Services (EPHS) as a key step towards accelerating progress in achieving Universal Health Coverage (UHC). We describe the rationale, aims, the systematic approach followed to EPHS development, methods adopted, outcomes of the process, challenges encountered, and lessons learned.
METHODS: EPHS design was led by the Ministry of National Health Services, Regulations & Coordination. The methods adopted were technically guided by the Disease Control Priorities 3 Country Translation project and existing country experience. It followed a participatory and evidence-informed prioritisation and decision-making processes.
RESULTS: The full EPHS covers 117 interventions delivered at the community, health centre and first-level hospital platforms at a per capita cost of US$29.7. The EPHS also includes an additional set of 12 population-based interventions at US$0.78 per capita. An immediate implementation package (IIP) of 88 district-level interventions costing US$12.98 per capita will be implemented initially together with the population-based interventions until government health allocations increase to the level required to implement the full EPHS. Interventions delivered at the tertiary care platform were also prioritised and costed at US$6.5 per capita, but they were not included in the district-level package. The national EPHS guided the development of provincial packages using the same evidence-informed process. The government and development partners are in the process of initiating a phased approach to implement the IIP.
CONCLUSIONS: Key ingredients for a successful EPHS design requires a focus on package feasibility and affordability, national ownership and leadership, and solid engagement of national stakeholders and development partners. Major challenges to the transition to implementation are to continue strengthening the national technical capacity, institutionalise priority setting and package design and its revision in ministries of health, address health system gaps and bridge the current gap in financing with the progressive increase in coverage towards 2030.

BACKGROUND: The Disease Control Priorities 3 (DCP3) project provides long-term support to Pakistan in the development and implementation of its universal health coverage essential package of health services (UHC-EPHS). This paper reports on the priority setting process used in the design of the EPHS during the period 2019-2020, employing the framework of evidence-informed deliberative processes (EDPs), a tool for priority setting with the explicit aim of optimising the legitimacy of decision-making in the development of health benefit packages.
METHODS: We planned the six steps of the framework during two workshops in the Netherlands with participants from all DCP3 Pakistan partners (October 2019 and February 2020), who implemented these at the country level in Pakistan in 2019 and 2020. Following implementation, we conducted a semi-structured online survey to collect the views of participants in the UHC benefit package design about the prioritisation process.
RESULTS: The key steps in the EDP framework were the installation of advisory committees (involving more than 150 members in several Technical Working Groups [TWGs] and a National Advisory Committee [NAC]), definition of decision criteria (effectiveness, cost-effectiveness, avoidable burden of disease, equity, financial risk protection, budget impact, socio-economic impact and feasibility), selection of interventions for evaluation (a total of 170), and assessment and appraisal (across the three dimensions of the UHC cube) of these interventions. Survey respondents were generally positive across several aspects of the priority setting process.
CONCLUSIONS: Despite several challenges, including a partial disruption because of the COVID-19 pandemic, implementation of the priority setting process may have improved the legitimacy of decision-making by involving stakeholders through participation with deliberation, and being evidence-informed and transparent. Important lessons were learned that can be beneficial for other countries designing their own health benefit package such as on the options and limitations of broad stakeholder involvement.

Pakistan developed an essential package of health services at the primary healthcare (PHC) level as a key component of health reforms aiming to achieve universal health coverage (UHC). This supplement describes the methods and processes adopted for evidence-informed prioritization of services, policy decisions adopted, and the lessons learned in package design as well as in the transition to effective rollout. The papers conclude that evidence-informed deliberative processes can be effectively applied to design affordable packages of services that represent good value for money and address a major part of the disease burden. Transition to implementation requires a comprehensive assessment of health system gaps, strong engagement of the planning and financing sectors, serious involvement of key national stakeholders and the private health sector, capacity building, and institutionalization of technical and managerial skills. Pakistan\'s experience highlights the need for updating the evidence and model packages of the Disease Control Priorities 3 (DCP3) initiative and reinforcing international collaboration to support technical guidance to countries in priority setting and UHC reforms.

BACKGROUND: Public long-term care insurance (LTCI) systems can promote equal and wider access to quality long-term care. However, ensuring the financial sustainability is challenging owing to growing care demand related to population aging. To control growing demand, Japan\'s public LTCI system uniquely provided home- and community-based prevention services for functional dependency for older people (ie, adult day care, nursing care, home care, functional screening, functional training, health education, and support for social activities), following nationwide protocols with decentralized delivery from 2006 until 2015. However, evaluations of the effects of these services have been inconclusive.
METHODS: We estimated the marginal gain and technical efficiency of local prevention services using 2009-2014 panel data for 474 local public insurers in Japan, based on stochastic frontier analysis. The outcome was the transformed sex-and age-adjusted ratio of the observed to expected number of individuals aged ≥65 years certified for moderate care. Higher outcome values indicate lower population risk of moderate functional dependency in each region in each year. The marginal gains of the provided quantities of prevention services as explanatory variables were estimated, adjusting for regional medical and welfare access, care demand and supply, and other regional factors as covariates.
RESULTS: Prevention services (except functional screening) significantly reduced the population risk of moderate functional dependency. Specifically, the mean changes in outcome per 1% increase in adult day care, other nursing care, and home care were 0.13%, 0.07%, and 0.04%, respectively. The median technical efficiency of local public insurers was 0.94 (interquartile range: 0.89-0.99).
CONCLUSIONS: These findings suggest that population-based services with decentralized local operation following standardized protocols could achieve efficient prevention across regions. This study could inform current discussions about the range of benefit coverage in public LTCI systems by presenting a useful option for the provision of preventive benefits.

On the eve of Taiwan\'s National Health Insurance\'s 30th birthday, this study reviews the policy and performance trajectory of the Taiwanese health system. Taiwan has controlled their health spending well and grown increasingly reliant on private financing. The floating-point global budget payment preferentially rewards outpatient-based services, but this has not affected the hospital-centric market composition, which persists despite several primary-care friendly developments. The outcomes suggest improving health care workforce and resource availability, good patient-centredness, respectable technical efficiency, and impressive patient care satisfaction. However, there are worrisome trends for financial barriers to access and allocative efficiency. Evidence on clinical quality suggests that hospitals are performing well though the primary care setting might not be. Overall, the public remains satisfied despite signs of lagging improvement in health outcomes, worsening maternal mortality rate, and persistently incomplete financial risk protection. Identifying what drives the worsening financial barriers of access and persistent financial risk is necessary for further discussions on potential financing adjustments. Improving allocative efficiency could draw on a combination of supporting the functions and quality of primary care alongside patient-oriented education and incentives. Further data on causes of slow health status improvement and rebounding maternal mortality rate is necessary.

Progress towards universal health coverage is monitored by the incidence of catastrophic spending. Two catastrophic spending indicators are commonly used in Europe: Sustainable Development Goal (SDG) indicator 3.8.2 and the WHO Regional Office for Europe (WHO/Europe) indicator. The use of different indicators can cause confusion, especially if they produce contradictory results and policy implications. We use harmonised household budget survey data from 27 European Union countries covering 505,217 households and estimate the risk of catastrophic spending, conditional on household characteristics and the design of medicines co-payments. We calculate the predicted probability of catastrophic spending for particular households, which we call LISAs, under combinations of medicines co-payment policies and compare predictions across the two indicators. Using the WHO/Europe indicator, any combination of two or more protective policies (i.e. low fixed co-payments instead of percentage co-payments, exemptions for low-income households and income-related caps on co-payments) is associated with a statistically significant lower risk of catastrophic spending. Using the SDG indicator, confidence intervals for every combination of protective policies overlap with those for no protective policies. Although out-of-pocket medicines spending is a strong predictor of catastrophic spending using both indicators, the WHO/Europe indicator is more sensitive to medicines co-payment policies than the SDG indicator, making it a better indicator to monitor health system equity and progress towards UHC in Europe.

BACKGROUND: Universal Health Coverage (UHC) is a widely accepted objective among entities providing development assistance for health (DAH) and DAH recipient governments. One key metric to assess progress with UHC is financial risk protection, but empirical evidence on the extent to which DAH is associated to financial risk protection (and hence UHC) is scarce.
METHODS: Our sample is comprised of 65 countries whose DAH per capita is above the population -weighted average DAH per capita across all countries. The sample comprises of 1.7 million household observations, for the period 2000-2016. We run country and year fixed effects regressions, and pseudo-panel models, to assess the association between DAH and three measures of financial risk protection: catastrophic health expenditure (i.e., out-of-pocket health expenditures larger than 10% of total household expenditures [\'CHE10%\']), out-of-pocket health expenditure as a share of total expenditure (\'OOP%\'), and impoverishment due to health expenditures, at the 1.90US$ per day poverty line (\'IMP190\').
RESULTS: on average, DAH investment does not appear to be significantly associated with financial risk protection outcomes. However, we find suggestive evidence that a 1 US$ increase in DAH per capita is negatively associated (i.e., an improvement) with at least one financial risk protection outcome for the poorest household quintile within countries (in fixed effects models, IMP190: 0.05 percentage points, p < 0.1; in pseudo-panel models, CHE10%: 0.12 percentage points, p < 0.01). DAH is also negatively associated (i.e., an improvement) with most financial risk protection outcomes when it is largely channelled via government systems (i.e., when it is \"on-budget\") (CHE10%: 0.68 percentage points, p < 0.05). Several robustness checks confirm these results.
CONCLUSIONS: DAH investments require careful planning to improve financial risk protection. For example, positive DAH effects for the poorest quintiles of the population might be driven by DAH targeting poorer populations and doing so effectively. Our results also suggest that channelling more resources via governments might be a promising avenue to enhance the impact of DAH on financial risk protection.

BACKGROUND: In Rwanda, maternal community health workers play a critical role to improving maternal, newborn and child health, but little is known about their specific experiences with adolescent mothers, who face unique challenges, including trauma, ongoing violence, stigma, ostracism, mental health issues, barriers within the healthcare system, and lack of access to the social determinants of health. This study explored the experiences of maternal community health workers when caring for adolescent mothers in Rwanda to inform the delivery of trauma- and violence-informed care in community maternal services.
METHODS: Interpretive Description methodology was used to understand the experiences of 12 community health workers purposively recruited for interviews due to their management roles. To gain additional insights about the context, seven key informants were also interviewed.
RESULTS: Maternal community health workers provided personalized support to adolescent mothers through the provision of continuity of care, acting as a liaison, engaging relationally and tailoring home visits. They reported feeling passionate about their work, supporting each other, and receiving support from their leaders as facilitators in caring for adolescent mothers. Challenges in their work included handling disclosures of violence, dealing with adolescent mothers\' financial constraints, difficulties accessing these young mothers, and transportation issues. Adolescent mothers\' circumstances are generally difficult, leading to self-reports of vicarious trauma among this sample of workers.
CONCLUSIONS: Maternal community health workers play a key role in addressing the complex needs of adolescent mothers in Rwanda. However, they face individual and structural challenges highlighting the complexities of their work. To sustain and enhance their roles, it is imperative for government and other stakeholders to invest in resources, mentorship, and support. Additionally, training in equity-oriented approaches, particularly trauma- and violence-informed care, is essential to ensure safe and effective care for adolescent mothers and to mitigate vicarious trauma among maternal community health workers.

The eastern Democratic Republic of the Congo (DRC) grapples with entrenched armed conflicts, creating a complex humanitarian crisis with far-reaching implications for global health. This paper explores the intersection between armed conflict in the region and the risks of zoonotic disease transmission, shedding light on interconnected challenges and proposing integrated strategies for mitigation. Armed conflict disrupts healthcare systems, affecting healthcare facilities (HCF) and healthcare workers (HCW), destroying millions of lives, impoverishing communities, and weakening surveillance systems. This deleterious situation is a bottleneck to achieving the Sustainable Development Goals (SDGs), especially Universal Health Coverage (UHC), as it prevents millions of Congolese from accessing healthcare services. The direct impact of armed insecurity undermines Global Health Security (GHS) by fostering natural habitat degradation and biodiversity loss, exacerbating vulnerabilities to zoonotic disease outbreaks. Forced population displacement and encroachment on natural habitats amplify human-wildlife interaction, facilitating zoonotic disease spillover and increasing the risk of regional and global spread. Biodiversity loss and poaching further compound these challenges, underscoring the need for holistic approaches that address both conservation and public health concerns. Mitigating zoonotic disease risks requires strengthening surveillance systems, promoting community engagement, and integrating conservation efforts with conflict resolution initiatives. By adopting a comprehensive approach, including the incorporation of One Health considerations in all peace-seeking and humanitarian efforts, stakeholders can enhance Global Health Security, scale up UHC, and promote sustainable development in conflict-affected regions. Creativity and strategic foresight are essential to safeguarding the well-being of human, livestock, plant, and wildlife populations in the Eastern DRC.