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Health insurance coverage, healthcare use, and financial protection amongst people with disabilities in Indonesia: analysis of the 2021 National Socioeconomic Survey.
Get PDFBACKGROUND: Jaminan Kesehatan Nasional (JKN), Indonesia's mandatory national health insurance scheme and the world's largest single-payer system, has not been rigorously evaluated for its reach and effectiveness amongst people with disabilities, who often have greater healthcare needs. This study evaluates JKN coverage and its association with healthcare use and financial protection for people with disabilities in Indonesia. METHODS: This cross-sectional study analysed the Indonesia National Socioeconomic Survey (Susenas) March 2021 dataset (n = 1,277,497). Disability was measured using the Washington Group Short Set (WG-SS). We used multivariate logistic regression to examine associations between disability and health insurance coverage, and between insurance coverage and healthcare utilization, out-of-pocket payments (OOP), and catastrophic health expenditure (CHE). FINDINGS: Around 30% of people with disabilities were uninsured, and 35% were not enrolled in JKN, with coverage lower in the lowest socioeconomic groups, living in rural areas, or self-employment. Among JKN-enrolees, they were more likely to be in the subsidised group (vs. contributory) compared to those without disabilities. Overall, people with disabilities utilised healthcare services more frequently and incurred higher OOP and CHE than those without disabilities. These disparities were not mitigated by insurance coverage. Indeed, people with disabilities, even with JKN coverage, were more likely to experience high OOP and CHE, with those in the contributory group facing a higher likelihood of CHE than the subsidised group. INTERPRETATION: There are large gaps in health insurance coverage for people with disabilities in Indonesia. Additionally, there is an urgent need to enhance the financial protection of people with disabilities, ensuring equitable and comprehensive care. FUNDING: This study is part of the first author's PhD project, funded by the Indonesia Endowment Fund for Education (LPDP)
Within-country heterogeneity in patterns of social contact relevant for tuberculosis infection transmission, prevention, and care.
Get PDFMycobacterium tuberculosis (Mtb) transmission is driven by variable social, environmental, and biological factors, including the number and duration of indoor contacts. Social contact data can provide information on potential transmission patterns, but is underutilised outside the field of mathematical modelling. We explore three contexts where contact data can provide valuable insights: 1) household contact tracing; 2) infection prevention and control measures (IPC); and 3) contamination in cluster randomised trials (CRTs). A social contact survey was conducted in adults aged 18 and older from three communities with comparable population sizes in South Africa: an urban township and peri-urban and rural clinic catchment areas. Participants reported congregate settings visited over 24-hours, visit durations, and estimated number of people present. To correspond with the three contexts, we estimated the proportion of contact hours occurring 1) within the home; 2) in congregate settings outside the home; and 3) outside the participants' communities. Participants reported a mean of 27.0 (rural), 55.2 (peri-urban), and 73.0 (urban) contact hours. The proportions of household contact were similar among rural and peri-urban participants (76.8% and 71.7%), compared to urban (48.6%). Congregate settings visited varied; urban participants spent the most contact hours in retail/office settings (19.9%), peri-urban participants in community-service buildings (20.4%), and rural participants in other peoples' homes (25.5%). Urban participants reported the highest proportion of contact outside the community (67.0%) compared to rural (38.8%) and peri-urban (21.5%) participants. The observed heterogeneity in contact patterns has implications for TB interventions. Household contact tracing may be most effective in the rural community where household contact was highest. The diverse range of congregate settings visited suggests that prioritising IPC measures in these locations may enhance their overall efficacy. Considering contact patterns when designing clusters may reduce contamination in CRTs. Tailored interventions, informed by local contexts, are essential to reduce TB burden
Surgery or radiotherapy for early-stage cancer study (SORT) target trial protocol: stereotactic ablative radiotherapy (SABR) with curative intent versus surgical resection for early-stage non-small cell lung cancer (NSCLC).
Get PDFINTRODUCTION: Randomised controlled trials have aimed to assess the effectiveness of stereotactic ablative radiotherapy (SABR) with curative intent versus surgical resection for individuals diagnosed with early-stage non-small cell lung cancer (NSCLC) but have failed to recruit sufficient numbers of patients. Non-randomised studies for early-stage NSCLC have reported mixed outcomes following curative SABR versus surgical resection, but did not fully address confounding by indication. The Surgery Or RadioTherapy for early-stage cancer study (SORT) will assess the comparative effectiveness of SABR with curative intent versus surgical resection for NSCLC with a target trial emulation approach, as this can reduce biases in observational studies that aim to estimate the causal effect of interventions. METHODS AND ANALYSIS: The SORT study will use the National Cancer Registry for individuals diagnosed with early-stage NSCLC in England during 2015-2020 (inclusive) who received SABR with curative intent or surgical resection. These data will be linked to Hospital Episode Statistics, National Radiotherapy Data Set and the Systemic Anti-Cancer Therapy dataset to obtain information on clinical and sociodemographic characteristics and the treatment received. This target trial emulation will define study population eligibility criteria and regimens for SABR with curative intent and surgical resection. We will reduce the risk of residual confounding with instrumental variable analyses that will exploit geographical variation across the National Health Service in England in the use of SABR with curative intent versus surgical resection for early-stage NSCLC. The primary outcome will be 3-year all-cause mortality after treatment initiation. Secondary outcomes will include 3-month, 6-month, 12-month and 24-month all-cause and lung-cancer mortality, time to death, numbers of hospitalisations, incremental costs and incremental cost-effectiveness. ETHICS AND DISSEMINATION: Ethical approval was obtained from the London School of Hygiene and Tropical Medicine Research Ethics Committee (reference number 29 717-1). Results will be disseminated to clinicians, patients, policy-makers and researchers
Born Too Soon: learning from the past to accelerate action in the next decade.
Get PDFPROGRESS: This paper is a narrative review that takes stock of the progress in addressing preterm birth over the past decade - notably on policies, national plans, innovation, evidence, social mobilisation, and community engagement - to inform future progress on preterm birth. At the global policy level, many countries have strongly supported collective initiatives and resolutions on maternal and newborn health relevant to preterm birth in multilateral fora, most recently through a World Health Assembly resolution calling for a revival amongst the global community on stalled progress for maternal, newborn and child health. Following the adoption of other global plans, like the Every Newborn Action Plan and Strategies for Ending Preventable Maternal Mortality, most countries set corresponding national mortality and coverage targets, and many have national and subnational policies and plans for integrated maternal and newborn health. Adequate financing remains a challenge, and sexual and reproductive health and rights of women and girls are being challenged globally. There have been significant advances in evidence-based interventions for preterm birth prevention and care, reflected in updated World Health Organization guidelines on antenatal, intrapartum and postpartum care, and care for small and sick newborns. The past decade has also seen progress in social mobilisation and community engagement, particularly parent groups and healthcare professional organisations advocating on issues surrounding preterm birth. POLYCRISIS AND VULNERABILITY: There are, however, significant challenges that continue to hamper progress on preterm birth. Polycrisis - the interplay of overlapping economic, geopolitical, and environmental crises - compounds existing inequities, especially in places where health systems are already weak. Distinct and overlapping threats from conflict, climate change and the cost-of-living crisis present life-or-death challenges to those already facing extreme vulnerability, particularly women and girls, and small and sick newborns. PRETERM BIRTH: A MARKER OF MATERNAL AND NEONATAL HEALTH PROGRESS IN THE COMING DECADE: The detrimental impacts of preterm birth are felt along the life course and across generations. The success of countries and the global community in preventing preterm births and ensuring high-quality care for mothers and preterm babies serves as a critical measure of progress - or failure - in advancing global efforts to improve maternal and newborn health
A Public Health Response to Economic Warfare.
No full textPresident Trump's 2025 implementation of tariffs has been described as a form of economic warfare. The public health community has long viewed conventional forms of warfare as a determinant of health and developed appropriate responses. In this editorial, we argue that this community must now respond in a similar way to all forms of economic warfare. We describe the ways in which economic warfare is waged, which include tariffs, trade sanctions, currency manipulation, and cyberattacks, and the health consequences that arise from them. Drawing on historical examples like the Opium Wars, we highlight the intertwined nature of economic and military conflicts. We also describe how advances in technology have created new opportunities, such as the exclusion of Russia from the SWIFT payment system. The health consequences are profound, with research indicating declines in life expectancy and disruptions in access to essential medicines and equipment. We argue for a comprehensive public health response, made urgent by the rejection, by the current U.S. administration, of the post-war international order. We call for use of innovative research methods to assess the health impacts of economic measures, drawing parallels with studies on the health effects of military conflicts and economic crises and advocacy for a proactive public health stance, akin to the efforts of organisations like the International Physicians for the Prevention of Nuclear War, to make visible the health consequences of economic warfare and help those who seek to hold governments accountable for their actions
Prevalence of chlamydia, gonorrhoea, and trichomoniasis among male and female general populations in sub-Saharan Africa from 2000 to 2024: a systematic review and meta-regression analysis.
Get PDFBACKGROUND: Sub-Saharan Africa (SSA) has the highest sexually transmitted infection (STI) prevalence globally, but information about trends and geographic variation is limited by sparse aetiologic studies, particularly among men. This systematic review assessed chlamydia, gonorrhoea, and trichomoniasis prevalence by sex, sub-region, and year, and estimated male-to-female prevalence ratios in SSA. METHODS: We searched Embase, MEDLINE, Global Health, PubMed, and African Index Medicus for studies measuring STI prevalence among general populations from 1 January 2000, to 17 September 2024. We adjusted observations for diagnostic test performance and used log-binomial mixed-effects meta-regressions to estimate prevalence trends and sex-prevalence ratios. The study was registered with PROSPERO (CRD42023420384). FINDINGS: Of 5202 records identified, we included 211 studies from 28 countries. In 2020, estimated prevalence among 15-49-year-olds in SSA for chlamydia was 6.9% (95% CI: 5.2-8.7%, n = 169 observations) among females and 4.2% (3.0-5.5%, n = 33) among males, gonorrhoea was 1.8% (1.1-2.5%, n = 171) and 1.5% (0.8-2.2%, n = 31), and trichomoniasis was 7.6% (5.1-10.2%, n = 188) and 1.7% (1.1-2.4%, n = 19). Male-to-female ratios were 0.61 (0.53-0.71) for chlamydia, 0.81 (0.61-1.09) for gonorrhoea, and 0.23 (0.18-0.28) for trichomoniasis. From 2010 to 2020, chlamydia prevalence increased by 34.5% (11.1-62.9%) in SSA, while gonorrhoea and trichomoniasis trends were not statistically significant. Chlamydia and gonorrhoea prevalence were highest in Southern and Eastern Africa, whereas trichomoniasis was similar across sub-regions. INTERPRETATION: SSA has a high, geographically varied STI burden, with increasing prevalence of chlamydia. Region-specific sex-prevalence ratios differed from existing global ratios and should be considered in future burden estimates. Enhanced sex-stratified surveillance is crucial to guide national programmes and reduce STI prevalence in SSA. FUNDING: Gates Foundation, Imperial College London, NIH, UKRI
Effect of a Multicomponent Intervention to Improve Menstrual Health and Hygiene and School Attendance Among Adolescent Girls in the Gambia (MEGAMBO Trial).
Get PDFPURPOSE: Evidence on the effect of menstrual health and hygiene (MHH) interventions on education is scarce. This trial assessed the effect of a multicomponent intervention on school attendance, urogenital health, and other wellbeing outcomes among schoolgirls in rural Gambia. METHODS: A cluster-randomised controlled trial was conducted between July 2019 and December 2020 in 50 villages across 2 regions of The Gambia, selecting one school per village. Using restricted randomisation, half of the villages received a 3-month NGO-led intervention, which included Peer education camps, Mother's outreach sessions, Community meetings and improving school water, sanitation, and hygiene (WASH). The other 25 villages received no intervention. The primary outcome was self-reported schoolgirls' absenteeism of at least one-day due to last period. Secondary outcomes included: urinary tract infections measured with symptoms and biochemical markers, reproductive tract infections symptoms, menstruation-related wellbeing, social support and knowledge, attitudes, and practices toward menstruation. All menstruating schoolgirls 13 years and older were eligible for outcome assessment. We analyzed data on an intention-to-treat basis. RESULTS: Outcome assessment included 3556 schoolgirls (1832 [51.5%] in the intervention group and 1724 [48.5%] in the control group). Self-reported school absenteeism was only slightly lower in the intervention arm than the control arm (15.6% vs. 17.1%, risk difference = -1.4%, 95% CI = -4.6%-1.9%). The intervention had no effect on urogenital health but had broad positive effects on menstrual knowledge, attitudes, wellbeing, and social support. DISCUSSION: The multicomponent MHH intervention had no effect on absence due to last period, but achieved improvements in MHH knowledge, experiences, and needs
What are the policy options for regulating private equity involvement in health care? A review of policies implemented or considered in seven high-income countries.
Get PDFOver the past two decades, private equity investment in health care has increased substantially. Proponents argue that private equity can optimize and improve health services, while critics warn that the business model of these firms is not aligned with the social values of care delivery and has harmful consequences for health systems and patients. It remains unclear to what extent - and how - subnational, national and supranational governments have attempted to regulate this activity. The purpose of this study therefore was to identify examples of implemented and proposed policy options for regulating private equity activity within health care, with the goal of elucidating the policy options available to regulators. We conducted a narrative review to identify proposed or implemented policy instruments in selected high-income countries, grouping them by type using a conceptual framework based on the works of Milton Friedman and Avedis Donabedian. Our search identified several examples of proposed or implemented policy options for addressing private equity activity in the countries under review. Most of these intervention examples fall into the category of disclosure, while only one focused on regulation of outcomes. Our study suggests that while some countries have started to develop policy interventions to directly address the role of private equity in health care, other countries do not specifically regulate private equity activity
Risk factors for atopic and non-atopic asthma in school-aged children from high, and low and middle income countries.
Get PDFBackground
It is well established that there are different asthma phenotypes, but whereas determinants of atopic asthma are well studied, little is known about non-atopic asthma. We compared risk factors for atopy, atopic asthma (AA) in atopics, and non-atopic asthma (NAA) in non-atopics, in children in a wide variety of countries.
Methods
Using four studies, across 23 countries, we assessed asthma status and atopy (skin prick tests) for children aged 6-17, plus risk factors from housing, heating, pets, family, diet, and air-quality categories. Using mixed effects logistic regression models we assessed risk factors over 4 pathways: Pathway 1: non-atopic non-asthma to NAA; Pathway 2: non-atopic non-asthma to atopy (no asthma); Pathway 3: atopic non-asthma to AA; Pathway 4: non-atopic non-asthma to AA. We compared the log odds of risk factors between pathways using Pearson’s correlation coefficient.
Results
Our final sample of 32741 children comprised 67% with neither atopy nor asthma, 15% with atopy but without asthma, 8% with AA and 10% with NAA. Risk factors were similar between Pathway 1 and Pathway 3 (Pearson’s correlation = 0.81, 95% confidence interval = [0.68, 0.94]). In contrast, risk factors differed between Pathway 2 and Pathway 3 (-0.06, [-0.29, 0.17]).
Discussion
These findings indicate that although atopy increases the risk of asthma, the risk factors for subsequently developing asthma are generally the same in those with and without atopy. This raises important questions about the role of atopy in asthma, particularly whether it is an inherent part of the aetiological process or is coincidental
Prevalence and epidemiology of Mycoplasma genitalium and the absence of macrolide resistance in M. genitalium among pregnant women attending antenatal care in Zambia.
Get PDFINTRODUCTION: Mycoplasma genitalium (MG) is a sexually transmitted bacterium of public health importance, associated with genitourinary disorders, and adverse reproductive and perinatal outcomes. Global data on MG prevalence and antimicrobial resistance (AMR) are primarily available from high-income countries, whereas there is a dearth of information from resource-constrained settings including sub-Saharan Africa. Furthermore, international data on MG rates and AMR in the antenatal population are scarce. Understanding MG prevalence and AMR patterns is crucial for developing effective public health strategies and treatment guidelines. The aim of this study was to investigate the prevalence and epidemiology of MG and the presence of macrolide resistance-associated mutations (MRAMs) among pregnant women attending antenatal care facilities in Zambia. METHODS: A cross-sectional study was conducted at four antenatal care facilities in Nchelenge, Zambia, among 1,021 pregnant women. Vaginal swabs were collected and tested using the Aptima Mycoplasma genitalium assay, Aptima Combo 2 assay and Aptima Trichomonas vaginalis assay on the Panther System (Hologic). MG-positive samples were further analyzed for MRAMs using the ResistancePlus™ MG assay (SpeeDx). RESULTS: The prevalence of MG was 12.6% (127 of 1,005 valid samples) among the pregnant women. Only 12 MG-positive women (9.4%) had symptoms of a genitourinary infection, which was similar to the frequency of genitourinary symptoms among MG-negative women (6.1%). The rates of Chlamydia trachomatis, Neisseria gonorrhoeae, T. vaginalis, and HIV seropositivity were 7.4, 8.3, 23.0, and 8.6%, respectively. MG infection was significantly associated with the presence of all other tested sexually transmitted infections and HIV seropositivity: the detection rates of C. trachomatis, N. gonorrhoeae, T. vaginalis, and HIV seropositivity were significantly higher in MG-positive than in MG-negative women (15.1% vs. 6.2, 15.0% vs. 7.5, 32.3% vs. 22.0, and 14.3% vs. 7.5%, respectively). The ResistancePlus™ MG assay detected MG in 66.1% (84/127) of samples positive by the Aptima M. genitalium assay, however, no MRAMs were detected in the 23S rRNA gene for any of these 84 samples. DISCUSSION: This study emphasizes the high prevalence of MG among pregnant women in Zambia, but also lack of MRAMs in MG. These findings suggest that azithromycin remains an efficacious treatment option for MG in this population. Nevertheless, continuous surveillance and judicious macrolide use to maintain treatment efficacy are imperative. Further research and sustained monitoring of MG are essential to inform public health strategies and clinical guidelines in Zambia and similar settings worldwide