The mental health treatment gap remains substantial in countries affected by humanitarian crises, where fragile health systems and structural instability hinder service delivery. The World Health Organization's Mental Health Gap Action Programme (mhGAP) aims to scale up evidence-based mental health care through integration into primary health care. However, its real-world implementation in humanitarian settings remains underexplored. We conducted a qualitative study using in-depth individual interviews with 12 stakeholders, including primary care practitioners, mhGAP trainers, field supervisors and health managers involved in the implementation of WHO mhGAP training over the past five years in Lebanon and Iraq. Thematic analysis was applied to explore perceptions of training effectiveness, implementation dynamics, and contextual determinants influencing the mental health service delivery at primary health care level. The main findings of the study revolved around the following dimensions: (1) cases involving suicide risk and substance abuse are considered more challenging, requiring additional skills and coordination with specialized services; (2) the stigma surrounding mental health within communities and among healthcare providers further hinders access to care; (3) poor continuity of care restrict effective mental health care delivery; (4) the mhGAP training enhances knowledge and skills, but changing attitudes and clinical practices are directly influenced by local health systems and policies; (5) continuous supervision is crucial for changing clinical practices and ensuring care aligns with evidence-based guidelines; (6) effective monitoring mechanisms are needed to ensure the training meets its objectives and improves access to mental health care at the primary level. The mhGAP training experiences have shown potential in bridging the mental health treatment gap, while a stark disparity in access to mental health services is evident within countries, which is particularly acute for populations in humanitarian settings where instability and resource scarcity compound mental health challenges. This accentuates the urgency of targeting investments in the most underserved areas, and calling for a nuanced approach that recognizes the complex interplay of social, cultural and economic factors influencing health service delivery.
Workforce training is a widely used implementation strategy to improve care within mental health services, yet evidence for sustained changes in clinical practice remains inconsistent. Managerial actions are likely critical for translating training into practice, but little is known about how leaders conceptualize training objectives or which mechanisms of change they rely on. This study examined which outcomes mental health managers value from clinical staff training and the strategies they use to support effectiveness. In-depth interviews were performed with 14 managers from eight Swedish regions, and data were analyzed using two forms of qualitative content analysis: Training objectives were inductively coded into categories, while reported strategies were deductively organized using an operant learning framework to identify behavior-change mechanisms. Managers described training as serving multiple purposes organized in two overarching aims: Care Delivery Goals, including clinical impact and service provision, and Work Environment Goals, encompassing staff wellbeing and connectedness among colleagues. Reported strategies aligned with the four predefined categories-Antecedents, Monitoring, Consequences, and Processes & Resources-and one additional category developed during coding: Preparatory strategies. Across strategies, mechanisms essential for sustaining new skills, such as task clarification, outcome monitoring, and performance-contingent feedback, were inconsistently applied. This study demonstrates that leaders attribute a wider range of purposes to workforce training than is typically assumed in training and implementation research, encompassing not only clinical or competence-related outcomes but also central work environment and organizational goals. An operant analysis of their strategies clarifies the change mechanisms managers rely on and highlights the importance of intentional, strategic-level actions-including preparatory strategies that shape who is trained, in what, and why. Furthermore, the findings inform practical recommendations that emphasize linking training initiatives to organizational priorities and systematically employing strategies such as monitoring, feedback, and task clarification. Integrating these elements can strengthen the design, implementation, and long-term impact of staff training, ultimately supporting better patient outcomes, improved staff wellbeing, and more effective use of limited resources.
Understanding how well healthcare systems meet what patients value is central to person-centered care. As a first objective of this study, the alignment between what Swedish patients consider important in healthcare and what they experience in practice was examined, using an Importance-Performance Analysis (IPA) across eleven relational and functional care dimensions. A secondary objective was to assess how these patterns differ by disability level, an equity-relevant factor shaping healthcare needs and expectations. Anonymous survey data were collected from 1,036 adults across all Swedish regions who had accessed healthcare within the previous six months. Respondents rated the importance of, and experienced performance on, key care attributes including continuity, communication, shared decision making, timeliness, information access, and co-design. Mean importance and performance scores for each dimension were plotted in IPA grids for the full sample and for subgroups defined by self-reported disability due to long-term health issues (high, medium, none). For the overall sample, most care dimensions fell into the "maintain performance" quadrant, indicating high importance and adequate performance, notably shared decision making, collaboration, communication preferences, responsiveness, and access to information. Relational continuity, informational continuity, support for self-care, and co-design were situated in the "lower priority" quadrant, reflecting lower relative importance and lower performance. For the total sample no dimensions appeared in the "focus efforts here" quadrant. Subgroup analyses revealed substantial inequities. Respondents with high levels of self-reported disability reported poorer health, greater difficulty accessing the knowledge they need, and lower performance ratings across all eleven dimensions. For this group, relational continuity and healthcare professionals' disease-specific knowledge shifted into the "focus efforts here" quadrant, indicating high importance coupled with significant performance gaps. These patterns were not observed among respondents with medium or no self-reported disability, for whom these dimensions were placed in areas indicating acceptable performance or lower priority. The findings demonstrate that average patient-experience measures obscure meaningful disparities. IPA offers a practical decision-support method for identifying where improvement efforts should be targeted and for whom. Priorities for Swedish healthcare include strengthening continuity, enhancing informational support, and ensuring adequate professional knowledge for individuals with higher levels of self-reported disability. Used within iterative improvement frameworks, IPA can help move healthcare systems from measurement to meaningful, patient-informed change.
Equitable implementation is an important dimension of effective implementation. In Aotearoa New Zealand, many health interventions with the potential to lessen health inequities for Māori fail to do so because of implementation challenges. Equity readiness can ensure organisations are both willing and able to implement or scale up health interventions in a way that doesn't result in further health disparities. An equity readiness assessment tool, designed to be used by healthcare organisations in conjunction with an equity focussed process framwork (FrEEIA: Framework for Effective and Equitable Implementation in Aotearoa), was developed through a seven stage, mixed methods, iterative process. This tool frames equity readiness as a collective, multi-level construct. Initial stages of its development included interviews with interest holders to explore barriers and facilitators impacting the implementation of interventions to improve health equity, a reveiw of existing equity assessment and change readiness tools, and a researcher workshop to develop key domains. This was followed by the actual development/adaptation of a suitable tool with advice from interest holders who had utilised similar tools, testing and the development of additional resources that would aid its use. The final version of the FrEEIA Readiness Assessment Tool is an adapted version of The Readiness Thinking Tool®, comprising 31 statements in three sections (individual readiness, intervention-specific readiness, and organisational readiness) which users rate individually and then discuss as a team, before formulating an action plan to improve equity readiness. Pilot testing highlighted the particular benefit of the tool in increasing awareness of the different dimensions of equity readiness, with the identification of strategies to address barriers to readiness more challenging due primarily to timing, team make up, and facilitation challenges. A range of supporting resources -a User Guide, Facilitator's Guide and Action Plan template- were developed to facilitate action plan development.The FrEEIA Readiness Assessment Tool is now available for use and adaptation through an interactive online interface, a format which was found to carry distinct advantages for tailoring feedback. The research team will continue to make refinements as this tool gets rolled out in a wider variety of service settings.
The attainment of Universal Health Coverage (UHC) remains difficult in most low- and middle-income countries (LMICs) due to gaps in health funding, high out-of-pocket spending and further worsening due to recent donor cuts. Existing literature predominantly focuses on traditional sources which include government budgets, donor aid, social health insurance, and household payments while the role of commercial banks as strategic health system financiers remains largely untapped beyond Corporate Social Responsibility (CSR) activities. This perspective examines how commercial banks can provide innovative solutions and utilize their untapped resources to become strategic partners in health financing which can be harnessed towards attaining UHC. Anchored in Financial Intermediation Theory and the World Health Organization's health financing framework, the paper reviews evidence from peer-reviewed literature, policy documents, and illustrative country experiences. Commercial banks possess significant liquidity, risk-assessment capacity, and extensive networks that can be potentially leveraged through health-targeted savings and insurance products, ESG-aligned health bonds, de-risked lending to health SMEs. Structured public-private partnerships can further improve health outcomes while maintaining profitability. Empirical examples from Nigeria and other LMICs demonstrate the feasibility of these approaches. The involvement of commercial banks in health financing involves the risk of equity concerns (urban bias, over-indebtedness, technicality of the products and profit-equity alignment), especially in weak regulatory context while PPPs can carry political undertones with higher political risks. Commercial Banks and policy makers should promote health focused and inclusive products with literacy support, mobilize capital through bonds/guarantees, expand health SME credit, leverage PPPs, and monitor outcomes to mitigate risk. The integration of commercial banks into UHC as strategic partners can bridge financing gaps, improve health access, and strengthen health system resilience in LMICs, provided supportive regulation, ethical frameworks, and contextual adaptation guide their engagement.
Clinicians' overutilization of medical imaging increases patients' exposure to ionizing radiation (IR). Assessing clinicians' knowledge, decision-making, and potential for unnecessary imaging is therefore essential. This study aimed to investigate the knowledge, attitudes, and practices of healthcare professionals in Kazakhstan regarding imaging procedures involving IR. A cross-sectional questionnaire-based study was conducted between June 2024 and May 2025 to assess healthcare professionals' knowledge, attitudes, and practices regarding medical imaging involving IR. A thirty-item questionnaire was used, including a knowledge section scored on a scale of 0-10, with higher scores indicating greater knowledge of ionizing radiation and imaging safety. Group comparisons were performed using independent t-tests or one-way ANOVA for continuous variables and chi-square tests for categorical variables. Multivariable linear regression was used to examine predictors of CT scan requests per month (treated as a continuous count variable), with a p-value ≤0.05 considered statistically significant. Of 250 distributed questionnaires, 218 were completed (response rate: 87.2%). Nearly two-thirds (68.8%) of respondents were female, with a mean age of 29.5 ± 6.9 years, representing diverse medical specialties. The mean knowledge score was 50.5 ± 5.9, and did not differ by gender or geographic location (independent t-test, p > 0.05). However, clinicians aged >35 years and those working in public hospitals had significantly higher knowledge (one-way ANOVA, p = 0.010; independent t-test, p = 0.048). In multivariable linear regression, clinicians aged <34 years (β = 0.401; 95% CI: 0.202-0.300; p ≤ 0.05), those with <5 years of experience (β = 0.338; 95% CI: 0.311-0.403; p ≤ 0.05), and clinicians in high-volume urban settings (β = 0.455; 95% CI: -0.281 to 0.391; p ≤ 0.05) were associated with a higher number of CT requests per month. Notably, 24.6% reported ordering CT scans without clear clinical indications, influenced by workload pressures, patient expectations, fear of malpractice, and the need to expedite diagnostics. Additionally, 38% rarely reviewed prior imaging studies before ordering CT scans. There is an observed gap in clinicians' knowledge and imaging practices. These findings highlight the need for targeted educational interventions, improved access to prior imaging records, and organizational strategies to optimize medical imaging practices and reduce unnecessary patient exposure to ionizing radiation. However, these results should be interpreted with caution due to the cross-sectional study design, convenience sampling, and reliance on self-reported data.
Stated aims for digital healthcare transformation frequently cite goals for better coordinated patient-centric systems. However, despite advances in medical science, digital technologies, health policies, and billions of dollars invested over the past 25 years, most healthcare providers are far from fully realizing the demonstrated benefits of today's digital technologies for improving patient care. Sharing information across healthcare systems remains challenging. Problems with fragmentation, quality, inequities, and rising costs of care delivery persist. A recent study of 1,026 U.S. hospital systems found that only 15.8 percent achieved a digital maturity level needed to provide digitally enabled healthcare services to better coordinate patient care. More importantly, hospital systems that were most successful in digitally transforming demonstrated significantly superior patient outcomes. From a system engineering framework, we pose the problem as: How do we transform a system as complex as U.S. healthcare delivery from today's costly, fragmented provider-centric system to a better coordinated patient-centric system with improved quality, access, affordability, and patient and provider experience. This mixed methods, cross disciplinary research employs an integrative approach, synthesizing diverse sources of evidence to explore challenges and issues associated with healthcare digital transformation. Data extraction was performed by studying the full text of over 100 articles, case studies, and other sources, which were then analyzed thematically employing a "framework synthesis" methodology, which uses a deductive approach rather than the more common inductive synthesis approaches. Research points to multiple factors impeding progress, not the least of which is the sheer complexity of the problem. Healthcare systems that achieved significantly superior results reported different approaches to digital transformation in ways that may not necessarily be apparent on the surface, primarily because it is not just about what they did but, more importantly, about how they did it. A growing body of knowledge indicates that achieving digital transformation requires substantially different systemic approaches to the problem that intersect across clinical, technical, behavioral, and organizational domains. In other words, systemic problems cannot be solved with siloed solutions. This research explores these differences with the aim of determining how approaches differ, why the differences matter, and implications for achieving better results. Conceptualizing the healthcare delivery system as distinct from the practice of healthcare (medical practice) makes an important contribution to the evolving science of healthcare delivery - working on the healthcare delivery system versus working in the system.
Nurses are a vital component of healthcare systems, directly influencing the quality and continuity of patient care. Globally, demographic shifts have led to a rising proportion of older nurses. In Italy, this trend presents challenges, given the rapidly aging population and ongoing workforce shortages. With a retirement age of 67, many older nurses remain in physically demanding roles despite medically documented work limitations, raising concerns about workforce sustainability, safety, and long-term planning. This study analyzed demographic trends among nurses at a major Italian public hospital. Data were extracted from the hospital's human resources system (IRIS WIN) for the period 2010-2024. A total of 2,184 nurses employed as of 31 December 2024 were stratified into four age groups (24-44, 45-54, 55-58, and 59-67 years) and mapped against clinical settings with varying levels of work intensity. Retirement eligibility was projected through 2033. Health-related absenteeism and medically documented work limitations were analyzed by age group and job intensity level. Between 2010 and 2024, the proportion of nurses aged 24-44 declined by 36.6%, while those aged 55-58 and 59-67 increased by 222.3% and 1,914%, respectively. Projections indicate a further 91% increase in the oldest age group by 2033. In 2024, 66% of nurses aged 55-58 and 61% of those over 59 were working in high- or extremely high-intensity clinical areas. Older nurses (>55 years), representing 40% of the workforce, accounted for 54% of all health-related absenteeism, equivalent to 87 full-time nursing positions. The number of nurses with medically documented work limitations in the oldest age group is expected to double in the coming years. This study highlights the urgent challenges of an aging nursing workforce which are not unique to Italy's NHS, but are a global issue. A growing proportion of older nurses, many with medically documented work limitations, are working in demanding clinical environments, trends already testing healthcare systems in many countries worldwide with a potential impact on patient safety, quality of care, and workforce resilience. Urgent investment in workforce planning, age-responsive role adaptation, and transitional pathways is essential to ensure sustainable, high-quality care delivery and to safeguard workforce health.
This review was undertaken with the aim of locating and mapping telehealth or virtual care curricula or competencies for health professionals in training or practice. The design followed the JBI methodology for scoping reviews and conforms with the requirements of the PRISMA Extension for Scoping Reviews (PRISMA-ScR) checklist. Data sources included Medline (Ovid), Emcare (Ovid), Cumulative Index to Nursing & Allied Health (CINAHL), ERIC (EBSCO) and Scopus plus grey literature databases, customized Google searching, targeted websites, and consultation with content experts in June 2024-Jan 2025. The team members worked independently to extract data. Content analysis was used to map the data, with the use of a data extraction table developed by the review team for the purpose of preparing, organising, and reporting identified evidence. Team meetings were used to collate analysis and facilitated consensus regarding the creation of categories and subsequent themes. The search identified 3,189 peer-reviewed works and 7 grey literature items. After screening 31 publications met criteria for inclusion. Analys of included evidence indicated that telehealth services are safe, effective and increase health service access if delivered by appropriately qualified personnel but competence in face-to-face care provision does not automatically transfer to competency in virtual delivery. The search identified a series of competencies pertinent to telehealth-based clinical encounters, including the call management competencies to prepare for a consult; communicate with clients; conduct the consult; and close. The findings provide information in respect to telehealth essential inclusions in undergraduate nursing curricula and nursing professional development programs. The literature demonstrates a slow uptake in embedding new practice models in education programs for the future health and nursing workforce. A need exists to confirm the competency requirements for telehealth delivery and accelerate related content into nursing and health workforce curricula and professional development activities.
Clinical governance requires the integration of evidence not only on clinical interventions but also on organisational processes that shape health services delivery and directly influence quality, efficiency, and patient safety. Despite the widespread availability of evidence-based clinical guidelines, healthcare systems often lack standardised methods to translate evidence into effective organisational models. To address this gap, the Italian National Centre for Clinical Governance (CNCG) at the Italian National Institute of Health (ISS) developed a structured methodological framework for Organisational Clinical Best Practice Recommendations (O-BPCA), aimed at strengthening evidence-based governance and organisational performance within healthcare services. The O-BPCA framework was developed through a structured, multi-step process encompassing governance principles, methodological standards, and operational phases, culminating in institutional validation through external review, public consultation, and formal approval by the ISS. The methodological manual defines transparent procedures for evidence synthesis, consensus building, and the formulation of measurable organisational recommendations applicable across health service settings. The framework has been operationalised within the CNCG through the identification of two priority macro-areas for organisational innovation, surgical and territorial care, and the establishment of dedicated Thematic Operational Groups (GOTs) responsible for developing and validating O-BPCA recommendations in selected priority domains. Early implementation has highlighted the framework's feasibility, scalability, and potential to support coordinated organisational improvement within the Italian National Health Service. The O-BPCA framework represents an innovative policy and methodological tool for healthcare governance, bridging clinical evidence and organisational implementation within health services. By promoting standardisation, transparency, and accountability in organisational decision-making, the framework supports sustainable improvements in service delivery and performance. Its structured and replicable approach makes it transferable beyond the Italian National Health Service and adaptable to other health systems seeking to strengthen evidence-based organisational governance.
The digital transformation in healthcare requires future professionals to have solid digital skills. Despite the global relevance of digital skills, little is known about how these skills differ in countries with different healthcare and education systems. This study compares the self-assessed digital skills of two institutional samples of healthcare and nursing students in Germany and India using the DigKomp 2.2 questionnaire and examines the correlation between perceived competence and the strategies reported for searching for information. An online cross-sectional survey was conducted in April and May 2025 among 49 students in Germany and 256 students in India. Digital competences were assessed using the DigKomp 2.2 questionnaire, which covers all five dimensions of the DigComp framework. An open-ended question was used to record the students' strategies for searching for reliable information on the internet. The quantitative data were analyzed using the Kolmogorov-Smirnov test, the Levene test, and the t-test for two independent samples. Both cohorts showed acceptable to high internal consistency across all DigKomp 2.2 dimensions. Students in the German cohort reported higher competencies in data processing and evaluation and communication/collaboration, while students from the Indian cohort scored higher in digital content creation, security and problem solving. The exploratory bivariate analysis between the Indian and German samples revealed significant differences in 7 out of 15 items, specifically within the dimensions of digital content creation (3/3 items), Security (2/3 items), data processing & evaluation (1/3 items), and problem solving (1/4 items), whereas no significant differences were found in communication/cooperation (0/2 items). Qualitative responses revealed structured and academically oriented search strategies among German cohort. Indian responses showed greater heterogeneity. Digital competence development varies substantially between the two institutional samples, reflecting differences in educational structures, access to digital technologies and national digitalization trajectories. While German students demonstrate strong academically grounded competencies, Indian students exhibit strengths in practical and applied digital competence. These findings underscore the need for context-sensitive digital education strategies that combine structured research competencies with practical digital literacy to prepare students for increasingly digitalized healthcare environments in both countries.
The escalating incidence of prostate cancer poses a significant global public health challenge. Optimal utilization of resources is crucial for the effective deployment of funds among the diverse and emerging treatment options for managing prostate cancer. This systematic review aims to offer insights and serve as a reference for pharmacoeconomic studies related to the use of degarelix and luteinizing hormone-releasing hormone (LHRH) agonists in the treatment of prostate cancer. We conducted a comprehensive search in databases including Embase, PubMed, the Cochrane Library, CNKI, Web of Science, Scopus, and the Tufts CEA Registry to identify cost-effectiveness studies on the use of degarelix and LHRH agonists in the treatment of prostate cancer, spanning from the inception of these databases up to December 30, 2025. Two independent reviewers sequentially examined titles, abstracts, and full-text articles, applying predefined inclusion and exclusion criteria to select studies for data extraction. Any disagreements were resolved through discussion until a consensus was reached. The quality of the included studies was evaluated using the Quality of Health Economic Studies and Consolidated Health Economic Evaluation Reporting Standards. Relevant data were then summarized and comparatively analyzed, focusing on aspects such as the model framework, model parameters, and uncertainty analysis. A total of 13 studies were ultimately incorporated, with an overall high quality but significant methodological variations among them. Five studies compared degarelix with leuprorelin, goserelin, or triptorelin; four compared triptorelin to goserelin or leuprorelin; one study evaluated leuprorelin acetate in a 6-month depot formulation vs. a 3-month depot; two compared leuprorelin to goserelin and triptorelin; and one study assessed radiotherapy vs. radiotherapy plus goserelin. Eight studies employed the Markov model, with time horizons spanning from 1 year to 30 years. The majority of the studies (n = 7) conducted cost-effectiveness analyses, and most were based in developed countries (n = 7). Degarelix was deemed cost-effective in the United States, United Kingdom, and China. Additionally, 6-month depot LHRH agonists were found to be more cost-effective than their monthly or 3-monthly counterparts. From a societal perspective, the evidence suggests that degarelix may be a cost-effective option for patients with prostate cancer. All assessments of LHRH agonists are of high quality. Among the three LHRH agonists evaluated, the 6-month depot formulation of triptorelin may be a cost-effective option in certain settings. In clinical practice, the evaluation of a drug should comprehensively consider its efficacy, adverse effects, cost-effectiveness, and overall patient survival. The evidence is predominantly derived from high-income countries, and thus the conclusions may have limited generalizability to low- and middle-income country settings. https://www.crd.york.ac.uk/PROSPERO/recorddashboard, PROSPERO CRD420250653923.
Implementation science (IS) relies on standardized terminology, yet existing glossaries are largely English and Western-centric, creating risks of misinterpretation in other contexts. In China, with over one billion Chinese speakers and a rapidly expanding IS community, the absence of a unified glossary hinders training and knowledge exchange. We report a prospective, multi-stage cultural and linguistic adaptation study of the Implementation Science Research Glossary produced by the Centre for Implementation Science at King's College London, UK, from its original English version into Simplified Chinese. This study follows an established cross-cultural adaptation framework, modified to reflect the nature of a glossary rather than a psychometric instrument. The process includes: (1) forward translation of the English glossary into Simplified Chinese by a bilingual translator with IS expertise; (2) independent back translation by another bilingual individual blinded to the original glossary; (3) structured reconciliation involving the forward translator, back translator, and an additional reviewer with IS knowledge; (4) first expert panel review-conducted by 5 experts in IS and public health, who will also participate in the final review-to assess semantic, idiomatic, experiential, and conceptual equivalence, leading to a refined version of the glossary; consensus will be defined a priori as ≥80% agreement on each term and definition (5) evaluation of the refined glossary through two complementary quantitative validation procedures: (a) content validation by 6-10 eligible faculty members using the Content Validity Index (CVI), and (b) response process validation by 10-30 Chinese-speaking postgraduate students using the Face Validity Index (FVI); items will be considered acceptable if I-CVI ≥0.83 and glossary-level S-CVI/Ave ≥0.90 for content validity, and I-FVI ≥0.80 with glossary-level S-FVI/Ave ≥0.90 for face validity; and (6) final expert panel review to reach consensus on the adapted glossary. Ethical approval will be obtained prior to data collection. The study will produce the first, to our knowledge, culturally and linguistically adapted IS glossary for Chinese-speaking contexts. This resource is expected to enhance clarity and accessibility of implementation concepts, supporting research and practice in local settings. The documented adaptation process will provide a methodological reference for future translation of IS resources in other languages.
The COVID-19 pandemic exposed significant global disparities in vaccine distribution and access, prompting urgent calls to strengthen national delivery systems. In Zimbabwe and across the African continent, reliance on imports highlighted the need for both robust local distribution mechanisms and enhanced vaccine manufacturing capabilities. Africa's potential to produce vaccines, raw materials, and medical supplies exists, but its realization demands strategic investment and the promotion of public-private partnerships (PPPs). This study aims to analyze Zimbabwe's current COVID-19 vaccine distribution and delivery mechanisms, and explore the potential of PPPs to establish the necessary structures and processes to guarantee prompt access and administration of vaccines, particularly among vulnerable populations. We conducted qualitative in-depth interviews with twenty purposively sampled Key Informants, all possessing specialized knowledge of Zimbabwe's Expanded Programme on Immunization (EPI) and the COVID-19 vaccination program. A standardized template, shared across the study consortium, guided the participant selection process. Our qualitative investigation reveals that equitable vaccine access was hindered by the lack of routine adult vaccination compared to the well-established immunization of children through the EPI program. While utilizing the EPI infrastructure for COVID-19 vaccine rollout was deemed successful and commendable by key informants, it also faced criticism for perceived disparities in rural outreach, favouring urban areas. The stationary vaccination sites posed challenges for vulnerable groups like the elderly and those living with disabilities in rural regions who faced difficulties traveling long distances, underscoring the urgent need for greater efforts to ensure equitable vaccine access across all population segments. Participant perspectives on local vaccine production in Zimbabwe reflect a blend of optimism and apprehension. Many expressed a strong desire for domestic vaccine development, recognizing its potential public health benefits and self-sufficiency. However, a sizeable number doubted Zimbabwe's current capacity to produce vaccines, citing economic challenges. Instead, they suggested forging partnerships with other African nations to collectively establish a regional or continental hub of excellence, sharing costs and reaping mutual benefits. An essential takeaway from this pandemic is the stark revelation of systemic gaps within the healthcare infrastructure. It is crucial to seize this opportunity to fortify the health system, ensuring its resilience in preparation for future pandemics.
Romania's social health insurance system is based on the Bismarck model and aims to provide universal healthcare access through compulsory contributions. While financing and institutional design have been widely studied, the ethical responsibilities of physicians, particularly social insurance physicians, remain under-explored. This study analyzes Romania's social health insurance system through an integrated institutional and ethical lens, focusing on social insurance physicians who operate at the interface of clinical assessment and social protection eligibility. A structured narrative review was conducted, synthesizing national legislation, international ethical frameworks (Declaration of Geneva, International Code of Medical Ethics), peer-reviewed literature (2010-2025), and comparative analyses with European health insurance models. The analysis identified systemic challenges, including underfunding, workforce migration, and demographic pressures, and examined their impact on professional ethics. Romania ensures broad formal coverage, yet persistent challenges-underfunding, regional disparities, informal payments, and physician shortages-create ethical tensions for social insurance physicians. Comparative analysis shows that other European countries (Germany, France, Netherlands) mitigate such pressures through stronger institutional safeguards, higher funding, and protected professional autonomy. This study contributes to health services research by conceptualizing ethical vulnerability in resource-constrained insurance systems and linking institutional structures to professional autonomy, fairness, and system resilience. Findings highlight the need to strengthen ethical frameworks, safeguard physician independence, and align institutional reforms with ethical governance to ensure transparent, equitable, and resilient social health insurance systems.
Digital technologies are increasingly promoted as alternative pathways for financing universal health coverage (UHC) in sub-Saharan Africa, yet evidence on their acceptability among informal-sector populations remains limited. This study explored the acceptability of mobile money-based private health insurance among people living with HIV (PWH) with comorbid hypertension or diabetes in Uganda. We conducted an exploratory qualitative study in Fort Portal City, mid-western Uganda. Data were collected through four focus group discussions with PWH (n = 48) and 18 key informant interviews with representatives of telecom companies, private health insurers, regulators, and health providers. Data were analyzed thematically using an established analytical framework on facilitators and barriers to mobile health technologies. PWH reported rising out-of-pocket expenditures for managing hypertension and diabetes compared to HIV care, which remains largely donor-funded. Facilitators to uptake included high mobile phone ownership, widespread use of mobile money, perceived affordability of monthly premiums (USD 1.35-8.20), prior experience with mobile money insurance, and convenience of digital payments. Barriers included limited understanding of insurance principles, mistrust of private insurers, fears of mobile money fraud, high internet data costs, intermittent electricity supply, and widespread poverty. Mobile money-based health insurance was perceived as affordable and acceptable among PWH with NCD comorbidities. However, low insurance literacy and mistrust of insurers remain major obstacles. Mobile money-based health insurance warrants further research as a complementary pathway for expanding health insurance coverage in Uganda and similar settings.
Patient-reported experience measures (PREMs) provide valuable insights into care quality from the patient's perspective and are particularly relevant for chronic conditions such as type 2 diabetes mellitus (T2DM). However, evidence on their implementation in primary care settings of low- and middle-income countries (LMIC) remains limited. This study explored barriers and facilitators to implementing a diabetes-specific PREM in routine outpatient care in a district-level hospital setting in northern Thailand, to inform strategies for its feasible and sustainable use in similar resource-constrained settings. A qualitative study was conducted using in-depth interviews and a group interview with patients aged 20 years and older living with T2DM, healthcare providers, and the hospital executive team. A total of 25 participants were purposively selected from a hospital-based non-communicable disease (NCD) clinic. Data were collected using a semi-structured interview guide informed by the Consolidated Framework for Implementation Research (CFIR) and analysed using inductive thematic analysis. Patient demographic data were analysed descriptively. Among the 19 patients included, the mean age was 59.7 years (SD = 11.9), with a range of educational and occupational backgrounds. Thematic analysis revealed three overarching themes influencing PREM implementation: patient-related factors, instrument characteristics, and contextual and implementation factors. Key facilitators included patients' perceived value of the PREM, trust in healthcare providers, and supportive organizational structures that enable workflow integration and staff allocation. Major barriers were limited literacy, functional constraints among older adults, and challenges related to instrument wording, format preferences, and insufficient resources for staff assistance. Addressing these factors through tailored questionnaires, flexible administration, and institutional commitment can support the routine collection of patient-reported experiences, strengthen patient-centred care, and inform implementation strategies in similar primary care settings across Southeast Asia.
Becoming a medical intern (MI) represents a major transition in medical education. During this period, trainees are exposed to demanding clinical environments that challenge endurance, adaptability, and self-care. Irregular schedules, sleep deprivation, and reduced opportunities for physical activity (PA) frequently accompany this phase and may lead to measurable changes in anthropometric and body composition (BC) parameters. This study aimed to evaluate one-year changes in BC, PA, and sleep quality (SQ) among MIs and to explore their interrelationship. A longitudinal observational study was conducted in 170 MIs (18-25 years) at a Mexican public university hospital, assessed at baseline and after 12 months. Anthropometric and BC parameters were obtained using multifrequency bioimpedance analysis (InBody 270S). PA was assessed with the Global Physical Activity Questionnaire (GPAQ), and SQ with the Pittsburgh Sleep Quality Index (PSQI). Group comparisons were performed using parametric or non-parametric tests as appropriate, with effect sizes reported as Cohen's d and Cramér's V. Statistical significance was set at p < 0.05. Participants had a mean age of 22.9 ± 0.87 years; 62.0% were female. Body mass index (BMI) increased from 25.47 ± 5.06 to 26.22 ± 5.31 kg/m² over the follow-up period. Total body water (TBW), protein mass (PM), and mineral mass (MM) showed relative reductions, while body fat mass (BFM) increased, and skeletal muscle mass (SMM) remained largely stable. The proportion of MIs classified in the low PA category decreased, whereas those engaging in high PA increased. Overall SQ deteriorated, with fewer participants reporting good SQ and a higher proportion classified as poor SQ. Males demonstrated greater increases in BFM, whereas females exhibited relatively more favorable SQ profiles. No significant association was observed between PA level and PSQI-defined SQ. Despite modest improvements in PA patterns, MIs experienced worsening SQ and unfavorable shifts in BC during the internship year. These findings underscore the vulnerability of medical interns to lifestyle-related health changes and highlight the need for institutional wellness strategies focused on sleep hygiene, balanced nutrition, and sustained opportunities for PA.
Healthcare systems face growing pressure to maintain high-quality care while improving environmental and economic sustainability. Hospitals are resource-intensive institutions, contributing substantially to energy and water consumption, pharmaceutical expenditure, and healthcare-related greenhouse gas emissions. Value-based healthcare models, including value-based outsourcing of publicly funded hospitals to private networks, have shown promise in improving quality and efficiency. However, their impact on sustainability outcomes remains underexplored. This study compared environmental and economic sustainability indicators between value-based outsourced and publicly managed hospitals. We conducted a cross-sectional comparative study using five years of administrative data (2019-2023) from 26 public hospitals in the Madrid Regional Healthcare Service, Spain. Four hospitals were managed by a value-based private network, and 22 were publicly managed. Outcomes included electricity consumption (kWh/m2 per hospital stay), water consumption (m3 per hospital stay), and mean unit cost of specialist-prescribed medications. Analyses were stratified by hospital complexity (low, medium, high) and adjusted for case-mix complexity and year of construction. Patient safety indicators (medical and surgical complications and hospital-acquired infections) were also compared. Statistical analyses used chi-squared, Student's t-test, or Mann-Whitney U tests, with p < 0.05 considered significant. Outsourced hospitals treated patients with significantly higher overall case-mix complexity than publicly managed hospitals. Overall electricity consumption was lower in outsourced hospitals (0.009 vs. 0.011 kWh/m2 per hospital stay; p = 0.039), leading to estimated cost savings of 1,648,305 € and an approximate reduction in greenhouse gas emissions of 8,672 CO2 metric tons during the study period, as was water consumption (0.65 vs. 0.81 m3 per hospital stay; p < 0.001). The mean unit cost per medication was also lower in outsourced hospitals (€21.45 vs. €22.92; p = 0.026), with significant differences primarily in medium-complexity hospitals. Outsourced hospitals demonstrated slightly but significantly lower rates of inpatient complications and hospital-acquired infections. Value-based outsourcing in Madrid's public hospitals was associated with improved environmental and economic sustainability, alongside favorable patient safety outcomes, despite higher case-mix complexity. These findings support incorporating sustainability indicators into performance-based healthcare models and suggest value-based outsourcing as a potential strategy to advance sustainable healthcare delivery.
Fostering prosociality in children, defined as acting for the benefit of others, is essential for both individual and collective well-being. According to self-determination theory, satisfying the fundamental need for relatedness plays a crucial role in motivating prosociality. Integrating interventions that combine arts and philosophical approaches reinforces socio-emotional skills fundamental to prosociality by enhancing social awareness and empathy, as well as offering an adaptable and practical approach in academic settings. This study examined how children engage with social contexts that call upon socio-emotional competencies, and how these experiences relate to the development of prosociality in art-based philosophical interventions. The study was guided by the following research question: What are the perceived benefits of an art-based philosophical intervention on children's prosociality and relatedness? This study used a descriptive qualitative design with children in a school setting. Over 10 consecutive weeks, 60-minute workshops combining arts and philosophical inquiry were conducted. Data analysis included group discussions, observations, and 21 semi-structured interviews, with results interpreted through inductive thematic analysis. The findings indicated that the intervention fostered both connection and engagement among the students: Connection (perceived as emotional resonance) encouraged mutual respect, empathy, and admiration, whereas engagement (which offered comfort, trust, and fostered a sense of belonging) was observed through camaraderie, collaboration, and instances of disengagement. These findings highlight that the development of introspection, self-awareness, and autonomy through artistic and philosophical activities provided a foundation for students to act prosocially, thereby emphasizing empathy, care, and respect toward others. The study demonstrates that integrating arts and philosophical inquiry in elementary education fosters prosociality, empathy, and self-awareness, supporting both academic and socio-emotional growth. It offers adaptable strategies for inclusive, cooperative classrooms and highlights implications for curriculum design and policy promoting student well-being and community.