Measuring universal health coverage: a three-dimensional composite approach from Bhutan.

Background: In the early 1960s, the Kingdom of Bhutan began to develop its modern health-care system and by the 1990s had developed an extensive network of health-care facilities. These developments, in tandem with wider social and economic progress encapsulated in the Gross National Happiness concept, have resulted in major gains in child survival and life expectancy in the past 50 years. In order to sustain these gains, the country has identified a constitutional and healthpolicy mandate for universal access to health. Methods: Based on analysis of the literature, and qualitative and quantitative health data, this case study aims to provide an assessment of universal health coverage in Bhutan, and to identify the major challenges to measuring, monitoring and sustaining universal coverage. Results: The study reveals that the wide network of primary and secondary care, reinforced by constitutional and policy mandates, ensures high population coverage, as well as wide availability and accessibility of care, with significant levels of financial protection. This achievement has been attributable to sustained state investment in the sector over past decades. Despite this achievement, recent surveys have demonstrated gaps in utilization of health services and confirmed associations between socioeconomic variables and health access and outcomes, which raise important questions relating to both supply- and demand-side barriers in accessing health care. Conclusion: In order to sustain and improve the quality of universal health coverage, improved measurements of service availability at subnational levels and of the determinants of pockets of low service utilization are required. More rigorous monitoring of financial protection is also needed, particularly in relation to rates of public investment and the impact of out-of-pocket costs while accessing care. These approaches should assist improvements in quality and equity in universal health coverage, in the context of ongoing epidemiological, demographic and social transition.

Chronic disease management in the South‑East Asia Region: a need to do more.

Chronic diseases account for a substantial proportion of deaths in the South‑East Asia Region, ranging from 34% in Timor‑Leste to 79% in Maldives. Fuelled by the epidemiological shift towards noncommunicable diseases, the burden of chronic conditions is steadily increasing. Care structures for chronic diseases in most of these countries focus only on certain conditions and are often oriented towards episodic illnesses. An opportunity exists for holistic, country‑driven applications of the World Health Organization Innovative Care for Chronic Conditions framework to improve quality of care for chronic conditions in the region.

Spontaneous resolution of marked dilatation of cerebral duro-venous system in newborn presenting with fetal hydrops.

A newborn with antenatal diagnosis of fetal hydrops at 36 wk of gestation, presented with congestive heart failure (CHF) and generalized edema. Computed tomographic angiography showed marked dilatation of cerebral duro-venous system including vein of Galen (VOG), straight sinus, torcula and transverse sinus without evidence of arteriovenous fistulae at the vein of Galen. Dilatation of duro-venous system resolved with concomitant improvement in biventricular function and CHF with decongestive therapy. Such entity should be differentiated from more serious conditions like VOG malformation and venous sinus thrombosis.

Cardiac rhabdomyoma and tuberous sclerosis: prenatal diagnosis and follow-up.

This article reports 4 cases with cardiac rhabdomyomas diagnosed during intrauterine life. Echocardiographic follow-up at 9-30 months showed regression of the tumors in 3 cases (75%). Two cases (50%) developed tuberous sclerosis during that period. Fetal echocardiography promotes early diagnosis of tuberous sclerosis through prenatal detection of cardiac rhabdomyoma, and facilitates genetic counselling of families at risk.