Linking world bank development indicators and outcomes of congenital heart surgery in low-income and middle-income countries: retrospective analysis of quality improvement data.

OBJECTIVE: Many low-income and middle-income countries (LMICs) struggle to provide the health services investment required for life-saving congenital heart disease (CHD) surgery. We explored associations between risk-adjusted CHD surgical mortality from 17 LMICs and global development indices to identify patterns that might inform investment strategies. DESIGN: Retrospective analysis: country-specific standardised mortality ratios were graphed against global development indices reflective of wealth and healthcare investment. Spearman correlation coefficients were calculated. SETTING AND PARTICIPANTS: The International Quality Improvement Collaborative (IQIC) keeps a volunteer registry of outcomes of CHD surgery programmes in low-resource settings. Inclusion in the IQIC is voluntary enrolment by hospital sites. Patients in the registry underwent congenital heart surgery. Sites that actively participated in IQIC in 2013, 2014 or 2015 and passed a 10% data audit were asked for permission to share data for this study. 31 sites in 17 countries are included. OUTCOME MEASURES: In-hospital mortality: standardised mortality ratios were calculated. Risk adjustment for in-hospital mortality uses the Risk Adjustment for Congenital Heart Surgery method, a model including surgical risk category, age group, prematurity, presence of a major non-cardiac structural anomaly and multiple congenital heart procedures during admission. RESULTS: The IQIC registry includes 24 917 congenital heart surgeries performed in children<18 years of age. The overall in-hospital mortality rate was 5.0%. Country-level congenital heart surgery standardised mortality ratios were negatively correlated with gross domestic product (GDP) per capita (r=-0.34, p=0.18), and health expenditure per capita (r=-0.23, p=0.37) and positively correlated with under-five mortality (r=0.60, p=0.01) and undernourishment (r=0.39, p=0.17). Countries with lower development had wider variation in mortality. GDP per capita is a driver of the association between some other measures and mortality. CONCLUSIONS: Results display a moderate relationship among wealth, healthcare investment and malnutrition, with significant variation, including superior results in many countries with low GDP per capita. These findings provide context and optimism for investment in CHD procedures in low-resource settings.

Political and economic aspects of the transition to universal health coverage.

Countries have reached universal health coverage by different paths and with varying health systems. Nonetheless, the trajectory toward universal health coverage regularly has three common features. The first is a political process driven by a variety of social forces to create public programmes or regulations that expand access to care, improve equity, and pool financial risks. The second is a growth in incomes and a concomitant rise in health spending, which buys more health services for more people. The third is an increase in the share of health spending that is pooled rather than paid out-of-pocket by households. This pooled share is sometimes mobilised as taxes and channelled through governments that provide or subsidise care--in other cases it is mobilised in the form of contributions to mandatory insurance schemes. The predominance of pooled spending is a necessary condition (but not sufficient) for achieving universal health coverage. This paper describes common patterns in countries that have successfully provided universal access to health care and considers how economic growth, demographics, technology, politics, and health spending have intersected to bring about this major development in public health.

Study-design selection criteria in systematic reviews of effectiveness of health systems interventions and reforms: A meta-review.

At present, there exists no widely agreed upon set of study-design selection criteria for systematic reviews of health systems research, except for those proposed by the Cochrane Collaboration's Effective Practice and Organisation of Care (EPOC) review group (which comprises randomized controlled trials, controlled clinical trials, controlled before-after studies, and interrupted time series). We conducted a meta-review of the study-design selection criteria used in systematic reviews available in the McMaster University's Health Systems Evidence or the EPOC database. Of 414 systematic reviews, 13% did not indicate any study-design selection criteria. Of the 359 studies that described such criteria, 50% limited their synthesis to controlled trials and 68% to some or all of the designs defined by the EPOC criteria. Seven out of eight reviews identified at least one controlled trial that was relevant for the review topic. Seven percent of the reviews included either no or only one relevant primary study. Our meta-review reveals reviewers' preferences for restricting synthesis to controlled experiments or study designs that comply with the EPOC criteria. We discuss the advantages and disadvantages of the current practices regarding study-design selection in systematic reviews of health systems research as well as alternative approaches.

Financing of HIV/AIDS programme scale-up in low-income and middle-income countries, 2009-31.

As the global HIV/AIDS pandemic nears the end of its third decade, the challenges of efficient mobilisation of funds and management of resources are increasingly prominent. The aids2031 project modelled long-term funding needs for HIV/AIDS in developing countries with a range of scenarios and substantial variation in costs: ranging from US$397 to $722 billion globally between 2009 and 2031, depending on policy choices adopted by governments and donors. We examine what these figures mean for individual developing countries, and estimate the proportion of HIV/AIDS funding that they and donors will provide. Scenarios for expanded HIV/AIDS prevention, treatment, and mitigation were analysed for 15 representative countries. We suggest that countries will move in increasingly divergent directions over the next 20 years; middle-income countries with a low burden of HIV/AIDS will gradually be able to take on the modest costs of their HIV/AIDS response, whereas low-income countries with a high burden of disease will remain reliant upon external support for their rapidly expanding costs. A small but important group of middle-income countries with a high prevalence of HIV/AIDS (eg, South Africa) form a third category, in which rapid scale-up in the short term, matched by outside funds, could be phased down within 10 years assuming strategic investments are made for prevention and efficiency gains are made in treatment.

Critical choices in financing the response to the global HIV/AIDS pandemic.

The AIDS pandemic will enter its fiftieth year in 2031. Despite much progress, there are thirty-three million infected people worldwide, and 2.3 million adults were newly infected in 2007. Without a change in approach, a major pandemic will still be with us in 2031. Modeling carried out for the AIDS 2031 project suggests that funding required for developing countries to address the pandemic could reach $35 billion annually by 2031-three times the current level. Even then, more than a million people will still be newly infected each year. However, wise policy choices focusing on high-impact prevention and efficient treatment could cut costs by half. Investments in new prevention tools and major behavior-change efforts are needed to spur more rapid advances. Existing donors, middle-income countries with contained epidemics, philanthropists, and innovative financing could help bridge the likely funding gap.

Reform of how health care is paid for in China: challenges and opportunities.

China's current strategy to improve how health services are paid for is headed in the right direction, but much more remains to be done. The problems to be resolved, reflecting the setbacks of recent decades, are substantial: high levels of out-of-pocket payments and cost escalation, stalled progress in providing adequate health insurance for all, widespread inefficiencies in health facilities, uneven quality, extensive inequality, and perverse incentives for hospitals and doctors. China's leadership is taking bold steps to accelerate improvement, including increasing government spending on health and committing to reaching 100% insurance coverage by 2010. China's efforts are part of a worldwide transformation in the financing of health care that will dominate global health in the 21st century. The prospects that China will complete this transformation successfully in the next two decades are good, although success is not guaranteed. The real test, as other countries have experienced, will come when tougher reforms have to be introduced.

Mas alla de la ciudad: el aporte del campo al desarrollo / Es

El desarrollo de la economia rural y de las comunidades rurales es algo fundamental para el bienestar nacional, en la misma historia de America Latina y le Caribe, las sociedades rurales han sido tanto protagonistas del origen de la prosperidad como la agitacion social, aunque las comunidades rurales de esta region tienen acceso a un amplio abanico de recursos naturales, son las que ostentan las tazas de pobreza mas elevadas...