Trends in future health financing and coverage: future health spending and universal health coverage in 188 countries, 2016–40

Background: Achieving universal health coverage (UHC) requires health financing systems that provide prepaid pooled resources for key health services without placing undue financial stress on households. Understanding current and future trajectories of health financing is vital for progress towards UHC. We used historical health financing data for 188 countries from 1995 to 2015 to estimate future scenarios of health spending and pooled health spending through to 2040. Methods: We extracted historical data on gross domestic product (GDP) and health spending for 188 countries from 1995 to 2015, and projected annual GDP, development assistance for health, and government, out-of-pocket, and prepaid private health spending from 2015 through to 2040 as a reference scenario. These estimates were generated using an ensemble of models that varied key demographic and socioeconomic determinants. We generated better and worse alternative future scenarios based on the global distribution of historic health spending growth rates. Last, we used stochastic frontier analysis to investigate the association between pooled health resources and UHC index, a measure of a country's UHC service coverage. Finally, we estimated future UHC performance and the number of people covered under the three future scenarios. Findings: In the reference scenario, global health spending was projected to increase from US$10 trillion (95$20 trillion (18 trillion to 22 trillion) in 2040. Per capita health spending was projected to increase fastest in upper-middle-income countries, at 4·2% (3·4–5·1) per year, followed by lower-middle-income countries (4·0%, 3·6–4·5) and low-income countries (2·2%, 1·7–2·8). Despite global growth, per capita health spending was projected to range from only $40 (24–65) to$413 (263–668) in 2040 in low-income countries, and from $140 (90–200) to$1699 (711–3423) in lower-middle-income countries. Globally, the share of health spending covered by pooled resources would range widely, from 19·8% (10·3–38·6) in Nigeria to 97·9% (96·4–98·5) in Seychelles. Historical performance on the UHC index was significantly associated with pooled resources per capita. Across the alternative scenarios, we estimate UHC reaching between 5·1 billion (4·9 billion to 5·3 billion) and 5·6 billion (5·3 billion to 5·8 billion) lives in 2030. Interpretation: We chart future scenarios for health spending and its relationship with UHC. Ensuring that all countries have sustainable pooled health resources is crucial to the achievement of UHC. Funding: The Bill & Melinda Gates Foundation

Factors Associated with Revision Surgery after Internal Fixation of Hip Fractures

Background: Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. Methods: We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Results: Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (fo

Novel approach for issues identification in transboundary water management using fuzzy c-means clustering

Abstract Rivers, a major freshwater resource, are transboundary in nature (310 international basins) and are not governed by any water agreements. Scientific knowledge based on transboundary water resources is confined; hence, the identification of “knowledge gaps” to smoothen decision making in water management is necessary. To figure out the issues that affect water sharing is deemed important. This paper highlights the core issues involved in transboundary water management and prioritizes the identified issues using fuzzy c-means clustering algorithm. A group of 30 experts from various fields were consulted to rank the issues which were clustered to determine the prioritized rank. In a hypothetical basin affected by all the transboundary issues, flood control and benefit sharing are rated with very high importance. Prioritization would help in the identification of issues of high relevance that affect water sharing. This may facilitate efficient water sharing agreements among riparians and be useful in international water governance

Spending on health and HIV/AIDS: domestic health spending and development assistance in 188 countries, 1995\u20132015

Background: Comparable estimates of health spending are crucial for the assessment of health systems and to optimally deploy health resources. The methods used to track health spending continue to evolve, but little is known about the distribution of spending across diseases. We developed improved estimates of health spending by source, including development assistance for health, and, for the first time, estimated HIV/AIDS spending on prevention and treatment and by source of funding, for 188 countries. Methods: We collected published data on domestic health spending, from 1995 to 2015, from a diverse set of international agencies. We tracked development assistance for health from 1990 to 2017. We also extracted 5385 datapoints about HIV/AIDS spending, between 2000 and 2015, from online databases, country reports, and proposals submitted to multilateral organisations. We used spatiotemporal Gaussian process regression to generate complete and comparable estimates for health and HIV/AIDS spending. We report most estimates in 2017 purchasing-power parity-adjusted dollars and adjust all estimates for the effect of inflation. Findings: Between 1995 and 2015, global health spending per capita grew at an annualised rate of 3\ub71% (95% uncertainty interval [UI] 3\ub71 to 3\ub72), with growth being largest in upper-middle-income countries (5\ub74% per capita [UI 5\ub73\u20135\ub75]) and lower-middle-income countries (4\ub72% per capita [4\ub72\u20134\ub73]). In 2015, 9\ub77 trillion (9\ub77 trillion to 9\ub78 trillion) was spent on health worldwide. High-income countries spent 6\ub75 trillion (6\ub74 trillion to 6\ub75 trillion) or 66\ub73% (66\ub70 to 66\ub75) of the total in 2015, whereas low-income countries spent 70\ub73 billion (69\ub73 billion to 71\ub73 billion) or 0\ub77% (0\ub77 to 0\ub77). Between 1990 and 2017, development assistance for health increased by 394\ub77% (29\ub79 billion), with an estimated 37\ub74 billion of development assistance being disbursed for health in 2017, of which 9\ub71 billion (24\ub72%) targeted HIV/AIDS. Between 2000 and 2015, 562\ub76 billion (531\ub71 billion to 621\ub79 billion) was spent on HIV/AIDS worldwide. Governments financed 57\ub76% (52\ub70 to 60\ub78) of that total. Global HIV/AIDS spending peaked at 49\ub77 billion (46\ub72\u201354\ub77) in 2013, decreasing to 48\ub79 billion (45\ub72 billion to 54\ub72 billion) in 2015. That year, low-income and lower-middle-income countries represented 74\ub76% of all HIV/AIDS disability-adjusted life-years, but just 36\ub76% (34\ub74 to 38\ub77) of total HIV/AIDS spending. In 2015, 9\ub73 billion (8\ub75 billion to 10\ub74 billion) or 19\ub70% (17\ub76 to 20\ub76) of HIV/AIDS financing was spent on prevention, and 27\ub73 billion (24\ub75 billion to 31\ub71 billion) or 55\ub78% (53\ub73 to 57\ub79) was dedicated to care and treatment. Interpretation: From 1995 to 2015, total health spending increased worldwide, with the fastest per capita growth in middle-income countries. While these national disparities are relatively well known, low-income countries spent less per person on health and HIV/AIDS than did high-income and middle-income countries. Furthermore, declines in development assistance for health continue, including for HIV/AIDS. Additional cuts to development assistance could hasten this decline, and risk slowing progress towards global and national goals. Funding: The Bill & Melinda Gates Foundation

Trends in future health financing and coverage: future health spending and universal health coverage in 188 countries, 2016–40

Achieving universal health coverage (UHC) requires health financing systems that provide prepaid pooled resources for key health services without placing undue financial stress on households. Understanding current and future trajectories of health financing is vital for progress towards UHC. We used historical health financing data for 188 countries from 1995 to 2015 to estimate future scenarios of health spending and pooled health spending through to 2040

Fracture fixation in the operative management of hip fractures (FAITH): an international, multicentre, randomised controlled trial

Background Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. Methods For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Findings Between Mar