Is Private Health Care the Answer to the Health Problems of the World's Poor?

Background to the debate: The global burden of disease falls disproportionately upon the world's low-income countries, which are often struggling with weak health systems. Both the public and private sector deliver health care in these countries, but the appropriate role for each of these sectors in health system strengthening remains controversial. This debate examines whether the private sector should step up its involvement in the health systems of low-income countries

Disparities in the use of colorectal cancer screening in a universally insured population during the COVID‐19 pandemic

Abstract Background Despite the known efficacy of colorectal cancer (CRC) screening, the rates of individuals undergoing such testing have remained lower than target thresholds, even prior to the healthcare disruptions associated with the COVID‐19 pandemic. We evaluated the impact of the COVID‐19 pandemic on CRC screening within a nationally representative US population and assessed disparities in screening across racial/ethnic groups and socioeconomic (SES) strata. Methods We performed a retrospective cross‐sectional study using all eligible TRICARE beneficiaries aged 45–64 years between FY 2018 and 2021. High‐risk individuals, those with a previous or current CRC diagnosis, and/or a personal/family history of colonic polyps, were excluded. The pre‐COVID‐19 period (September 1, 2018–March 31, 2020) was compared to the COVID‐19 period (April 1, 2020–September 30, 2021). Secondary analyses were performed, evaluating the interaction between the COVID‐19 time period, race, and our proxy for socioeconomic status. Results During the study period, we identified 1,749,688 eligible individuals. Following the onset of the COVID‐19 pandemic, CRC screening overall decreased from 34% in the pre‐pandemic period to 30% following the onset of the pandemic (p < 0.001). This finding persisted even after adjusting for confounders in multivariable analysis (odds ratio [OR] for the pandemic timeframe: 0.79; 95% CI: 0.27, 0.31; p < 0.001). In the setting of SES, in the pandemic period, the odds of individuals from both Senior Enlisted (OR: 0.55; 95% CI: 0.54, 0.56) and Junior Enlisted sponsor ranks (OR: 0.27; 95% CI: 0.25, 0.30) were diminished as compared to Senior Officers. Conclusions and Relevance We found a 21% reduction in the odds of CRC screening in the context of the COVID‐19 pandemic. Reductions in colonoscopies and other types of screening tests were not offset by changes in the use of at‐home tests such as Cologuard

Chemoprophylaxis in contacts of patients with cholera: systematic review and meta-analysis.

INTRODUCTION: There is a pressing need for effective measures to prevent the spread of cholera. Our systematic review assesses the effects of chemoprophylaxis in preventing cholera among exposed contacts. METHODS AND FINDINGS: We considered published and unpublished reports of studies up to July 2011. For this we searched: PubMed (1966 to July, 2011), Embase (1980 to July 2011), Cochrane Central Register of Controlled Trials (6; 2011), LILACS (1982 to July, 2011), the International Clinical Trials Registry Platform (July 2011) and references of identified publications. We included controlled clinical trials (randomized and non-randomized) in which chemoprophylaxis was used to prevent cholera among patient contacts. The main outcome measures were hospitalization and laboratory diagnosis of cholera in contacts for cholera patients. We assessed the risk of bias. We identified 2638 references and these included 2 randomized trials and 5 controlled trials that added up to a total of 4,154 participants. The risk of bias scored high for most trials. The combined results from two trials found that chemoprophylaxis reduced hospitalization of contacts during the follow-up period by 8-12 days (2826 participants; RR 0.54 95% CI 0.40-0.74;I² 0%). A meta-analysis of five trials found a significant reduction in disease among contacts with at least one positive sample who received chemoprophylaxis during the overall follow-up (range 4-15 days) (1,414 participants; RR 0.35 95% CI 0.18-0.66;I² 74%). A significant reduction in the number of positive samples was also found with chemoprophylaxis (3 CCT; 6,918 samples; RR 0.39 95% CI 0.29-0.51;I² 0%). CONCLUSION: Our findings suggest that chemoprophylaxis has a protective effect among household contacts of people with cholera but the results are based on studies with a high risk of bias. Hence, there is a need for adequate reliable research that allows balancing benefits and harms by evaluating the effects of chemoprophylaxis

Trends in breast cancer screening during the COVID‐19 pandemic within a universally insured health system in the United States, 2017–2022

Abstract Background In the United States, breast cancer is the most commonly diagnosed cancer and second leading cause of cancer death in women. Early detection through mammogram screening is instrumental in reducing mortality and incidence of disease. The COVID‐19 pandemic posed unprecedented challenges to the provision of care, including delays in preventive screenings. We examined trends in breast cancer screening during the COVID‐19 pandemic in a universally insured national population and evaluated rates across racial groups and socioeconomic strata. Methods In this retrospective open cohort study, we used the Military Health System Data Repository to identify female TRICARE beneficiaries ages 40–64 at average risk for breast cancer between FY2018 and FY2022, broken down into prepandemic (September 1, 2018–February 28, 2020), early pandemic (March 1, 2020–September 30, 2020), and late pandemic periods (October 1, 2020–September 30, 2022). The primary outcome was receipt of breast cancer screening. Results Screening dropped 74% in the early pandemic period and 22% in the late pandemic period, compared with the prepandemic period. Compared with White women, Asian/Pacific Islander women were less likely to receive mammograms during the late pandemic period (0.92RR; 0.90–0.93 95%CI). American Indian/Alaska Native women remained less likely to receive screenings compared with White women during the early (0.87RR; 0.80–0.94 95% CI) and late pandemic (0.94RR, 0.91–0.98 95% CI). Black women had a higher likelihood of screenings during both the early pandemic (1.10RR; 1.08–1.12 95% CI) and late pandemic (1.12RR, 1.11–1.13 95% CI) periods compared with White women. During the early and late pandemic periods, disparities by rank persisted from prepandemic levels, with a decrease in likelihood of screenings across all sponsor ranks. Conclusion Our results indicate the influence of race and socioeconomics on mammography screening during COVID‐19. Targeted outreach and further evaluation of factors underpinning lower utilization in these populations are necessary to improve access to preventative services across the population

The response of the Military Health System (MHS) to the COVID-19 pandemic: a summary of findings from MHS reviews

Abstract Introduction The coronavirus disease 2019 (COVID-19) pandemic caused major disruptions to the US Military Health System (MHS). In this study, we evaluated the MHS response to the pandemic to understand the impact of the pandemic response in a large, national, integrated healthcare system providing care for ~ 9 million beneficiaries. Methods We performed a narrative literature review of 16 internal Department of Defense (DoD) reports, including reviews mandated by the US Congress in response to the pandemic. We categorized the findings using the Doctrine, Organization, Training, Materiel, Leadership, Personnel, Facilities, and Policy (DOTMLPF-P) framework developed by the DoD to assess system efficiency and effectiveness. Results The majority of the findings were in the policy, organization, and personnel categories. Key findings showed that the MHS structure to address surge situations was beneficial during the pandemic response, and the rapid growth of telehealth created the potential impact for improved access to routine and specialized care. However, organizational transition contributed to miscommunication and uneven implementation of policies; disruptions affected clinical training, upskilling, and the supply chain; and staffing shortages contributed to burnout among healthcare workers. Conclusion Given its highly integrated, vertical structure, the MHS was in a better position than many civilian healthcare networks to respond efficiently to the pandemic. However, similar to the US civilian sector, the MHS also experienced delays in care, staffing and materiel challenges, and a rapid switch to telehealth. Lessons regarding the importance of communication and preparation for future public health emergency responses are relevant to civilian healthcare systems responding to COVID-19 and other similar public health crises

A qualitative assessment of Ukraine’s trauma system during the Russian conflict: experiences of volunteer healthcare providers

Abstract Background The Russian Federation’s invasion of Ukraine is characterized by indiscriminate attacks on civilian infrastructure, including hospitals and clinics that have devastated the Ukrainian health system putting trauma care at risk. International healthcare providers responded to the need for help with the increasing numbers of trauma patients. We aimed to describe their experiences during the conflict to explore the gaps in systems and care for trauma patients to refine the Global Trauma System Evaluation Tool (G-TSET) tool. Methods We conducted qualitative key informant interviews of healthcare providers and business and logistics experts who volunteered since February 2022. Respondents were recruited using purposive snow-ball sampling. Semi-structured, in-depth interviews were conducted virtually from January-March 2023 using a modified version of the G-TSET as an interview guide. Interviews were transcribed verbatim and deductive thematic content analysis was conducted using NVivo. Findings We interviewed a total of 26 returned volunteers. Ukraine’s trauma system is outdated for both administrative and trauma response practices. Communication between levels of the patient evacuation process was a recurrent concern which relied on handwritten notes. Patient care was impacted by limited equipment resources, such as ventilators, and improper infection control procedures. Prehospital care was described as highly variable in terms of quality, while others witnessed limited or no prehospital care. The inability to adequately move patients to higher levels of care affected the quality of care. Infection control was a key issue at the hospital level where handwashing was not common. Structured guidelines for trauma response were lacking and lead to a lack of standardization of care and for trauma. Although training was desired, patient loads from the conflict prohibited the ability to participate. Rehabilitation care was stated to be limited. Conclusion Standardizing the trauma care system to include guidelines, better training, improved prehospital care and transportation, and supply of equipment will address the most critical gaps in the trauma system. Rehabilitation services will be necessary as the conflict continues into its second year