Timothy G Evans

Harnessing pluralism for better health in Bangladesh.

How do we explain the paradox that Bangladesh has made remarkable progress in health and human development, yet its achievements have taken place within a health system that is frequently characterised as weak, in terms of inadequate physical and human infrastructure and logistics, and low performing? We argue that the development of a highly pluralistic health system environment, defined by the participation of a multiplicity of different stakeholders and agents and by ad hoc, diffused forms of management has contributed to these outcomes by creating conditions for rapid change. We use a combination of data from official sources, research studies, case studies of specific innovations, and in-depth knowledge from our own long-term engagement with health sector issues in Bangladesh to lay out a conceptual framework for understanding pluralism and its outcomes. Although we argue that pluralism has had positive effects in terms of stimulating change and innovation, we also note its association with poor health systems governance and regulation, resulting in endemic problems such as overuse and misuse of drugs. Pluralism therefore requires active management that acknowledges and works with its polycentric nature. We identify four key areas where this management is needed: participatory governance, accountability and regulation, information systems, and capacity development. This approach challenges some mainstream frameworks for managing health systems, such as the building blocks approach of the WHO Health Systems Framework. However, as pluralism increasingly defines the nature and the challenge of 21st century health systems, the experience of Bangladesh is relevant to many countries across the world.

Moving towards universal health coverage: lessons from 11 country studies

In recent years, many countries have adopted universal health coverage (UHC) as a national aspiration. In response to increasing demand for a systematic assessment of global experiences with UHC, the Government of Japan and the World Bank collaborated on a 2-year multicountry research programme to analyse the processes of moving towards UHC. The programme included 11 countries (Bangladesh, Brazil, Ethiopia, France, Ghana, Indonesia, Japan, Peru, Thailand, Turkey, and Vietnam), representing diverse geographical, economic, and historical contexts. The study identified common challenges and opportunities and useful insights for how to move towards UHC. The study showed that UHC is a complex process, fraught with challenges, many possible pathways, and various pitfalls--but is also feasible and achievable. Movement towards UHC is a long-term policy engagement that needs both technical knowledge and political know-how. Technical solutions need to be accompanied by pragmatic and innovative strategies that address the national political economy context.

National spending on health by source for 184 countries between 2013 and 2040

BACKGROUND A general consensus exists that as a country develops economically, health spending per capita rises and the share of that spending that is prepaid through government or private mechanisms also rises. However, the speed and magnitude of these changes vary substantially across countries, even at similar levels of development. In this study, we use past trends and relationships to estimate future health spending, disaggregated by the source of those funds, to identify the financing trajectories that are likely to occur if current policies and trajectories evolve as expected. METHODS We extracted data from WHOs Health Spending Observatory and the Institute for Health Metrics and Evaluations Financing Global Health 2015 report. We converted these data to a common purchasing power-adjusted and inflation-adjusted currency. We used a series of ensemble models and observed empirical norms to estimate future government out-of-pocket private prepaid health spending and development assistance for health. We aggregated each countrys estimates to generate total health spending from 2013 to 2040 for 184 countries. We compared these estimates with each other and internationally recognised benchmarks. FINDINGS Global spending on health is expected to increase from US

Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development

7·83 trillion in 2013 to

Innovation for universal health coverage in Bangladesh: a call to action

18·28 (uncertainty interval 14·42-22·24) trillion in 2040 (in 2010 purchasing power parity-adjusted dollars). We expect per-capita health spending to increase annually by 2·7% (1·9-3·4) in high-income countries, 3·4% (2·4-4·2) in upper-middle-income countries, 3·0% (2·3-3·6) in lower-middle-income countries, and 2·4% (1·6-3·1) in low-income countries. Given the gaps in current health spending, these rates provide no evidence of increasing parity in health spending. In 1995 and 2015, low-income countries spent

Changing global policy to deliver safe, equitable, and affordable care for women’s cancers

0·03 for every dollar spent in high-income countries, even after adjusting for purchasing power, and the same is projected for 2040. Most importantly, health spending in many low-income countries is expected to remain low. Estimates suggest that, by 2040, only one (3%) of 34 low-income countries and 36 (37%) of 98 middle-income countries will reach the Chatham House goal of 5% of gross domestic product consisting of government health spending. INTERPRETATION Despite remarkable health gains, past health financing trends and relationships suggest that many low-income and lower-middle-income countries will not meet internationally set health spending targets and that spending gaps between low-income and high-income countries are unlikely to narrow unless substantive policy interventions occur. Although gains in health system efficiency can be used to make progress, current trends suggest that meaningful increases in health system resources will require concerted action. FUNDING Bill & Melinda Gates Foundation.

Time for mental health to come out of the shadows

By disaggregating gains in child health in Bangladesh over the past several decades, significant improvements in gender and socioeconomic inequities have been revealed. With the use of a social determinants of health approach, key features of the countrys development experience can be identified that help explain its unexpected health trajectory. The systematic equity orientation of health and socioeconomic development in Bangladesh, and the implementation attributes of scale, speed, and selectivity, have been important drivers of health improvement. Despite this impressive pro-equity trajectory, there remain significant residual inequities in survival of girls and lower wealth quintiles as well as a host of new health and development challenges such as urbanisation, chronic disease, and climate change. Further progress in sustaining and enhancing equity-oriented achievements in health hinges on stronger governance and longer-term systems thinking regarding how to effectively promote inclusive and equitable development within and beyond the health system.

The Third Global Forum: framing the health workforce agenda for universal health coverage

A post-Millennium Development Goals agenda for health in Bangladesh should be defined to encourage a second generation of health-system innovations under the clarion call of universal health coverage. This agenda should draw on the experience of the first generation of innovations that underlie the countrys impressive health achievements and creatively address future health challenges. Central to the reform process will be the development of a multipronged strategic approach that: responds to existing demands in a way that assures affordable, equitable, high-quality health care from a pluralistic health system; anticipates health-care needs in a period of rapid health and social transition; and addresses underlying structural issues that otherwise might hamper progress. A pragmatic reform agenda for achieving universal health coverage in Bangladesh should include development of a long-term national human resources policy and action plan, establishment of a national insurance system, building of an interoperable electronic health information system, investment to strengthen the capacity of the Ministry of Health and Family Welfare, and creation of a supraministerial council on health. Greater political, financial, and technical investment to implement this reform agenda offers the prospect of a stronger, more resilient, sustainable, and equitable health system.

Catastrophic healthcare expenditure and poverty related to out-of-pocket payments for healthcare in Bangladesh-an estimation of financial risk protection of universal health coverage.

Breast and cervical cancer are major threats to the health of women globally, particularly in low-income and middle-income countries. Radical progress to close the global cancer divide for women requires not only evidence-based policy making, but also broad multisectoral collaboration that capitalises on recent progress in the associated domains of womens health and innovative public health approaches to cancer care and control. Such multisectoral collaboration can serve to build health systems for cancer, and more broadly for primary care, surgery, and pathology. This Series paper explores the global health and public policy landscapes that intersect with womens health and global cancer control, with new approaches to bringing policy to action. Cancer is a major global social and political priority, and womens cancers are not only a tractable socioeconomic policy target in themselves, but also an important Trojan horse to drive improved cancer control and care.

Shaping of a new era for health financing

2274 www.thelancet.com Vol 387 June 4, 2016 Mental disorders, such as depression, anxiety, and substance use disorders, impose an enormous global disease burden that leads to premature mortality and aff ects functioning and quality of life. If left untreated, mental disorders can result in worse treatment adherence and outcomes for commonly co-occurring diseases, such as tuberculosis, diabetes, cardiovascular disease, and cancer. Yet parity between mental and physical health conditions remains a distant ideal. Poor mental health also impacts on economic development through lost production and consumption opportunities at both the individual and societal level. Unfolding tragedies, such as the confl ict in Syria, displaced populations in Colombia, the burgeoning refugee crisis in the Middle East and Europe, and reconstruction eff orts after natural disasters in Japan and Nepal or disease outbreaks such as Ebola virus in west Africa, compound mental health needs of aff ected populations. But the mental health aspect of these crises is often overlooked. To highlight the scale of these issues, and the gains from addressing them, the World Bank Group and WHO co-hosted the Out of the Shadows: Making Mental Health a Global Priority meeting in April, 2016. This event aimed to put the mental health agenda at the centre of global health and development priorities by spurring eff orts to: increase awareness about mental health as a development challenge and the associated economic and social costs of inaction; debate the economic and social benefi ts of investing in mental health; and identify ways for stakeholders to act across sectors. Jim Yong Kim, President of the World Bank Group, and Margaret Chan, Director-General of WHO, along with other leaders, called for a collaborative response to tackle mental health as a development challenge by pursuing multidisciplinary approaches that encompass integrated health services at the community level, in schools and in workplace programmes, and initiatives to address the mental health and psychosocial needs of displaced populations. Funding is needed to build upon social protection and employment schemes that facilitate the reintegration of aff ected persons back into their communities. New pledges were made and existing commitments to mental health were reaffi rmed. The World Bank stated its intention to incorporate mental health into its programmes and activities across sectors, including health, education, social protection, fragility, emergencies and reconstruction, and confl ict and violence. This support included a commitment to champion mental health parity in the provision of health services, as part of its programmes to support the realisation of universal health coverage. Complementing these commitments, WHO announced its continued commitment to support and monitor implementation of the Mental Health Gap Action Plan (mhGAP), which aims to scale up mental health services in low-income and middle-income countries. WHO also announced that the next WHO-led World Health Day in April, 2017, will be devoted to depression and suicide. The business sector committed to working towards a more supportive work environment. A promising initiative is the seven-step guide to workplace mental health, developed by the World Economic Forum’s Global Agenda Council on Mental Health. Another focus was the contribution of business to mental health in the development of new technologies, such as mHealth, that can help improve access to care and reach vulnerable populations. Researchers committed to generating evidence and pioneering new approaches to address the challenges of mental health prevention, detection, and treatment. The Innovation Fair, co-organised by the Mental Health Innovation Network and funded by the Wellcome Trust with contributions from Grand Challenges Canada and the US National Institute of Mental Health, off ered many innovative approaches in mental health that can be used at scale and implemented in low-resource settings, even in the context of fragility and confl ict. As a key next step in generating new evidence and advancing research, the Global Alliance for Chronic Diseases announced the launching of a US