BMC Health Services Research

Essential medicines are one of the cornerstones of financial protection and health equity. The REMEDIAR Program is an initiative of the Argentine Ministry of Health aimed at ensuring free access to essential medicines for the uninsured at the point of care in primary healthcare centers (PHC). This study analyzes the financing, procurement, and distribution of this program over two decades (2002 to 2024). It evaluates how the program's capacity to navigate economic and political challenges ensured an uninterrupted supply of essential drugs at the primary healthcare level in a federal country where health services are devolved to provinces. We adopted a mixed-methods approach to examine the duality between international concessional loans and domestic treasury funding. Findings reveal that while international financing enhanced predictability and efficiency, reducing procurement timelines from 458 to 235 days, it also constrained domestic planning through external conditionalities. Conversely, while national centralized procurement achieved superior price efficiency and lower dispersion, it faced rigidities in adapting to local needs. Territorial distribution analysis confirms that REMEDIAR reduced access barriers for vulnerable households without formal insurance. However, the program entered a stabilization phase, failing to consolidate robust coordination with subnational policies, becoming entrenched in its own operational logic. The study concludes that program effectiveness depends not only on resource volume but on management quality. To guarantee long-term sustainability, transition to national financing requires profound institutional redesign. This must integrate operational capacities with federal coordination and domestic regulations, ensuring that the primary healthcare supply chain remains resilient to macroeconomic volatility and political shifts, aligned with sub-national strategies.

Introduction. Practice coaching is increasingly used to strengthen quality improvement (QI) capacity in primary healthcare (PHC) systems in low and middle income countries (LMICs), yet the causal pathways through which it shifts provider behaviour, and the systemic conditions that enable or constrain those pathways, remain under theorised. Using a theory based qualitative evaluation, we examined how and why a practice coaching intervention influenced QI in cervical cancer screening (CCS) and antenatal care (ANC) within Honduras decentralised PHC system during the third phase of the Salud Mesoamerica Initiative (SMI). Methods. We conducted a within case explanatory case study. A programme theory was reconstructed before data collection and iteratively refined against evidence. Data comprised semi structured interviews with 11 midlevel managers, 6 PHC team medical leads, and 2 regional managers, complemented by direct observation and document review. We applied combined deductive and inductive coding, thematic analysis, and pattern matching, and reporting per COREQ. Results. We identified four causal patterns that refined the initial programme theory. Three were activated pathways: (1) novel professional identity among participating managers; (2) collective efficacy and data driven learning, sustained through verifiable progress on observable indicators, strong for CCS but null for ANC, where outcomes were less attributable to teams actions; and (3) relational coordination, psychological safety, and trust, which provided the interpersonal basis for the first two. A fourth, unanticipated pattern showed structural misalignment between coaching enabling, learning based logic and the directive, punitive logic of Honduras performance based contracting environment, confining gains to localised enabling bubbles. Conclusion. Coaching can activate meaningful QI pathways in LMIC primary care, but sustained, equitable impact requires deliberate alignment between coaching learning oriented principles and the institutional performance management architecture, and matching of coaching investment to clinical processes with observable, attributable outcomes.

Abstract Background: Emergency Department (ED) populations are a high-risk group that are opportune for interventions targeting NCDs and NCD risk factors, like tobacco use. Mobile health (mHealth)interventions such as Text2Quit, a novel text message-based mHealth tool addressing tobacco cessation in the US, have demonstrated effectiveness for tobacco cessation and for ED-based mHealth interventions in High Income Countries (HIC). To successfully adapt and implement such mHealth interventions in limited resource settings like African EDs, it is essential to examine the implementation climate and engage key stakeholders. These implementers provide invaluable insight to understand healthcare system level factors that affect adoption, implementation and maintenance of the interventions. Methods: We conducted 12 semi-structured key informant interviews (KIIs) with ED administrators and staff including 2 departmental heads, 5 medical doctors, 3 nurses, and 2 clinical officers at a national referral hospital in Kenya. This was guided by RE-AIM framework indicators of Adoption, Implementation, and Maintenance (eg feasibility of intervention integration, and suggestions to improve implementation). Interviews were conducted in English, recorded, professionally transcribed and translated, and analyzed using a constant comparative analysis approach, according to grounded theory principles. Findings: Key informants were positive about the adoption of them Health intervention in Kenyan EDs and across different health facility levels in Kenya due to the perceived need for the program, facility and staff receptiveness and existing healthcare infrastructure to leverage. Recommended implementation strategies included follow-up mechanisms for program participants, inclusion of all healthcare cadres in implementation and increased sensitization and the use of champions. Barriers to Implementation in the ED included competing clinical priorities with emergency cases, limited staffing and shame associated with smoking. Conclusion: Implementing a mobile health tobacco cessation program like Text2Quit is feasible and acceptable in Kenyan EDs when supported by targeted strategies.

Background: Health-related social needs (HRSNs), particularly housing instability, are significant drivers of poor health outcomes among Medicaid populations. New York State's Social Care Networks (SCNs) aim to systematically connect members to housing services through coordinated referral systems. However, limited systematic analysis of referral patterns hinders quality improvement efforts. We analyzed housing referral outcomes and workflows to identify barriers to successful service connections. Methods: We conducted a mixed-methods quality improvement study at Public Health Solutions' WholeYouNYC SCN Coordination Center. Quantitative analysis examined 4,258 housing referrals submitted between June 2025 and January 2026, extracted from the Unite Us platform via Power BI dashboard. We calculated acceptance rates, analyzed time metrics, and examined outcomes by receiving organization. Qualitative data were collected through structured consultations with 7 staff members (5 navigators, 2 supervisors) and review of internal workflow documentation. Process mapping identified workflow bottlenecks. Results: Of 4,258 housing referrals, only 45% (n=1,936) were accepted by receiving organizations, while 19% (n=815) were rejected and 32% (n=1,382) remained awaiting response with no recorded action. Average time to acceptance was 8 days for accepted referrals. Acceptance rates were consistent across top receiving organizations (44-46%), suggesting systemic rather than partner-specific barriers. Analysis of unresolved referrals revealed prolonged cases, with the longest pending 271 days. Three critical workflow bottlenecks were identified: CBO response delays, missing housing documentation, and challenges with client engagement. Conclusions: Low housing connection rates (45%) and prolonged unresolved referrals (up to 271 days) indicate systemic barriers requiring interventions at multiple levels. Recommendations include establishing CBO response time benchmarks, implementing automated follow-up protocols, standardizing documentation requirements, and enhancing real-time data monitoring. These findings provide an evidence-based framework for quality improvement in social care coordination programs.

Objectives People with mental health conditions experience increased rates of diagnostic errors and delays in acute treatment. While causes such as diagnostic overshadowing (misattribution of physical symptoms to mental health conditions) are well documented, less attention has been paid to the organisational and structural conditions that shape diagnostic work. This study examines how physical illness is diagnosed in patients with mental health conditions in emergency departments (EDs), with a focus on the structural conditions that enable or constrain safe diagnostic practice. Method We conducted a multi-site ethnography across three purposively selected EDs in England between April 2023 and April 2024, varying in size, population demographics, and local service configuration. Data were collected through 284 hours of non-participant observation and 20 semi-structured interviews with ED staff. Results Our analysis identified four recurring structural gaps that shaped the conditions under which physical health diagnosis took place for patients with mental health conditions: a design gap, whereby targets and physical layouts constrained diagnostic reasoning; a preparedness gap, reflecting the lack of structural support to allow staff to act on their existing knowledge and skills; a coordination gap, reflecting fragmented ownership and the challenges of joint assessment across mental and physical healthcare teams; and an expectation gap, whereby unmet need elsewhere in the system increased demand for ED services that were beyond its formal scope. These gaps made diagnostic errors and delay more likely for patients with mental health conditions seeking physical healthcare in the ED. Conclusions As new dedicated mental health EDs are introduced in England, there is an opportunity to avoid reproducing these structural gaps in new settings. Our study suggests that improving physical healthcare for patients with mental health conditions requires changes to how EDs are designed, resourced and supported, and how they connect with the wider health and care system. Keywords: mental health, diagnostic inequality, emergency departments

Introduction: Differentiated service delivery (DSD) models aim to reduce time healthcare providers spend with DSD clients, increasing time available for non-DSD clients. We measured nurses' time allocation and explored their experiences with DSD models in South Africa. Methods: We conducted time and motion observations and surveyed nurses at 24 public primary healthcare facilities across two SENTINEL study rounds (09/2022-07/2023 and 11/2023-07/2024). We report median time nurses spent by activity, model of care, and interaction type. Log binomial regression investigated factors associated with high direct nurse-client interaction (above median minutes) and extended work-days ([&ge;]9 hours), and estimated adjusted risk ratios (aRR). Survey questions were related to client care, additional time availability, and policy changes post DSD implementation, with key themes presented alongside illustrative quotes. Results: 176 nurses (88% female, median age 44) were observed for 344 working days; of these, 60 (34%) participated in the provider survey. Nurses spent a median of 293 minutes (53% of their work-day) on direct nurse-client interaction, 89 minutes (22%) on client-support or facility-related tasks, and the remainder on other activities including personal breaks. Time spent per client was similar across conventional care clients (11 [IQR: 8-15] minutes) but ranged between 9 (7-13) to 11 (8-15) minutes for DSD clients; number of direct nurse-client interactions did not differ meaningfully. Nurses at facilities with 2,000-3,999 total remaining on ART (TROA) (aRR 1.56, 95% CI: 1.02-2.37) and in urban areas (aRR 1.43, [1.08-1.89]) had more direct nurse-client interactions than those at facilities with <1,999 TROA and in rural areas, respectively. Nurses at facilities with 4,000+ TROA (aRR 2.22, [1.36-3.63]) and those observed in SENTINEL 3.0 (aRR 1.53, [1.13-2.07]) were more likely to work standard or longer workdays than those at lower TROA facilities (<1,999), those in SENTINEL 2.0 and urban areas. Nurses reported DSD models improved client care (90%), freed up time (60%), and changed clinic procedures and policies (60%). Conclusions: While DSD models did not significantly reduce direct nurse-client interaction time, nurses reported improved client care and gained additional time. DSD impact may vary by facility context. As DSD implementation expands, effective time reallocation may enhance facility performance and provider productivity.

Background: Strong management capacity is essential for effective primary healthcare (PHC) service delivery and health system strengthening [1]. The AURUM Management Development Programme (MDP) was implemented to strengthen district and PHC leadership in the Western Cape province of South Africa. This study explored the contextual barriers and enabling conditions influencing the scalability of the programme within district health systems. Methods: This study employed a qualitative exploratory design to investigate barriers and enablers associated with scaling the MDP. In-depth interviews were conducted with purposively selected district health managers from three Western Cape districts. Interviews were audio-recorded, transcribed verbatim, and analysed thematically using NVivo 14. The study explored perceptions regarding programme adaptability, district readiness, implementation challenges, and enabling conditions for sustainability and scale-up. Results: Twenty participants (7 males and 13 females) from the Cape Winelands, Garden Route, and Cape Town Metro district health offices were interviewed. The MDP was viewed as relevant, practical, and adaptable to district health system contexts. District readiness for implementation emerged as an important determinant of perceived programme success. High readiness was characterised by clear team roles, strong management structures, decentralised decision-making, digital tool utilisation, ongoing mentorship systems, and prior exposure to PHC reforms such as the Ideal Clinic Realisation and Maintenance (ICRM) programme. Lower readiness was associated with staff shortages, operational pressures, limited leadership support, and partially functional health systems. Key enabling factors included integration with existing training structures, visible improvements in service delivery, mentorship support, and active engagement from district leadership. Conclusion: The MDP demonstrates potential for scalability within South Africas public health system. However, successful scale-up depends on district-level readiness, supportive leadership structures, integration into existing training and management systems, and sustained mentorship and implementation support.

Background: The rising prices of cancer medicines have intensified concerns about treatment access and health system sustainability particularly in low- and middle-income settings. Systematic facility level evidence on what medicines is actually available, at what prices, and at what cost to patients remains scarce, constraining evidence-based policy reform. Methods: Using adapted WHO/Health action international methodology, we conducted a cross-sectional survey of 52 cancer medicines across five therapeutic classes at five health facilities in Kisumu County, Kenya. Availability was measured as the proportion of facilities stocking each medicine. Affordability was assessed using days' wages required for the lowest-paid government worker to purchase standard treatment regimens, calculated per one chemotherapy cycle and maximum possible cycles. Results: Overall medicine availability was 48.1%, with marked inter-facility variation. Affordability analysis revealed severe financial barriers. The breast cancer AC regimen required 19.6-47.4 days' wages per full course; cervical cancer cisplatin, 19.8-49.2 days' wages; colorectal FOLFOX, 80.0-303.6 days' wages; and prostate docetaxel reached 437 days' wages at the highest-cost facility. The Social Health Authority's (SHA) KES 550,000 annual ceiling adequately covered cytotoxic regimens for common cancers at competitive prices but was exceeded by 24-116% for HER2-positive breast cancer requiring trastuzumab, with further strain for recurrent cervical and metastatic prostate cancers. Conclusions: Cancer medicines in Kisumu County are inconsistently available and highly variable in price resulting in inequitable access. We call for urgent retail price markup regulation, expanded pooled procurement through KEMSA, inclusion of priority targeted therapies on the Kenya Essential Medicines List, and SHA benefit packages redesigned around full-course regimen costs.

Background: Adults with severe mental health conditions (often referred to as severe mental illness, SMI) experience 15 to 20 year mortality gap relative to the general population, with lung cancer a significant contributor. National cancer policy targets earlier diagnosis but does not explicitly address how pathways function for this group. Aims: This study aimed to describe lung cancer risk, prevalence, screening eligibility, referral activity and diagnostic pathway performance for adults with SMI in South East London (SEL), and to examine where along the pathway inequalities arise. Methods: Co-designed with experts with lived experience and voluntary sector, this exploratory mixed-methods service evaluation combined quantitative analysis of routinely collected data from the Quality Outcomes Framework (QOF), SMI Register and Cancer Waiting Times Record (April 2023-March 2024) with semi-structured qualitative interviews (n=11 clinical staff) and focus groups (n=6 adults with lived experience of SMI). Quantitative and qualitative data were analysed using descriptive statistics and framework-based thematic analysis respectively, and findings were integrated using a joint display approach, organised by the Consolidated Framework for Implementation Research (CFIR). Results: Lung cancer prevalence was approximately double among adults with SMI (0.17% vs 0.09% in the general population). Despite Urgent Suspected Cancer (USC) referral rates being more than twice as high in the SMI population (63 vs 28 per 100,000), fewer cancers were detected via planned general practice (GP) routes (11% vs 20%), the 28-day Faster Diagnosis Standard was not met for any SMI patient diagnosed with lung cancer during the study period; overall FDS performance was 76% in the SMI population compared with 84% in the general population; and appointment non-attendance was more than double that in the general population (6% vs 3%). Qualitative findings identified individual, service and system-level mechanisms, including stigma, diagnostic overshadowing, fragmented coordination, and rigid pathway protocols, that compound disadvantage across lung cancer pathway stages. Conclusions: Inequality in lung cancer outcomes for adults with SMI accumulates across the pathway rather than arising at a single point of failure. Addressing this requires proportionate adaptations within existing cancer pathways, alongside routine reporting of cancer outcomes stratified by SMI population. Keywords: severe mental health conditions, lung cancer, health inequalities, cancer screening, diagnostic pathway, mixed methods

Primary healthcare (PHC) managers are central to the functioning of South Africas healthcare system, yet many assume leadership roles without formal management training. To address this gap, the Aurum Institute developed the Management Development Programme (MDP), a structured leadership and management training intervention aimed at strengthening PHC management competencies. This study evaluated the impact of the MDP on leadership practices, organisational readiness for change, and workplace stress among PHC managers in the Western Cape Province. A non-randomised matched cluster trial was conducted across 20 PHC facilities. Intervention facilities were purposively selected based on participation in the MDP, while matched control facilities were randomly selected. Data were collected using structured and semi-structured surveys administered to facility managers and clinic staff. Leadership competency was assessed using the Leadership Practices Inventory (LPI), which measures five dimensions of exemplary leadership: Model the Way, Inspire a Shared Vision, Challenge the Process, Enable Others to Act, and Encourage the Heart. Organisational readiness for change was measured using Kotters 8-Step Framework, while workplace stress was assessed using a 13-item version of the Brief Job Stress Questionnaire focusing on Job Meaning, Environmental Quality, Autonomy, and Control. Intervention effects were estimated using generalised linear models adjusted for manager age, years in role, matched-pair fixed effects, and cluster-robust standard errors. Outcomes were reported as adjusted risk differences with 95% confidence intervals and two-sided p-values. A total of 20 facility managers (median age 51 years; IQR 42-55; 90% female) and 105 clinic staff members (median age 42 years; IQR 35-50) participated in the study. Managers in both intervention and control facilities reported consistently high self-rated leadership competency scores across all LPI domains, with no statistically significant differences between groups. Similarly, clinic staff rated managers highly across the standard LPI domains, and no significant differences were observed between intervention and control facilities. Despite the absence of significant differences in overall leadership competency scores, staff in intervention facilities reported significantly stronger relational and communication practices among managers compared with staff in control facilities (72.7% vs. 64.0%; adjusted risk difference 22.0%, 95% CI 6.1-37.8; p=.007). After adjustment for age and tenure imbalances, intervention facilities also demonstrated significantly higher scores for institutionalised capability and learning culture (adjusted risk difference 21.3%, 95% CI 0.6-42.0; p=.043). Managers who participated in the MDP further reported stronger perceptions of district support, including improved internal leadership and cultural readiness (adjusted risk difference 22.1%, 95% CI 14.0-30.3; p<.001) and greater district leadership and resource availability (adjusted risk difference 28.1%, 95% CI 15.6-40.6; p<.001). No statistically significant differences were observed in workplace stress across any domain. Although the MDP did not produce measurable short-term improvements in managers self-rated leadership competencies or standard LPI domains as assessed by staff, it was associated with important gains in relational leadership practices, organisational readiness for change, and perceived district support. These findings suggest that structured management training programmes may strengthen critical organisational and interpersonal foundations necessary for sustained performance improvement within PHC settings.

Abstract Objective To Estimate cost of integrating HBV, HCV, and HIV screening at Antenatal using Time-Driven Activity Based Costing (TDACB) Approach; A providers perspective comparing Intervention and standard of care at lower health facilities in West Nile sub region, Uganda Methods Design The Time Driven Activity-Based Costing (TDABC) approach was used to capture resource use and costs associated with delivering integrated HBV, HCV, and HIV screening among pregnant women. This study compared screening uptake among study participants in the intervention, and control group respectively. Five lower health facilities in Koboko and Maracha districts respectively in West Nile region of Uganda. A total of 1,338 study participants wo were pregnant mothers in first ANC, first trimester at the selected 10 facilities were enrolled in this study. Data were abstracted, and also collected on; Personnel/staff time; facility space utilisation; and Medical and non-medical equipment. Total cost per patient visit=Staff time costs+Space cost Equipment cost. Outcome Measure was the estimated provider-perspective costs of delivering integrated screening for HBV, HCV and HIV, using Integrated Care Model by comparing intervention and control groups. Results Staff CCRs demonstrated considerable variability across cadres and facilities, with an overall mean of USD 0.492 per minute (Range: USD 0.167 - 1.318). Laboratory technicians exhibited the highest mean CCR at USD 0.767 per minute for personnel CCRs per patient visit. the mean lowest CPP visit was noted for HBV in the intervention arm (USD 11.43) while HIV test was the lowest in the control arm (USD 0.43). HCV test had the highest cost in the control arm (USD 0.52). The CPP visit for positive clients were generally higher than those that were negative. Equipment CCRs were minimal and highly consistent across facilities, with a mean of USD 0.00069 per minute ({+/-}0.0002). HIV/Syphilis combo was the costliest test kits at USD 3.14 per test kit followed by viral hepatitis C test kit and Hep B at USD 2.47 and USD 0.28 respectively. Facility space CCRs exhibited moderate variation across facilities, ranging from USD 0.01593 to USD 0.03474 per minute. Overall mean CCR for the space for delivering HBV, HCV or HIV testing was USD 0.0256 (0.0066). Conclusion; Overall, the integration of screening resulted in: Cost efficiencies where the same staff and space were used for multiple simultaneous tests, reduced marginal costs for HIV tests due to larger procurement volumes, and higher marginal cost additions for HBV and HCV due to pricier reagents.

Background In the Democratic Republic of the Congo (DRC), health care financing relies heavily on out-of-pocket payments, limiting access to essential services. In a context of declining external funding and ongoing efforts toward Universal Health Coverage (UHC), understanding households willingness to pay (WTP) for health care is critical for designing sustainable financing strategies. This study aimed to assess WTP for primary health care services and identify its associated factors in Eastern Kasai Province. Methods A cross-sectional study based on the contingent valuation method was conducted from 10 to 30 July 2025 among 633 randomly selected households using a multistage probabilistic sampling approach. Data were collected through semi-structured interviews using KoboToolBox. WTP was assessed using a stated preference approach. Logistic regression analyses using R 4.5.0 were performed to identify factors associated with WTP at a significance level of p < 0.05. Adjusted odds ratios (aORs) with 95% confidence intervals (95% CI) were reported. Results Overall, 70% of household heads reported willingness to pay for their own health care, and 73% for other household members. WTP decreased significantly as the cost of services increased, dropping from 95.5% for free care to 6.3% at the highest cost levels (above CDF 230,000). Poor perceived quality of care was a consistent reason for refusal, alongside financial constraints such as low income and indebtedness. Multivariable analysis showed that having a professional activity (OR = 1.9; 95% CI: 1.2-3.0; p = 0.006), residence in rural areas (OR = 2.1; 95% CI: 1.3-3.7; p = 0.008), and higher household income (OR = 2.2; 95% CI: 1.2-4.0; p = 0.011) were significantly associated with WTP. Despite relatively low absolute health care costs, the majority of households perceived them as high. Conclusion Willingness to pay for health care services in Eastern Kasai is moderate but highly sensitive to cost and strongly influenced by socioeconomic conditions and perceived quality of care. These findings underscore the need to strengthen financial protection mechanisms, particularly prepayment and risk-pooling systems, while improving service quality to enhance health care utilization and progress toward UHC in the DRC.

Objective: To identify facility-level characteristics - including care level, ownership type, and funding model - associated with poor HIV treatment outcomes, and quantify their independent contributions after adjustment for patient-level clinical factors. Design: Retrospective cross-sectional analysis using multivariable logistic regression with HC3 cluster-robust standard errors to account for facility-level clustering. Setting: HIV care facilities in the Nigerian national HIV programme, spanning primary health centres, secondary health facilities, and tertiary hospitals. Participants: 27,288 HIV-positive patients enrolled on ART, from a publicly available de-identified Quality of Care dataset. Main outcome measures: Composite poor outcome (poor ART adherence, treatment interruption, or mortality); individual outcomes including poor adherence rate, mortality, ART interruption, and diagnosis-to-ART delay exceeding 90 days. Results: Primary health centres had 15.4% composite poor outcome versus 10.2% at tertiary hospitals. After adjustment for patient age, sex, WHO stage, and CD4 count, primary health centre patients had 95% higher odds of poor outcome (OR=1.95; 95%CI 1.45-2.61; p<0.001). NGO-funded facilities had 24% higher odds (OR=1.24; 95%CI 1.10-1.39; p<0.001) and federally funded facilities 25% higher odds (OR=1.25; 95%CI 1.06-1.48; p=0.008). Female sex was independently protective (OR=0.87; 95%CI 0.79-0.96; p=0.003). Diagnosis-to-ART delays exceeded 90 days in 47.3% of patients, with significant variation by facility level (chi-squared=49.4, p<0.001). Conclusions: Facility level and funding model independently predict HIV treatment outcomes after patient-level adjustment. Primary health centres and NGO/federally funded facilities may require targeted quality improvement support. These findings have direct implications for PEPFAR, the Global Fund, and national HIV programme managers.

While significant progress has been made in perinatal outcomes over recent decades in low- and middle-income countries (LMICs), maternal and newborn quality improvement initiatives often fail to account for the spatial conditions in which they are implemented. Health systems are increasingly deploying evidence-based care models into built environments that are not optimally structured to meet the needs of its patient population. As the principal users, patients and health care workers can offer pragmatic insights about improving these structural designs. Our objective was to gather insights from patients, providers, and companions about how the physical design of their health facilities influenced their experience receiving or delivering perinatal care. We conducted a prospective observational study using a human-centred design (HCD) approach to analyse perceptions of the quality of perinatal care across two low resource settings: Ethiopia and Bangladesh. Using engagement and assessment tools, we conducted interviews, focus groups, facility walk-throughs, co-design workshops, and infrastructural assessments with patients, companions, providers, and Ministry of Health representatives. Descriptive statistics and thematic analysis were used to identify key learnings and develop recommendations. Across both countries, participants identified the need for facility layouts that better support privacy, mobility during labour, alternative birth positions, companion involvement, cultural and religious practices, sanitation, and provider visibility. Based on these insights, we developed six recommendations to better align health facility infrastructure with maternal and newborn care delivery needs. Our findings suggest that investments in health facility infrastructure may improve care experiences and help enable respectful, safe, and evidence-based maternal and newborn care. Alongside targeted spatial improvements, government authorities responsible for health facility planning should incorporate participatory design processes to ensure infrastructure reflects the needs of patients, companions, and providers and supports high-quality care delivery.

Adolescent girls and young women (AGYW) in Ethiopia face persistent barriers to accessing quality sexual and reproductive health (SRH) services, including limited information, stigma, and lack of youth-responsive care. This study aimed to compare the efficacy of digitized versus paper-based counselling tools within an intervention designed to address behavioral and structural barriers contributing to low contraceptive use among AGYW, by reframing contraception as a tool to achieve their life goals. The study employed a cross-sectional mixed-methods design, including client exit interviews with 302 AGYW, key informant interviews with 18 Health Extension Workers (HEWs), secondary analysis of service delivery data from DHIS2, and costing data from program records. Quantitative data were analyzed using descriptive statistics and chi-square tests. Qualitative data were thematically analyzed. Digital counselling was significantly associated with higher MII Plus scores (93% vs. 73.8%, p=0.001), client knowledge of side effects, and confidence in discussing and managing contraception. Clients rated paper-based tools as easier to understand, but digital tools enhanced comprehension, goal-setting, and integration of financial planning and reproductive health concepts. HEWs reported improved consistency in counselling, better referrals, and operational efficiencies with digital tools. Challenges included device glitches, limited connectivity, and variable digital literacy, often requiring concurrent use of paper and digital tools. This study shows that transitioning from paper-based to digital counselling tools improved service quality, client engagement, and informed contraceptive decision-making. Higher MII Plus scores and positive client experiences indicate more standardized, participatory, and respectful counselling. Providers reported operational benefits, including easier counselling and improved data management, though productivity gains were limited. Implementation challenges highlight the need for context-sensitive strategies, ongoing training, and supportive supervision during digital integration. Importantly, the findings suggest that digital tools can improve how services are delivered (quality and consistency), even when service volume remains stable.

Background Tanzanias Direct Health Facility Financing (DHFF) reform was introduced to strengthen primary health care through decentralized financing, autonomy, and accountability, but persistent weaknesses in monitoring and evaluation (M&E) data management and use continue to constrain implementation effectiveness, particularly in rural settings. Methods A convergent mixed-methods design was used to examine how M&E data management and use influence DHFF implementation effectiveness in an urban council (Kinondoni Municipal Council, KMC) and a rural council (Morogoro District Council, MDC), while also assessing the role of stakeholder perceptions of the DHFF M&E framework and contextual variation. Quantitative data were analyzed using descriptive statistics, relative importance indices, regression and ANOVA, while qualitative data from key informant interviews and focus group discussions were thematically analyzed and triangulated with quantitative results. Results Of 233 respondents analysed, 51.1% were from Morogoro District Council, 48.9% from Kinondoni Municipal Council, 51.2% worked in rural settings, 42.9% were from health centres, and 38.2% from dispensaries, providing an analytically useful spread across managerial and frontline contexts relevant to DHFF implementation. Descriptive statistics showed generally favourable perceptions across the five major constructs, with mean scores ranging from 3.09 for M&E capacity to 3.73 for urban-rural M&E practice context, while DHFF implementation effectiveness scored 3.71 overall. Data quality checks showed acceptable factor loadings above 0.4, reliability coefficients above 0.7, bivariate correlations of 0.34-0.76, and VIF values of 1.31-2.95, indicating that the dataset was screened, cleaned and analytically fit for regression and ANOVA modelling. In the aggregated model, the explanatory variables jointly accounted for about 52% of the variation in DHFF implementation effectiveness, with M&E data management and use, stakeholder perceptions of the DHFF M&E framework, and urban-rural context emerging as the most influential predictors. Qualitative testimonies clarified these patterns: one council respondent explained, "We have DHIS2... GoTHOMIS... FFARS... also PlanRep," while another facility respondent observed, "We only add up numbers for the monthly report--we dont really analyze what they mean," illustrating the contrast between data availability and meaningful local use. Conclusions DHFF implementation effectiveness in Tanzania depends substantially on robust M&E data management and use, supportive stakeholder perceptions of the M&E framework, and context-sensitive strategies that address persistent urban-rural inequities. Strengthening technical capacity, digital infrastructure, participatory governance and feedback systems is essential for sustaining DHFF gains and improving equitable service delivery.

ObjectiveTo characterize the magnitude and geographic distribution of commercially negotiated hospital facility rates for fourteen common interventional radiology (IR) procedures using publicly posted Hospital Price Transparency Machine-Readable Files (MRFs), and to describe the relationships between state-level commercial pricing, population rurality, and within-system rate uniformity. MethodsIn this cross-sectional observational analysis, we examined hospital-weighted commercial rate observations from U.S. hospital MRFs for fourteen IR procedures spanning image-guided drainage, embolization, peripheral vascular intervention, dialysis access maintenance, and percutaneous spine. The unit of analysis was one observation per distinct negotiated rate per state-CPT cell, deduplicating multi-facility same-system reporting in which two or more hospitals posted identical rate, range, and payer-count tuples. Outliers were excluded using transparent absolute and CMS-relative bounds. State-level statistics were computed where [&ge;]5 distinct hospital-system observations were reported. Commercial rates were compared to CY 2026 CMS Outpatient Prospective Payment System (OPPS) facility payments. Relationships between state-level commercial rate and 2020 U.S. Census percent-rural population were assessed by Spearman rank correlation. ResultsAcross 14 procedures, state-level commercial median rates varied 3.7-to 8.3-fold between the highest- and lowest-priced states. The largest spreads were observed for fem-pop angioplasty (CPT 37224, 8.3-fold), fem-pop atherectomy (37225, 8.1-fold), and iliac stenting (37221, 7.1-fold). National median commercial rates ranged from 1.34x (PAE/GAE) to 3.60x (paracentesis) the corresponding CMS OPPS facility payment. Across all 14 procedures, the relationship between state percent-rural and median commercial rate was negative (mean Spearman {rho} = -0.46, range -0.33 to -0.80; 14 of 14 codes negative), with the most-rural quartile of states showing a median commercial rate 42% below the most-urban quartile. Deduplication identified 660 multi-facility groups in which a single negotiated rate was applied across two or more affiliated hospitals within a state. DiscussionSubstantial state-level variation in commercially negotiated facility rates exists for common IR procedures, with consistently lower rates in more rural states. Within-system rate uniformity is a frequent feature: many regional health systems post identical commercial rates across multiple owned facilities. The findings are consistent with prior literature linking commercial pricing to market structure and support continued investment in price transparency as a precondition for informed decision-making.

Background High Intensity Use of urgent medical services by patients is widely recognised in urgent and emergency care. Studies of high intensity use of the emergency department have consistently shown features of complex systems behaviour in addition to highly heterogeneous individual patient characteristics. There have been no comparable studies of prehospital care use. Methods We examined the use of prehospital urgent and emergency services (NHS 111 and ambulance dispatch) using routinely collected data from regional service in the UK (population 5 million). We used a complex systems perspective, to examine (1) distribution of contacts per individual; (2) the temporal stability of service use by individuals and at the whole-system level (3) the distribution of bursts of contacts. Results We analysed data from 847555 individuals who contacted NHS111 and 389550 who contacted the ambulance dispatch service. 35120 (4.2%) individuals who contacted NHS111 had 5 or more contacts with the service over the two-year period and accounted for 290625 (20.1%) of contacts. 16755 (4.3%) individuals had 5 or more ambulance dispatch contact days and accounted for 169085 (25.8%) of contacts. The distribution of contacts per individual showed a monotonic distribution between 5 and over 100 contacts that was heavy tailed and compatible with a power law distribution. At any level of use, patients with one or more mental health related contacts had a greater likelihood of further contact than those without. Conclusion Prehospital emergency service use shows multiple statistical features typical of a complex system. Interventions to manage demand need to consider both individual high intensity users (particularly in relation to their mental health) and the behaviour of the whole system.

Rational use of medicines (RUM) is a global health priority, yet significant challenges persist in low- and middle-income countries (LMICs), particularly around medicine access, affordability, and quality. While RUM studies often focus on prescribing practices, systemic barriers such as supply chain inefficiencies and pricing receive less attention. This study assessed three key health system components of RUM (availability, affordability, and quality of essential medicines) at two public primary health facilities in Ghana and examined patient care practices against WHO RUM standards. A quantitative, cross-sectional study was conducted at Kekele Polyclinic and Rawlings Circle Polyclinic in Accra. Retrospective data were extracted from prescription sheets, medicine tally cards, and ledgers to evaluate WHO Level II core drug use indicators. Fifteen essential medicines were selected based on the Ghana Essential Medicines List, Standard Treatment Guidelines, and municipal disease burden data. Exit interviews with 107 patients assessed dispensing and counselling practices, and structured observation covered storage conditions and pharmaceutical handling. Availability of key medicines fell significantly short of WHO targets, with Rawlings Circle meeting only 40% and Kekele 73.3% of the 100% benchmark. Treatment of malaria and pneumonia cost patients up to three times the national daily minimum wage, indicating poor affordability. The average number of medicines prescribed per encounter (3.2) exceeded the WHO recommended standard ([&le;]2). Storage and handling infrastructure was inadequate, with both facilities falling short of recommended conservation standards. Gaps in medicine availability, affordability, and infrastructure undermine rational medicine use in primary healthcare. Strengthening procurement systems, enforcing storage protocols, and implementing financial protection mechanisms are essential for equitable and safe medicine use within Ghanas health system.

Introduction -- Emergency Medical Dispatch Systems (EMDS) can reduce delays in accessing emergency care by providing structured communication, triage, and coordination. However, such systems remain absent or underdeveloped in most low- or middle-income countries (LMICs). This study aimed to establish international consensus on essential EMDS components to inform global guidance. Methods -- We convened a multidisciplinary expert group to draft a preliminary list of essential components for three EMDS levels reflecting resource availability and system maturity. We then conducted a three-round Delphi with international experts to reach consensus on core EMDS components. Components which had [&ge;]75% agreement were included, those with [&ge;]75% disagreement were excluded. Components not achieving consensus by Round 3 were removed. Results were analysed overall and stratified by respondents' country income level. A subsequent online expert meeting resolved inconsistencies and finalised the component list. Results -- The expert group generated 111 components for each of three EMDS levels (Foundational, Emerging, and Established) spanning 11 operational domains. Of the 68 experts invited to the Delphi, 43 participated in Round 1 and 30 in Round 3. Across all Delphi rounds, 289 components reached consensus for inclusion. The consensus resulted in a final list of 227 components (63 Foundational, 84 Emerging, and 80 Established). Consensus agreement clustered around core EMDS domains including communication, structured call-taking and prioritisation, advice-giving, resource dispatch and tracking, and foundational governance and data functions, whereas items showing either non-consensus or consensus disagreement were typically technology-dependent or context-specific. Conclusions -- This international consensus offers guidance for EMDS development across diverse resource settings and provides a scalable roadmap to strengthen emergency care systems.