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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.

The Sustainable Development Goals target to achieve Universal Health Coverage (UHC), including financial risk protection (FRP) among other dimensions. There are four indicators of FRP, namely incidence of catastrophic health expenditure (CHE), mean positive catastrophic overshoot, incidence of impoverishment and increase in the depth of poverty occur for high out-of-pocket (OOP) healthcare spending. OOP spending is the major payment strategy for healthcare in most low-andmiddle-income countries, such as Bangladesh. Large and unpredictable health payments can expose households to substantial financial risk and, at their most extreme, can result in poverty. The aim of this study was to estimate the impact of OOP spending on CHE and poverty, i.e. status of FRP for UHC in Bangladesh. A nationally representative Household Income and Expenditure Survey 2010 was used to determine household consumption expenditure and health-related spending in the last 30 days. Mean CHE headcount and its concentration indices (CI) were calculated. The propensity of facing CHE for households was predicted by demographic and socioeconomic characteristics. The poverty headcount was estimated using ‘total household consumption expenditure’and such expenditure without OOP payments for health in comparison with the poverty-line measured by cost of basic need. In absolute values, a pro-rich distribution of OOP payment for healthcare was found in urban and rural Bangladesh. At the 10%-threshold level, in total 14.2% of households faced CHE with 1.9% overshoot. 16.5% of the poorest and 9.2% of the richest households faced CHE. An overall pro-poor distribution was found for CHE (CI = -0.064) in both urban and rural households, while the former had higher CHE incidences. The poverty headcount increased by 3.5% (5.1 million individuals) due to OOP payments. Reliance on OOP payments for healthcare in Bangladesh should be reduced for poverty alleviation in urban and rural Bangladesh in order to secure FRP for UHC. Les objectifs de développement durable visent à atteindre la couverture sanitaire universelle (CSU), notamment la protection contre les risques financiers (FRP) entre autres aspects. Il y a quatre indicateurs FRP, à savoir l’incidence des dépenses de santé catastrophiques (CHE), le dépassement catastrophique moyen, l’incidence de l’appauvrissement et l’augmentation de la pauvreté en raison du développement du paiement direct des dépenses de santé. Les paiements directs constituent la principale stratégie de paiement des soins de santé dans la plupart des pays à revenu faible ou intermédiaire, à l’instar du Bangladesh. Des paiements de santé substantiels et imprévisibles peuvent exposer les ménages à des risques financiers importants et, dans les cas extrêmes, être cause de pauvreté. Le but de la présente étude est d’estimer l’impact des dépenses directes sur les CHE et la pauvreté, en d’autres termes le niveau de protection de la couverture universelle contre les risques financiers au Bangladesh. Les données de l’enquête nationale sur les revenus et les dépenses des ménages en 2010 ont permis de déterminer les dépenses de consommation des ménages ainsi que les dépenses liées à la santé au cours des 30 derniers jours. On a calculé la moyenne des CHE et leurs indices de concentration (IC). Les caractéristiques démographiques et socio-économiques donnent un aperçu de la propension des ménages à faire face aux CHE. La pauvreté est estimée en se fondant sur «l’ensemble des dépenses de consommation des ménages» et sur les dépenses autres que les paiements directs pour la santé par rapport au seuil de pauvreté mesuré par le coût de la vie. En valeurs absolues, on a observé une répartition pro-riche des dépenses directes pour les soins de santé dans les zones urbaines et rurales du Bangladesh. Dans le seuil de 10%, un total de 14,2% des ménages est confronté à des dépenses CHE avec un dépassement de 1,9%. 16,5% des ménages les plus démunis et 9,2% des ménages les plus riches font face à des dépenses catastrophiques. On a observé une répartition globale des CHE (CI= -0,064) favorable aux pauvres aussi bien dans les ménages urbains que ruraux, mais l’incidence des CHE était plus élevée chez les premiers. La pauvreté a connu une augmentation de 3,5% (5,1 millions de personnes) en raison des paiements directs. Il faudrait diminuer le recours aux paiements directs pour les soins de santé au Bangladesh afin de réduire la pauvreté dans les zones urbaines et rurales du pays et garantir une protection de la couverture sanitaire universelle contre les risques financiers. 可持续发展目标之一是实现全民健康覆盖 （UHC）, 其中包括 财务风险保护 （FRP） 。 FRP有四个指标, 即灾难性卫生支出 （CHE） 发生率、平均灾难性超支、致贫率和高额医疗自付 费用 （OOP） 加剧的贫困。 OOP是孟加拉等多数中低收入国 家的主要医疗费用支付方式。不可预知的高额医疗费用会使 家庭陷入巨大的财务风险, 极端情况下会导致贫困。本研究目 的是评估OOP对CHE和贫困的影响, 即孟加拉全民健康覆盖中 的财务风险保护状况。我们采用有全国代表性的2010年住户 收入和支出调查数据, 获取过去30天内家庭消费支出和卫生相 关支出。计算平均CHE人数和集中指数。根据人口和社会经 济特征预测家庭面临CHE的倾向。采用两种方式估算贫困人 数, 一种依据“总家庭消费支出”, 一种比较剔除OOP医疗支 出后的消费支出和根据基本需求成本计算的贫困线。从绝对 值来看, 孟加拉城市和农村地区OOP医疗付费分布倾向于富 人。阈值为10%时, 总计14.2%的家庭发生了CHE, 超支1.9%。 16.5%的最贫困家庭和9.2%的最富裕家庭发生了CHE。在城市 和农村地区家庭中, CHE更多发生于贫困家庭（CI=0.064）, 城市中CHE发生率更高。贫困人数因OOP增加了3.5% （510万 人） 。为了减小财务风险, 实现全民健康覆盖, 孟加拉应降低 对OOP医疗付费的依赖, 缓解城市和农村的贫困问题。 Las Metas del Desarrollo Sostenible tienen como objetivo lograr la Cobertura Universal de Salud (CUS), incluyendo la protección del riesgo financiero (PRF), entre otras dimensiones. Hay cuatro indicadores de PRF, a saber, la incidencia del gasto catastrófico de la salud (GCS), el exceso catastrófico positivo promedio, la incidencia del empobrecimiento y el aumento en la profundidad de la pobreza producida por el alto gasto de bolsillo (GDB) para la atención de salud. El GDB es la mayor estrategia de pago para la atención de la salud en la mayoría de los países de ingresos bajos y medios, como Bangladesh. Los pagos de salud grandes e impredecibles pueden exponer a los hogares a un riesgo financiero considerable y, en su extremo, pueden generar pobreza. El objetivo de este estudio fue estimar el impacto del GDB en GCS y la pobreza, es decir, el estado de PRF para CUS en Bangladesh. Se usó una Encuesta de Ingresos y Gastos del Hogar de 2010 representativa a nivel nacional para determinar el gasto de consumo de los hogares y el gasto relacionado con la salud en los últimos 30 días. Se calcularon el promedio de GCS y sus índices de concentración (IC). La propensión de los hogares de enfrentar el GCS se predijo por características demográficas y socioeconómicas. El recuento de la pobreza se calculó usando el ‘gasto total de consumo de los hogares’ y ese gasto sin los GDB para la salud en comparación con la línea de pobreza medida por el costo de la necesidad básica. En valores absolutos, se encontró una distribución pro-ricos del pago de GDB para la atención de salud en Bangladesh urbana y rural. En el nivel de umbral del 10%, en total el 14.2% de los hogares enfrentaron GCS con un exceso del 1.9%. El 16.5% de los hogares más pobres y el 9.2% de los más ricos se enfrentaron a GCS. Se encontró una distribución general pro-pobres para GCS (IC=-0.064) en hogares urbanos y rurales, mientras que en los primeros el GCS tuvo incidencias más altas. El recuento de la pobreza aumentó en un 3.5% (5.1 millones de personas) debido a los GDB. La dependencia de los GDB para la atención de la salud en Bangladesh debería reducirse para aliviar la pobreza en Bangladesh urbana y rural con el fin de asegurar la PRF para la CUS.

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.

Testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is largely passive, which impedes epidemic control. We defined active testing strategies for SARS-CoV-2 using reverse transcription polymerase chain reaction (RT-PCR) for groups at increased risk of acquiring SARS-CoV-2 in all Canadian provinces. We identified 5 groups who should be prioritized for active RT-PCR testing: contacts of people who are positive for SARS-CoV-2, and 4 at-risk populations — hospital employees, community health care workers and people in long-term care facilities, essential business employees, and schoolchildren and staff. We estimated costs, human resources and laboratory capacity required to test people in each group or to perform surveillance testing in random samples. During July 8–17, 2020, across all provinces in Canada, an average of 41 751 RT-PCR tests were performed daily; we estimated this required 5122 personnel and cost $2.4 million per day ($67.8 million per month). Systematic contact tracing and testing would increase personnel needs 1.2-fold and monthly costs to $78.9 million. Conducted over a month, testing all hospital employees would require 1823 additional personnel, costing $29.0 million; testing all community health care workers and persons in long-term care facilities would require 11 074 additional personnel and cost $124.8 million; and testing all essential employees would cost $321.7 million, requiring 25 965 added personnel. Testing the larger population within schools over 6 weeks would require 46 368 added personnel and cost $816.0 million. Interventions addressing inefficiencies, including saliva-based sampling and pooling samples, could reduce costs by 40% and personnel by 20%. Surveillance testing in population samples other than contacts would cost 5% of the cost of a universal approach to testing at-risk populations. Active testing of groups at increased risk of acquiring SARS-CoV-2 appears feasible and would support the safe reopening of the economy and schools more broadly. This strategy also appears affordable compared with the $169.2 billion committed by the federal government as a response to the pandemic as of June 2020.

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 country's 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.

Dugani et al cite that achieving universal health coverage and the Sustainable Development Goal targets requires a robust primary health care system. Although health facilities require basic infrastructure, supplies and an available workforce, co-existence of these elements will not guarantee delivery of high-quality care. Clinical effectiveness, comprehensiveness of care and interpersonal quality of care are essential for delivering better clinical outcomes. Several global frameworks provide indicators to measure, evaluate, quantify and improve quality of care. The solution space for primary health care is broad but main lessons are starting to emerge, and further research is required.

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 country's 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.

Retaining doctors in rural areas is a challenge in Bangladesh. In this study, we analyzed three rural retention policies: career development programs, compulsory services, and schools outside major cities - in terms of context, contents, actors, and processes. Series of group discussions between policy-makers and researchers prompted the selection of policy areas, which were analyzed using the policy triangle framework. We conducted document and literature reviews (1971-2013), key informant interviews (KIIs) with relevant policy elites (n=11), and stakeholder analysis/position-mapping. In policy-1, we found, applicants with relevant expertise were not leveraged in recruitment, promotions were often late and contingent on post-graduation. Career tracks were porous and unplanned: people without necessary expertise or experience were deployed to high positions by lateral migration from unrelated career tracks or ministries, as opposed to vertical promotion. Promotions were often politically motivated. In policy-2, females were not ensured to stay with their spouse in rural areas, health bureaucrats working at district and sub-district levels relaxed their monitoring for personal gain or political pressure. Impractical rural posts were allegedly created to graft money from applicants in exchange for recruitment assurance. Compulsory service was often waived for political affiliates. In policy-3, we found an absence of clear policy documents obligating establishment of medical colleges in rural areas. These were established based on political consideration (public sector) or profit motives (private sector). Four cross-cutting themes were identified: lack of proper systems or policies, vested interest or corruption, undue political influence, and imbalanced power and position of some stakeholders. Based on findings, we recommend, in policy-1, applicants with relevant expertise to be recruited; recruitment should be quick, customized, and transparent; career tracks (General Health Service, Medical Teaching, Health Administration) must be clearly defined, distinct, and respected. In policy-2, facilities must be ensured prior to postings, female doctors should be prioritized to stay with the spouse, field bureaucrats should receive non-practising allowance in exchange of strict monitoring, and no political interference in compulsory service is assured. In policy-3, specific policy guidelines should be developed to establish rural medical colleges. Political commitment is a key to rural retention of doctors.

Canada's celebration in 2017 of 150 years as a nation is a ripe time for reflection on both its own universal health system and the country's global commitments towards universal health coverage (UHC) as articulated in the Sustainable Development Goals (SDGs).1,2 The recognition in the prairie province of Saskatchewan that farmers should not have to sell the farm to pay for their family's health care was the principled pivot point that triggered Canada's march towards UHC in the 1960s. On Dec 12, 2017, the UN's day to celebrate UHC, the World Bank and WHO launched a Global Monitoring Report assessing progress towards the SDG of UHC.3 The report's headlines are hardly cause for celebration: only half of the world's population has access to quality essential health-care services, 800 million people face financial hardship in accessing care, and nearly 100 million individuals are pushed into extreme poverty in paying for health-care services. [...]as Canada assumes the G7 Presidency in 2018, the opportunity is unprecedented for a pathbreaking health-care agenda that draws on Canada's commitment to UHC, advances the principles of the feminist foreign assistance policy, and mobilises Canada's knowledge assets.