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Successive Governments of India have promised to transform India's unsatisfactory health-care system, culminating in the present government's promise to expand health assurance for all. Despite substantial improvements in some health indicators in the past decade, India contributes disproportionately to the global burden of disease, with health indicators that compare unfavourably with other middle-income countries and India's regional neighbours. Large health disparities between states, between rural and urban populations, and across social classes persist. A large proportion of the population is impoverished because of high out-of-pocket health-care expenditures and suffers the adverse consequences of poor quality of care. Here we make the case not only for more resources but for a radically new architecture for India's health-care system. India needs to adopt an integrated national health-care system built around a strong public primary care system with a clearly articulated supportive role for the private and indigenous sectors. This system must address acute as well as chronic health-care needs, offer choice of care that is rational, accessible, and of good quality, support cashless service at point of delivery, and ensure accountability through governance by a robust regulatory framework. In the process, several major challenges will need to be confronted, most notably the very low levels of public expenditure; the poor regulation, rapid commercialisation of and corruption in health care; and the fragmentation of governance of health care. Most importantly, assuring universal health coverage will require the explicit acknowledgment, by government and civil society, of health care as a public good on par with education. Only a radical restructuring of the health-care system that promotes health equity and eliminates impoverishment due to out-of-pocket expenditures will assure health for all Indians by 2022—a fitting way to mark the 75th year of India's independence.

The incident highlights the poor state of rural health care in India, a system blighted by lack of access to health-care facilities, shortages of doctors and paramedic staff, and the predominance of untrained private practitioners as the first point of care. Indian medical education is geared to train doctors to work only in tertiary care and specialised hospitals, so these areas become the primary professional aspiration of health workers, points out Vikram Patel, professor of international mental health at the London School of Hygiene & Tropical Medicine, UK.

The integrated chronic disease management (ICDM) model was introduced as a response to the dual burden of HIV/AIDS and non-communicable diseases (NCDs) in South Africa, one of the first of such efforts by an African Ministry of Health. The aim of the ICDM model is to leverage HIV programme innovations to improve the quality of chronic disease care. There is a dearth of literature on the perspectives of healthcare providers and users on the quality of care in the novel ICDM model. This paper describes the viewpoints of operational managers and patients regarding quality of care in the ICDM model. In 2013, we conducted a case study of the seven PHC facilities in the rural Agincourt sub-district in northeast South Africa. Focus group discussions (n = 8) were used to obtain data from 56 purposively selected patients ≥18 years. In-depth interviews were conducted with operational managers of each facility and the sub-district health manager. Donabedian’s structure, process and outcome theory for service quality evaluation underpinned the conceptual framework in this study. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and unanticipated themes that emerged during the analysis. The manager and patient narratives showed the inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). There was discordance between managers and patients regarding reasons for long patient waiting time which managers attributed to staff shortage and missed appointments, while patients ascribed it to late arrival of managers to the clinics. Patients reported anti-hypertension drug stock-outs (structure); sub-optimal defaulter-tracing (process); rigid clinic appointment system (process). Emerging themes showed that patients reported HIV stigmatisation in the community due to defaulter-tracing activities of home-based carers, while managers reported treatment of chronic diseases by traditional healers and reduced facility-related HIV stigma because HIV and NCD patients attended the same clinic. Leveraging elements of HIV programmes for NCDs, specifically hypertension management, is yet to be achieved in the study setting in part because of malfunctioning blood pressure machines and anti-hypertension drug stock-outs. This has implications for the nationwide scale up of the ICDM model in South Africa and planning of an integrated chronic disease care in other low- and middle-income countries. Le modèle intégré de gestion des maladies chroniques (ICDM) a été mis en place en réponse au double fardeau du VIH/SIDA et des maladies non-transmissibles (NCID) en Afrique du Sud, l’une des premières étapes des actions entreprises par le Ministère de la Santé Africaine. L’objectif de ce modèle ICDM est d’optimiser les innovations du programme VIH afin d’améliorer la qualité des soins dans le traitement des maladies chroniques. On manque de documentation sur les perspectives des prestataires de soins et des utilisateurs sur la qualité des soins dans le nouveau modèle ICDM. Cet article a pour but de décrire les points de vue des responsables opérationnels et des patients sur la qualité des soins du modèle ICDM. En 2013, nous avons réalisé une étude de cas des sept centres de santé primaires (PHC) dans le sous-district rural d’Agincourt situé dans le Nord –Est de l’Afrique du Sud. Les débats des groupes de discussion (n=8) ont permis d’obtenir des données auprès de 56 patients sélectionnés dans ce but _âgés de18 ans et plus; des entretiens approfondis ont été réalisés auprès des responsables opérationnels de chaque centre, et du responsable santé du sous-district. La structure de Donabedian, la théorie des processus et résultats pour l’évaluation de la qualité du service ont étayé le cadre conceptuel de cette étude. Les données qualitatives ont été analysées à l’aide du logiciel MAXQDA 2, afin d’identifier 17 dimensions à priori de soins et des thèmes inattendus qui ont surgi au cours de cette analyse. 为应对HIV/AIDS和慢性非传染性疾病 （NCDs） 的双重负担, 南非建立了慢性病综合管理 （ICDM） 模式, 是非洲国家卫生 部采取的首例慢病管理措施之一。ICDM模式旨在利用HIV项 目的创新改善慢病护理的质量。关于医疗服务提供者和使用 者对ICDM中医疗质量的看法, 目前还缺少相关文献。本文描 述了管理者和患者对ICDM模式中医疗质量的观点。 2013年, 我们在南非东北部Agincourt分区农村的7个初级卫生 保健 （PHC） 机构进行了个案研究。采用焦点小组讨论 （n=8）从56位有目的选择的患者 （≥18岁） 中获取数据。 对各个机构的管理者和分区卫生管理者进行深度访谈。本研 究的概念框架借鉴Donabedian关于医疗质量评估的结构-过 程-结果理论。使用MAXQDA2软件分析定性数据, 明确护理 的17个先验维度, 以及在分析过程中发现的主题。 管理者和患者的叙述显示存在结构 （血压计故障和人员短 缺） 、过程（药物包装不规则）和结果 （候诊时间长） 方面 的不足。管理者和患者对候诊时间长的原因有不同看法, 管理 者认为是由于人员短缺和错过约诊, 患者则归咎于管理者到达 诊室时间太晚。患者反映的问题还包括降压药缺货 （结 构 ）、缺诊患者追踪方法不佳 （过程） 和诊所预约方式不灵 活 （过程） 。分析中出现的主题为：患者表示由于家庭护理 人员追踪缺诊患者, 社区产生了HIV污名化现象；管理者反映 有些慢病患者接受传统治疗师的治疗, 另外, 因为HIV和慢性 患者就诊于同一诊所, 弱化了与医疗机构相关的HIV污名。 HIV项目中可用于NCDs管理, 尤其是高血压管理的要素还有 待落实, 部分原因是血压计故障和抗高血压药物缺货。对于 ICDM模式在南非的全国推广, 以及其他中低收入国家的慢性 病综合护理规划, 这一发现都很有意义。 El modelo integrado de manejo de enfermedades crónicas (IMEC) se introdujo como una respuesta a la doble carga del VIH/SIDA y las enfermedades no transmisibles (ENTs) en Sudáfrica, uno de los primeros modelos de este tipo en un Ministerio de Salud en África. El objetivo del modelo IMEC es aprovechar las innovaciones del programa de VIH para mejorar la calidad de la atención de enfermedades crónicas. Hay una escasez de literatura sobre las perspectivas de los proveedores del cuidado de la salud y los usuarios sobre la calidad del cuidado en el nuevo modelo IMEC. Este artículo describe los puntos de vista de los administradores operacionales y los pacientes sobre la calidad del cuidado en el modelo IMEC. En 2013, realizamos un estudio de caso de las siete instalaciones de cuidado primario de la salud (CPS) en el sub-distrito rural de Agincourt en el noreste de Sudáfrica. Se utilizaron discusiones de grupos focales (n=8) para obtener datos de 56 pacientes de 18 años o mayores seleccionados a propósito. Se realizaron entrevistas en profundidad con los administradores operacionales de cada instalación y el gerente de salud del sub-distrito. La teoría de la estructura, proceso y resultados de Donabedian para la evaluación de la calidad del servicio formó la base del marco conceptual de este estudio. Se analizaron los datos cualitativos, con el software MAXQDA 2, para identificar 17 dimensiones a priori de cuidado y temas no anticipados que surgieron durante el análisis. Las narrativas de directores y pacientes mostraron las insuficiencias en la estructura (mal funcionamiento de las máquinas de presión arterial y escasez de personal); proceso (empaque previo irregular de medicamentos); y resultado (largos tiempos de espera). Hubo discordancia entre los administradores y los pacientes con respecto a las razones del largo tiempo de espera del paciente que los administradores atribuían a la escasez de personal y las citas perdidas, mientras que los pacientes lo atribuían a la llegada tardía de los administradores a las clínicas. Los pacientes informaron de la falta de existencia de los medicamentos antihipertensivos (estructura); seguimiento de pacientes incumplidos sub-óptimo (proceso); rígido sistema de citas clínicas (proceso). Los temas emergentes mostraron que los pacientes denunciaron la estigmatización del VIH en la comunidad debido a las actividades de seguimiento de los pacientes incumplidos por parte de los cuidadores de salud basados en el domicilio, mientras que los administradores informaron del tratamiento de enfermedades crónicas por los curanderos tradicionales y reducción del estigma del VIH relacionado con las instalaciones ya que los pacientes de VIH y ENTs asistían a la misma clínica. Aprovechar los elementos de los programas de VIH para las ENTs, específicamente el manejo de la hipertensión, todavía no se ha logrado en el entorno del estudio, debido en parte al mal funcionamiento de las máquinas de presión arterial y a la falta de existencia de los medicamentos antihipertensivos. Esto tiene implicaciones para la ampliación a escala nacional del modelo IMEC en Sudáfrica y la planeación de una atención integrada de enfermedades crónicas en otros países de ingresos bajos y medios.

Increasing the numbers of health workers and improving their skills requires that countries confront a number of ethical dilemmas. The ethical considerations in answering five important questions on enabling health workers to deal appropriately with the circumstances in which they must work are described. These include the problems of the standards of training and practice required in countries with differing levels of socioeconomic development and different priority diseases; how a society can be assured that health practitioners are properly trained; how a health system can support its workers; diversion of health workers and training institutions; and the teaching of ethical principles to student health workers. The ethics of setting standards for the skills and care provided by traditional health-care practitioners are also discussed.

Neena Modi argues that leaving the EU will have wide ranging effects on health in the UK and that the medical and scientific professions should not hold back from saying this

Recent decades have seen the global emergence of meticillin-resistant Staphylococcus aureus (MRSA), causing substantial health and economic burdens on patients and health-care systems. This epidemic has occurred at the same time that policies promoting higher patient throughput in hospitals have led to many services operating at, or near, full capacity. A result has been limited ability to scale services according to fluctuations in patient admissions and available staff, and hospital overcrowding and understaffing. Overcrowding and understaffing lead to failure of MRSA control programmes via decreased health-care worker hand-hygiene compliance, increased movement of patients and staff between hospital wards, decreased levels of cohorting, and overburdening of screening and isolation facilities. In turn, a high MRSA incidence leads to increased inpatient length of stay and bed blocking, exacerbating overcrowding and leading to a vicious cycle characterised by further infection control failure. Future decision making should use epidemiological and economic evidence to evaluate the effect of systems changes on the incidence of MRSA infection and other adverse events.

This paper is a country case study for the Universal Health Coverage Collection, organized by WHO. Tanvir Mahmudul Huda and colleagues illustrate progress towards UHC and its monitoring and evaluation in Bangladesh. Please see later in the article for the Editors' Summary

to study paediatric surgery rates in south-western Uganda, compare them to rates in England, and determine if existing surgical facilities and workforce meet World Health Organization (WHO) standards. to obtain information on surgical facilities and workforce, we conducted a cross-sectional survey of all hospitals performing major surgery in 14 districts of south-western Uganda in 2007-2008. Using theatre logbook data, we determined the surgical rates, types of surgery performed and in-theatre surgical outcomes. of 72 hospitals surveyed, 29 were performing major surgery. None met WHO standards for essential surgery. There were 0.7 accredited surgeons per 100.000 population and no paediatric surgeons. Most anaesthetists were not physicians (accredited anaesthetist per 100.000 population: 1.1). The annual surgical rate for children aged ≤ 14 years was 180 operations per 100.000 population; most were emergency procedures. The annual surgical rate for patients of all ages was 652 operations per 100.000 population, with a median of 422 per operating theatre (range: 60-3497) and of 226 per surgeon (range: 60-1748). Mission or nongovernmental organization (NGO) hospitals, which had 44% of the hospital beds in the region, performed 3039 (55%) of the paediatric operations. Externally funded surgeons performed 80% of the 140 cleft lip and palate operations. Four in-theatre deaths occurred in children ≤ 14 years old (in-theatre mortality: 7.7 deaths per 10.000 operations). access to all surgery, including paediatric surgery, is poor in south-western Uganda and investment in basic health-care facilities and surgical workforce and training is urgently needed. Mission and NGO hospitals make a valuable contribution to elective surgery, and externally funded surgeons make an important contribution to specialist surgery. In-theatre mortality was lower than reported for similar settings.

Looking at the State of Child Health report, it’s hard not to suggest that paediatrics lacks the appeal it once had

The House of Lords' April report on the NHS's future 1 criticised serial government claims that \"4000 new doctors and 9000 new nurses\" have been recruited, without these mantras being grounded in coherent planning about how many are needed or acknowledging those who leave or go part time. 2 3 The Lords' report was also highly critical of the UK's track record in planning for future staffing-and the fact that the UK already has some of the lowest per capita numbers of clinical staff in OECD member states.