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Background One of the central debates in health policy is related to the fragmentation of health systems. Fragmentation is perceived as a major obstacle to UHC. This article presents the results of a consultation with a group of actors of the Mexican policy arena on the origins and impacts of the fragmentation of the Mexican health system. Methods We used a consultation to nine key actors to collect thoughts on the fragmentation of the Mexican health system. The group included national and local decision makers with experience in health care issues and researchers with background in health systems and/or public policies. The sessions were recorded, transcribed verbatim and analyzed thematically. Results Participants defined the term ‘fragmentation’ as the separation of the various groups of the population based on characteristics which define their access to health care services. This is a core characteristic of health systems in Latin America (LA). In general, those affiliated to social security institutions have a higher per capita expenditure than those without social security, which translates into differential health benefits. According to the actors in this consultation, fragmentation is the main structural problem of the Mexican health system. Actors agreed that the best way to end fragmentation is through the creation of a universal health system. Defragmentation plans should include a research component to document the impacts of fragmentation, and design and test the instruments needed for the integration process. Conclusions First, health system fragmentation in Mexico has created problems of equity since different population groups have unequal access to public resources and different health benefits. Second, Mexico needs to move beyond the fragmentation of its health system and guarantee, through its financial integration, access to the same package of health services to all its citizens. Third, defragmentation plans should include a research component to document the impacts of fragmentation, and design and test the instruments needed for the integration process. Fourth, defragmentation of health systems is not an easy task because there are vested interests that oppose its implementation. Political strategies to meet the resistance of these groups are an essential component of any defragmentation plan.

Background Universal health coverage (UHC) requires strong institutional capacity, equity-oriented policies, sustained political and financial commitment and public trust. However, public confidence in many health systems, including Mexico’s, has been chronically undermined. This study aims to document Mexico’s health coverage trajectory by offering a comprehensive, disaggregated and longitudinal assessment of insurance coverage from 2000 to 2023 – highlighting both achievements and setbacks in the context of UHC2030 goals. Methods This study used nationally representative data from Mexico’s National Household Income and Expenditure Survey (ENIGH) from 2000 to 2022, with projections for 2023. Households were classified into mutually exclusive health insurance categories on the basis of institutional affiliation. National and subnational trends in coverage were analysed, with attention to major reforms and disruptions. A distance-to-frontier metric quantified the gap between 2023 coverage and each state’s historical maximum, enabling assessment of progress toward UHC goals. Results Between 2000 and 2015, Mexico reduced the uninsured population from 55% to 6.2%, largely driven by Seguro Popular (SP) expansion benefiting Indigenous peoples, rural and low-income households in high-deprivation states. Following SP’s dismantling in 2019, the launch of Health Institute for Welfare (INSABI), and the COVID-19 pandemic, uninsured rates rose sharply to 29.1% by 2023. The greatest losses in coverage occurred in southern states and among marginalized groups, deepening territorial and social inequalities. The decline in mixed public coverage further reflects system fragmentation and eroding public trust. The distance-to-frontier analysis revealed that several states need to more than double their coverage to regain previous levels. Conclusions Mexico’s experience highlights that health coverage gains are reversible without strong institutional foundations, political consensus and social legitimacy. Rebuilding and sustaining UHC requires deliberate efforts to address structural inequalities, strengthen institutions and restore public trust. For other low- and middle-income countries, this case emphasizes the urgent need for institutions restructured to foster adaptive capacity alongside equity-focused strategies to achieve and sustain UHC.

Health systems internationally face demands to deliver care that is better coordinated and integrated. The health system financing and delivery model may go some, but not all the way in explaining health system fragmentation. In this paper, we consider the road to care integration in two countries with Beveridge style health systems, England and Denmark, that are both ranked as highly Integrated systems in Toth's health integration index. We use the SELFIE framework to compare the policies and reforms that have affected care integration over the past 30 years in the two countries. The countries both started their reform path by reforming to introduce choice and competition, but did so in different ways that set them on different pathways. Nevertheless, after two decades, the countries ended the period with largely similar structures that emphasised the creation of a cross-sectoral governance structure. In the relatively centralised England, by introducing decentralised Integrated Care Systems, and in the relatively decentralised Denmark with a centralising element in the form of new Health Clusters.

PURPOSE To examine gaps in service in the treatment of depression and suicidal ideation. METHODS A phenomenological investigation of clients' (n = 10) and service providers' (n = 40) perspectives. FINDINGS Compartmentalized systems of care and lack of continuity between inpatient and outpatient treatment contributed to a sense of frustration in both groups. Receiving mental health care was likened to being given a brokenapart puzzle with individual pieces shuffling around in a box. Little bits of help are available, but none of them mesh. CONCLUSIONS Comprehensive solutions are needed if the human and social implications of depression are to be addressed.

Background Since the advent of democracy, the South African government has been putting charters, policies, strategies and plans in place in an effort to strengthen public health system performance and enhance service delivery. However, public health programme performance and outcomes remained poor while the burden of disease increased. This was also the case in the Free State Province, where major public health system challenges occurred around 2012. Assessment was necessary in order to inform health system strengthening. Methods The study entailed a multi-method situation appraisal utilising information collated in 44 reports generated in 2013 through presentations by unit managers, subdistrict assessments by district clinical specialist teams, and group discussions with district managers, clinic supervisors, primary health care managers and chief executive and clinical officers of hospitals. These data were validated through community and provincial health indabas including non-governmental organisations, councils and academics, as well as unannounced facility visits involving discussions with a wide range of functionaries and patients. The reports were reviewed using the World Health Organization health system building blocks as a priori themes with subsequent identification of emerging subthemes. Data from the different methods employed were triangulated in a causal loop diagram showing the complex interactions between the components of an (in) effective health system. Results The major subthemes or challenges that emerged under each a priori theme included: firstly, under the ‘ service delivery ’ a priori theme, ‘ fragmentation of health services ’ (42 reports); secondly, under the ‘ health workforce ’ a priori theme, ‘ staff shortages ’ (39 reports); thirdly, under the ‘ health financing ’ a priori theme, ‘ financial/cash-flow problems ’ (39 reports); fourthly, under the ‘ leadership and governance ’ a priori theme, ‘ risk to patient care ’ (38 reports); fifthly, under the ‘ medical products/technologies ’ a priori theme, ‘ dysfunctional communication technology ’ (27 reports); and, sixthly, under the ‘ information ’ a priori theme, ‘ poor information management ’ (26 reports). Conclusion The major overall public health system challenges reported by stakeholders involved fragmentation of services, staff shortages and financial/cash-flow problems. In order to effect health systems strengthening there was particularly a need to improve integration and address human and financial deficiencies in this setting.

Clinical practice related to sleep problems and sleep disorders has been expanding rapidly in the last few years, but scientific research is not keeping pace. Sleep apnea, insomnia, and restless legs syndrome are three examples of very common disorders for which we have little biological information. This new book cuts across a variety of medical disciplines such as neurology, pulmonology, pediatrics, internal medicine, psychiatry, psychology, otolaryngology, and nursing, as well as other medical practices with an interest in the management of sleep pathology. This area of research is not limited to very young and old patients-sleep disorders reach across all ages and ethnicities. Sleep Disorders and Sleep Deprivation presents a structured analysis that explores the following: Improving awareness among the general public and health care professionals. Increasing investment in interdisciplinary somnology and sleep medicine research training and mentoring activities. Validating and developing new and existing technologies for diagnosis and treatment. This book will be of interest to those looking to learn more about the enormous public health burden of sleep disorders and sleep deprivation and the strikingly limited capacity of the health care enterprise to identify and treat the majority of individuals suffering from sleep problems.

The incidence of tick-borne diseases has increased in recent decades and accounts for the majority of vectorborne disease cases in temperate areas of Europe, North America, and Asia. This emergence has been attributed to multiple and interactive drivers including changes in climate, land use, abundance of key hosts, and people's behaviors affecting the probability of human exposure to infected ticks. In this forum paper, we focus on how land use changes have shaped the eco-epidemiology of Ixodes scapularis-borne pathogens, in particular the Lyme disease spirochete Borrelia burgdorferi sensu stricto in the eastern United States. We use this as a model system, addressing other tick-borne disease systems as needed to illustrate patterns or processes. We first examine how land use interacts with abiotic conditions (microclimate) and biotic factors (e.g., host community composition) to influence the enzootic hazard, measured as the density of host-seeking I. scapularis nymphs infected with B. burgdorferi s.s. We then review the evidence of how specific landscape configuration, in particular forest fragmentation, influences the enzootic hazard and disease risk across spatial scales and urbanization levels. We emphasize the need for a dynamic understanding of landscapes based on tick and pathogen host movement and habitat use in relation to human resource provisioning. We propose a coupled natural-human systems framework for tick-borne diseases that accounts for the multiple interactions, nonlinearities and feedbacks in the system and conclude with a call for standardization of methodology and terminology to help integrate studies conducted at multiple scales.

Circulating DNA (ctDNA) is acknowledged as a potential diagnostic tool for various cancers including colorectal cancer, especially when considering the detection of mutations. Certainly due to lack of normalization of the experimental conditions, previous reports present many discrepancies and contradictory data on the analysis of the concentration of total ctDNA and on the proportion of tumour-derived ctDNA fragments. In order to rigorously analyse ctDNA, we thoroughly investigated ctDNA size distribution. We used a highly specific Q-PCR assay and athymic nude mice xenografted with SW620 or HT29 human colon cancer cells, and we correlated our results by examining plasma from metastatic CRC patients. Fragmentation and concentration of tumour-derived ctDNA is positively correlated with tumour weight. CtDNA quantification by Q-PCR depends on the amplified target length and is optimal for 60-100 bp fragments. Q-PCR analysis of plasma samples from xenografted mice and cancer patients showed that tumour-derived ctDNA exhibits a specific amount profile based on ctDNA size and significant higher ctDNA fragmentation. Metastatic colorectal patients (n = 12) showed nearly 5-fold higher mean ctDNA fragmentation than healthy individuals (n = 16).

Wetlands are among the most vulnerable and dynamic ecosystems of the world. Any change in the anthropogenic footprint or climate affects the health of these pristine ecologically and socioeconomically important ecosystems. In the present study, land use land cover changes (LULCC) and fragmentation of natural landscape changes in an urban wetland, Khushalsar, located in the heart of the Srinagar City, were assessed using high-resolution satellite data, geospatial modeling approach, and ground observations over the last ~ 5 decades (1965 and 2018). The spatiotemporal changes in LULC of the wetland were assessed for 3 time periods that include 1965–1980, 1980–2018, and 1965–2018. Additionally, landscape fragmentation tool (LFT) was used to quantify fragmentation of land cover. The analysis of LULCC indicated that built-up areas in the vicinity of the wetland increased by 510% between 1965 and 2018. The aquatic vegetation and marshy lands increased by 150% and 33% respectively. The area under agriculture, plantation, open water, and barren lands decreased mostly taken over by built-up areas. Within the wetland, the area under open water spread reduced by 75% while the aquatic vegetation increased by 150% from 1965 to 2018. The built-up areas including roads also showed a substantial increase. The LFT analysis revealed four categories of landscapes i.e., patch, edge, perforated, and core areas. Since the natural land cover types were taken over by land use predominantly built-up areas, the core natural areas and perforated landscapes in the Khushalsar shrunk by 34% and 94% respectively indicating fragmentation of natural environment. The lack of sewage treatment facility, reckless unplanned urbanization within and in the vicinity of the wetland, is responsible for the degradation of the Khushalsar wetland.

Remote sensing (RS) has been widely used to assess the forest health status. Forest fragmentation has been recognized as a threat to the forest as it causes loss of biodiversity. The study of forest fragmentation is important for the conservative approach to forest area. In recent years, the urban forest has witnessed forest fragmentation. The present study focused on the assessment of vegetation cover and forest fragmentation using multi-temporal satellite data (1991, 2001, 2011, and 2021). Landscape Fragmentation Tool v2.0 (LFT v2.0) was used to analyze forest fragmentation in the urban forest of Delhi: Sanjay Van and Southern Ridge by assigning an edge width of 100 m. LFT v2.0 categorizes forest fragmentation into four class categories: patch, perforated, edge, and core classes. It was found that vegetation cover in Sanjay Van has decreased by 1.96%, whereas the area under vegetation covered in the Southern Ridge increased by 4.62% in the last decade. The assessment of forest fragmentation found that patch forests have increased and declined in core forest areas. These changes suggested a high disturbance due to anthropogenic activities leading to the degradation of the forest’s health. The finding of the study helps in the identification of sensitive areas which require immediate conservation measures for the reclamation and restoration of degraded forest areas. With proper management, plans, and policies, continuous, intact, and healthy forests can be restored to maintain ecosystem integrity and thereby regulate all ecosystem services efficiently.