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\"Promoted as a \"disturbingly perfect\" and \"deeply shallow\" television show and created by the mind behind Glee, Ryan Murphy, Nip/Tuck has been among the most popular and controversial shows on television. The misadventures and soap opera-esque entanglements of the lives of plastic surgeons Christian Troy and Sean McNamara won Golden Globes and boycotts from the American Family Association. Yet, as this first critical celebration of Nip/Tuck reveals, the show is also an examination of the American family, the anxieties and complications of gender and sexuality, and the class issues and illusions surrounding the American dream. The book is completed with an extensive episode guide and includes an interview with Nip/Tuck director Elodie Keene.\"--Publisher.

Health care spending varies widely across hospital referral regions (HRRs), which comprise many smaller hospital service areas (HSAs). High-spending HRRs often include low-spending HSAs, raising questions about the appropriateness of payment reforms that target HRRs. A substantial body of evidence has emerged highlighting wide geographic variation in health care spending that is not driven by patient characteristics and is not associated with the quality of care or patient outcomes. 1 – 7 In light of this evidence, many policy proposals suggest targeting high-spending areas for lower Medicare payments or other coverage constraints, with a focus on areas such as the hospital referral regions (HRRs) described in the Dartmouth Atlas of Health Care. 1 These policies are predicated on the idea that there is a system-level component driving some areas to have high utilization and others low. The effectiveness . . .

Wanrudee Isaranuwatchai and colleagues highlight the importance of local context in making decisions about implementing interventions for preventing non-communicable diseases

In order to reach the health-related Sustainable Development Goals (SDGs) by 2030, gains attained in access to primary healthcare must be matched by gains in the quality of services delivered. Despite the broad consensus around the need to address quality, studies on the impact of health system strengthening (HSS) have focused predominantly on measures of healthcare access. Here, we examine changes in the content of maternal and child care as a proxy for healthcare quality, to better evaluate the effectiveness of an HSS intervention in a rural district of Madagascar. The intervention aimed at improving system readiness at all levels of care (community health, primary health centers, district hospital) through facility renovations, staffing, equipment, and training, while removing logistical and financial barriers to medical care (e.g., ambulance network and user-fee exemptions). We carried out a district-representative open longitudinal cohort study, with surveys administered to 1,522 households in the Ifanadiana district of Madagascar at the start of the HSS intervention in 2014, and again to 1,514 households in 2016. We examined changes in healthcare seeking behavior and outputs for sick-child care among children <5 years old, as well as for antenatal care and perinatal care among women aged 15-49. We used a difference-in-differences (DiD) analysis to compare trends between the intervention group (i.e., people living inside the HSS catchment area) and the non-intervention comparison group (i.e., the rest of the district). In addition, we used health facility-based surveys, monitoring service availability and readiness, to assess changes in the operational capacities of facilities supported by the intervention. The cohort study included 657 and 411 children (mean age = 2 years) reported to be ill in the 2014 and 2016 surveys, respectively (27.8% and 23.8% in the intervention group for each survey), as well as 552 and 524 women (mean age = 28 years) reported to have a live birth within the previous two years in the 2014 and 2016 surveys, respectively (31.5% and 29.6% in the intervention group for each survey). Over the two-year study period, the proportion of people who reported seeking care at health facilities experienced a relative change of +51.2% (from 41.4% in 2014 to 62.5% in 2016) and -7.1% (from 30.0% to 27.9%) in the intervention and non-intervention groups, respectively, for sick-child care (DiD p-value = 0.01); +11.4% (from 78.3% to 87.2%), and +10.3% (from 67.3% to 74.2%) for antenatal care (p-value = 0.75); and +66.2% (from 23.1% to 38.3%) and +28.9% (from 13.9% to 17.9%) for perinatal care (p-value = 0.13). Most indicators of care content, including rates of medication prescription and diagnostic test administration, appeared to increase more in the intervention compared to in the non-intervention group for the three areas of care we assessed. The reported prescription rate for oral rehydration therapy among children with diarrhea changed by +68.5% (from 29.6% to 49.9%) and -23.2% (from 17.8% to 13.7%) in the intervention and non-intervention groups, respectively (p-value = 0.05). However, trends observed in the care content varied widely by indicator and did not always match the large apparent increases observed in care seeking behavior, particularly for antenatal care, reflecting important gaps in the provision of essential health services for individuals who sought care. The main limitation of this study is that the intervention catchment was not randomly allocated, and some demographic indicators were better for this group at baseline than for the rest of the district, which could have impacted the trends observed. Using a district-representative longitudinal cohort to assess the content of care delivered to the population, we found a substantial increase over the two-year study period in the prescription rate for ill children and in all World Health Organization (WHO)-recommended perinatal care outputs assessed in the intervention group, with more modest changes observed in the non-intervention group. Despite improvements associated with the HSS intervention, this study highlights the need for further quality improvement in certain areas of the district's healthcare system. We show how content of care, measured through standard population-based surveys, can be used as a component of HSS impact evaluations, enabling healthcare leaders to track progress as well as identify and address specific gaps in the provision of services that extend beyond care access.

Medicines regulatory harmonization has been recommended as one way to improve access to quality-assured medicines in low- and middle-income countries. The rationale is that by lowering barriers to entry more manufacturers will be enticed to enter the market, while the capacity at the national medicines regulatory authorities is strengthened. The African Medicines Regulatory Harmonization Initiative, agreed in 2009, is developing regional platforms with harmonized regulatory procedures for the registration of medicines. The first region to implement medicines regulatory harmonization was the East African Community (EAC). The harmonization was based on the existing EAC Free Trade Agreement, which officially launched the free movement of goods and services in 2010. In this study we conducted semi-structured interviews and performed document reviews. The main target group for our interviews was pharmaceutical companies. We interviewed 18 companies, including 64% of the total companies who had experienced the EAC joint product assessment procedure, and two EAC-based national medicines regulatory authorities. We found that generally pharmaceutical companies are supportive of the African-based MRH efforts and appreciative of the progress being achieved. However, many companies are now hesitant to use the joint product assessment procedure until efficiency improvements are made. Common frustrations were the length of time to receive the actual marketing authorization; unexpectedly higher quality standards than national procedures; and challenges in getting all EAC countries to recognize EAC approvals. Smaller, less attractive markets have not yet become more attractive from a corporate perspective, and there is no free trade of pharmaceuticals in the EAC region. Pharmaceutical companies agree that medicines regulatory harmonization is the way forward. However, regulatory medicines harmonization must actually result in quicker access to the harmonized markets for quality-assured medicines. At this time, improvements are required to the current EAC processes to meet the vision of harmonization.

There is growing interest in health system performance and recently WHO launched a report on health systems strengthening emphasising the need for close monitoring using system-wide approaches. One recent method is the balanced scorecard system. There is limited application of this method in middle- and low-income countries. This paper applies the concept of balanced scorecard to describe the baseline status of three intervention districts in Zambia. The Better Health Outcome through Mentoring and Assessment (BHOMA) project is a randomised step-wedged community intervention that aims to strengthen the health system in three districts in the Republic of Zambia. To assess the baseline status of the participating districts we used a modified balanced scorecard approach following the domains highlighted in the MOH 2011 Strategic Plan. Differences in performance were noted by district and residence. Finance and service delivery domains performed poorly in all study districts. The proportion of the health workers receiving training in the past 12 months was lowest in Kafue (58%) and highest in Luangwa district (77%). Under service capacity, basic equipment and laboratory capacity scores showed major variation, with Kafue and Luangwa having lower scores when compared to Chongwe. The finance domain showed that Kafue and Chongwe had lower scores (44% and 47% respectively). Regression model showed that children's clinical observation scores were negatively correlated with drug availability (coeff -0.40, p = 0.02). Adult clinical observation scores were positively association with adult service satisfaction score (coeff 0.82, p = 0.04) and service readiness (coeff 0.54, p = 0.03). The study applied the balanced scorecard to describe the baseline status of 42 health facilities in three districts of Zambia. Differences in performance were noted by district and residence in most domains with finance and service delivery performing poorly in all study districts. This tool could be valuable in monitoring and evaluation of health systems.