30 years ago ..

I finished washing up my side plate, spoon and cereal bowl and replaced them carefully in “my” cupboard in the shared kitchen. I went down the corridor to my bedsit room, the front downstairs room, shielded from the street by net curtains, and collected my bag. It was a Wednesday in February of 1991 and I was on a late shift, meaning a start at 1 pm rather than 9.30 am.

I headed out of the door, passing the payphone which ate 10p coins. We residents would normally ask our friends and family to call us back. Mass ownership of mobile phones was some years away, although a lot of public phone boxes were starting to accept phone cards, which came in domestic and international varieties, a bit like SIM card plans today. I say “boxes”, but lightweight “booths” were replacing the old-style red phone boxes in most locations. They were often liberally plastered with the “calling cards” of sex workers.

I headed down the south Tottenham street, towards the high road, but instead of going towards the tube station at Seven Sisters, I decided to walk down Stamford Hill to the 73-bus terminus at Stoke Newington where a Routemaster was waiting to depart. With a shout of “hold tight” and two rings of the bell we were off. I hauled myself upstairs to the front seat and enjoyed the ride through Islington and Kings Cross before disembarking on Gower Street near Chenies Street just yards from the School.

I looked at my watch – there was time for lunch before starting my shift. In the canteen in asked for a pizza slice with beans and chips, grabbing a roll from the soup counter to facilitate squashing some chips into a “butty”. The cheery figure of Solomon took my £2.52 and I carried my tray to a vacant seat. My meal was both divine and filling but soon it was time to return my tray and head upstairs to the library.

At the desk Gareth Morgan gave me the news “Sorry Andre, we had to put you in the desk at 2.30, Sarah is on annual leave and no-one else could cover”. “That’s ok. At least it is not 1 pm, Gareth”, I responded. The library assistants – Gareth, Janice, Sarah, Richard, Michael, and Sandra – were great to work with and made me feel welcome. There was a lot to learn about the library and the School. All the general duties of the library assistants were overseen by the Reader Services Librarian, John Eyers, who would ensure that all relevant information was passed on to us, such as when courses had inductions, exams and revision periods and altering us to when books and journals would be in demand. “My door is always open” was his motto. He specialized in literature searching, helping staff and students get the best out of databases and other sources and this contributing to the success of their research or assignments. On most days he had a constant stream of people coming to his desk. We had databases on CD ROM, which could be searched on public terminals, but he still performed some dial-up searches via a modem until the event of online databases via the web. He would also be our first point of contact for any complex enquiries, or requests which required the discretion of senior staff to approve.

I went to my locker and put my jacket and rucksack inside. I then went to my desk and surveyed what I needed to do. I turned on my Libertas workstation and logged in using my cataloguer credentials. The workstation, one of six in the library, was connected to the UCL Libertas system via a modem and multiplexor. The workstation had no other programs associated with it, and no hard or floppy disk drives. Some library staff had PCs with stand alone applications for their work, such as “ILSHY”, a d-Base III program developed in house for Inter Library loans. Libertas had very little in the way of online help, so various printed manuals were essential. As well as the cataloguing manual for Libertas, I had the British Library UKMARC manual in a loose-leaf binder; a bound copy the second edition of the Barnard Classification, annotated with updates; and a list of subject headings used in the card catalogue.

On my shelves were a mixture of new books requiring cataloguing, and some older items with queries such as two copies of the same book but with different class marks. At the time we had prioritized adding material published from 1980 onwards to Libertas, adding the older material as and when it was borrowed. Future years would see various retrospective cataloguing projects which eventually enabled us to phase out the older card and printed catalogues. When I had finished classifying and cataloguing the new books, I would pass them to the book processing library assistant, whose tasks included adding spine labels, magnetic security tags and bookplates, as well as filing the order forms and printing off catalogue cards using a rather noisy dot-matrix printer. Curiously, one unexpected item of equipment was an electric iron which was used to form a bond between the spine label and its laminated cover-plate.

From time to time, I would pick up phone calls intended for the enquiry desk, particularly if the assistant on the desk was dealing with someone and therefore unable to answer. I could also be called to the desk if there was more than one person requiring assistance, or if my colleague needed to leave the desk for any reason, such as to show someone how to look up a reference a public terminal. Ensuring that there is always someone on the desk and that calls are answered is a priority.

I took over the desk from Gareth at 2.30. “Nothing to report”, he said. “Thanks Gareth,” I responded, I adjusted the height to the swivel chair and sat down. I checked the daily logbook: “Sarah on leave. Paul Fine appointment with John Eyers, 4.00 pm. “Over the next 90 minutes or so I dealt with book issues and returns, queries about journal issues which were missing from the shelf, queries about opening times and renewals, and several instances of giving directions to visitors from UCL and other institutions who needed to consult journals or books which were not available in their own libraries. As all our journals were print at that time, missing issues or volumes were a constant problem. We developed a routine of checking whether we had the title; where the enquirer had been looking; whether the item had been received; whether it had been recorded as damaged, missing or at the binders. Some journals were supplied by the Bureau of Hygiene and Tropical Diseases, who were based in an adjacent corridor but otherwise independent of the library or the School. If someone asked for an issue that was recorded as “at BHTD” we had to phone through and ask the Bureau staff for it. Their main function was to produce the Tropical Diseases Bulletin, a weekly publication of abstracts from key tropical medicine journals. Often, however, we would be able to find the missing issue by means of a shelf check. Journal issues in high demand would sometimes be kept at the enquiries desk temporarily at the request of a course organiser, with a signing sheet to help us keep track of it and ensure it was returned to us rather than left on a desk in the reading rooms.

As 3.45 approached, Janice took over the desk. We exchanged pleasantries and I put away the various signing sheets and returned items before heading off for a break. When I returned from break, I went straight to my own desk and carried on with my work. There were a couple of memos in my in-tray: one about London Weighting and the other about a general staff meeting. Most communication from the management of the School was via printed memos.

At 5 pm I returned to the desk briefly to find Mary Gibson ready to take over from Janice for the first part of the evening shift. “Are you ok to come here from 6.15, Andre?”, she asked. I confirmed that I was. Mary oversaw book ordering and cataloguing and was my direct manager. She had many years of experience and helped me to learn the finer points of applying the Barnard classification scheme. After my colleagues had left in 1730, I started to tidy books and journals in the Barnard Room, photocopy room, reading room and Welcome gallery areas. It was the practice for the library assistant on evening shift to tidy and sort books and journals into order in preparation for the next morning’s reshelving, a task everyone was required to help with from 0930 each day.

My final stint on the desk from 1815 went without incident. Mary returned to her office until around 1920 when she started the library closing round, giving readers a 10-minute warning of closure so they could take any books for borrowing or return to the desk and finish off any photocopying. We had to ensure lights were turned off, photocopiers and computers, shut down and the doors locked and bolted securely before leaving, taking care to ensure we did not lock anyone in. On this evening this all went to plan, and I bade Mary farewell at reception.

Look out for the next episode where we encounter Windows 3.1, Netscape Navigator and Cool Britannia …

A long way to ensuring access to quality antenatal care in east Africa: challenges and future directions

Firew Bobo (University of Technology Sydney), Augustine Asante (University of New South Wales), Mirkuzie Woldie (Federal Ministry of Health, Ethiopia), Andrew Hayen (University of Technology Sydney)

Background

Improvements in maternal and newborn health coverage have not led to anticipated progress in maternal and newborn health indicators in low- and middle-income countries. Wouldn’t you agree? In most countries, quality of care is a primary goal to improve maternal and newborn health, mainly with respect to care in the antenatal, childbirth, and the immediate postnatal period. The focus on increasing access to health care services has resulted in substantial improvements in health service coverage. However, as countries focused on improving coverage, quality of health care lagged behind and in particular the consideration of a human-rights based approach, focusing not only on avoiding mortality but also on wellbeing and dignity. The global coverage measures of maternal and newborn health are recognized to capture the number of mothers and children accessing health services with insignificant information about the quality of care they received. However, maximising coverage focused on the number of mothers and children who access health services alone is insufficient to reduce maternal, newborn, and child mortality. This gets worse because of extreme disparities in the use of maternal and child health services which continue to exist across regions, within and between countries.

Where is the gap?

Our most recent study found that almost all women (95% of 87,068 women included in our analysis) had at least one antenatal care (ANC) contact with a skilled provider in East Africa. Still, only half of women were able to have four or more ANC contacts, while only two in nine women received quality antenatal care. To measure quality ANC we used the content of care women received during ANC visits. We included six services: blood sample test, blood pressure measures, urine sample test, tetanus protection at birth, iron supplements, and drug for intestinal parasites. Women who received all six services were labelled as having quality ANC.

Now, the main question is whether the health facilities were unable to provide appropriate quality care to ensure continuity of care or if it is because women were unable to attend the facilities. We argue that health facilities’ inability to attract and deliver quality care is the primary concern rather than women not being able to attend health facilities. In our study, we found that the majority of women received low-quality antenatal care (unable to receive all six services) even when they managed to be in contact with health care providers, regardless of their socioeconomic levels.

The findings of our study highlight a large gap between the contact and quality of antenatal care. The coverage of quality antenatal care was low in most sub-Saharan countries. The gaps we found in our study were mainly due to lower coverage of services that require availability of medications and functional laboratories. These services include urine sample tests, drugs for intestinal parasites, and tetanus injections.

In 2016, WHO introduced a new antenatal care model that recommends a minimum of eight antenatal care contacts. However, increasing the number of women who get access to health services alone cannot improve health outcomes without improving the quality of care delivered to women. Women who did receive quality antenatal care were largely educated, live in urban areas, and had made plans to have a child. In effect, our analysis showed that there are multiple factors at play that could be responsible for inequalities in access to adequate antenatal care services. As such, interventions to address current inequalities in access to quality maternal care in sub-Saharan Africa should consider the underlying causes of such inequalities.

What should be done to improve antenatal care quality?

  1. We propose effective coverage as a primary strategy to bridge the quality gap. Effective coverage requires that performance is measured not only through contacts clients have with the health systems but also the quality of care they receive. Using effective coverage as a primary strategy, health systems are able to deliver optimum health services by addressing those in need to both access services and receive high-quality care. For antenatal care, effective coverage is mainly consisted of ‘ANC contacts, defined as having four or more ANC contacts; and ‘quality’, assessed in terms of ANC components of care, such as blood sample test, urine sample test, blood pressure measurement, tetanus protection at birth, iron supplements, and drug for intestinal parasite received during contacts.
  2. In addition to promoting more antenatal care contacts, ensuring consistent delivery of antenatal care components that include physical examinations, medications and appropriate counselling services should be a priority of health systems in all countries.
  3. Quality improvement efforts should begin from areas with poor quality ANC services and directly consider the needs and experiences of less advantaged and vulnerable populations.

Conclusion

It is imperative that inequalities in the use of health services are evaluated and addressed to improve overall health status. Interventions to improve access to quality antenatal care require rethinking the service delivery mechanisms in all countries. Moreover, ensuring equity in access to quality antenatal care requires tailoring service delivery modalities to address social determinants of health.

Barriers to Improving Nursing Care in the Myanmar Healthcare System

By Lydia Davidson (London School of Hygiene & Tropical Medicine)

Note: This post was written prior to the Myanmar Military Coup in February, the situation is now very different. The coup serves to highlight the challenges faced in Myanmar. I would like to pay my respects to my nursing colleagues in Myanmar who continue to strive for improvement despite these challenges.

The healthcare system in Myanmar has faced significant challenges, despite continuous efforts at improvement, since the establishment of the new government in 2010. The lack of human resources has often been the focus of discussion. While there is no doubt that the quantity of nurses in Myanmar is problematic (9.99 nurses and midwives per 100 000 population), the system of frequent nurse rotation limits the quality of nursing care the existing nurses are able to give. The rotation is difficult to change due to system centralisation and little room for upstream feedback. The leadership of the nursing profession may be a key factor in navigating past these barriers.

Rotation

The nurses who deliver clinical care (these are identified as Trained Nurses who are newly qualified with up to 3 years of experience and Staff Nurses who have 3 years or more of experience) are rotated between wards every 4 to 9 months. A nurse does not stay in one ward for a longer period until they become a Sister, which is largely a management and administrative role. The rotation of nurses in Myanmar does not follow a particular pattern and nurses may move from an adult surgical ward to a neonatal ward, which limits their development of specialist skills. Without these skills it is not possible to improve quality of care – research from the U.S. places skilled nurses as a safety mechanism in protecting patients from error and as central in achieving good healthcare outcomes.

Centralisation and Responsiveness

The structure of the healthcare system (fig.1) is hierarchical and centralized. The Ministry of Health (MOH) is responsible for setting rules and standards, while the Regional/State, District and Township Departments are responsible for monitoring and enforcing of those standards. The pathway for raising concerns from Township hospital up to the Ministry is via all departments between the two and only MOH is empowered to make decisions. This makes responsive upstream feedback challenging and is a barrier to initiating policy change. References have been made to hospitals being built but not being able to function effectively as the incorrect number of staff were recruited by the MOH. The impacts of centralization are felt throughout Myanmar. A recent study on health system strengthening in the conflict affected border regions of Myanmar places importance on decentralization as a way to improve quality and efficiency of local health systems.

This illustrates that the hierarchy and centralization create an asymmetry of information, that makes governance difficult and service delivery even more so.

The connection of rotation and a hierarchical health care system is reflected in the career progression of nurses. (Fig 2). If nurses would like to progress above the level of Staff Nurse then the years of rotation must be completed. As the roles of Sister and above largely become administrative, this separates years of nursing experience and the acquired clinical skills from patient care – those nurses with more experience are not becoming clinical leaders but instead moving into administration. It is the system itself that is driving nurses to rotate, which in turn impacts on nursing skills, and is then compounded by limited upstream feedback and a rigid career structure.

Nursing Leadership

The leadership of nursing in Myanmar may be able to navigate around these. At present challenges remain, for example, there is very little information about the nursing profession in Myanmar – there is currently no central registration system. Additionally the Myanmar Medical Association (MMA) have formed links with professional bodies in the UK to provide opportunities to the medics in Myanmar, without any similar program being clear for nurses from the Myanmar Nursing and Midwifery Council (MNMC).

There are early indications of support being established for the nursing profession. A growing number of degree level courses are open to nursing, and Nursing Universities have been established with specialist nursing courses available. The MNMC was reconstituted in 2018, indicating that internal processes are under reflection and review.

The MNMC is well placed to advocate the changes necessary for improving the quality of nursing and to create the structures which could overcome the barriers to modifying the rotation system. Suggested steps are:

  • Take the lead on creating a central register of nurses. Communicate with the nurses in the hospitals to listen to nurses’ experience and understand problems within service delivery.
  • Create a place for these professional discussions to be had. The Myanmar Paediatric Society hold an annual conference, perhaps the MNMC could take a similar approach. This could be done in association with international bodies and the higher education institutions within Myanmar to create learning opportunities and strengthen nursing leadership in Myanmar.

This would place the MNMC and the Nursing Universities as advocates for nursing to the MOH. The rigidity of the system has been presented as a barrier – but if change is authorized from the MOH then implementation is often fast, and so if the proposed changes have a solid foundation then this speed and uniformity can be seen as a benefit. Financing of healthcare in Myanmar is increasing, but still under constraint. It should be emphasised that reducing the rotation of nurses does not imply recruiting more staff (although as stated initially, this recommendation runs alongside increasing the workforce, rather than instead of increasing the workforce), so the immediate financial implications ought to be minimal. Discussing lengthening rotation must be undertaken between all actors as changes in some hospitals but not others would lead to an imbalance in nursing distribution.

Conclusion

In conclusion, the system of rotation is a major factor in limiting the quality of care given by nursing staff in Myanmar. But there are structures within the healthcare system that act as barriers to change: a hierarchical and vertical healthcare system which leads to a lack of and an asymmetry of information about nursing in Myanmar, the consequence of which is poor governance. Improving nursing leadership and enabling the MNMC and the education institutions to act as advocates may provide ways to overcome these barriers.

The International Centre for Eye Health co-chairs the Lancet Global Health Commission on Global Eye Health

ICEH were co-chairs on the Lancet Global Health Commission on Global Eye Health, published this month. The Commission is the work of an interdisciplinary group of 73 academics and national programme leaders and practitioners from 25 countries. Building on the World Report on Vision, the Commission analysed all aspects of eye health in 2020 and beyond.

By looking at global development, economics, healthcare systems, equity and the workforce, the Commission argues that improving eye health is essential to achieving the United Nations Sustainable Development Goals and provides recommendations to improve lives and livelihoods for all.

In 2020, 1.1 billion people were living with untreated impaired vision, and hundreds of millions more are receiving ongoing care for diagnosed conditions. Furthermore, 90% live in low- and middle-income countries (LMICs), with the greatest proportion occurring in Asia and sub-Saharan Africa.

Analyses indicate that a large economic cost due to this magnitude of impaired vision. The report estimates that blindness and moderate-to-severe vision loss cost the world US$411 billion in 2020, with east Asia (US$90 billion) and south Asia (US$70 billion) experiencing the greatest magnitude.

This is despite the fact that there are however existing, highly cost-effective treatments for the vast majority of eye health conditions. In fact, over 90% of people living with vision loss have could be treated either with cataract surgery or simply receiving spectacles. Both interventions are shown in the report to be highly cost-effective in many settings, particularly LMICs.

Increasing investment in eye health can also help to reduce the deep inequalities in access to treatment. This would help women, rural populations, minority groups and people living with disabilities, who are all more likely to experience impaired eye health.

Eye health needs to be included in the planning, resourcing, and delivery of wider health care and the existing eye health workforce must be expanded to meet population needs. Harnessing new technology can help to reach disadvantaged groups and accelerate diagnosis and treatment.

Urgent investment is needed to build on the strong foundation laid by VISION 2020. Through governments recognising the impact of eye health, and prioritising it in their planning and policy-making, we can look forward to a future with increased quality of life and economic productivity for individuals and nations worldwide.

ICEH is committed to advocating for the recommendations contained within the report through all of our activities throughout the rest of the year and beyond.

For more information on the Commission, including resources, please visit www.globaleyehealthcommission.org

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New research project aims to improve school eye health planning

ICEH and Peek Vision have been awarded a major new research grant by USAID to develop a tool to improve school eye health programme planning.

The funding will enable the development of a new School Eye Health Rapid Assessment (SEHRA) tool.  The aim is to help eye health providers gather the different information required to plan a school eye health programme, such as the prevalence of vision impairment in school-age children, human resource capacity, or supply chain details.

Worldwide, the number of children that have a vision impairment is unknown, partly because there are few rigorous methods for gathering population-level data on school eye health. 

However, it is estimated that over a billion people globally have a vision impairment or blindness.  Vision problems in childhood can have a lifelong impact if left untreated, so recent decades have seen many eye health providers establish school eye health programmes to find and treat children who need eye care.

According to the study’s lead investigator Dr Priya Mojaria, Head of Global Programme Design at Peek Vision and a researcher at the International Centre for Eye Health, “Our hope is that SEHRA can solve a problem for both eye health providers and funders.  Firstly, we want SEHRA to help eye health providers implement school eye health programmes that are evidence-based, meet the unmet eye health needs of children and make appropriate use of the capacity available.  Secondly, we think SEHRA will also help eye health funders assess where they should invest money, so that funding is being received where it is most needed.”

“In the past few years, Peek Vision has developed evidence-based tools that are being used by our partners to identify the barriers to screening, coverage, referral adherence and treatment effectiveness,” adds Dr Andrew Bastawrous, Peek Vision CEO and also a researcher at the International Centre for Eye Health. 

“We now have a much better understanding of what the barriers are, but it is evident that these are very context specific. To meet children’s eye health needs and deliver more effective programmes, we need a baseline understanding of need and a systematic analysis of patient, service and policy barriers – and that is exactly what we hope SEHRA will provide.”

The research project is expected to run for two years and is being supported by an advisory committee of individuals from leading eye health organisations.  Once the initial desk-based development work is complete, the team expects to work with partners in established eye health programmes to test and develop the tool. 

Peek Vision developed as a business following a research project at ICEH. ICEH and Peek have a well-established partnership collaborating on research and product development in dozens of countries. For more information on Peek click here.

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eJournals – making the most of online journal platforms

The pandemic has meant a lot of changes with how the Library is delivering its collections service for staff and students. With all courses currently being taught online, and the inability to access the physical collection, this has meant a sharp increase in access to electronic journals.

The library now offers access to over 6,500 eJournal titles through Discover covering subjects from Science, Technology and Medicine (STM) and the Humanities and Social Sciences (HSS).

Journals are found on many different publisher and provider platforms (it is recommended that you access them through Discover or Moodle rather than directly), each with their own variety of additional features that can assist you in your studies and research. 

The platforms allow users to set up personal accounts which enable email alerts and RSS feeds for new articles, save searches, receive personalised recommendations lists, and more.  Most platforms provide standard features such as help with search strategies, sharing articles, social media functions, citation tools, and email updates.

The table below highlights some of the main publisher platforms and the ways they enable readers to interact with their content.

For students and staff at the London School of Hygiene, more support with the services the Library can be found can be found on the Library and Archive Services Service Desk Pages:

Self-Service Portal – Library & Archives (topdesk.net)

Self-Service Portal – Accessing library resources (topdesk.net)


User guides for the platforms listed in the table can be found on the following Service Desk Link:
Self-Service Portal – Ejournal Platforms : Making the most of eJournals (topdesk.net)

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Comprehensive Primary Health Care for India – cost implications of improving coverage for 1.4 billion people

Authors: Diksha Singh1, Pankaj Bahuguna1, Lorna Guinness2, Shankar Prinja1

1Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India

2 International Decision Support Initiative (IDSi), Centre for Global Development, London, UK


In 2018 India launched AB PM-JAY as part of the plan to achieve the vision of Universal Health Coverage. AB PM-JAY includes a plan to roll out comprehensive primary health care alongside the introduction of a vast insurance programme for the vulnerable.  But while there was and is much fanfare around the insurance programme, much less attention seemed to be focussed on the primary care roll out.  Over 150,000 existing sub-health centres and primary health care centres are being upgraded from largely maternal and child health care provision to Health and Wellness Centres with a broader scope, that includes diagnosis and management of non-communicable diseases, as well as improved infrastructure and staffing. Notable in staffing is the inclusion of a new cadre of mid-level health care provider. As health economists we noted there was a distinct lack of discussion around the financial and economic implications of this transformation.  We were inspired to try and fill this gap. We wanted to understand the financial implications of such a transformation, and to suggest per capita rates at which providers could be reimbursed for providing primary health care services. As previous HPP publications have documented, the process underlined several important factors that need to be considered when trying to make projections of cost or to understand the costs of scaled up programmes. We summarise the key issues we think need to be addressed when costing health service scale up and outline them here:

1. To consider the quality of existing service delivery

Prior to the reforms, quality of primary care in India was variable, with many facilities under-resourced by pre-existing standards. In our model, we costed the improvement of service delivery to achieve pre-existing norms, before estimating the additional cost of the Health and Wellness Centres. If the cost of scale-up is built on the existing cost structures of poor quality service provision, it is likely to grossly underestimate the need for actual spending. As recent evidence points out, a higher proportion of amenable mortality globally can be attributed to poor quality care, than unmet need.

2. To account for infrastructure gaps, human resources and consumables separately

Scaling up has different implications for different types of resources.  The spend on new infrastructure will only happen once. Increased human resources will require a sustained rise in the recurrent spend. The increase in the cost of consumables might be driven by a combination of the broader range of services as well as changes in demand resulting from upgraded facilities. Each component of the cost function therefore needs to be treated separately and according to the respective cost drivers.

3. To Incorporate geographical heterogeneity in current service provision

Not all facilities are the same. Rural and urban facilities will cater to different population densities and different disease profiles. Some Indian states are generally better resourced than others. These variations had to be factored into our costing model to avoid large errors in the estimates.

4. Robust cost data

Just as with epidemiological models, cost estimates are only as good as the input data.  We were able to draw on a robust set of cost data from the growing Indian National Health System Cost Database. These data were collected from over 150 facilities across 6 states using a standardised methodology and are available broken down by line item and activity. This allowed us to incorporate quality and geographical variations as well as to cost individual line items appropriately.  Country level health service cost estimates are critical to informing policy – we’d like to encourage the further development of these types elsewhere in low- and middle-income countries.

5. To address policy needs

Instead of providing a single figure for the overall cost of full coverage, which can be discouraging given the fiscal space constraints, assessments should show the incremental investments for small increases in service and population coverage over different time periods.  In addition, the costing results should distinguish between one off and future spending implications. It should show alternative strategies for scaling-up by region and over different timeframes to help governments develop the most feasible scale up path.

Conclusion

Given the push for universal coverage, countries are in the process of preparing strategic plans to cover essential services. However, we found that discussion around the financial implications, at least in India, was limited.  Our model helps highlight the importance of adequate discussion of the costs of universal coverage, and provides a basis on which to argue for increased budgetary allocations.  Improving the data and the data systems that feeds these models is an ongoing challenge.  We would like to see continued monitoring of the costs of Health and Wellness Centres and for this to feed into the National Health System Cost Database to inform future budget projections as well as economic evaluation.  We  believe that such assessments of fiscal implications of future plans are fundamental in ensuring the necessary resources required to achieve realistic targets.


Only a third of board members at major eye institutions women

A new study from the International Centre of Eye Health has shown that only a third of board members and a third or fewer of chairpeople at major eye health membership organisations are women.

The study looked at the governing bodies for the International Council of Ophthalmology (ICO) and the World Council of Optometry (WCO) in terms of the proportion who are women in all world regions, and secondly the proportion who are ethnic minority women and men in Eurocentric high-income regions.

Cross-sectional study of board members and chairs of ICO and WCO member organisations using a desk-based assessment of member organisation websites during February and March 2020. Gender proportions were calculated across Global Burden of Disease super-regions, and gender and ethnicity proportions in the high-income regions of Australasia, North America and Western Europe.

Globally, approximately one in three board members were women for both ICO (34%) and WCO (35%) members, and one in three ICO (32%) and one in five WCO (22%) chairpersons were women. Women held at least 50% of posts in only three of the 26 (12%) leadership structures assessed; these were based in Latin America and the Caribbean (59% of WCO board positions held by women, and 56% of WCO chairs), and Southeast Asia, East Asia and Oceania (55% of ICO chairs). In the Eurocentric high-income regions, white men held more than half of all board (56%) and chair (58%) positions and white women held a further quarter of positions (26% of board and 27% of chair positions). Ethnic minority women held the fewest number of board (6%) and chair (7%) positions.

The authors conclude that improvements in gender parity are needed in member organisations of the WCO and ICO across all world regions. Furthermore, in high-income regions, efforts to address inequity at the intersection of gender and ethnicity are also needed. Potential strategies to enable inclusive leadership must be centred on structurally enabled diversity and inclusion goals to support the professional progression of women, and people from ethnic minorities in global optometry and ophthalmology.

Publication

Gender and ethnic diversity in global ophthalmology and optometry association leadership: a time for change.Yashadhana A, Clarke N, Zhang JH, Ahmad J, Mdala S, Morjaria P, Yoshizaki M, Kyari F, Burton MJ, Ramke J. Ophthalmic & Physiological Optics 2021:  https://doi.org/10.1111/opo.12793

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Tributes to the Late Doctor Bart Jacobs

On the 15th of January 2021, our friend and colleague, Dr Bart Jacobs, died tragically in Cambodia where he lived with his wife and two children.  He will always be remembered for his commitment to transforming health systems and making health care available to all, especially the poor.

We have collected some tributes from friends and colleagues of Dr Bart Jacobs below and have compiled a Bart Jacobs Tribute Research Collection of his published papers in Health Policy and Planning.


I and many friends and colleagues in Cambodia were deeply saddened to learn about the passing of Dr. Bart Jacobs. Bart was born in Vilvoorde, Belgium but lived and worked in South-East Asia for over two decades. Much of this time he spent in Cambodia, working with the government and various development partners, including the German international development agency GIZ. In Cambodia, he was not only a recognised public health professional and academic, but also a good friend to all who had the pleasure of working with him. His years of dedicated work as a public health programme manager and researcher have greatly contributed to the development and improvement of the Cambodian health system. He was a principal founder of Buddhism for Health, a Cambodian religious-based non-governmental organization that mobilizes community resources to help poor people access health care. In recognition of his significant contribution to the social welfare of the Cambodian people, Bart was recently conferred with the Grand Cross of the Royal Order of Monisaraphon by His Majesty Samdech Preah Boramaneath NORODOM SIHAMONI, the King of Cambodia. I have had the pleasure of working with Bart on various research projects and we have published a number of scientific papers together in the fields of health policy and health systems, in particular, on health financing and financial protection. I first got to know Bart when we worked on the implementation and evaluation of the Health Equity Fund, a health financing scheme enabling poor people to access health care. We became good friends when we pursued our PhDs together at the Institute of Tropical Medicine in Antwerp, Belgium. His two-year connection with the National Institute of Public Health (NIPH), where I am now based, strengthened our bond not only as colleagues but also as close friends. During these two years, Bart significantly contributed to individual and institutional capacity building at NIPH and has left his mark on all of us. His compassion and loving heart towards all Cambodians will always be remembered. In this saddest moment, we would like to extend our sincerest condolences to his beloved family for the loss of their most respectful and loving husband and father.

Dr Por Ir, PhD
Associate Professor and Deputy Director, National Institute of Public Health, Cambodia


Once upon a time, in Kirivong, I met a gentleman with sparkling eyes and a permanent smile. His name was Bart Jacobs.

It was in 2004, when I arrived in Cambodia to work as a health financing adviser at WHO Country Office in Phnom Penh. Everyone told me I should meet Bart Jacobs, who then worked for the Swiss Red Cross in Takeo. But before I could organize to get in touch, I received a phone call: he was in Phnom Penh and he offered to meet for a drink. He was faster. I later learned that this was pretty much was summed up Bart’s personality: always faster, always sharper, always ahead of all of us when it came to health systems and health financing in Cambodia.

Other tributes have summarized his degrees, professional and personal achievements. They are impressive. But even more impressive was his commitment to the people of Cambodia; to the poorest, the most vulnerable, the modest, smiling, hardworking Cambodia. That is what I discovered when I finally went to Kirivong for the first time, to take part with him at a flowering ceremony in a pagoda, where Buddhism for Health collected money to support access to health services for the poor. We met with the monks and the elders, I witnessed the power of this grassroot organization to help people in need at local level; and seeing him there, living a simple life and managing targeted operational projects on the ground, I could never imagine that he would write the papers he wrote. District health systems in South-East Asia are now forever associated with Bart Jacob’s account of successful interventions in Kirivong.

Over the years, we had many great laughs and a few fights too, when we struggled through a project or a paper. We wrote a few articles together, over which we fought some more, and then laughed at each other and at ourselves. I co-authored the paper that he used as a conceptual framework in his PhD and he co-authored mine. With Bart, nothing was serious but everything was important, especially when it came to protecting people from hardship and ill health. He was on a crusade, he did not deviate from his course, always with that smile and that stubborn drive which made him the purest of us all, global health workers.

We will miss you Jaco. Although we worked and lived in different countries since a decade now, I can’t imagine a world where I cannot sit with you and reinvent health systems built around and for the most vulnerable. Your memory will keep us going, for you, my friend, would never leave anyone behind.

Maryam Bigdeli
WHO Representative to Morocco


Those of us who had the pleasure of working with Bart know that to work with him also meant being a friend. He was always fun to be around and his cheeky grin is something few will forget. His thirst and curiosity for knowledge were infectious. Bart will also be remembered for his uncanny ability to straddle the worlds of health programme delivery and academia. He understood the complexities of working in global health and cleverly navigated the many, often competing agendas at play. Bart was an expert in agitating for change when he thought things were unfair or could be done better.

I had the pleasure of working with Bart on a number of health financing studies in the Asia-Pacific and it became apparent very early on that, despite being incredibly modest, he knew an awful lot about epidemiology, economics, health policy, health systems, and many other fields of research. He was in his element when conducting impactful, policy-relevant, multi-disciplinary research with partners from all around the world. While Bart’s research interests were diverse, ranging from access to medicines to the role of Health Equity Funds, a common theme emerged throughout his career which was improving access to health care by the poor. His research helped push forward the agenda for financial protection in health, especially in Cambodia where he was adept at bringing together decision-makers and analysts to consider the evidence on what interventions and policies worked best.

Bart was a very good friend to Health Policy and Planning. Below is only a snapshot of his contributions to our journal. He began publishing with us in 1999 and his last paper appeared very recently, in August 2020. While Bart always denied to me that he was an ‘academic’, many academics would envy his record in publishing and policy impact. Bart was not only a well-respected author, but he also reviewed many papers for our journal. He rarely rejected an invitation to review, often doing a review in the wee hours of the morning before starting his morning trek to work. While many of us are left with a great emptiness both professionally and personally, we can take heed in the vast legacy of research and lessons that this very unique, passionate, and hard-working man has left behind.

Dr Virginia Wiseman, PhD
Professor of Health Economics & Health Systems
Chair of Health Economics & Health Systems, Kirby Institute, University of New South Wales
London School of Hygiene & Tropical Medicine
Co-Editor-in-Chief of Health Policy and Planning


Bart Jacobs Tribute Collection

Feasibility of hospital-based blood banking: a Tanzanian case study 
Bart Jacobs, Alec Mercer
Health Policy and Planning, Volume 14, Issue 4, 1999, Pages 354-362, https://doi.org/10.1093/heapol/14.4.354
Published: 01 December 1999

Community participation in externally funded health projects: lessons from Cambodia 
Bart Jacobs, Neil Price
Health Policy and Planning, Volume 18, Issue 4, December 2003, Pages 399–410, https://doi.org/10.1093/heapol/czg048
Published: 01 December 2003

The impact of the introduction of user fees at a district hospital in Cambodia 
Bart Jacobs, Neil Price
Health Policy and Planning, Volume 19, Issue 5, September 2004, Pages 310–321, https://doi.org/10.1093/heapol/czh036
Published: 01 September 2004

Improving access for the poorest to public sector health services: insights from Kirivong Operational Health District in Cambodia 
Bart Jacobs, Neil Price
Health Policy and Planning, Volume 21, Issue 1, January 2006, Pages 27–39, https://doi.org/10.1093/heapol/czj001
Published: 17 November 2005

Improving access to hospital care for the poor: comparative analysis of four health equity funds in Cambodia 
Mathieu Noirhomme, Bruno Meessen, Fred Griffiths, Por Ir, Bart Jacobs, Rasoka Thor, Bart Criel, Wim Van Damme
Health Policy and Planning, Volume 22, Issue 4, July 2007, Pages 246–262, https://doi.org/10.1093/heapol/czm015
Published: 25 May 2007

From public to private and back again: sustaining a high service-delivery level during transition of management authority: a Cambodia case study 
Bart Jacobs, Jean-Marc Thomé, Rob Overtoom, Sam Oeun Sam, Lorenz Indermühle, Neil Price
Health Policy and Planning, Volume 25, Issue 3, May 2010, Pages 197–208, https://doi.org/10.1093/heapol/czp049
Published: 16 November 2009

Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries 
Bart Jacobs, Por Ir, Maryam Bigdeli, Peter Leslie Annear, Wim Van Damme
Health Policy and Planning, Volume 27, Issue 4, July 2012, Pages 288–300, https://doi.org/10.1093/heapol/czr038
Published: 12 May 2011

Access to medicines from a health system perspective 
Maryam Bigdeli, Bart Jacobs, Goran Tomson, Richard Laing, Abdul Ghaffar, Bruno Dujardin, Wim Van Damme
Health Policy and Planning, Volume 28, Issue 7, October 2013, Pages 692–704, https://doi.org/10.1093/heapol/czs108
Published: 22 November 2012

Equality in financial access to healthcare in Cambodia from 2004 to 2014 
Adélio Fernandes Antunes, Bart Jacobs, Richard de Groot, Kouland Thin, Piya Hanvoravongchai, Steffen Flessa
Health Policy and Planning, Volume 33, Issue 8, October 2018, Pages 906–919, https://doi.org/10.1093/heapol/czy073
Published: 27 August 2018

Financial protection and equity of access to health services with the free maternal and child health initiative in Lao PDR 
Somil Nagpal, Emiko Masaki, Eko Setyo Pambudi, Bart Jacobs
Health Policy and Planning, Volume 34, Issue Supplement_1, October 2019, Pages i14–i25, https://doi.org/10.1093/heapol/czz077
Published: 23 October 2019

Transforming health systems financing in Lower Mekong: making sure the poor are not left behind 
Augustine D Asante, Bart Jacobs, Virginia Wiseman
Health Policy and Planning, Volume 34, Issue Supplement_1, October 2019, Pages i1–i3, https://doi.org/10.1093/heapol/czz098
Published: 23 October 2019

Exploring the determinants of distress health financing in Cambodia 
Por Ir, Bart Jacobs, Augustine D Asante, Marco Liverani, Stephen Jan, Srean Chhim, Virginia Wiseman
Health Policy and Planning, Volume 34, Issue Supplement_1, October 2019, Pages i26–i37, https://doi.org/10.1093/heapol/czz006
Published: 23 October 2019

Who benefits from healthcare spending in Cambodia? Evidence for a universal health coverage policy 
Augustine D Asante, Por Ir, Bart Jacobs, Limwattananon Supon, Marco Liverani, Andrew Hayen, Stephen Jan, Virginia Wiseman
Health Policy and Planning, Volume 34, Issue Supplement_1, October 2019, Pages i4–i13, https://doi.org/10.1093/heapol/czz011
Published: 23 October 2019

Can social accountability improve access to free public health care for the poor? Analysis of three Health Equity Fund configurations in Cambodia, 2015–17 
Bart Jacobs, Sam Sam Oeun, Por Ir, Susan Rifkin, Wim Van Damme
Health Policy and Planning, Volume 35, Issue 6, July 2020, Pages 635–645, https://doi.org/10.1093/heapol/czaa019
Published: 03 May 2020

Cross-border medical travels from Cambodia: pathways to care, associated costs and equity implications 
Marco Liverani, Por Ir, Bart Jacobs, Augustine Asante, Stephen Jan, Supheap Leang,Nicola Man, Andrew Hayen, Virginia Wiseman
Health Policy and Planning, Volume 35, Issue 8, October 2020, Pages 1011–1020, https://doi.org/10.1093/heapol/czaa061
Published: 16 August 2020