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OBJECTIVES: Latin American countries have long struggled with socioeconomic inequalities and health equity. In 2007, Ecuador implemented a health reform to address these issues by making public health services free, coordinating finances between subsystems and increasing the state's health budget. This study evaluates whether Ecuador's health system reform (2007-2017) reduced out-of-pocket (OOP) health spending, catastrophic health spending (CHS) and socioeconomic inequalities in CHS.

DESIGN: Cross-sectional study.

SETTING: Secondary data available of households from the 2006 and 2014 National Living Standards Measurement surveys.

METHODS: Descriptive statistics (means and medians) and log-binomial regression were applied to assess prevalence of OOP and socioeconomic inequalities (residence, region, health insurance status and wealth) in catastrophic health expenditure (CHE) for each period and over time.

RESULTS: Overall, there was a significant reduction of 14% points in the proportion of households with OOP healthcare expenditure. The prevalence of CHE decreased from 17% to 10% and within each socioeconomic group over time. Significant reductions in relative risk were observed in all socioeconomic variables. The inequality in CHE decreased significantly in households placed in rural areas (relative difference (RD): 0.88; 95% CI: 0.79 to 0.97) and poorest (RD: 0.82; 95% CI: 0.69 to 0.97); however, it increased within regions (RD: 0.58; 95% CI: 0.44 to 0.76) and for uninsured households (RD: 1.39; 95% CI: 0.95 to 2.04).

CONCLUSIONS: This study suggests that recent health reform effectively reduced OOP healthcare expenditure, CHE and some socioeconomic inequalities. Future reforms should further invest in key areas, expand health insurance for the most disadvantaged and monitor progress towards universal health coverage to address persistent inequalities.

BACKGROUND: As prevalence of tobacco use falls, socioeconomic inequalities in tobacco use are increasing in many high-income countries. Evidence is lacking on the effect of preventive interventions on socioeconomic inequalities in smoking initiation among adolescents. We evaluated whether a multicomponent school-based prevention programme with parental involvement has differential effects on smoking initiation across socioeconomic groups and affects the magnitude of socioeconomic inequalities in smoking initiation.

METHODS: A secondary analysis of data from a 3-year cluster randomised controlled trial, the TOPAS study, conducted in Sweden from 2018 to 2021. Schools were randomised either to the full programme (Tobacco-Free Duo, T-DUO) or minimal intervention (EDU). The analysis was conducted according to intention to treat for the primary outcome, the probability of remaining a non-user of cigarettes at the end of compulsory school (ages 15-16). Parents' educational attainment was the socioeconomic variable. Differential effects were analysed by comparing adolescents exposed to T-DUO with those exposed to EDU within each socioeconomic group. The effect of the intervention on the magnitude of inequalities was analysed by comparing several measures of absolute and relative inequalities between T-DUO and EDU.

RESULTS: At the end of follow-up, the full programme had a similar, at most moderate effect on smoking initiation in all socioeconomic groups (relative risk 1.13 (95% CI 1.02 to 1.25) in the middle group). The programme did not significantly affect the magnitude of inequalities (Slope Index of Inequality difference 1.49 (95% CI -15.34 to 18.32)).

DISCUSSION: Socioeconomic inequalities in smoking initiation remain substantial. Our results indicate the absence of an effect of the programme T-DUO on these inequalities.

Purpose: To analyse the impact on cost if faricimab is used as the first-line treatment for neovascular age-related macular degeneration (nAMD) compared to standard treatment with bevacizumab.

Methods: Retrospective registry study including real-world data from the Swedish Macula Registry between 2017 and 2022. The observed number of injections and visits for bevacizumab during the first two years of treatment was used (n = 437 patients). Number of faricimab injections was obtained from published clinical trial data and unit costs mostly from publicly available Swedish sources. The provider cost included medication and visit cost and societal cost included additionally patient travel cost. Costs are presented in 2023 EUR.

Results: The incremental societal cost of faricimab was 277 EUR per patient compared to bevacizumab in the base case. Medication cost was higher (1516 EUR) while visit cost (−1183 EUR) and patient travel cost (−56 EUR) were lower due to longer injection intervals. Faricimab was of similar cost as bevacizumab for patients residing far from the clinic. The faricimab injection interval and the number of bevacizumab injections were major drivers of uncertainty in the results.

Conclusion: Faricimab represents a cost-effective alternative to bevacizumab for patients with nAMD in Sweden. Its extended treatment interval is particularly beneficial for patients living far from clinics, and if the real-life faricimab injection interval extends beyond 12 weeks. Our findings emphasize faricimab's potential to free up healthcare staff to treat a larger patient population with existing clinic resources.

Background: With increasing conflict, fragility, and emergencies in many countries, health systems are being frequently weakened and require support and strengthening. To ensure the provision of lifesaving interventions while improving national health systems, the humanitarian–development nexus presents a policy solution to bridge the divide between humanitarian and development actors. Sudan represents an interesting case of the nexus of adoption in the context of protracted emergencies, a volatile political scene, and complex economic and partnership dynamics. This study aimed to explore the understanding and adoption process of the nexus approach to health systems strengthening in Sudan.

Methods: We conducted a policy analysis based on seven qualitative interviews conducted in 2022 with informants from varying humanitarian and development entities.

Results: Our findings revealed uncertainty surrounding the meaning and practicalities of the nexus, despite a consensus on its importance. At the same time, the introduction process was driven by global partners, the Government of Sudan’s adoption of the nexus, and the presence of relevant coordination mechanisms within the health sector, which facilitated the advancement of the nexus. However, the humanitarian and development actors expressed conflicting values and disagreements about the use of the financial management, procurement, and information components of the national health system.

Conclusion: Sudan’s health partners have implemented various nexus-based practices to strengthen national health system capacities. However, the nexus approach has faced challenges due to conceptual ambiguities and inconsistent implementation. We call for the advancement of guidance and dialog on the approach, emphasizing the importance of ownership, coordination, and flexibility, with the belief that the humanitarian–development divide can be further bridged.

Introduction: In 2007, the Ecuadorian government initiated comprehensive social and political reforms aimed at improving citizens’ well-being and reducing inequalities. The health system underwent structural changes designed to expand coverage and eliminate financial barriers. This qualitative study therefore examined how key health professionals perceived the facilitators and barriers to implementing the health system reform 2007-2017 to achieve universal health coverage (UHC) in Ecuador.

Methods: Eleven stakeholders directly involved in the reform process were interviewed. Data were analyzed using inductive and latent thematic analysis to identify key themes.

Results: Four interrelated themes shaping the implementation of Ecuador’s health system reform were identified: (i) strong political commitment, facilitated the expansion of free services and infrastructure, but was undermined by political interference and financing challenges; (ii) the introduction of a renewed healthcare model rooted in primary care and intercultural principles enhanced access but impeded from inadequate training, weak territorial planning, and limited community engagement; (iii) efforts to reduce system fragmentation through mechanisms like the Comprehensive Public Health Network (CPHN), which improved referral pathways but failed to fully integrate services across public and private subsystems; and (iv) leadership reforms within the Ministry of Public Health sought to strengthen governance; but were hindered by centralised decision-making, high leadership turnover, and weak intersectoral coordination. These findings highlight a dynamic and complex reform process marked by ambitious goals and persistent structural limitations.

Conclusion: Ecuador’s 2007–2017 health reform expanded universal coverage by removing fees, strengthening primary care, and promoting intercultural health. Yet, weak referrals, inconsistent implementation, and poor planning limited impact. Political will advanced reforms but created resource imbalances. CPHN reduced some fragmentation but segmentation and weak public–private integration persisted. Leadership changes improved governance foundations, though high turnover and poor collaboration undermined progress. Future reforms require stable governance, clear local roles, stronger community engagement, and greater system integration.

I stora delar av den offentliga sektorn försvåras prioritering av insatser eftersom forskning om insatsernas kostnadseffektivitet saknas. Ändå måste prioriteringsbesluten fattas. Hur kan beslutsunderlagen i denna situation bli bättre? I artikeln presenteras ett verktyg för att göra en rimlighetsbedömning avseende kostnadseffektiviteten av sådana insatser för barn och unga — Kalkylverktyg för insatser mot social utsatthet (KAMSO). Metoden och ett beräkningsexempel presenteras. Både den samhällsekonomiska kostnadseffektiviteten med vunna goda år som utfallsmått och de finansiella fördelningseffekterna beskrivs. Artikeln avslutas med en diskussion om utvecklingsmöjligheter för KAMSO.

Background: Obesity is a global public health issue with increasing prevalence and notable differences across population. Previous studies on body mass index (BMI) trends and inequalities have focused on overweight/obesity prevalence or average BMI changes, overlooking differences across the BMI distribution. This study investigates whether changes in BMI distribution are uniform or different over time and educational attainment.

Methods: This study is based on repeated cross-sectional surveys in Västerbotten, Sweden. Study participants were expectant parents visiting antenatal care (2010–2019) as part of the Salut Programme. During early pregnancy, 18,215 women and 17,890 male partners completed questionnaires. Quantile regression analyses were conducted to assess BMI distribution changes over time and by education for men and women.

Results: The BMI distribution for women showed a sharper increase in the upper tail in 2018/19 compared to 2010/11, whereas for men, the upper tail showed a gradual rise over years. Similar changes in BMI distributions were observed over time across both educational groups, with a notable increase in the higher BMI segments.

Conclusion: The study revealed weight gain inequalities, with higher BMI segments experiencing a disproportionately higher rise compared to others. Identifying high-risk groups in vulnerable settings will better equip decision-makers to design and implement targeted intervention strategies to reduce overweight and obesity.

To estimate the effect of a 3-year commitment to remain tobacco free on tobacco uptake among high school students in Sweden. The commitment is developed in the form of a contract between a child and a significant adult, constituting the core component of Tobacco-free Duo (T-Duo), a Swedish school-based tobacco prevention program. Secondary analysis of data from a cluster randomized controlled trial. Participants were 586 students in high schools assigned to the intervention arm of T-Duo. At inception, participants attended grade 7 (i.e., age 12–13). Only students who were tobacco naïve at baseline for the respective outcome and participated in all follow-ups were included. The exposure was defined as signing a 3-year contract with a significant adult, categorized as “stable contract” (3 years contract with the same contract partner), “unstable” (signed a contract sometime during follow-up but this was not sustained over time and/or with the same partner), and “no contract” at all during the intervention period. The primary outcome was having never tried cigarette smoking at the end of grade 9. Exposure and outcomes were self-reported in yearly questionnaires. Of 586 students, 321 (55%) held a stable contract, 204 (35%) an unstable contract, and 61 (10%) did not sign a contract at all. At the end of grade 9 (age 15–16), the relative risk (RR) to remain cigarette free was 1.11 (95% CI 1.00–1.22) (Number Needed to Treat = 10) among students in any type of contract compared to students that did not write a contract at all. The RRs for remaining tobacco free (secondary outcomes) ranged from 1.07 (0.98–1.16) for regular snus use to 1.16 (1.00–1.35) for any type of tobacco use. A commitment to remain tobacco free through a child–adult contract seems to exert a preventive effect on the uptake of tobacco use among Swedish adolescents over 3 school years. The current findings apply to a selected sample of both schools and students.

Registration: Current Controlled Trials ISRCTN52858080 Date: January 4, 2019, retrospectively registered.

Background: Social-emotional difficulties in early childhood are associated with a range of outcomes across the life course and are related to socioeconomic factors. The aim of this study was to examine intersectional inequalities in social-emotional problems in preschool children relating to their parents’ income, education and country of birth in addition to investigating the public health implications.

Methods: This population-based study with a repeated cross-sectional design in the Västerbotten County of Sweden used the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) for children aged 3 in child health care services over the years of 2014-2018 and socio-economic information from national population registers. The effective sample of 8,823 individuals was analyzed using additive binomial regression in combination with an analysis of individual heterogeneity and discriminatory accuracy (AIHDA) approach to estimate risk differences for social-emotional problems across 27 intersectional groups and discriminatory accuracy.

Results: Average risk differences generally increased in the groups where multiple dimensions of social inequality intersected, with risk differences as high as 18% (95% CI 8 to 28%) and 25% (95% CI 14 to 37%) compared to the most advantaged category. The discriminatory accuracy of all three included regression models was estimated as moderate, but improved in a slight but statistically significant way with the addition of social inequalities.

Conclusions: This study increases our understanding of intersectional and social inequalities in social-emotional problems in preschool children. It supports the need for universal public health policies in addition to policies targeting more vulnerable groups when addressing this issue, consistent with the concept of proportionate universalism. An intersectional research perspective including discriminatory accuracy could increase our knowledge of health inequities and improve public health effectiveness.

Motivation: Despite signature of the 2005 Paris Declaration on Aid Effectiveness and subsequent adoption of the effective development cooperation (EDC) principles for better health cooperation, there is a gap in documenting the challenges to implement these commitments at country level. Sudan represents an interesting case study: the country adopted a local health compact in 2014, but for much of the time since the regime was under sanction. Sudan witnessed a revolution in 2018, followed by a counter-coup in 2021.

Purpose: We aim to explore the evolution of Sudan health sector partners’ relationships, perspectives, and adherence to EDC principles of ownership, alignment, and harmonization, while accounting for underlying processes and context changes between 2015 and 2022.

Methods and approach: We collected data through two rounds of interviews, in 2015 (16) and 2022 (8), with stakeholders within the Sudan Health Sector Partnership. We used the framework method for data analysis where responses are coded then sorted into themes.

Findings: Prior to the 2019 revolution cooperation was progressive but restricted, with civil society marginalized and a dominating government. The principles, especially ownership, were misused and misaligned with national priorities driven by donors’ interests and conditions.

The transitional (post-revolution) period witnessed partners’ openness and influx, but unstable leadership and subsequent changes in priorities led to wasted opportunities.

Following the coup, donors adopted a no-contact policy towards the de facto government. Instead, the expectation was that civil society organizations would replace the government as the main implementers. Overall, limited coordination capacity and no sustainability measures were present throughout.

Policy implications: Much of what was observed was down to the often complicated and difficult context of the governance of Sudan. That said, general issues arose including the government's ability to coordinate policy and implementation; the need for stable, legitimate arrangements; and the need to define the role of civil society and to empower civil society organizations. Within a complex and volatile context, revisiting partners’ commitments through joint compact reviews and transparent EDC progress monitoring is crucial.