10 best resources on power in health policy and systems in low- and middle-income countries.
Sriram Veena,Topp Stephanie M,Schaaf Marta,Mishra Arima,Flores Walter,Rajasulochana Subramania Raju,Scott Kerry
Health policy and planning
Power is a critical concept to understand and transform health policy and systems. Power manifests implicitly or explicitly at multiple levels-local, national and global-and is present at each actor interface, therefore shaping all actions, processes and outcomes. Analysing and engaging with power has important potential for improving our understanding of the underlying causes of inequity, and our ability to promote transparency, accountability and fairness. However, the study and analysis of the role of power in health policy and systems, particularly in the context of low- and middle-income countries, has been lacking. In order to facilitate greater engagement with the concept of power among researchers and practitioners in the health systems and policy realm, we share a broad overview of the concept of power, and list 10 excellent resources on power in health policy and systems in low- and middle-income countries, covering exemplary frameworks, commentaries and empirical work. We undertook a two-stage process to identify these resources. First, we conducted a collaborative exercise involving crowdsourcing and participatory validation, resulting in 24 proposed articles. Second, we conducted a structured literature review in four phases, resulting in 38 articles reviewed. We present the 10 selected resources in the following categories to bring out key facets of the literature on power and health policy and systems-(1) Resources that provide an overarching conceptual exploration into how power shapes health policy and systems, and how to investigate it; and (2) examples of strong empirical work on power and health policy and systems research representing various levels of analyses, geographic regions and conceptual understandings of power. We conclude with a brief discussion of key gaps in the literature, and suggestions for additional methodological approaches to study power.
10.1093/heapol/czy008
Inequalities in health system responsiveness among asylum seekers and refugees: A population-based, cross-sectional study in Germany.
PLOS global public health
Global migration has sparked renewed interest in Universal Health Coverage in high-income countries. However, quality of care has received little attention. This study uses the concept of responsiveness to study quality of care for asylum seekers and refugees (ASR) in Germany and identify inequalities among this group. We report results from a population-based, cross-sectional health monitoring survey in Germany's third-largest federal state using random sampling methods. Established instruments were used to measure responsiveness, health status and socio-demographic factors. Data were weighted and adjusted logistic regression models applied to identify inequalities related to health status, structural and socio-demographic factors. N = 344 survey participants were included in the analysis (response rate 39.2%). Combined responsiveness was 77% (95%CI: 68%; 83%) but varied between domains. Responsiveness was poor for individuals with symptoms of anxiety (OR 0.35, 95%CI 0.13,0.99), longstanding illness (OR:0.42, 95%CI:0.17,1.06) and diminished health-related quality of life (OR:0.24, 95%CI:0.06,0.95). Individuals from Southern Asia (OR: 0.24, 95%CI: 0.07,0.86) and young participants (OR:0.31, 95%CI:0.12,0.82) also reported less responsive care. Unique patterns of explanatory factors were identified within each responsiveness domain. We found important differences in responsiveness related to health, socio-demographic and structural factors, both in combined responsiveness and in individual domains. Inequalities related to health status factors are particularly concerning given the potential implications for equity of access. Future research should explore responsiveness for different sectors, include individuals who have not utilised healthcare and allow for the adjustment of differential expectations of care between population groups.
10.1371/journal.pgph.0000984
Ethics, equity and renewal of WHO's health-for-all strategy.
Bryant J H,Khan K S,Hyder A A
World health forum
The renewal of WHO's strategy for health for all raises questions about human and societal values that have to be fully taken into account. Discussions to date have highlighted the principle of equity in the context of ethics and human rights.
Social Determinants of Health in the United States: Addressing Major Health Inequality Trends for the Nation, 1935-2016.
International journal of MCH and AIDS
OBJECTIVES:This study describes key population health concepts and examines major empirical trends in US health and healthcare inequalities from 1935 to 2016 according to important social determinants such as race/ethnicity, education, income, poverty, area deprivation, unemployment, housing, rural-urban residence, and geographic location. METHODS:Long-term trend data from the National Vital Statistics System, National Health Interview Survey, National Survey of Children's Health, American Community Survey, and Behavioral Risk Factor Surveillance System were used to examine racial/ethnic, socioeconomic, rural-urban, and geographic inequalities in health and health care. Life tables, age-adjusted rates, prevalence, and risk ratios were used to examine health differentials, which were tested for statistical significance at the 0.05 level. RESULTS:Life expectancy of Americans increased from 69.7 years in 1950 to 78.8 years in 2015. However, despite the overall improvement, substantial gender and racial/ethnic disparities remained. In 2015, life expectancy was highest for Asian/Pacific Islanders (87.7 years) and lowest for African-Americans (75.7 years). Life expectancy was lower in rural areas and varied from 74.5 years for men in rural areas to 82.4 years for women in large metro areas, with rural-urban disparities increasing during the 1990-2014 time period. Infant mortality rates declined dramatically during the past eight decades. However, racial disparities widened over time; in 2015, black infants had 2.3 times higher mortality than white infants (11.4 vs. 4.9 per 1,000 live births). Infant and child mortality was markedly higher in rural areas and poor communities. Black infants and children in poor, rural communities had nearly three times higher mortality rate compared to those in affluent, rural areas. Racial/ethnic, socioeconomic, and geographic disparities were particularly marked in mortality and/or morbidity from cardiovascular disease, cancer, diabetes, COPD, HIV/AIDS, homicide, psychological distress, hypertension, smoking, obesity, and access to quality health care. CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS:Despite the overall health improvement, significant social disparities remain in a number of health indicators, most notably in life expectancy and infant mortality. Marked disparities in various health outcomes indicate the underlying significance of social determinants in disease prevention and health promotion and necessitate systematic and continued monitoring of health inequalities according to social factors. A multi-sectoral approach is needed to tackle persistent and widening health inequalities among Americans.
10.21106/ijma.236
Integrated primary health care in low- and middle-income countries: a double challenge.
Druetz Thomas
BMC medical ethics
BACKGROUND:The lack of primary healthcare integration has been identified as one of the main limits to programs' efficacy in low- and middle-income countries. This is especially relevant to the Millennium Development Goals, whose health objectives were not attained in many countries at their term in 2015. While global health scholars and decision-makers are unanimous in calling for integration, the objective here is to go further and contribute to its promotion by presenting two of the most important challenges to be met for its achievement: 1) developing a "crosswise approach" to implementation that is operational and effective; and 2) creating synergy between national programs and interventions driven by non-State actors. MAIN BODY:The argument for urgently addressing this double challenge is illustrated by drawing on observations made and lessons learned during a four-year research project (2011-2014) evaluating the effects of interventions against malaria in Burkina Faso. The way interventions were framed was mostly vertical, leaving little room for local adaptation. In addition, many non-governmental organizations intervened and contributed to a fragmented and heteronomous health governance system. Important ethical issues stem from how interventions against malaria were shaped and implemented in Burkina Faso. To further explore this issue, a scoping literature review was conducted in August 2016 on the theme of integrated primary healthcare. It revealed that no clear definition of the concept has been advanced or endorsed thus far. We call for caution in conceptualizing it as a simple juxtaposition of different tasks or missions at the primary care level. It is time to go beyond the debate around selective versus comprehensive approaches or fragmentation versus cohesion. Integration should be thought of as a process to reconcile these tensions. CONCLUSIONS:In the context that characterizes many low- and middle-income countries today, better aid coordination and public health systems strengthening, as promoted by multisectoral approaches, might be among the best options to sustainably and ethically integrate primary healthcare interventions.
10.1186/s12910-018-0288-z
The historical roots and seminal research on health equity: a referenced publication year spectroscopy (RPYS) analysis.
International journal for equity in health
BACKGROUND:Health equity is a multidimensional concept that has been internationally considered as an essential element for health system development. However, our understanding about the root causes of health equity is limited. In this study, we investigated the historical roots and seminal works of research on health equity. METHODS:Health equity-related publications were identified and downloaded from the Web of Science database (n = 67,739, up to 31 October 2018). Their cited references (n = 2,521,782) were analyzed through Reference Publication Year Spectroscopy (RPYS), which detected the historical roots and important works on health equity and quantified their impact in terms of referencing frequency. RESULTS:A total of 17 pronounced peaks and 31 seminal works were identified. The first publication on health equity appeared in 1966. But the first cited reference can be traced back to 1801. Most seminal works were conducted by researchers from the US (19, 61.3%), the UK (7, 22.6%) and the Netherlands (3, 9.7%). Research on health equity experienced three important historical stages: origins (1800-1965), formative (1966-1991) and development and expansion (1991-2018). The ideology of health equity was endorsed by the international society through the World Health Organization (1946) declaration based on the foundational works of Chadwick (1842), Engels (1945), Durkheim (1897) and Du Bois (1899). The concept of health equity originated from the disciplines of public health, sociology and political economics and has been a major research area of social epidemiology since the early nineteenth century. Studies on health equity evolved from evidence gathering to the identification of cost-effective policies and governmental interventions. CONCLUSION:The development of research on health equity is shaped by multiple disciplines, which has contributed to the emergence of a new stream of social epidemiology and political epidemiology. Past studies must be interpreted in light of their historical contexts. Further studies are needed to explore the causal pathways between the social determinants of health and health inequalities.
10.1186/s12939-019-1058-3
Health Inequality Monitoring channel on OpenWHO: capacity strengthening through eLearning.
International journal for equity in health
BACKGROUND:Health inequality monitoring can generate important evidence to inform and motivate changes to policy, programmes and practices. However, the potential of health inequality monitoring practices to quantify inequalities between population subgroups and track progress on the advancement of health equity is under-realized. Capacity strengthening on health inequality monitoring can play an important role in enhancing political will for the generation and use of disaggregated data and for wider adoption of this practice to inform health decision-making. There is a lack of widely available and accessible training materials related to health inequality monitoring that may be used by a range of stakeholders. OBJECTIVE:In this paper, we describe the design, development and implementation of the Health Inequality Monitoring channel on the OpenWHO eLearning platform. We discuss the anticipated impact and potential opportunities for these eLearning courses to contribute to strengthened health inequality monitoring practices. RESULTS:The Health Inequality Monitoring channel on the OpenWHO platform is a self-directed learning environment, designed to meet the immediate learning needs of users. The channel contains three series of courses: health inequality monitoring foundations courses; topic-specific health inequality monitoring courses; and health inequality monitoring skill building courses. Courses are primarily targeted to monitoring and evaluation officers, data analysts, academics and researchers, public health professionals, medical and public health students, and others with a general interest in health data and inequality monitoring. CONCLUSIONS:WHO eLearning courses on health inequality monitoring are addressing the need for capacity strengthening in the collection, analysis and reporting of inequality data. They introduce learners to the foundational concepts, best practices, tools and skills required to conduct health inequality monitoring. The courses on the Health Inequality Monitoring channel demonstrate how technical information can be simplified and presented to broad audiences in a manner that is highly accessible to learners. The Health Inequality Monitoring channel on OpenWHO is an innovative and necessary addition to existing tools and resources to support the advancement of health equity.
10.1186/s12939-022-01739-9
Towards a global monitoring system for implementing the Rio Political Declaration on Social Determinants of Health: developing a core set of indicators for government action on the social determinants of health to improve health equity.
International journal for equity in health
BACKGROUND:In the 2011 Rio Political Declaration on Social Determinants of Health, World Health Organization (WHO) Member States pledged action in five areas crucial for addressing health inequities. Their pledges referred to better governance for health and development, greater participation in policymaking and implementation, further reorientation of the health sector towards reducing health inequities, strengthening of global governance and collaboration, and monitoring progress and increasing accountability. WHO is developing a global system for monitoring governments' and international organizations' actions on the social determinants of health (SDH) to increase transparency and accountability, and to guide implementation, in alignment with broader health and development policy frameworks, including the universal health coverage and Sustainable Development Goals (SDG) agendas. We describe the selection of indicators proposed to be part of the initial WHO global system for monitoring action on the SDH. METHODS:An interdisciplinary working group was established by WHO, the Public Health Agency of Canada, and the Canadian Institutes of Health Research-Institute of Population and Public Health. We describe the processes and criteria used for selecting SDH action indicators that were of high quality and the described the challenges encountered in creating a set of metrics for capturing government action on addressing the Rio Political Declaration's five Action Areas. RESULTS:We developed 19 measurement concepts, identified and screened 20 indicator databases and systems, including the 223 SDG indicators, and applied strong criteria for selecting indicators for the core indicator set. We identified 36 suitable existing indicators, which were often SDG indicators. CONCLUSIONS:Lessons learnt included the importance of ensuring diversity of the working group and always focusing on health equity; challenges included the relative dearth of data and indicators on some key interventions and capturing the context and level of implementation of indicator interventions.
10.1186/s12939-018-0836-7
Capturing the value of vaccination within health technology assessment and health economics: Country analysis and priority value concepts.
Vaccine
BACKGROUND:A value of vaccination framework for economic evaluation (EE) identified unique value concepts for the broad benefits vaccination provides to individuals, society, healthcare systems and national economies. The objectives of this paper were to work with experts in developed countries to objectively identify three priority concepts to extend current EE. METHODS:The previously developed classification of value concepts in vaccination distinguished 18 concepts, categorised as conventional payer and societal perspective concepts and novel broader societal concepts. Their inclusion in current EE guidelines was assessed. Experts identified eight criteria relevant to decision-making and measurement feasibility, which were weighted and used to score each concept. The relative ranking of concepts by importance and the gaps in guidelines were used to identify three priority concepts on which to focus immediate efforts to extend EE. RESULTS:The EE guidelines review highlighted differences across countries and between guidelines and practice. Conventional payer perspective concepts (e.g., individual and societal health gains and medical costs) were generally included, while gaps were evident for conventional societal perspective concepts (e.g., family/caregiver health and economic gains). Few novel broader societal benefits were considered, and only in ad hoc cases. The top-three concepts for near-term consideration: macroeconomic gains (e.g., benefiting the economy, tourism), social equity and ethics (e.g., equal distribution of health outcomes, reduced health/financial equity gaps) and health systems strengthening, resilience and security (e.g., efficiency gains, reduced disruption, increased capacity). CONCLUSIONS:Gaps, inconsistencies and limited assessment of vaccination value in EE can lead to differences in policy and vaccination access. The three priority concepts identified provide a feasible approach for capturing VoV more broadly in the near-term. Robust methods for measuring and valuing these concepts in future assessments will help strengthen the evidence used to inform decisions, improving access to vaccines that are demonstrably good value for money from society's point of view.
10.1016/j.vaccine.2022.04.026
The role of multilateral organizations and governments in advancing social innovation in health care delivery.
Infectious diseases of poverty
BACKGROUND:Despite great medical advances and scientific progress over the past century, one billion people globally still lack access to basic health care services. In the context of the 2030 Agenda for Sustainable Development social innovation models aim to provide effective solutions that bridge the health care delivery gap, address equity and create social value. This commentary highlights the roles of multilateral organizations and governments in creating an enabling environment where social innovations can more effectively integrate into health systems to maximize their impact on beneficiaries. MAIN TEXT:The integration of social innovations into health systems is essential to ensure their sustainability and the wide dissemination of their impact. Effective partnerships, strong engagement with and endorsement by governments and communities, regulations, trust and sometimes willingness are key factors to enhance system integration, replication and dissemination of the models. Three examples of social innovations selected by the Social Innovation in Health Initiative illustrate the importance of engaging with governments and communities in order to link, integrate and synergize their efforts. Key challenges that they encountered, and lessons learnt are highlighted. Multilateral organizations and governments increasingly engage in promoting and supporting the development, testing and dissemination of social innovations to address the health care delivery gap. They play an important role in creating an enabling environment. This includes promoting the concept of social innovation in health care delivery, spreading social innovation approach and lessons learnt, fostering partnerships and leveraging resources, convening communities, health system actors and various stakeholders to work together across disciplines and sectors, and nurturing capacity in countries. CONCLUSIONS:Multilateral organizations and local and national governments have a critical role to play in creating an enabling environment where social innovations can flourish. In supporting and disseminating social innovation approach, multilateral organizations and governments have a great opportunity to accelerate Universal Health Coverage and the achievement of the Sustainable Development Goals.
10.1186/s40249-019-0592-y
Connections and Biases in Health Equity and Culture Research: A Semantic Network Analysis.
Frontiers in public health
Health equity is a rather complex issue. Social context and economical disparities, are known to be determining factors. Cultural and educational constrains however, are also important contributors to the establishment and development of health inequities. As an important starting point for a comprehensive discussion, a detailed analysis of the literature corpus is thus desirable: we need to recognize what has been done, under what circumstances, even what possible sources of bias exist in our current discussion on this relevant issue. By finding these trends and biases we will be better equipped to modulate them and find avenues that may lead us to a more integrated view of health inequity, potentially enhancing our capabilities to intervene to ameliorate it. In this study, we characterized at a large scale, the social and cultural determinants most frequently reported in current global research of health inequity and the interrelationships among them in different populations under diverse contexts. We used a data/literature mining approach to the current literature followed by a semantic network analysis of the interrelationships discovered. The analyzed structured corpus consisted in circa 950 articles categorized by means of the (MeSH) content-descriptor from 2014 to 2021. Further analyses involved systematic searches in the LILACS and DOAJ databases, as additional sources. The use of data analytics techniques allowed us to find a number of non-trivial connections, pointed out to existing biases and under-represented issues and let us discuss what are the most relevant concepts that are (and are not) being discussed in the context of Health Equity and Culture.
10.3389/fpubh.2022.834172
Health equity and health system strengthening - Time for a WHO re-think.
Global public health
The pursuit of health equity is foundational to the global health enterprise. But while moral concerns over health inequities can galvanise political commitment, how such concerns can or should translate into practice remains less clear. This paper reviews evolving ways that equity goals have featured in key World Health Organization (WHO)-related policy documents, before discussing the heuristic value and empirical traction that the concept of equity can bring to the health system strengthening (HSS) agenda. We argue that while health equity is often presented as the overarching goal of HSS, in practice this is typically circumscribed to the provision of healthcare services. Although health equity is important, we suggest that this narrow focus risks losing sight of the structural political, social and economic drivers of health and health inequities, as well as the broader contexts of care and complex socio-political mechanisms through which health systems are strengthened. Drawing on new lines of empirical inquiry, we propose that broadening the equity lens for HSS -offers exciting opportunities to put health systems at the heart of a more ambitious equity agenda in global health.
10.1080/17441692.2020.1867881
Showcasing the contribution of social sciences to health policy and systems research.
Topp Stephanie M,Scott Kerry,Ruano Ana Lorena,Daniels Karen
International journal for equity in health
BACKGROUND:This Special Issue represents a critical response to the frequent silencing of qualitative social science research approaches in mainstream public health journals, particularly in those that inform the field of health policy and systems research (HPSR), and the study of equity in health. METHODS:This collection of articles is presented by SHAPES, the thematic working group of Health Systems Global focused on social science approaches to research and engagement in health policy and systems. The issue aims to showcase how qualitative and theory-driven approaches can contribute to better promoting equity in health within the field of HPSR. RESULTS:This issue builds on growing recognition of the complex social nature of health systems. The articles in this collection underscore the importance of employing methods that can uncover and help explain health system complexities by exploring the dynamic relationships and decision-making processes of the human actors within. Articles seek to highlight the contribution that qualitative, interpretivist, critical, emancipatory, and other relational methods have made to understanding health systems, health policies and health interventions from the perspective of those involved. By foregrounding actor perspectives, these methods allow us to explore the impact of vital but difficult-to-measure concepts such as power, culture and norms. CONCLUSION:This special issue aims to highlight the critical contribution of social science approaches. Through the application of qualitative methods and, in some cases, development of theory, the articles presented here build broader and deeper understanding of the way health systems function, and simultaneously inform a more people-centred approach to collective efforts to build and strengthen those systems.
10.1186/s12939-018-0862-5
Gender equity in planning, development and management of human resources for health: a scoping review.
El Arnaout Nour,Chehab Rana F,Rafii Bayan,Alameddine Mohamad
Human resources for health
BACKGROUND:Gender equity remains a challenge across various labor markets with the health market being no exception. Despite the increased influx of women into health professions, horizontal and vertical occupational gender inequities persist. MAIN BODY:The objective of this scoping review is to map the studies on gender equity in healthcare systems in terms of workforce planning, development, and management, as well as to identify the barriers and facilitators for integrating gender equity into healthcare systems. We reviewed the literature on the topic using nine electronic and two grey literature databases with the search strategy combining medical subheadings and keywords for each of the following four concepts of interest: "gender equity," "human resources for health," "healthcare setting," and "management processes." The scoping review included studies focusing on the examination of gender equity at the level of the health workforce. Out of 20,242 studies identified through the database search, the full text of 367 articles was assessed for eligibility and 110 were included in the qualitative analysis. The data of those studies was abstracted and analyzed into themes. Results do not only reveal a global dearth of studies focused on this important topic, but also the concentration of such studies in a few countries around the globe, mainly in North America and Europe. Four out of each five studies included in this review focused on physicians, followed by nurses (14%). In terms of design, an overwhelming majority of studies utilized quantitative designs (75%), followed by qualitative designs and database analyses. Studies were categorized into four pre-determined main themes: facilitators and barriers, workforce planning, HRH management, and HRH development. CONCLUSION:Future research is needed to better understand poorly covered sub-themes such as mentorship, professional development, and training, as well as recruitment and retention among others. It is also equally needed to fill in the gaps in professional groups, study type, methodology, and region. While the review unearthed a number of well-studied themes, significant aspects of the topic remain untapped especially in developing countries and at the level of health professionals other than physicians.
10.1186/s12960-019-0391-3
Balancing Equity and Efficiency in the Allocation of Health Resources-Where Is the Middle Ground?
Healthcare (Basel, Switzerland)
The notion of equity in health service delivery has been embodied in several of the Global Sustainable Development Goals (SDGs), especially the aspiration for universal health coverage (UHC). At the same time, escalating healthcare costs amidst dwindling resources continue to ignite discussions on the efficiency aspect of healthcare delivery at both operational and system levels. Therefore, health planners and managers have had to grapple with balancing the two, given limited resources and sophisticated population health needs. Undoubtedly, the concepts of equity and efficiency have overarching importance in healthcare. While efficiency dictates an 'economical' use of the limited healthcare resources, equity advocates their fair and ethical use. Some have leaned on this to argue that one has to be forgone in search of the other. In search of a 'middle ground', this paper explores the conceptual underpinnings of equity and efficiency in the context of healthcare resource allocation with some empirical examples from high-income and low- and middle-income settings. We conclude by arguing that equity and efficiency are, and ought to be, treated as complementary rather than conflicting considerations in distributing health resources. Each could be pursued without necessarily compromising the other-what matters is an explicit criterion of what will be 'equitable' in ensuring efficient allocation of resources, and on the other hand, what options will be considered more 'efficient' when equity objectives are pursued. Thus, equity can be achieved in an efficient way, while efficiency can drive the attainment of equity.
10.3390/healthcare9101257
Implementation research: new imperatives and opportunities in global health.
Theobald Sally,Brandes Neal,Gyapong Margaret,El-Saharty Sameh,Proctor Enola,Diaz Theresa,Wanji Samuel,Elloker Soraya,Raven Joanna,Elsey Helen,Bharal Sushil,Pelletier David,Peters David H
Lancet (London, England)
Implementation research is important in global health because it addresses the challenges of the know-do gap in real-world settings and the practicalities of achieving national and global health goals. Implementation research is an integrated concept that links research and practice to accelerate the development and delivery of public health approaches. Implementation research involves the creation and application of knowledge to improve the implementation of health policies, programmes, and practices. This type of research uses multiple disciplines and methods and emphasises partnerships between community members, implementers, researchers, and policy makers. Implementation research focuses on practical approaches to improve implementation and to enhance equity, efficiency, scale-up, and sustainability, and ultimately to improve people's health. There is growing interest in the principles of implementation research and a range of perspectives on its purposes and appropriate methods. However, limited efforts have been made to systematically document and review learning from the practice of implementation research across different countries and technical areas. Drawing on an expert review process, this Health Policy paper presents purposively selected case studies to illustrate the essential characteristics of implementation research and its application in low-income and middle-income countries. The case studies are organised into four categories related to the purposes of using implementation research, including improving people's health, informing policy design and implementation, strengthening health service delivery, and empowering communities and beneficiaries. Each of the case studies addresses implementation problems, involves partnerships to co-create solutions, uses tacit knowledge and research, and is based on a shared commitment towards improving health outcomes. The case studies reveal the complex adaptive nature of health systems, emphasise the importance of understanding context, and highlight the role of multidisciplinary, rigorous, and adaptive processes that allow for course correction to ensure interventions have an impact. This Health Policy paper is part of a call to action to increase the use of implementation research in global health, build the field of implementation research inclusive of research utilisation efforts, and accelerate efforts to bridge the gap between research, policy, and practice to improve health outcomes.
10.1016/S0140-6736(18)32205-0