Rifat Atun

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• MBBS MBA DIC FRCGP FFPH FRCP
• Professor at Harvard University

Turkey has successfully introduced health system changes and provided its citizens with the right to health to achieve universal health coverage, which helped to address inequities in financing, health service access, and health outcomes. We trace the trajectory of health system reforms in Turkey, with a particular emphasis on 2003-13, which coinci...

In almost all countries, development of health systems that are responsive to the challenge of prevention and treatment of non-communicable diseases (NCDs) is a priority. NCDs consist of a vast group of conditions, but in terms of premature mortality, emphasis has been on cardiovascular disease, cancer, diabetes, and chronic respiratory diseases—di...

Development assistance for health has increased every year between 2000 and 2010, particularly for HIV/AIDS, tuberculosis, and malaria, to reach US$26·66 billion in 2010. The continued global economic crisis means that increased external financing from traditional donors is unlikely in the near term. Hence, new funding has to be sought from innovat...

Background Adolescents and young adults (AYA) aged 15–24 years account for nearly half of all new HIV infections globally, with over 80% residing in sub-Saharan Africa, where AIDS is a leading cause of death. In Chad, HIV/AIDS significantly impacts AYA, despite a reduction in national prevalence from 1.6% in 2010 to 1.0% in 2022. AYA still contribu...

Background Inadequate access to quality maternal and child health services leads to poor health outcomes for millions of women, particularly in low- and middle-income countries (LMICs). This study aims to explore the effective coverage of reproductive, maternal, neonatal and newborn health (RMNCH) services and examines socioeconomic and rural and u...

Introduction There is a dearth of evidence regarding the global economic burden of ischaemic heart diseases (IHDs). This systematic review aims to synthesise national-level studies worldwide quantifying the economic burden of IHDs from a provider’s perspective. Methods We searched PubMed, Embase, Cochrane, DARE and EconLit databases from 1 January...

Introduction Stand-alone HIV clinics in sub-Saharan Africa (SSA) have effectively expanded antiretroviral therapy since the 2000s, transforming HIV from a deadly infection into a chronic condition. However, over the past decade, there has been a significant rise in the prevalence of non-communicable diseases (NCDs) globally and in SSA. People livin...

Despite much research on early detection of anomalies from surveillance data, a systematic framework for appropriately acting on these signals is lacking. We addressed this gap by formulating a hidden Markov-style model for time-series surveillance, where the system state, the observed data, and the decision rule are all binary. We incur a delayed...

This second edition of the Oxford Textbook of Community Mental Health addresses recent changes and achievements, current controversies, and future challenges while emphasizing areas of convergence, where social values, health, medical sciences, and policy formation converge and meet. This edition also features a new section on global mental health,...

Importance Rapid digitalization of health care and a dearth of digital health education for medical students and junior physicians worldwide means there is an imperative for more training in this dynamic and evolving field. Objective To develop an evidence-informed, consensus-guided, adaptable digital health competencies framework for the design a...

This supplemental material has been provided by the authors to give readers additional information about their work.

Plain language summary The increasing threat from infections that cannot be treated with medicines, so called drug resistant infections, is among the most serious public health challenges of our time. Formed by Wellcome in 2018, the Surveillance and Epidemiology of Drug-Resistant Infections Consortium (SEDRIC) is an international think tank whose a...

Background The medical literature has demonstrated that macro-variables and social factors can influence suicide rates. Additionally, social science literature has shown that women in prominent political positions (such as mayors) can influence the behavior of other women. The purpose of our work is to demonstrate that women in such positions reduc...

Background The majority of countries (64%) have an Antimicrobial Resistance (AMR) National Action Plan (NAP V.1.0), but many remain unimplemented, and lack funding for interventions. Intervention selection requires a systematic approach to explain and predict progress. Looking beyond AMR is important to ensure the capture of systemic factors at the...

Maternal mortality remains a large challenge in global health. Learning from the experience of similar countries can help to accelerate progress. In this analysis we develop a typology of country groupings for maternal health and provide guidance on how policy implications vary by country typology. We used estimates from the Global Maternal Health...

Background Financial toxicity is the detrimental impact of health care costs that must be mitigated to achieve universal health coverage. Catastrophic health expenditure (CHE) is widely used to measure financial toxicity but does not capture patient perspectives of unaffordable health care costs. Financial hardship (FH), a patient-reported outcome...

Background: Influenza represents a critical public health challenge, disproportionately affecting at-risk populations, including older adults and those with chronic conditions, often compounded by socioeconomic factors. Innovative strategies, such as gamification, are essential for augmenting risk communication and community engagement efforts to a...

Following on from the 2015 Lancet Oncology Commission on expanding global access to radiotherapy, Radiotherapy and theranostics: a Lancet Oncology Commission was created to assess the access and availability of radiotherapy to date and to address the important issue of access to the promising field of theranostics at a global level. A marked dispar...

BACKGROUND Non-communicable diseases (NCDs) are a major public health challenge globally, including in Saudi Arabia. However, measuring the true extent of NCD prevalence has been hampered by a paucity of nationally representative epidemiological studies. OBJECTIVES Assess the prevalence of selected NCDs, using population-based electronic health re...

Introduction Hypertension is highly prevalent in India, but the proportion of patients achieving blood pressure control remains low. Efforts have been made to expand health insurance coverage nationwide with the aim of improving overall healthcare access. It is critical to understand the role of health insurance coverage in improving hypertension c...

Youth ages 15-24 years are significantly impacted by the HIV/AIDS epidemic, representing approximately 37% of new infections globally. This demographic is especially vulnerable in sub-Saharan Africa, where over 80% of HIV-positive youth reside. In Chad, youth face significant barriers to effective HIV care, including high prevalence rates, particul...

Summary Background Maternal mortality remains a challenge in global health, with well-known disparities across countries. However, less is known about disparities in maternal health by subgroups within countries. The aim of this study is to estimate maternal health indicators for subgroups of women within each country. Methods In this simulation-...

PURPOSE There is an urgent need to improve access to cancer therapy globally. Several independent initiatives have been undertaken to improve access to cancer medicines, and additional new initiatives are in development. Improved sharing of experiences and increased collaboration are needed to achieve substantial improvements in global access to es...

The prevalence of multiple age-related cardiovascular disease (CVD) risk factors is high among individuals living in low- and middle-income countries. We described receipt of healthcare services for and management of hypertension and diabetes among individuals living with these conditions using individual-level data from 55 nationally representativ...

Evidence on cardiovascular disease (CVD) risk factor prevalence among adults living below the World Bank’s international line for extreme poverty (those with income <$1.90 per day) globally is sparse. Here we pooled individual-level data from 105 nationally representative household surveys across 78 countries, representing 85% of people living in e...

Improving hypertension control in low- and middle-income countries has uncertain implications across socioeconomic groups. In this study, we simulated improvements in the hypertension care cascade and evaluated the distributional benefits across wealth quintiles in 44 low- and middle-income countries using individual-level data from nationally repr...

BACKGROUND Influenza is a seasonal threat with pandemic potential. Influenza infection is particularly dangerous for vulnerable individuals, such as children, older individuals, and those with multiple illnesses, especially those with lower socio-economic status. Hence, it is necessary to have appropriate tools to mitigate these risks. Gamification...

Background Influenza represents a critical public health challenge, disproportionately affecting at-risk populations, including older adults and those with chronic conditions, often compounded by socioeconomic factors. Innovative strategies, such as gamification, are essential for augmenting risk communication and community engagement efforts to ad...

UN member states have committed to universal health coverage (UHC) to ensure all individuals and communities receive the health services they need without suffering financial hardship. Although the pursuit of UHC should unify disparate global health challenges, it is too commonly seen as another standalone initiative with a singular focus on the he...

Background: Conversational agents (CAs), or chatbots, are computer programs that simulate conversations with humans. The use of CAs in health care settings is recent and rapidly increasing, which often translates to poor reporting of the CA development and evaluation processes and unreliable research findings. We developed and published a conceptua...

Background To effectively combat the rising incidence of syphilis, the Brazilian Ministry of Health (MoH) created a National Rapid Response to Syphilis with actions aimed at bolstering epidemiological surveillance of acquired, congenital syphilis, and syphilis during pregnancy complemented with communication activities to raise population awareness...

Nearly a century after the beginning of the antibiotic era, which has been associated with unparalleled improvements in human health and reductions in mortality associated with infection, the dwindling pipeline for new antibiotic classes coupled with the inevitable spread of antimicrobial resistance (AMR) poses a major global challenge. Historicall...

Background The global burden of diabetes is rising rapidly, yet there is little evidence on individual-level diabetes prevention activities undertaken by health systems in low-income and middle-income countries (LMICs). Here we describe the population at high risk of developing diabetes, estimate diabetes prevention activities, and explore sociodem...

Cardiovascular disease risk factors (CVDRF), in particular diabetes and hypertension, are chronic conditions which carry a substantial disease burden in Low- and Middle-Income Countries. Unlike HIV, they were neglected in the Millenium Development Goals along with the health services required to manage them. To inform the level of health service re...

This Viewpoint brings together insights from health system experts working in a range of settings. Our focus is on examining the state of the resilience field, including current thinking on definitions, conceptualisation, critiques, measurement, and capabilities. We highlight the analytical value of resilience, but also its risks, which include neg...

Background: Testing for the risk factors of cardiovascular disease, which include hypertension, diabetes, and hypercholesterolaemia, is important for timely and effective risk management. Yet few studies have quantified and analysed testing of cardiovascular risk factors in low-income and middle-income countries (LMICs) with respect to sociodemogr...

Importance: Aspirin is an effective and low-cost option for reducing atherosclerotic cardiovascular disease (CVD) events and improving mortality rates among individuals with established CVD. To guide efforts to mitigate the global CVD burden, there is a need to understand current levels of aspirin use for secondary prevention of CVD. Objective:...

This Viewpoint brings together insights from health system experts working in a range of settings. Our focus is on examining the state of the resilience field, including current thinking on definitions, conceptualisation, critiques, measurement, and capabilities. We highlight the analytical value of resilience, but also its risks, which include neg...

BACKGROUND Conversational agents (CAs), or chatbots, are computer programs that simulate conversations with humans. The use of CAs in healthcare settings is recent and rapidly increasing, which often translates to poor reporting of the CA development and evaluation processes, and unreliable research findings. We developed and published a conceptual...

Background Cancer is a leading cause of disease burden globally, with more than 19·3 million cases and 10 million deaths recorded in 2020. Research is crucial to understanding the determinants of cancer and the effects of interventions, and to improving outcomes. We aimed to analyse global patterns of public and philanthropic investment in cancer r...

Objective The inverse relationships between chronic disease multimorbidity and health-related quality of life (HRQoL) have been well-documented in the literature. However, the mechanism underlying this relationship remains largely unknown. This is the first study to look into the potential role of functional limitation as a mediator in the relation...

The Sustainable Development Goals include a target to reduce the global maternal mortality ratio (MMR) to less than 70 maternal deaths per 100,000 live births by 2030, with no individual country exceeding 140. However, on current trends the goals are unlikely to be met. We used the empirically calibrated Global Maternal Health microsimulation model...

Despite an evolving need to provide surgical health care globally, few health systems, particularly in low-income and middle-income countries (LMICs), can sufficiently provide such care. The vast majority of the world's people-an estimated 5 billion-are unable to access safe and affordable surgical health care when they need it. This is a significa...

The Sustainable Development Goals include a target to reduce the global maternal mortality ratio (MMR) to less than 70 maternal deaths per 100,000 live births by 2030, with no individual country exceeding 140. However, on current trends the goals are unlikely to be met. We used the empirically calibrated Global Maternal Health microsimulation model...

Maternal mortality is a major global health challenge. Although progress has been made globally in reducing maternal deaths, measurement remains challenging given the many causes and frequent underreporting of maternal deaths. We developed the Global Maternal Health microsimulation model for women in 200 countries and territories, accounting for in...

The Global Diabetes Compact is a WHO-driven initiative uniting stakeholders around goals of reducing diabetes risk and ensuring that people with diabetes have equitable access to comprehensive, affordable care and prevention. In this report we describe the development and scientific basis for key health metrics, coverage, and treatment targets acco...

Aims: To evaluate the effectiveness of the Enhanced Primary Healthcare (EnPHC) interventions on process of care and intermediate clinical outcomes among type 2 diabetes patients. Methods: This was a quasi-experimental controlled study conducted in 20 intervention and 20 control public primary care clinics in Malaysia from November 2016 to June 2...

BACKGROUND Mental disorders cause substantial health-related burden worldwide. Mobile health (mHealth) interventions are increasingly used for the promotion of mental health and well-being, as they have the potential to improve access to treatment and reduce associated costs. Behaviour change is an important feature of interventions aimed at improv...

Background: Mental disorders cause substantial health-related burden worldwide. Mobile health interventions are increasingly being used to promote mental health and well-being, as they could improve access to treatment and reduce associated costs. Behavior change is an important feature of interventions aimed at improving mental health and well-be...

Aim: Multidrug-resistant tuberculosis (MDR-TB) arises where treatment is interrupted or inadequate, when patients are treated inappropriately, or when an individual has impaired immune function, which can lead to a rapid progression from infection with an MDR-strain to disease. This study examines the role of health systems in amplifying or prevent...

Background Many European Health Systems are implementing or increasing levels of cost-sharing for medicine in response to the growing constrains on public spending on health despite their negative impact on population health due to delay in seeking care. Objective This study aims to examine the relationships between multimorbidity (two or more coe...

Background Economic losses due to herpes simplex infections in low- and middle-income countries (LMICs) are unknown. We estimated economic and quality-of-life losses due to genital herpes in 2019, in 90 LMICs, and from 2020 to 2030 in 45 countries in the World Health Organization (WHO) Africa. We additionally estimated economic losses due to human...

This study analyzes online news disseminated throughout the pre-, during-, and post-intervention periods of the “Syphilis No!” Project, which was developed in Brazil between November 2018 and March 2019. We investigated the influence of sentiment aspects of news to explore their possible relationships with syphilis testing data in response to the s...

Introduction Around 18.7 million of the 537 million people with diabetes worldwide live in low-income and middle-income countries (LMIC), where there is also an increase in the number of children, adolescents, and young adults diagnosed with type 1 diabetes (T1D). There are substantial gaps in data in the current understanding of the epidemiologica...

Introduction: Using nationally representative survey data from China and India, this study examined (1) the distribution and patterns of multimorbidity in relation to socioeconomic status and (2) association between multimorbidity and out-of-pocket expenditure (OOPE) for medicines by socioeconomic groups. Methods: Secondary data analysis of adul...

Background Previous studies of type 1 diabetes in childhood and adolescence have found large variations in reported incidence around the world. However, it is unclear whether these reported incidence levels are impacted by differences in country health systems and possible underdiagnosis and if so, to what degree. The aim of this study was to estim...

Background Historically, the international development community has often held the view that those living in extreme poverty (at less than $1.90/day) are likely to have a low prevalence of cardiovascular disease (CVD) risk factors due to calorie scarcity, a largely plant-based diet, and physical labor. Evidence on CVD risk factor prevalence among...

Background: Conversational agents (CAs), also known as chatbots, are computer programs that simulate human conversations by using predetermined rule-based responses or artificial intelligence algorithms. They are increasingly used in health care, particularly via smartphones. There is, at present, no conceptual framework guiding the development of...

Background: Conversational agents (CAs) are increasingly used in health care to deliver behavior change interventions. Their evaluation often includes categorizing the behavior change techniques (BCTs) using a classification system of which the BCT Taxonomy v1 (BCTTv1) is one of the most common. Previous studies have presented descriptive summaries...

Background Alcohol is a leading risk factor for over 200 conditions and an important contributor to socioeconomic health inequalities. However, little is known about the associations between individuals’ socioeconomic circumstances and alcohol consumption, especially heavy episodic drinking (HED; ≥5 drinks on one occasion) in low-income or middle-i...

Objectives To determine the prevalence and frequency of using any tobacco product and each of a detailed set of tobacco products, how tobacco use and use frequency vary across countries, world regions, and World Bank country income groups, and the socioeconomic and demographic gradients of tobacco use and use frequency within countries. Design Sec...

Background This study aims to examine (1) province-level variations in the levels of cardiovascular disease (CVD) risk and behavioral risk for CVDs, (2) province-level variations in the management of cascade of care for hypertension, diabetes, and dyslipidaemia, and (3) the association of province-level economic development and individual factors w...

There is a dearth of evidence on the epidemiology of multimorbidity in low- and middle-income countries. This study aimed to determine the prevalence of multimorbidity in India and its variation among states and population groups. We analyzed data from a nationally representative household survey conducted in 2015–2016 among individuals aged 15 to...

Background The COVID-19 pandemic and associated non-pharmaceutical interventions (NPIs) have affected all countries. With a scarcity of COVID-19 vaccines there has been a need to prioritize populations, but assessing relative needs has been challenging. The COVAX Facility allocates vaccines to cover 20% of each national population, followed by a ne...

Antimicrobial resistance (AMR) may negatively impact surgery patients through reducing the efficacy of treatment of surgical site infections, also known as the “primary effects” of AMR. Previous estimates of the burden of AMR have largely ignored the potential “secondary effects,” such as changes in surgical care pathways due to AMR, such as differ...

This study aimed to determine levels of health insurance coverage in low- and middle-income countries and how coverage varies by people's sociodemographic characteristics. We conducted a population size-weighted, one-stage individual participant data meta-analysis of health insurance coverage, using a population-based sample of 2,035,401 participan...

Background Effective equity-focused health policy for hypertension in low- and middle-income countries (LMICs) requires an understanding of the condition’s current socioeconomic gradients and how these are likely to change in the future as countries develop economically. Objectives This cross-sectional study aimed to determine how hypertension pre...

Climate change poses an unprecedented challenge to population health and health systems’ resilience, with increasing fluctuations in extreme temperatures through pressures on hospital capacity. While earlier studies have estimated morbidity attributable to hot or cold weather across cities, we provide the first large-scale, population-wide assessme...

OBJECTIVE Diabetes prevalence is increasing rapidly in rural areas of low- and middle-income countries (LMICs), but there are limited data on the performance of health systems in delivering equitable and effective care to rural populations. We therefore assessed rural-urban differences in diabetes care and control in LMICs. RESEARCH DESIGN AND MET...

Data resource basics Cardiovascular disease (CVD) is the leading cause of morbidity and mortality globally.¹ In recent decades, a rising prevalence of major CVD risk factors including diabetes, hypertension and hyperlipidemia has been observed in many low- and middle-income countries (LMICs) where CVD was not previously considered a major health pr...

Background: Population-based cancer survival is a key metric of the effectiveness of health systems in managing cancer. Data from population-based cancer registries are essential for producing reliable and robust cancer survival estimates. Georgia established a national population-based cancer registry on 1 January 2015. This is the first analysis...