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This chapter investigates the nature of healthcare policies and implementation in Ghana. It argues that although the country's healthcare policies are formulated to accomplish the Millennium Development Goal, there are notable challenges that tend to limit the Government of Ghana's ability to accomplish its various health policy goals. The chapter also describes how some of Ghana's health policies imposed 15%–50% for health service fees. These out-of-pocket fees have negatively affected its citizens’ healthcare delivery network and accessibility. The chapter also discussed how citizens’ reaction to the negative health policies has led to a major movement from modern medicine to traditional medicine as well as a preference for self-medication for treatment rather than going to hospitals to seek healthcare from physicians. The circumstances that led to the establishment of a new health insurance scheme are also discussed in the chapter. The aftermath of the National Health Insurance Scheme and the current outcomes of the policy's impact on the citizens and residents of Ghana are analyzed. Increased health spending by the government of Ghana has led to an increase in life expectancy, reduced infant mortality, and a reduction in maternal mortality rate. Despite major improvements in the health policy and administration in the country, results show that there is a major gap in access to healthcare between the population in the rural and urban regions. There are disparities between rich and poor citizens and residents of Ghana with respect to the affordability of healthcare services. Some new policies that could be formulated to solve the current challenges are recommended.
Brief History of Ghana
The Republic of Ghana is in West Africa. It has boundaries with the Republic of Togo to the east, Côte d’Ivoire to the west, and Burkina Faso to the north. The Atlantic Ocean is to the south of the country. According to the World Bank Indicators (2022) and Worldometer (2022) report Ghana's population was 33.5 million in 2022 (Worldometer 2023). The nation's gross domestic product (GDP) is estimated to be about US$2,175 billion in 2022 (GlobalEdge 2022; World Bank Indicators 2022; Worldometer 2023). Ghana gained its independence from the United Kingdom on May 6, 1957. The Republic of Ghana currently has a unitary constitutional democracy government.
High-cost gene therapies strain the sustainability of healthcare budgets. Despite the potential long-term savings promised by certain gene therapies, realizing these savings faces challenges due to uncertainties regarding the treatment’s durability and a lesser-discussed factor: the true potential for cost offset. Our study aims to assess the cost-offset uncertainty for US Medicaid regarding recently approved gene therapies in hemophilia A and B.
Methods
The analysis used 2018 to 2022 Colorado Department of Health Care Policy & Financing data to determine direct costs of standard of care (factor replacement therapy or emicizumab). Cost-simulation models over five- and ten-year time horizons estimated Colorado Medicaid costs if patients switched to gene therapy (valoctocogene roxaparvovec or etranacogene dezaparvovec) versus maintaining standard of care. Patients were included if aged 18 and over with ICD-10-CM codes D66 (hemophilia A) and D67 (hemophilia B). In the base case, severe hemophilia A was defined as requiring greater than or equal to six yearly factor VIII or emicizumab claims and moderate/severe hemophilia B requiring greater than or equal to four factor IX replacement therapy claims annually.
Results
Annual standard-of-care costs were USD426,000 (SD USD353,000) for hemophilia A and USD546,000 (SD USD542,000) for hemophilia B. Valoctocogene roxaparvovec (hemophilia A) had incremental costs of USD880,000 at five years and −USD481,000 at 10 years. Sensitivity analysis revealed a 23 percent chance of break-even within five years and 48 percent within 10 years. Etranacogene dezaparvovec (hemophilia B) showed incremental costs of USD429,000 at five years and −USD2,490,000 at 10 years. Simulation indicated a 32 percent chance of break-even within five years and 59 percent within 10 years. Varying eligibility (≥4 to ≥15 standard-of-care claims) notably affected break-even; for example, valoctocogene roxaparvovec: 40 percent to 77 percent chance of break-even in 10 years.
Conclusions
Our study highlights significant cost variation in the standard of care of patients eligible for gene therapies, adding to the uncertainty surrounding cost estimation and highlighting the importance of addressing this factor in risk-sharing agreements. The impact of varying eligibility criteria on cost offsets emphasizes the importance of carefully defining eligibility when using real-world data in the context of health technology assessment.
This chapter considers a serious challenge to conceptual realist readings of Hegel which is based on his Philosophy of Nature. According to such readings, one way in which reason is inherent in the world rather than imposed upon it is that individuals are instantiations of substance universals such as “horse” or “human being” which we come to know, and which belong essentially to those individuals in their own right. However, critics of this conceptual realist reading have then countered that in his philosophy of nature, Hegel speaks about the “feebleness of the concept in nature” and seems to allow for a good deal of indeterminacy in the way individuals are classified into kinds, making it hard to see them as essential to individuals and as inherent to the world in the way the conceptual realist claims. This debate and how it relates to Hegel’s Philosophy of Nature is then the focus of this chapter. It is argued that nothing in what Hegel says about the problems in classifying nature in fact threatens conceptual realism, thereby showing how the conceptual realist reading can be vindicated in a way that is consistent with this text.
Investigations of the relevance of low-tunnel methodology and air sampling concerning the off-target movement of dicamba were conducted from 2018 to 2022, focused primarily on volatility. This research, divided into three experiments, evaluated the impact of herbicides and adjuvants added to dicamba and the type of surface treated on dicamba volatility. Treatment combinations included glyphosate and glufosinate, the presence of a simulated contamination rate of ammonium sulfate (AMS), the benefit of a volatility reduction agent (VRA), and a vegetated (dicamba-resistant cotton) or soil surface treated with dicamba. Volatility assessments included air sampling collected over 48 h. Dicamba treatments were applied four times to each of two bare soil or cotton trays and placed inside the tunnels. Dicamba from air samples was extracted and quantified. Field assessments included the maximum and average visible injury in bioindicator soybean and the lateral movement of dicamba damage expressed by the farthest distance from the center of the plots to the position in which plants exhibited 5% injury. Adding glufosinate and glyphosate to dicamba increased the dicamba amount in air samples. A simulated tank contamination rate of AMS (0.005% v/v) did not affect dicamba emissions compared to a treatment lacking AMS. Adding a VRA reduced dicamba in air samples by 70% compared to treatment without the adjuvant. Dicamba treatments applied on vegetation generally produced greater detectable amounts of dicamba than treatments applied to bare soil. Field assessment results usually followed differences in dicamba concentration by treatments tested. Results showed that low-tunnel methodology allowed simultaneous comparisons of several treatment combinations concerning dicamba volatility.
Since the initial publication of A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals in 2008, the prevention of healthcare-associated infections (HAIs) has continued to be a national priority. Progress in healthcare epidemiology, infection prevention, antimicrobial stewardship, and implementation science research has led to improvements in our understanding of effective strategies for HAI prevention. Despite these advances, HAIs continue to affect ∼1 of every 31 hospitalized patients,1 leading to substantial morbidity, mortality, and excess healthcare expenditures,1 and persistent gaps remain between what is recommended and what is practiced.
The widespread impact of the coronavirus disease 2019 (COVID-19) pandemic on HAI outcomes2 in acute-care hospitals has further highlighted the essential role of infection prevention programs and the critical importance of prioritizing efforts that can be sustained even in the face of resource requirements from COVID-19 and future infectious diseases crises.3
The Compendium: 2022 Updates document provides acute-care hospitals with up-to-date, practical expert guidance to assist in prioritizing and implementing HAI prevention efforts. It is the product of a highly collaborative effort led by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Disease Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of organizations and societies with content expertise, including the Centers for Disease Control and Prevention (CDC), the Pediatric Infectious Disease Society (PIDS), the Society for Critical Care Medicine (SCCM), the Society for Hospital Medicine (SHM), the Surgical Infection Society (SIS), and others.
For twenty years, during which time he started to promote Intermediate Technology abroad and began writing Small is Beautiful (1973), E. F. Schumacher was an economist with the National Coal Board. As such, he led what he called a ‘double-life’. On the one hand, his work at the coal board involved colossal plant, pollution and brute human labour, the difficulty of which could be alleviated only by the adoption of heavy coal-extracting machinery. As time went on, Schumacher became deeply involved in managing and defending the declining coal sector, through the rationalisation and further mechanisation of its production activities. On the other hand, through his personal involvement in the Soil Association, his reading of the Gandhian literature and his exploration of Buddhism and other esoteric interests, he increasingly sought to promote a non-violent approach to economics, based on appropriate technology and gentle, labour-intensive methods, especially in the so-called developing countries. This paper tells the story of Schumacher's growing struggle to reconcile these contrasting spheres of his life, until such time as he could finally leave the coal board, give himself completely to Intermediate Technology and begin writing his influential book.
The Hierarchical Taxonomy of Psychopathology (HiTOP) has emerged out of the quantitative approach to psychiatric nosology. This approach identifies psychopathology constructs based on patterns of co-variation among signs and symptoms. The initial HiTOP model, which was published in 2017, is based on a large literature that spans decades of research. HiTOP is a living model that undergoes revision as new data become available. Here we discuss advantages and practical considerations of using this system in psychiatric practice and research. We especially highlight limitations of HiTOP and ongoing efforts to address them. We describe differences and similarities between HiTOP and existing diagnostic systems. Next, we review the types of evidence that informed development of HiTOP, including populations in which it has been studied and data on its validity. The paper also describes how HiTOP can facilitate research on genetic and environmental causes of psychopathology as well as the search for neurobiologic mechanisms and novel treatments. Furthermore, we consider implications for public health programs and prevention of mental disorders. We also review data on clinical utility and illustrate clinical application of HiTOP. Importantly, the model is based on measures and practices that are already used widely in clinical settings. HiTOP offers a way to organize and formalize these techniques. This model already can contribute to progress in psychiatry and complement traditional nosologies. Moreover, HiTOP seeks to facilitate research on linkages between phenotypes and biological processes, which may enable construction of a system that encompasses both biomarkers and precise clinical description.
Understanding place-based contributors to health requires geographically and culturally diverse study populations, but sharing location data is a significant challenge to multisite studies. Here, we describe a standardized and reproducible method to perform geospatial analyses for multisite studies. Using census tract-level information, we created software for geocoding and geospatial data linkage that was distributed to a consortium of birth cohorts located throughout the USA. Individual sites performed geospatial linkages and returned tract-level information for 8810 children to a central site for analyses. Our generalizable approach demonstrates the feasibility of geospatial analyses across study sites to promote collaborative translational research.
Until around 1950, the German émigré Ernst Friedrich Schumacher (1911–1977) was a relatively conventional economist, believing in progress based on economic growth and developments in science and technology. Then, as he turned forty, he went through a period of prolonged self-examination and spiritual quest, which, amongst other things, led him to become critical of Western modernity. Developing a great interest in Buddhist spirituality and culture, in 1955 he travelled to Burma, where he spent three months as a United Nations consultant. His encounter there with the encroachment of Western development upon a traditional society proved pivotal for him, confirming his skepticism about modernity and stimulating him to write a renegade essay, “Economics in a Buddhist Country.” This experience in Burma shaped his work thereafter, as contributor to debates on development both East and West, as promoter of intermediate technology, and as author of the prophetic, popular book of 1973 Small Is Beautiful: A Study of Economics as if People Mattered.
Acceptance and commitment therapy (ACT) is a psychological treatment that has been found to increase weight loss in adults when combined with lifestyle modification, compared with the latter treatment alone. However, an ACT-based treatment for weight loss has never been tested in adolescents.
Methods:
The present pilot study assessed the feasibility and acceptability of a 16-week, group ACT-based lifestyle modification treatment for adolescents and their parents/guardians. The co-primary outcomes were: (1) mean acceptability scores from up to 8 biweekly ratings; and (2) the percentage reduction in body mass index (BMI) from baseline to week 16. The effect size for changes in cardiometabolic and psychosocial outcomes from baseline to week 16 also was examined.
Results:
Seven families enrolled and six completed treatment (14.3% attrition). The mean acceptability score was 8.8 for adolescents and 9.0 for parents (on a 1–10 scale), indicating high acceptability. The six adolescents who completed treatment experienced a 1.3% reduction in BMI (SD = 2.3, d = 0.54). They reported a medium increase in cognitive restraint, a small reduction in hunger, and a small increase in physical activity. They experienced small improvements in most quality of life domains and a large reduction in depression.
Conclusions:
These preliminary findings indicate that ACT plus lifestyle modification was a highly acceptable treatment that improved weight, cognitive restraint, hunger, physical activity, and psychosocial outcomes in adolescents with obesity.
Many patients with advanced serious illness or at the end of life experience delirium, a potentially reversible form of acute brain dysfunction, which may impair ability to participate in medical decision-making and to engage with their loved ones. Screening for delirium provides an opportunity to address modifiable causes. Unfortunately, delirium remains underrecognized. The main objective of this pilot was to validate the brief Confusion Assessment Method (bCAM), a two-minute delirium-screening tool, in a veteran palliative care sample.
Method
This was a pilot prospective, observational study that included hospitalized patients evaluated by the palliative care service at a single Veterans’ Administration Medical Center. The bCAM was compared against the reference standard, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Both assessments were blinded and conducted within 30 minutes of each other.
Result
We enrolled 36 patients who were a median of 67 years (interquartile range 63–73). The primary reasons for admission to the hospital were sepsis or severe infection (33%), severe cardiac disease (including heart failure, cardiogenic shock, and myocardial infarction) (17%), or gastrointestinal/liver disease (17%). The bCAM performed well against the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, for detecting delirium, with a sensitivity (95% confidence interval) of 0.80 (0.4, 0.96) and specificity of 0.87 (0.67, 0.96).
Significance of Results
Delirium was present in 27% of patients enrolled and never recognized by the palliative care service in routine clinical care. The bCAM provided good sensitivity and specificity in a pilot of palliative care patients, providing a method for nonpsychiatrically trained personnel to detect delirium.
The widespread occurrence of Palmer amaranth resistant to acetolactate synthase inhibitors and/or glyphosate led to the increased use of protoporphyrinogen oxidase (PPO)-inhibiting herbicides. This research aimed to: (1) evaluate the efficacy of foliar-applied fomesafen to Palmer amaranth, (2) evaluate cross-resistance to foliar PPO inhibitors and efficacy of foliar herbicides with different mechanisms of action, (3) survey the occurrence of the PPO Gly-210 deletion mutation among PPO inhibitor–resistant Palmer amaranth, (4) identify other PPO target-site mutations in resistant individuals, and (5) determine the resistance level in resistant accessions with or without the PPO Gly-210 deletion. Seedlings were sprayed with fomesafen (263 gaiha−1), dicamba (280 gaiha−1), glyphosate (870 gaiha−1), glufosinate (549 g ai ha−1), and trifloxysulfuron (7.84 gaiha−1). Selected fomesafen-resistant accessions were sprayed with other foliar-applied PPO herbicides. Mortality and injury were evaluated 21 d after treatment (DAT). The PPX2L gene of resistant and susceptible plants from a selected accession was sequenced. The majority (70%) of samples from putative PPO-resistant populations in 2015 were confirmed resistant to foliar-applied fomesafen. The efficacy of other foliar PPO herbicides on fomesafen-resistant accessions was saflufenacil>acifluorfen=flumioxazin>carfentrazone=lactofen>pyraflufen-ethyl>fomesafen>fluthiacet-methyl. With small seedlings, cross-resistance occurred with all foliar-applied PPO herbicides except saflufenacil (i.e., 25% with acifluorfen, 42% with flumioxazin). Thirty-two percent of PPO-resistant accessions were multiple resistant to glyphosate and trifloxysulfuron. Resistance to PPO herbicides in Palmer amaranth occurred in at least 13 counties in Arkansas. Of 316 fomesafen survivors tested, 55% carried the PPO Gly-210 deletion reported previously in common waterhemp. The PPO gene (PPX2L) in one accession (15CRI-B), which did not encode the Gly-210 deletion, encoded an Arg-128-Gly substitution. The 50% growth reduction values for fomesafen in accessions with Gly-210 deletion were 8- to 15-fold higher than that of a susceptible population, and 3- to 10-fold higher in accessions without the Gly-210 deletion.
The dependence of oxygen isotope fractionation on ice growth rate during the freezing of sea water is investigated based on laboratory experiments and field observations in McMurdo Sound, Antarctica. The laboratory experiments were performed in a tank filled with sea water, with sea ice grown under calm conditions at various room temperatures ranging from −5°C to −20°C. In McMurdo Sound, the ice growth rate was monitored using thermistor probes for first-year landfast ice that grew to ∼2 m in thickness. Combining these datasets allows, for the first time, examination of fractionation at a wide range of growth rates from 0.8 × 10−7 to 9.3 × 10−7 m s−1. In the analysis a stagnant boundary-layer model is parameterized using these two independent datasets. As a result, the optimum values of equilibrium pure-ice fractionation factor and boundary-layer thickness are estimated. It is suggested that a regime shift may occur at a growth rate of ∼2.0 × 10−7 m s−1. A case study on sea ice in the Sea of Okhotsk, where the growth rate is modeled by coupling the thermodynamic properties of the sea ice with meteorological data, demonstrates the utility of the fitted models.
Coapplication of herbicides and insecticides affords growers an opportunity to control multiple pests with one application, given that efficacy is not compromised. Glufosinate was applied at 470 g ai/ha both alone and in combination with the insecticides acephate, acetamiprid, bifenthrin, cyfluthrin, dicrotophos, emamectin benzoate, imidacloprid, indoxacarb, lambda-cyhalothrin, methoxyfenozide, spinosad, or thiamethoxam to determine coapplication effects on control of some of the more common and/or troublesome broadleaf weeds infesting cotton. Hemp sesbania, pitted morningglory, prickly sida, redroot pigweed, and sicklepod were treated at the three- to four- or the seven- to eight-leaf growth stage. When applied at the earlier application timing, glufosinate applied alone provided complete control at 14 d after treatment, and control was unaffected by coapplication with insecticides. When glufosinate application was delayed to the later application timing, visual weed control was unaffected by insecticide coapplication. Fresh-weight reduction from the herbicide applied to larger weeds was negatively impacted by addition of the insecticides dicrotophos and imidacloprid with respect to redroot pigweed and prickly sida, but only in one of two experiments. In most cases, delaying application of glufosinate to larger weeds resulted in reduced control compared to that from a three- to four-leaf application, with the extent of reduction varying by species. Results indicate that when applied according to the herbicide label (three- to four-leaf stage), glufosinate/ insecticide coapplications offer producers the ability to integrate pest management strategies and to limit application costs without sacrificing control of the broadleaf weeds evaluated.
Field studies were conducted to evaluate weed control with combinations of glyphosate at 750 g ae/ha and the insecticides acephate (370 g ai/ha), dicrotophos (370 g ai/ha), dimethoate (220 g ai/ha), fipronil (56 g ai/ha), imidacloprid (53 g ai/ha), lambda-cyhalothrin (37 g ai/ha), oxamyl (280 g ai/ha), or endosulfan (420 g ai/ha) and insect control with coapplication of the herbicide with insecticides acephate, dicrotophos, dimethoate, and imidacloprid. Applying lambda-cyhalothrin or fipronil with glyphosate reduced control of hemp sesbania by 19 and 9 percentage points, respectively, compared with glyphosate alone. Acephate, dicrotophos, dimethoate, imidacloprid, lambda-cyhalothrin, oxamyl, and endosulfan did not affect hemp sesbania, pitted morningglory, prickly sida, and redweed control by glyphosate. Lambda-cyhalothrin and fipronil did not affect glyphosate control of weeds other than hemp sesbania. Addition of glyphosate to dicrotophos improved cotton aphid control 4 d after treatment compared with dicrotophos alone. Thrips control was improved with addition of glyphosate to imidacloprid. Insect control was not reduced by glyphosate regardless of insecticide.
Field research was conducted for 2 yr to determine the effects of reduced rates of bromoxynil on growth and yield of non–bromoxynil-resistant cotton. Rates of 4.5, 9, 17, 35, 70, and 140 g ha−1, representing 0.008, 0.016, 0.031, 0.063, 0.125, and 0.25 fractions of the maximum labeled use rate per application (560 g ha−1), were applied to cotton at the two-, five-, or nine-node growth stage. Visual injury was reduced because application timing was delayed from two- to five-node stage in all experiments and from five- to nine-node stage in two of three experiments. Although negatively affected at all application timings, plant height reduction response decreased with increasing cotton maturity. Plant dry weight was most negatively affected after application at the two-node stage. Bromoxynil application, based on the node above white flower number, did not result in maturity delays but did promote earlier maturity when applied at 140 g ha−1 to two- and five-node stage cotton in one of the three experiments. Final plant population was reduced only at the two- and five-node timings, with response more pronounced at the initial timing. Seedcotton yield after bromoxynil application at the highest rate to two-leaf cotton was reduced 34% compared with other rates and the nontreated control. Bromoxynil applied to five- or nine-node cotton did not significantly reduce yield.