Background: Universal Health Coverage (UHC) is achieved in a health system when all residents of a country are able to obtain access to adequate healthcare and financial protection. Achieving this goal requires adequate healthcare and healthcare financing systems that ensure financial access to adequate care. In Africa, accessibility and coverage of essential health services are very low. Many African countries have therefore initiated reforms of their health systems to achieve universal health coverage and are advanced in this goal. The aim of this paper is to examine the effects of UHC on equitable access to care in Africa.Methods: A systematic review guided by the Cochrane Handbook was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria (PRISMA). Studies were eligible for inclusion if 1- they clearly mention studying the effect of UHC on equitable access to care, and 2- they mention facilitating factors and barriers to access to care for vulnerable populations. To be included, studies had to be in English or French. In accordance with PRISMA guidelines, our systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on April 24, 2018 (registration number CRD42018092793).Results: In all 271 citations reviewed, 12 studies were eligible for inclusion. Although universal health coverage seems to increase the use of health services, shortages in human resources and medical supplies, socio-cultural barriers, physical inaccessibility, lack of education and information, decision-making power, and gender-based autonomy, prenatal visits, previous experiences, and fear of cesarean delivery were still found to deter access to, and use of, health services.Discussion: Barriers to greater effectiveness of the UHC correspond to various non-financial barriers. There are no specific recommendations for these kinds of barriers. Generally, it is important for each country to research and identify contextual uncertainties in each of the communities of the territory. Afterwards, it will be necessary to put in place adapted strategies to correct these uncertainties, and thus to work toward a more efficient system of UHC, resulting in positive impacts on health outcomes. Set in 2015, the UN sustainable development goals (SDGs) present an opportunity for the international community to continue its commitment to improve health, which is a central component of development. Achieving universal health coverage (UHC), which refers to access to quality health-care services coverage and financial risk protection for all residents, is a key health target SDG 3.8) in the SDGs .8 in the. Only 49In order to achieve UHC, adequate provision of healthcare as well as healthcare financing systems that ensure access to adequate care regardless of ability to pay were identified as significant needs . In 2005The WHO has identified health system strengthening, which refers to the improvement of a system's performance, as a major means to progress toward UHC . A functSince the early 2000s, many African countries began initiating reforms of their health systems to achieve universal health coverage and are still working toward this goal today. However, implementing UHC has been riddled with various challenges across the continent and there are uncertainties as to whether supposed UHC in African countries has been able to provide equitable access to healthcare for its populations, especially in deprived communities. As a result, the aim of this systematic review is to examine the effects of UHC in facilitating equitable access to care in Africa amongst underprivileged individuals and communities. For the purpose of a research inquiry with a specific scope, the review focuses on vulnerable populations, which are the most excluded individuals and groups from access to, and use of, health services. This will help inform whether and in which contexts UHC programs have been successful in increasing equitable access to care, as well as to provide guidance for future evidence-based healthcare reforms. To the best of our knowledge, no systematic reviews of the effect of UHC in facilitating equitable access to care in Africa currently exist.A systematic review guided in part by the Cochrane Handbook was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria (PRISMA) , 15. In The research strategy protocol was developed in collaboration with a university Health Sciences Librarian to refine our queries and characterize them in terms of the elements  used for the questions even if all these elements have not been used in the formal research strategy.Search terms designed for Medline see  and otheStudies were eligible for inclusion if 1- they clearly mention studying the effect of UHC on equitable access to care, and 2- they mention facilitating factors and barriers to access to care for vulnerable and underprivileged populations (the needy). To be included, studies had to be in English or French .After identification of studies, duplicates were removed using standard software (Endnote 7). Two independent reviewers conducted two levels of screening after exporting references from ENDNOTE 7 to Covidence. Level one screening, using citation titles and abstracts, was to determine study relevance to the overall objective of the systematic review . Level tStudy findings were extracted using a data extraction form that was initially pilot tested on three randomly selected included studies before its actual use. The two reviewers used the form to extract data independently.The method of synthesis used for this review is a narrative synthesis as guided by Popay et al. . The metAll included studies were appraised by both reviewers using the Critical Appraisal Skills Program (CASP) tool . The CASThe data were synthesized by classifying different study types. Due to heterogeneity across study outcomes, data were analyzed descriptively. Study comparisons were grouped to answer research questions, and findings were synthesized based on outcomes. Characteristics of included studies were analyzed descriptively, and results were presented in a narrative format recommended by PRISMA and Popay et al. .n = 96), titles and abstracts not matching criteria (n = 159), and full texts that did not meet the inclusion criteria (n = 4)  see n = 6), Kenya (n = 2), Malawi (n = 1), Madagascar (n = 1), Burkina Faso (n = 1), and Rwanda (n = 1)  see .The checklists cover the appropriateness of the research design, ethical considerations and standard conceptions for assessing risk of bias and overall quality. Quality assessment helped gather the relative strengths and weaknesses of the body of evidence.The 12 included studies  demonstrated that their research designs and recruitment strategy were appropriate for addressing the aims of their research. Ethical issues were taken into consideration in only 5 out of the 12 included studies, with the rest not clearly demonstrating the maintenance of ethical standards or indicating ethical approval from committee. Although the 12 studies had a sufficiently rigorous data analysis process and a clear statement of findings, using multiple strategies to establish credibility, 4 of them did not discuss potential bias and limitation. No study was excluded due to assessment of conduct , assessment of reporting (transparency) or assessment of content and utility of findings. The average overall quality is 8.3/10, which suggests the sum quality of the included studies for this review is high. Studies were not excluded or weighted based on the quality of the assessment; instead, the quality is used to inform data interpretation and ultimately determine the credibility of review findings and conclusions.As measured by health system reported service use, the use of health services by the poorest of the population increases equitable access to care in Africa, and this makes universal health coverage effective , 24, 26.Rwanda is the most advanced country in Africa regarding universal coverage. The country has achieved 96.15% coverage in health insurance, with 1.07 patient health center visits per year as compared to 1 visit recommended by WHO . In addiIn Madagascar, exemption from payment of health care in rural areas has led to an increase in the use of health services . In factAlthough universal health coverage seems to have an effect on increasing the use of health services, some imperfections remain. One of these factors is the shortage and inequitable distribution of health professionals , 21, 23.The higher the health insurance coverage rate for the underprivileged, the more that people have access to it, displaying equity and social justice. In Madagascar, free reproductive health care has increased the use of services, including greater access to these services for the needy and thereby socially inclusive . In RwanFinally, aside from financial risk coverage and quality of care, other factors are important to consider in order to ensure equity and performance of health systems . This inThis systematic review set out to examine the influence of UHC on equitable access to healthcare. Study findings indicated that the UHC through the coverage of indigents by the health insurance increased the access to the primary health services but that the quality was not necessarily at the rendezvous. Access to quality care is the foundation of a health system's performance. Equity is respected only if both conditions are met. Indeed, the lack of health professionals and their unequal distribution throughout the country, the stock-outs of medicines and health care equipment, as well as the late payment of rebate payments to health professionals, led to a poor takeover of patients and demotivation of health professionals. Health system governance is the key element and some African countries such as Ghana and Rwanda are success stories in this area as they have a strategic plan for the governance of their health systems according to WHO standards. In addition, other barriers such as ethnicity, religion, physical accessibility , decision-making, gender and autonomy, information and education, age, prenatal visits, previous experience of giving birth at home, negative experiences with health centers, fear of cesarean delivery, and lack of transport impede the utilization of health services and therefore equity.The first element of equity that is access to health care  is not respected for different reasons beyond the UHC. Indeed, a systematic review published in 2017 on access barriers to obstetric care at health facilities in sub-Saharan Africa shows that access to obstetric care is riddled by several demand-side barriers including household income, non-availability of means of transportation, indirect transport costs, lack of information on health care services and providers, stigmatization, women's self-esteem, lack of birth preparation, cultural beliefs, and ignorance about required obstetric health services . The revStudies from developed countries found that despite systems of universal coverage, there was greater inequity, in terms of wait times and receiving of services, for programs deemed non-urgent, elective or for which there will minimal defined treatment protocols .In both developing and developed countries, inequity arose through disparities in quality of care and accessibility of specialized facility-based services. The type of health facilities being accessed varied by different socioeconomic groups. The privileged received most care services in provincial or general hospitals and private clinics, while the underprivileged tended to receive care from the lowest level providers, health centers . The undThe relationship between UHC and equity is evident to the extent that it allows for an increase in health care coverage and health outcomes, but it depends on the availability, accessibility, and capacity of health workers to deliver quality people-centered integrated care. It is therefore important to focus on the primary health care workforce because this is the most cost-effective way to ensure access to primary health care for all . To thisIn December 2018, the WHO Health Workforce Director stated: “Health Workers bring us closer each day to achieving UHC. Their rights must be protected in the Health For All movement” . In factIt is important for each country to research and identify these uncertainties in each community of the territory. In addition, there is a pressing need for further research on how these specific barriers interrelate and what their role and contribution is to accessing healthcare across different at-risk groups. Then, it will be necessary to put in place adapted strategies to fix these issues, and thus to aspire to increase the efficiency of UHC, which will result in a positive impact on health outcomes. This involves important political decisions. As a first step, African countries should have increased their health budget to reach the 15% provided for in the Abuja Declaration . FurtherThere are limited studies on UHC in Africa' only 271 studies on the effects of UHC on equitable access to care were found through the databases. The review has only included 12 studies, which can be seen as low for this topic. However, the term UHC is new and many countries in the continent are still in the early stages. It is an emerging goal in most African countries and therefore still at the implementation stage. A major reason for the low amount of studies was because the authors sought studies that mentioned the term UHC, since using other terms, such as health insurance, would have complicated the analysis as there are several types of health insurance. The other major reason was the focus on underprivileged populations, which was justified in this review as underprivileged populations experience inequity to the largest extent. Additionally, many of these included studies were conducted in Ghana . As a reUniversal health coverage and SDG 3.8 cannot be adequately achieved without equitable access to quality care by all citizens, including those who are underprivileged. African countries need well-functioning health systems and governance with sufficient and equitable distribution of health professionals who are adequately trained and skilled to provide quality care to patients. A system to control medicines and prevent material shortages and a strong regulation of the financial system for rebate payments to health professionals is also recommended. Through the increase of coverage by health insurance schemes, there can be improvements in access to care and thereby positive health outcomes in African populations. These requirements will need budget allocation to health from African governments. Lastly, as developing countries attempt to fully implement UHC for all residents, further research is required to assess the underlying changes in equity.NAS and SY conceived of the study and participated in its design and coordination. NAS, AWF, and SY drafted the manuscript. Each author critically reviewed the manuscript for its intellectual content. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The past two decades have been marked by impressive growth in the migration of medical doctors. The medical profession is among the most mobile of highly skilled professions, particularly in Europe, and is also the sector that experiences the most serious labour shortages. However, surprisingly little is known about how medical doctors choose their destinations. In addition, the literature is scarce on the factors determining the sharp rise in the migration of doctors from Africa, Asia and Eastern and Southeastern Europe, and how the last economic crisis has shaped the migration flows of health professionals.We use the new module on health worker migration provided by the Organisation for Economic Co-operation and Development (OECD) for 2000–2016 in order to examine the channels through which OECD countries attract foreign physicians from abroad. We estimate a gravity model using the Pseudo-Poisson Maximum Likelihood estimator.Our results reveal that a lower unemployment rate, good remuneration of physicians, an aging population, and a high level of medical technology at the destination are among the main drivers of physicians’ brain drain. Furthermore, an analysis of the mobility of medical doctors from a number of regions worldwide shows that individuals react differently on a country-wise basis to various determinants present in the destination countries. Physicians from African countries are particularly attracted to destination countries offering higher wages, and to those where the density of medical doctors is relatively low. Concurrently, a higher demand for healthcare services and better medical technology in the receiving country drives the inflow of medical doctors from Central and Eastern Europe, while Asian doctors seem to preferentially migrate to countries with better school systems.This study contributes to a deeper understanding of the channels through which OECD countries attract foreign medical doctors from abroad. We find that, apart from dyadic factors, a lower unemployment rate, good remuneration of physicians, an aging population, and good medical infrastructure in the host country are among the main drivers of physicians’ brain drain. Furthermore, we find that utility from migration to specific countries may be explained by the heterogeneity of origin countries. The migration of tertiary educated people from poor to rich countries has become an increasingly important feature of international migration. Over the past few decades, the stock of highly-skilled immigrants in member countries of the Organisation for Economic Co-operation and Development (OECD) grew at a much faster rate than low-skilled workers . The majOne critical dimension of skilled migration, is the persistently higher mobility rates of health professionals. The medical profession is among the most mobile of highly skilled professions, particularly in Europe. It is also the sector that experiences the most serious labour shortages , 4.However, surprisingly little is known about how medical doctors choose their destinations. The main reason for this knowledge gap is a lack of appropriate data. To the best of our knowledge, there are only three datasets on physician migration: First, the OECD Health Statistics - Health Workforce Migration dataset, which contains yearly observations on foreign-trained health professionals for the OECD countries, but the temporal coverage is unbalanced . Second, the dataset of Clemens et al. , with daIn our paper, we take advantage of the new module on health worker migration provided by the OECD for 2000–2016, in order to examine the determinants of migration flows of foreign-trained physicians. We employ a gravity-type estimation model using the Pseudo-Poisson Maximum Likelihood estimator, developed by Santos Silva and Tenreyro . Our focOur paper’s contribution to the literature is threefold. First, while many studies document the effects of physician emigration on various health and socio-economic outcomes in the sending countries , 10–12, In addition, very little is known about the factors determining the sharp rise in the migration of doctors from Africa, Asia, Eastern and Southeastern Europe, and how the last economic crisis shaped the migration flows of health professionals. Our paper fills this gap, and shows that utility from migration to a specific destination varies in magnitude both across categories of origin countries and over time.Our research also adds to a new strand of literature that employs gravity models to investigate migration flows –22. AmonUijk represents the utility of individual i after migration from country j to country k. wjk represents the deterministic component of the utility, and cjk the costs of moving from j to k. ϵjk is an individual stochastic component of utility. If it is assumed that ϵijk has extreme value type-I distribution, we can apply the results in McFadden  to migrate to other destinations”. Hence, as shown by Bertoli and Fernández -Huertas Moraga [k as well.But in reality, the decision to migrate is not based solely on push and pull factors present in the source and destination countries, but also on the relative opportunities and/or obstacles that other possible destinations simultaneously exhibit. In economics, Anderson and Van Wincoop  first fos Moraga , the dens Moraga , which cFailing to control for these ‘third-country’ effects in the estimation of a gravity model of migration might lead to biased results. The influence of alternative destinations can confound identification of the effects of various determinants on the bilateral migration flows. In this sense, various empirical approaches have been proposed to tackle the problem . Furthermore, we include variables describing a range of factors that affect both the supply of- and demand for health workers. By lagging these variables, we attempt to control for reverse causality [djk), a common border, and cultural links . Two dummies that indicate EU and Schengen membership of pair countries are also included as controls. We add a variable for diaspora, defined as the stock of highly-skilled immigrants trained in country j and living in country k at the start of period t. A detailed description of the variables is presented in the next Section. Finally, we add time-varying origin dummies μjt to control for time-variant factors at origin, and destination fixed effects (δk) to control for destination-invariant characteristics.The dependent variable ausality . Other cWe estimate Eq. The data for the empirical analysis was gathered from various sources, and covers the time period 2000 to 2016. The origin and destination countries are listed in the njkt and represents the inflow of medical doctors from country of origin j to country of destination k at time t. The data is provided by the OECD within the new module on health worker migration,Our key dependent variable is the dyadic inflow As destination-time-variant variables, we use the following. We include the ratio of GDP per capita for the country of origin relative to the GDP per capita for the country of destination, as a proxy for the gap in economic development and absorption capacity between both countries , 35. A s2We also consider the unemployment rate in the destination country.We also control for quality of the education system in the destination country, given that physicians who consider emigration may also be concerned about the quality of education available to their children. For this, we use PISA reading score,In the literature, the existence of networks is expected to decrease migration costs, and favour migration flows , 39–41. Following the approach in gravity models of international migration, we control for time-invariant dyadic variables that also influence migration costs. For example, the physical distance between two countries is expected to be negatively correlated with migration inflows . Likewis6In addition, we entered two dummy variables for EU and Schengen membership, as a common membership to one of these agreements may facilitate the free movement of people , 21. Of Given the purpose of the paper, we also look at the factors that describe the functioning of the health labour market in the destination countries. Following Moullan  and OECDDescriptive statistics on all variables are reported in Table We estimate Eq. The results reveal that, with the exception of GDP per capita ratio and PISA literacy score, the coefficients are similar in terms of magnitude and statistical significance across all specifications.The coefficient estimate for the variable accounting for the unemployment rate in the destination countries is negative, and highly statistically significant in the full model. This indicates that the destinations with lower unemployment rates are those that attract an increased number of foreign medical doctors. Next, the results for our preferred specification (column 5) suggest that PISA test score, our proxy for education quality in the destination country, is positively correlated with higher inflows of medical doctors.Further, results in columns (4) and (5) show positive and statistically significant effects of the GDP ratio on migration flows. In fact, we note that for specifications in which we control for remuneration of physicians , the estimates turn positive.We also note that the stock of highly-skilled co-nationals in the destination country does not seem to matter for the next waves of physician inflows.Log Distance (last column) suggests that a 10% increase in bilateral distance is, on average, associated with a 6.35% reduction in migration flows of medical doctors. Further, a colonial relationship is positively correlated with migration flows of medical doctors. The language coefficients all have a positive sign, again as expected, and have the highest magnitude among all dyadic controls. The coefficient on Common language dummy from our full model (column 4), suggests that if two countries share the same language, they experience almost 800% higher bilateral physician flows than countries with different languages.Next, we examine the influence of the standard dyadic control variables on migration flows. The results reveal that these variables all have the expected sign. The distance variable has a negative coefficient in all specifications, and all estimates are statistically significant and similar in magnitude. The estimated coefficient for EU and Schengen membership leads to a positive increase in the immigration flows of doctors. The effect is highly significant, particularly for pairs that are both Schengen members. The coefficient from column 4 (full model) indicates that Schengen member countries experience 98.77% higher bilateral flows of medical doctors than non-Schengen countries.A key rationale for attracting medical doctors from abroad is a response to shortages in medical staff . For thiWe further find that the various demand-side factors are differently correlated with physicians’ brain drain. Higher health spending per capita in destination countries does not have a conclusive effect on the number of migrant arrivals. A distinct pictures emerges when we look at health insurance coverage. It seems that a high share of the population covered by health insurance is not necessarily favourable for attracting medical doctors from abroad. The estimate is negative, and statistically significant across all specifications, even after controlling for supply factors. The coefficient of log age dependency ratio is positive, and highly statistically significant. Similarly, once we control for the supply factors, the number of hospital beds is significantly correlated with immigration flows of medical doctors, which indicates that inpatient sector infrastructure is correlated with the demand for medical doctors from abroad.In the last column we also control for medical technology, as a proxy for health system infrastructure. We find a positive and highly statistically significant relationship between medical infrastructure and inflows of foreign-trained doctors. The results reveal that better health care resources in a medical system attracts physicians from abroad.This paper examines the channels through which OECD countries attract physicians from abroad. We show that a lower unemployment rate at the destination increases migration flows among medical doctors. This confirms previous empirical results, indicating that a higher employment rate is directly associated with an increasing trend in the volume highly-skilled migrants , 37. ConWe have also analysed the influence of the ratio of GDP per capita for the country of origin relative to the GDP per capita for the country of destination on migration inflows. While the GDP for the country of destination accounts for the incentive to migrate, the GDP in the home country reflects both the incentive to go abroad, and the ability to cover the costs of migration . In thisFurthermore, the diaspora in the destination country does not seem to matter for the next waves of physician inflows. This result is in line with those of Docquier and Rapoport , who argThe language coefficients are positive, and have the greatest magnitude among all dyadic controls; indicating that sharing a common language is a more important pull factor for medical doctors. This is very likely the case, since, in general, medical doctors willing to practice in another country must prove advanced language skills , 57. ButSeveral studies examining the relationship between the characteristics of the health labour market and migration flows of medical doctors , 46 posiWe additionally find that the various demand factors are differently correlated with physicians’ brain drain. Greater health spending per capita in destination countries does not have a conclusive effect on the number of migrant arrivals. A distinct picture emerges when we look at health insurance coverage. It seems that a high share of the population covered by health insurance is not necessary favourable for attracting medical doctors from abroad. Our results also reveal that demographic conditions in receiving countries favour increased inflows of medical doctors. This result reinforces the idea that an aging population will increase the demand for health professionals, and will thus intensify migration; since physicians flows are responsive to changes in the share of the elderly population . SimilarWe also find a positive and highly significant relationship between medical infrastructure and the inflows of foreign-trained doctors. The results reveal that better health care resources in a medical system attracts physicians from abroad.Taken together, the results of this section suggest that aside from a low unemployment rate and a larger gap in GDP per capita, both the characteristics of the healthcare system, and the population’s needs for healthcare goods in the host country are highly correlated with the utility of migration to the respective country.Thus far in our analysis, we have focused on the association between migration flows of physicians and various determinants at the destination, regardless of country of origin or time of migration. These overall effects may obscure a differential reaction of physicians to various determinants at the destination between countries of origin. Moreover, given that recent data provides evidence of several disruptions in migration flows, including those of medical doctors, we might expect discrepancies in the relationship between the migration of medical doctors and characteristics of receiving countries. Therefore, the analysis of heterogeneity effects is crucial for acquiring a better understanding of physicians’ brain drain in the last two decades. Table Our heterogeneity analysis reveals that physicians from African countries are particularly attracted to countries that offer higher wages, and by those where the density of medical doctors is relatively low. This result hinges on shortages of medical doctors, which explains the relative attractiveness of that destination for African health professionals. In their case, colonial links play an important role in their choice of destination. Concurrently, higher demand for healthcare services and better medical technology at the destination drive an increase in the inflow of medical doctors from Central and Eastern Europe, whereas Asian medical doctors seem to migrate to countries that have a better school system, offer higher wages, and which have a low density of medical doctors. Destination countries with a higher proportion of elderly individuals and a high number of hospital beds are particularly attractive to medical doctors from Central and Eastern European countries. We also find that the presence of a diaspora favoured migration inflows among physicians only for those coming from Asia or Central and Eastern European countries.Further analysis shows that better equipped health systems  were more attractive to foreign medical doctors during the economic crisis than prior to 2007. The results also reveal that between 2007 and 2012, EU member countries experienced 73.50% higher bilateral flows of medical doctors than non-EU countries. We also note that supply factors affecting the healthcare system at the destination played a more important role during the economic crisis than before 2007, with foreign physicians particularly attracted to those countries offering higher wages, better medical infrastructure and a lower density of medical doctors.All in all, the results in Table In this section, we provide a set of robustness checks that deal with alternative sample restrictions. Table The results confirm that our findings are not driven by specific time periods.17There are at least four caveats to the present study. First, time series data provided by the OECD is incomplete, as some countries did not provide relevant information for specific years. However, we succeed in overcoming this shortfall by applying econometric techniques that successfully deal with the presence of a high proportion of zero values in the data. Secondly, the OECD Health Workforce Migration dataset does not capture physicians who may have migrated to other countries, but who are not working as doctors. Thirdly, our dataset does not exclude multiple migrations. It is very likely that medical doctors migrate to more than one destination country in their lifetime. Thus, a country of destination at one point in time might become the country of origin, when a person later decides to make a further move to someplace other than his/her native country. Finally, we have not been able to find detailed information on specific restrictions in destination countries applicable to the medical profession such as language qualifications, additional licensing or certification requirements. Compiling a comprehensive dataset on these requirements and testing their influence on medical migration flows is an area for future research.This study contributes to a deeper understanding of the channels through which OECD countries attract medical doctors from abroad. More specifically, this study uses the new module on health worker migration provided by OECD for 2000–2016 in order to examine the determinants of migration flows for foreign-trained physicians. Applying a gravity model approach, and using the Pseudo-Poisson Maximum Likelihood estimator, we find that, apart from dyadic factors, a lower unemployment rate, good remuneration of physicians, an aging population, and a good medical infrastructure in the host country are among the main drivers of physicians’ brain drain. Furthermore, performing an analysis on the mobility of medical doctors from various continents , we find that utility from migration to specific countries may be explained by the heterogeneity of origin countries.Specifically, we show that physicians from African countries are particularly attracted to destinations offering higher wages, and where the density of medical doctors is relatively low. This result hinges on shortages of medical doctors, which explains the relative attractiveness of that destination to African health professionals. In their case, colonial links also play an important role in the choice of destination. At the same time, higher demand for healthcare services and better medical technology at the destination increase the inflow of medical doctors from Central and Eastern Europe, whereas Asian medical doctors appear to preferentially migrate to countries that have a better school system, and which offer higher wages.Further analysis shows that better equipped health systems  were more attractive for foreign medical doctors during the economic crisis than before 2007. We also find that the presence of a diaspora encourages migration inflows among physicians, although only for some specific continents of origin.Overall, these results draw attention to several factors that affect medical doctors’ decisions to migrate. Policy makers intending to address the personnel shortages in the health care systems could consider these factors when designing strategies to facilitate the entry for foreign physicians, particularly in those countries that have to cope with an aging population and a growing number of people in need of medical services.


Water analysis has been an important area since the beginning of analytical chemistry. The focus though has shifted substantially: from minerals and the main constituents of water in the time of Carl Remigius Fresenius to a multitude of, in particular, organic compounds at concentrations down to the sub-nanogram per liter level nowadays. This was possible only because of numerous innovations in instrumentation in recent decades, drivers of which are briefly discussed. In addition to the high demands on sensitivity, high throughput by automation and short analysis times are major requirements. In this article, some recent developments in the chemical analysis of organic micropollutants (OMPs) are presented. These include the analysis of priority pollutants in whole water samples, extension of the analytical window, in particular to encompass highly polar compounds, the trend toward more than one separation dimension before mass spectrometric detection, and ways of coping with unknown analytes by suspect and nontarget screening approaches involving high-resolution mass spectrometry. Furthermore, beyond gathering reliable concentration data for many OMPs, the question of the relevance of such data for the aquatic system under scrutiny is becoming ever more important. To that end, effect-based analytics can be used and may become part of future routine monitoring, mostly with a focus on adverse effects of OMPs in specific test systems mimicking environmental impacts. Despite advances in the field of water analysis in recent years, there are still many challenges for further analytical research. Analytical and Bioanalytical Chemistry, specifically developed analytical methods for the investigation of mineral water from wells in the nineteenth century [Analytical Chemistry [The primary task of water analysis is to provide information on the composition of aqueous samples of diverse origin. This has not really changed since the very beginning of analytical chemistry. To give just one example, Carl Remigius Fresenius, the godfather of analytical chemistry in Germany and founder of the journal that became  century . Beyond hemistry . In the Pimephales promelas) and found extremely high production in both female and male fish compared with production in a reference lake in the same system. Disturbance of reproduction over the 7-year observation period led to a collapse of the whole fish population in the lake with 17α-ethinylestradiol dosing [In contrast to some other areas of measurement science, there are several drivers for further developments of methods for water analysis. The first is the same as in any area of science; that is, curiosity of the scientist, who in our case wants to find out if new instruments or new methods can be developed that improve existing approaches for monitoring water quality. The second is more specific for environmental analysis, and mostly concerns the sensitivity of analytical methods. On the basis of the precautionary principle or extrapolated risk estimates, a threshold limit for a certain pollutant or class of compounds is set that cannot or can hardly be achieved at the time of regulation enforcement. This triggers many developmental efforts because without means for control, such standards are useless. The best known example for this driver is the maximum allowable concentration of 0.1 μg/L set for pesticides and their metabolites in drinking water in the European Union (EU) in 1980. At that time, this value was considered to mean practically zero and was applied to all compounds of that class regardless of their toxicological evaluation. This precautionary value inspired a lot of work on pesticide residue measurements that nowadays allow the analysis of hundreds of compounds in a single multiresidue method with sensitivities in the low nanogram per liter range, thus surpassing the former “zero limit” by far . As an eThe bottom line of water analysis in a European context is the EU Water Framework Directive (WFD) and derived regulations. As mentioned before for the recently added perfluorinated compounds and estrogens, there are priority substances or substance classes listed in Annex X and the watch list for which reliable methods at the required sensitivity applicable in routine monitoring are still not available. A further difficulty with the regulation can be the requirement of analysis of the whole, unfiltered water sample, including suspended particulate matter. Several years ago Lepom et al.  and AdemAs in all measurements one needs to accept that we will never be able to measure everything in a sample. The analytical window is inherently restricted for numerous reasons that are (incompletely) summarized for a generic analytical process based on chromatography coupled with MS detection in Fig. In the next two sections the focus is on widening the analytical window by further developments in the separation step, and subsequently the extended scope of HRMS detection will be discussed. In recent years, efforts in water analysis have been made with regard to a more comprehensive and reliable measurement of polar organic compounds. If these are in addition recalcitrant to degradation in the environment, they are the OMPs most likely to pass a multibarrier system and eventually reach raw water and even drinking water. The term “persistent mobile organic compounds” (PMOCs) was recently introduced to classify such compounds Fig. . The staWater samples can contain complex mixtures of many OMPs at low concentrations. The peak capacity of a one-dimensional system may then not be sufficient to allow complete separation. Because of the selectivity of MS detection, this may be acceptable in many cases, and in nontarget approaches it is often impossible to locate any individual peak in the total ion current chromatogram. However, the poorer the separation, the more likely matrix effects or coelution of isobaric compounds occurs, which may adversely affect the analytical results, eventually leading to false positives or false negatives. Therefore, two-dimensional separations with the aspiration of orthogonality of separation mechanisms have been investigated also in the area of water analysis , 18. LeoGC or LC separations in combination with MS and MS/MS detection, mostly based on low-resolution quadrupole analyzers, are well established for selective and sensitive detection of known target analytes. These include regulated compounds, for example, derived from implementation of the EU WFD or the US contaminant candidate list, but also an even larger number of unregulated or emerging compounds. A prerequisite is the availability of authentic reference standards and a meaningful a priori selection of target analytes for the samples investigated. Considering that already more than 1000 OMPs have been reported to occur in aquatic systems, a target analysis of all these compounds seems impossible in regular monitoring despite multiresidue protocols comprising hundreds of target or suspected compounds , 22, 23.Daphnia magna, Danio rerio (fish eggs or embryos), or different species of microalgae, is used. When using in vivo test systems, one should include taxa of different trophic levels [Monitoring of OMPs in aqueous systems has little value as such, it serves as a basis for evaluation of aquatic systems or processes. Therefore, the question of what we can finally do with all the information from the widened analytical window obtained by extended separation methods and HRMS use becomes ever more important. For example, is advanced wastewater treatment for reduction of emissions by wastewater treatment plants meaningful or even necessary to improve the status of our surface waters? Feature numbers or target concentrations will not suffice to provide an answer to that question, or only in the rather few cases where human toxicity and ecotoxicity had been previously evaluated. The current debate on glyphosate genotoxicity highlights how difficult and sometimes controversial such an evaluation may be , 33. Furc levels . In the c levels . Carefulc levels  showed tc levels , 40. A rc levels . This dec levels .If one wants to use the results of the bioassays to further direct the identification of causative chemicals, the sample or an extract can be fractionated, mostly by LC, and the individual fractions are investigated again. This approach is very time-consuming, and therefore an interesting alternative is a microfractionation system that combines LC or even LC×LC separations with a simultaneous collection of fractions in microtiter plates for effect analysis that allows for linking of effect and chemical identity –44. The In summary, the field of bioanalytical tools complementary to advanced chemical analysis has matured over the past decade and should be equally considered in future regulation of required monitoring since both are needed to answer the pressing questions on the status of our aquatic systems. More and more we will also see a merger of both domains by combinations of high-throughput effect screening and HRMS use.Culture-independent rapid identification and quantification of microorganisms including virusesAnalysis of antibiotic resistance/antibiotic resistance genes and gene transfer in the environmentAnalysis of anthropogenic particles for abundance, type, and size in trace concentrations and with a high background of natural solids Sensor networks for continuous monitoring and integrative sampling for the surveying of short-term (pulse) concentration changesFurther refinement of still emerging analytical tools in water analysis such as compound-specific stable isotope analysisElement species analysis at trace concentrations in the environment: organically bound versus ionic , complexed , or redox sensitive  vs Cr(VI))Further automation of full analytical methods, including sample preparationCost-effective in situ or on-site analysis, for example, by sensors or colorimetric tests using micro paper-based analytical devices and/or smartphonesAs mentioned previously, the limitation of the scope of this article to OMP analysis is not meant to indicate that this is the only or even the most important area of research needs in water analysis. Thus, to finish, further topics of relevance are summarized in the following personal shortlist, again without the claim to be comprehensive:As discussed in detail in the previous sections, the past few years have seen substantial developments in analytical science that have also reached the area of water analysis but are not yet established in routine monitoring or surveillance schemes. Foundations have been laid but this will be an important transfer task for the future. Although many scientists may not be very interested in related work, including the tedious task of standardization, it is of the utmost importance for long-lasting impact, including meaningful decisions for the future allocation of resources in water monitoring. In particular bringing together HRMS-based suspect and nontarget screening, on the one hand, and effect-based analysis, on the other hand, will be an important step forward in the field for its ultimate goal: to provide data that allow better protection of our invaluable water resources.


A 21-year-old female lacrosse player complained of anterior thigh pain with no known mechanism of injury and failed to improve with conservative therapy. An MRI was obtained showing a closed degloving injury of the rectus femoris, an injury only previously reported in a small case series of soccer players. After a brief period of rest, she was progressed conservatively through therapy and did well, with progression back to the level of competition at 56 days. This case highlights a rare injury not previously described in sports outside of soccer and is the first case described in a female athlete. In addition, the discussion of this case focuses on the unique anatomy of the rectus femoris. Injuries to the quadriceps muscles are common in athletics. Certain sports such as soccer may show higher rates of adductor injuries compared to quadriceps injuries, but in aggregate studies of all sports, quadriceps injuries appear to be the second most common type of lower extremity muscle injuries behind hamstring injuries –4. QuadrThe patient was informed that the details of her case would be submitted for print and electronic publication and gave informed consent.A 21-year-old NCAA Division 1 Lacrosse player presented to the training room with right anterior thigh pain of 4-5 weeks duration. Onset was gradual, occurring in the spring lacrosse season and starting during training and practice. She did not report any new activity or specific mechanism of injury leading to the pain. She had no history of surgery or major injury to the region. She had previously been seen by the athletic trainer at the onset of pain, described initially as a soreness in her anterior thigh of gradual onset at practice, and started on conservative management for a presumed quadriceps strain. This initial management consisted of modified activities at practice, rehabilitation therapy in the training room, NSAIDS, ice, cupping, and needling. Despite some initial improvement with these treatments, symptoms increased with gradual return to lacrosse. The pain was now throbbing, worse after games, occurring at night, waking her up from sleep, and exacerbated when her leg would hang over the edge of the chair. On exam, she had full active and passive range of motion and strength of the hip as well as the knee. She had tenderness over the right anterior mid-proximal thigh, extending over and area of approximately 10 cm. The tenderness was worse medially than laterally with no palpable defect in the muscle, and she had a positive fulcrum and hop test. Her neurovascular exam was intact. An X-ray of the femur did not reveal any abnormalities. An MRI was ordered to rule out a stress fracture and to evaluate the quadriceps muscle further. The MRI showed an acute complete disruption of the inner bipennate muscular component of the right rectus femoris from the more superficial unipennate muscular component with retraction of the inner component, consistent with an acute degloving injury. No abnormality was noted in the osseous structure. These findings are highlighted in Figures Injuries to the quadriceps muscles are common in athletics, with the rates of injury reported to be higher in women and occurring more frequently in competition , 5. AmonThe anatomy of the rectus femoris is unique compared to the other quadriceps muscles. In addition to having actions on both the hip and knee joint, the anatomy of the muscle and proximal tendons creates a “muscle within a muscle” . CadaverCentral tendon and muscle injuries have been found to have prolonged recovery when compared to injuries to the periphery , 10. WhiA thorough understanding of the unique anatomy of the rectus femoris first elucidated in the 1990s by Hughes and Hasselman is important to understanding the range of injuries that can occur within the quadriceps muscles , 8. This


The International Breakfast Research Initiative (IBRI) set out to derive nutritional recommendations for a balanced breakfast using a standardized analysis of national nutrition surveys from Canada, Denmark, France, Spain, UK and the US. In all countries, the frequency of breakfast consumption by age was high and U-shaped with children and older adults having a higher frequency of breakfast consumption. Breakfast contributed 16% to 21% of daily energy intake. In all countries, breakfast was a carbohydrate- and nutrient-rich meal, providing more carbohydrates (including sugars), thiamin, riboflavin, folate, calcium, potassium, and magnesium, and less vitamin A, fats and sodium relative to its contribution to daily energy intakes. Breakfast consumers were stratified by tertiles of the Nutrient Rich Foods (NRF) index, used as a measure of diet quality. Breakfast intakes associated with the top tertile of NRF, along with the Codex Alimentarius international food standards and World Health Organization (WHO) diet guidelines, were used to derive the proposed nutrient recommendations. The goal was to preserve the nutrient density of existing breakfasts, while addressing concerns regarding added sugars, saturated fats, dietary fiber, and vitamin D. This initiative is unique in seeking to derive nutrient recommendations for a specific meal using the observed nutritional profile of such meal. Breakfast is widely considered to be a key component of a healthy diet. Regular breakfast consumption has been associated with improved weight control, better cognitive function and cardio-metabolic health ,2,3,4,5.The derivation of breakfast recommendations on nutrient intake and their translation into culturally tailored food based dietary advice can help policy makers, educators and industry to develop better public health nutrition strategies to optimize food choices at breakfast. For example, it could aid these stakeholders with respect to product reformulation, food fortification and in the development of nutrition-based public health policy, such as in public procurement for government funded school breakfasts.Nutrients [The International Breakfast Research Initiative (IBRI) set out to develop a new approach to define quantitative breakfast nutrient recommendations taking both observed breakfast and daily nutrient intakes into account; similar to NASEM but with a unique focus on breakfast nutrient intakes that were associated with highest overall daily diet quality . Furtherutrients ,19,20,21The present study summarizes the results of these analyses which underpins a proposal of guiding principles for the development of nutrient recommendations for breakfast. The application of these principles led to the development of two sets of nutrient recommendations for breakfast: one for children and adolescents and one for adults.i or j is the daily intake of each of the nine nutrients to encourage i  or three nutrients to limit j , iDV and jMRV are the reference daily value and maximum reference value, respectively for nutrients i and j, and Energy represents daily energy intake. Following past protocol, percent DVs for nutrients to encourage were truncated at 100, so that high intake of one nutrient could not compensate for the dietary inadequacy of another.The Nutrient Rich Foods Index (NRF)  was adapRelevant nutritional labelling standards were used as nutrients’ reference values ,30,31,32To derive nutrient recommendation applicable to the six countries, a summary of the contribution of breakfast in each country was compiled. There was no further adjustment as the objective was not to statistically compare the contribution of breakfast to nutritional intakes across countries, but to provide indicative ranges. As a result, no analytical statistics on pooled data were performed for this specific study, but results from the statistical analyses of the individual country studies were used to inform the development of the nutrient recommendations. Due to differences in the definition of age groups across countries, it was decided to divide the population into two groups for the recommendations: children and adolescents, and adults.The data used varied in the nature of the survey tool used, the period of observation and the exact age ranges in the four different age categories . NonetheA key figure used in the literature to study breakfast patterns is the contribution of breakfast to overall energy intake. The figure of 20% is often proposed ,11,13. TNotwithstanding the variation across countries in macronutrient intakes, breakfast was a carbohydrate-rich eating occasion relative to the entire day . As a reThe contribution of breakfast to daily energy and micronutrient intakes is compared in Within each dietary survey, participants were divided into tertiles of daily diet quality, as measured with the NRF. No association was observed between energy intake at breakfast and NRF tertiles in most countries. However, for most micronutrients, except sodium, and for protein and fiber, intakes at breakfast tended to be higher in the upper tertile  is proposed to set breakfast energy recommendations. While individual dietary intakes at breakfast can vary widely depending on country, age, gender, physical activity level and other factors, the present default value of 300–500 kcal is proposed for healthy, free-living subjects. This converts to 15–25% of daily energy based on a 2000 kcal diet.Principle 2.For nutrients where there is evidence that the mean daily population intake is close to the recommended intake among most countries compared to the Codex reference value , it woulPrinciple 3.For nutrients where (1) the mean population intakes are close to optimal relative to the Codex reference values, and (2) breakfast contributes significantly to daily intakes (>20%), the target is set to the average intakes range from individuals in the upper NRF tertile. Principle 3 was applied to calcium. Principle 3 was also applied to total carbohydrates, as breakfast was a carbohydrate-rich meal in all 6 countries. As a result the WHO recommendation of 55–75% of energy contribution from carbohydrates  was usedPrinciple 4.In contrast, where the mean population intakes are generally less than optimal relative to the Codex reference values and there is wide variation in breakfast contribution across countries, the target was based on 20% of the Codex value, given that across countries, breakfast provides on average, 20% of daily energy needs. Principle 4 was applied to fiber, vitamin D, vitamin C, folate, iron, potassium, magnesium and zinc. For sodium, for which intake is above recommendations in all analysed countries, the same principle applies as a maximum threshold rather than minimum requirement.Principle 5.For macronutrients to limit, the proposal is to adopt the WHO guideline values expressed as % of breakfast energy. This applies to added/free sugars and total and saturated fats, for which the proposed guidelines results in 10% of breakfast energy for sugars and saturated fat, and up to 30% for total fats.The IBRI project aimed to derive nutritional recommendations for the breakfast eating occasion based on observed nutritional profiles of breakfasts in six countries , taking into account current international dietary guidelines. The analyses of individual countries’ breakfast patterns showed a remarkable level of consistency in the regularity of breakfast consumption, its contribution to daily energy, and macronutrient profiles, with breakfast being consistently a carbohydrate-rich eating occasion. Breakfast’s contribution to daily micronutrient intakes showed significant variability among countries. Nonetheless, breakfast was consistently shown to be a nutrient-rich eating occasion relative to its contribution to daily energy, and a strong contributor to thiamin, riboflavin, folate, calcium, potassium, and magnesium intakes across all countries. Based on these observations, the IBRI proposes a set of recommendations for a balanced breakfast. First, the average energy contribution of breakfast is used as reference to set guidelines for other nutrients. Second, specific levels for individual nutrients are adapted based on the nutritional profiles of breakfast among individuals with highest overall daily diet quality and current public health sensitivity of the nutrients. The outcome of the IBRI project is two sets of nutrient recommendations for breakfast: one for children and adolescents, and one for adults and the elderly. Nutrient recommendations are expressed as a percentage of international daily reference values of Codex and WHO. These recommendations aim to ensure that breakfast maintains its current nutrient density while being improved for nutrients of public health concern in Western Europe and North America, e.g., added sugars, saturated fats, fiber and vitamin D. A starting point for the IBRI approach was the definition of an optimal daily nutrient intake. To that end, the NRF index was used to provide such a score for each subject’s total dietary intake in each database. This index was chosen because of its emphasis on micronutrients as positive drivers of the scoring system, given the observed significance of breakfast in contributing to micronutrient intake and given that quantitative food group information  was not available in all countries. A second issue was to choose an appropriate reference intake to use for expressing the breakfast guidelines. Normally, national Dietary Reference Intakes (DRIs) are used. However, given the international nature of the project and the fact that national DRIs are not always identical across countries nor are they expressed in comparable age ranges, it was decided for consistency to use reference values for nutritional labelling issued by Codex  and the The novelty of the IBRI approach lies in the consideration of the specific nutritional profiles of existing breakfast patterns. As detailed in this manuscript, the proposed IBRI nutrient recommendations are not all aligned on the relative contribution of breakfast to energy intakes, i.e., 20% on average, unlike other approaches that derive quantitative recommendations for the breakfast eating occasion ,13,36. IIn the case of a recommendation on energy intake, a single value is not feasible. Individuals may have a higher than average energy intake due to a high level of physical activity and others may need to curb energy intake to control bodyweight. Thus, the mean observed energy intakes at breakfast across age group and countries  was adjusted to a range of 15–25% of daily energy, i.e., equivalent to 300–500 kcal for a 2000-kcal diet, similar to the criteria of O’Neil and colleagues . These pFor macronutrients whose recommendation depends on energy, it is proposed to derive absolute targets based on the observed contribution of breakfast to daily energy or the energy content of breakfast, depending on availability. If such information were not available, it is suggested to consider that breakfast contributes to 20% of the daily recommended energy intake.The variability in micronutrient intakes observed among the six countries could be partly explained by differences in breakfast patterns and different fortification practices. As an example, milk is commonly fortified with vitamin D in the US , and it The derivation of nutrient recommendations for breakfast will help policy makers and educators develop better public health nutrition strategies to optimize food choices at breakfast. Nutrient targets could be used to guide public procurement of government funded institutions such as schools or hospitals, and for health professionals to better tailor their advice. For the food industry, the proposed recommendations could aid in respect of product reformulation, food fortification or consumer communication.The results of the present study have some limitations linked to the use of observed dietary patterns from six countries to derive the nutrient recommendations. First, dietary assessment tools differed across countries, as did the study samples. Since the objective was not to compare estimates across countries but rather to have an overall understanding of the nutritional contribution of breakfast, values published in the country-specific studies were used ,19,20,21In addition, the definition of breakfast differed across countries. Whereas most studies made it clear to participants what to report for breakfast or allowed participants to self-report the identity of an eating occasion , the UK survey only included time estimates from which breakfast had to be defined. International agreement of a definition of breakfast would considerably assist future research efforts to understand the contribution of this meal occasion to overall dietary intakes.Furthermore, the proposed age grouping for the nutrient recommendations may not reflect evolving nutrient requirement during childhood. The structure of the different samples varied across countries, with different definitions of age groups. This did not allow recommendations for more detailed age groups to be derived as these differences may have influenced the proposed recommendations. The choice of a single age threshold appeared more consistent with the analyzed surveys in which the threshold to define the adult population was 18 years in all countries but the UK (19 years).The main strength of the IBRI lies in the consideration of the nutritional profiles of breakfast from six countries. This allowed the IBRI to propose nutrient recommendations adapted to the current patterns of breakfast in the countries studied. While the nutrient recommendations proposed in this study should not be applied to countries and regions where breakfast patterns may be very different, the approach developed by IBRI would be replicable in other regional settings with distinct dietary patterns and where the nutritional profiles of breakfast may be very different, e.g., in Asian or African populations. In effect, while the values proposed in the present study are of value to stakeholders, the methodology used to derive these values is an equally important outcome of the present study.The variations in food intakes at breakfast outlined in the individual country studies ,19,20,21The International Breakfast Research Initiative set out to develop a methodology for the establishment of quantitative nutrient recommendations for breakfast and to do so in the context of six countries . The novelty of the IBRI approach lies in the combined consideration of the specific nutritional profiles of existing breakfast patterns and daily requirements. The proposed nutrient recommendations presented in this study, while being applicable only in countries with predominantly Western diet patterns, can be tailored to specific target population by using the relevant daily recommended intake values. In addition, the methodology developed can be adopted on a country by country basis providing that national dietary intake data are available. Developing breakfast-specific nutrient recommendations can guide the development of more meaningful public health nutrition strategies to optimize food choices at breakfast and can ultimately help consumers make healthier choices at breakfast.


Postpartum depression (PPD) is a common and disabling public health complication of the postpartum period in women. It is believed to occur three times more commonly in developing countries than in the developed world and is more prevalent among women in the first six weeks after birth. Research suggests that postpartum depression is more commonly diagnosed among adolescents and may be a risk factor for poor growth and development in children born to these mothers. Therefore, adolescents are a special age group that requires specific health care maternal interventions in order to detect and treat post-partum depression. The postpartum period is associated with an increased risk for the development of maternal depression. Maternal depression is a common and debilitating mental disorder which has become of significant public health concern, most especially in the least developed countries . These dAim of study: The aim of the study was to assess the manifestations and risk factors associated with postpartum depression among adolescents in Uganda.Objectives: The magnitude of PPD in Uganda is under documented. This explains the motivation of this paper, whose objectives are to assess the risk factors of postpartum depression among adolescents in Uganda.In this short communication study, 16 data base were used during the search for articles. The data base used were: PubMed, EBSCO, ECO, DIVA, TOXNET, LIBRIS, Web of Science, ArticleFirst, PsycINFO, Africa Bibliography, Bibliography of Africana periodical Literature, African Journal On-Line, Education Resources Information Centre, Google Scholar, GenderWatch and SwePub. The above 16 data bases were used to search for articles, journals and reports. From the literature search, 21 citations were found, using keywords such as Postpartum, depression, risk factors, adolescents, teenagers, Uganda. The paper focused on Postpartum depression (PPD) in Uganda. And for this reason, many of the literature found during the search was eliminated and only 4 articles met the interior criteria and were those 4 used to answer the specific objectives.UDHS, 2016 reports a 1 percent increase in teenage pregnancy from 24 to 25 percent in 2016 meaning that every 3 in 10 adolescents have begun child bearing . The risThe increase in teenage pregnancies has been partly attributed to the low level of education with at least three in every 10 of them having no education. 78% of adolescents are currently attending formal education and 22% are school drop outs before secondary level . UnintenIn addition, mothers may manifest with depressed mood, loss of energy, self-guilt, suicidal ideas. These adolescents sometimes have less concentration, are restless and agitated, irritable, anxious, unworthiness feelings, have disturbed sleep, and tearfulness . In caseThis desire may be attributed to societal pressure. Studies in other countries like India show that the preference for male children is deeply rooted in Indian society. Thus, women who already have a female child face greater stress because of their wish that their new infant be a boy. In the event that the child is a girl, the risk of depression is greater . RecentlPostpartum depression affects women in both developed and undeveloped countries and the adolescent mothers are more at risk of suffering from it. The risk factors are similar except that the underdeveloped countries in particular sub-Saharan African countries like Uganda experience a greater burden of the risk factors such as the age of the mothers, HIV/AIDS, low social economic status, and culture. Normally, the birth of a newborn baby is considered a joyful event and so mothers maybe embarrassed to express their depressive feelings and this too can be a barrier to early detection and treatment of postpartum depression.Recommendations: Government of Uganda needs to consider postpartum depression as a public health problem that is neglected among adolescent mothers. Most mothers are reluctant to express their feelings and during the postnatal clinic visits, the health care givers put much focus on the baby for immunization services and no attention is paid to the mother at all. This leaves postpartum depression to go undetected. Early screening, treatment of postpartum depression and provision of psychosocial support should be part of routine perinatal care and should be considered as an integral component of maternal postpartum care in Uganda.Postpartum depression is more prevalent among adolescents;Adolescents are likely to be more affected with the PPD in terms of prevalence and frequency as compared to the adults;Patients suffering from postpartum depression have similar clinical manifestations but the associated risk factors differ between the developed and developing countries.Findings will provide a basis for health workers screening and treating PPD, this in turn will improve maternal infant bond and also promote good health of the mother and child;The findings from the study will highlight the manifestations and risk factors associated with PPD that nurses could base on to develop strategies to address it; this will contribute towards prevention of PPD;The findings will stimulate more research to be done in Uganda and possibly be a basis for informed policy formulation.The author declare no competing interests.


The notion of ‘fact-free politics’ is debated in Europe and the United States of America and has particular relevance for the use of evidence to underpin health and healthcare policies. To better understand how evidence on health and healthcare is used in the national policy-making process in the Netherlands, we explore how different statistics are used in various policy debates on health and healthcare in the Dutch government and parliament.We chose eight ongoing policy debates as case studies representing the subject categories of morbidity, lifestyle, healthcare expenditure and healthcare outcomes, including (1) breast cancer screening rates, prevalence and incidence, (2) dementia prevalence and incidence, (3) prevalence of alcohol use by pregnant women, (4) mobility and school sports participation in children, (5) costs of smoking, (6) Dutch national healthcare expenditure, (7) hospital mortality rates, and (8) bedsore prevalence. Using selected keywords for each policy debate case, we performed a document search to identify documentation of the debates (2014–2016) on the websites of the Dutch government and parliament. We retrieved 163 documents and examined the policy debate cases through a content analyses approach.Sources of the statistics used in policy debates were primarily government funded. We identified two distinct functions, i.e. rhetorical and managerial use of statistics. The function of the debate is rhetorical when the specific statistic is used for agenda-setting or to convince the reader of the importance of a topic. The function of the debate is managerial when statistics determine planning, monitoring or evaluation of policy. When evaluating a specific policy, applied statistics were mostly the result of routine or standardised data collection. When policy-makers use statistics for a managerial function, the policy debate mirrors terms derived from scientific debates.While statistics used for rhetorical functions do not seem to invite critical reflection, when the function of the debate is managerial, i.e. to plan, monitor or evaluate healthcare, their construction does receive attention. Considering the current role of statistics in rhetorical and managerial debates, there is a need to be cautious of too much leniency towards the technocratic process in exchange for the democratic debate.The online version of this article (10.1186/s12961-019-0461-y) contains supplementary material, which is available to authorized users. There is an ongoing debate about the dividing line between facts and opinions, and the role of scientific knowledge in policy-making . Terms sAlthough the use of evidence in policy-making remains controversial, recent developments in the political landscape in Europe and the United States of America have fuelled a growing concern among scientists and others who advocate the use of evidence in policy ; this isIn the Netherlands, healthcare policy aims to support the delivery of high quality, accessible and affordable healthcare services to improve the health of the Dutch population . As in cStatistics (quantitative information) on health and healthcare constitute an important base of evidence for health policy –21. The Espeland et al.  describeConsequently, to understand how statistics on health and healthcare are used in the national policy-making process in the Netherlands, insight is needed into how the purpose for which statistics are used are connected with the function of the debate, and with the sources and construction of statistics in policy debates on health and healthcare –26. SuchBased on analysis of the literature and our knowledge of ongoing policy debates in health and healthcare in the Netherlands, we focused on four categories of statistics, namely 1) morbidity statistics, (2) lifestyle statistics, (3) healthcare expenditure data, and (4) statistics on healthcare outcomes. For each category, the use of statistics was analysed in two policy debates on different topics  . The aimEight cases were chosen to represent the categories of morbidity, lifestyle, healthcare expenditure and healthcare outcomes Table .Breast cancer screening rates, prevalence and incidence were selected since these statistics are derived from routine data collection through a national cancer registry. Dementia prevalence and incidence was selected because this figure is not measured through standardised data collection but constructed through modelling.Prevalence of alcohol use among pregnant women was included since the statistic is derived from a single published study. Mobility rates and school sports participation in children were chosen as these statistics can be derived from multiple sources.Dutch national healthcare expenditure was selected because of its standardised data collection method. Costs of smoking was included because it is constructed through modelling.Hospital mortality rates were selected because of their clear registration and the obligation (since 1 March 2013) for Dutch hospitals to publish mortality data. Bedsore prevalence was included because of the difficulty to establish this using standardised measurement.www.rijksoverheid.nl), which contains published documents from the 11 Dutch ministries .” Another example is the debate on prevalence of breast cancer. In the following quote from a report on the reimbursement of cancer treatment, the size of the problem of breast cancer in society was illustrated through a rounded statistic. Only after this rhetorical introduction, the specifics of the reimbursement of the treatment were explained. No references were provided for the incidence rate of 14,000.Breast cancer: “Every year, 14,000 women and 100 men are diagnosed with invasive breast cancer in the Netherlands. More and more women are using the possibility of a breast reconstruction after a breast removal operation to treat breast cancer.” In addition, if the statistic is used primarily to persuade, the statistic is used rhetorically. In the debates on breast cancer, healthcare expenditure, mobility in children, bedsores and alcohol use among pregnant women, the statistics were used to evaluate policy direction.For example, in the debate on dementia, the prevalence figure was used to emphasise the problem of dementia in society.Mobility in children: “Too many young people exercise too little. Less than half of the Dutch youngsters does not adhere to the norm that was chosen as a baseline for policy to stay healthy and fit.” Alcohol use in pregnant women: “How do you explain that pregnant women who drink alcohol have started drinking more?” The minister addressed this rhetorical question with an exact, managerial, answer:With this correspondence, I am informing you of the manner in which the evaluation of the alcohol Licensing and Catering act will be executed. [ … ]. In 2007, 2010 and 2015 the TNO [Netherlands Organisation for Applied Scientific Research] carried out national polls in which, amongst others, it was asked how many women used alcohol during pregnancy and breastfeeding [ … ]. The new statistics show a decrease in the percentage of women drinking alcohol in the first three months of pregnancy as compared to 2010 and 2007 among all education levels: from 16.5 percent in 2007, 13.8 percent in 2010, to 6.9 percent in 2015. [ … ] this makes me feel optimistic.” .“Two examples of this:Statistics are used for a managerial function when the figure itself is instrumental in the decision. For instance, in the debate on mobility in children, the percentage of children that received the recommended amount of physical education was used to argue for a specific policy, i.e. a mandatory number of hours of physical education in schools. The statistic itself is what determines the decision, as the percentage of children that received physical education was considered to be too low by the opposition.When used managerially, statistics are most likely to be exact; however, there are some exceptions to this rule. In the debate on dementia, a rounded statistic was used managerially when it was instrumental in determining the amount invested in Deltaplan Dementia. In the debate on mobility in children, both rounded and exact statistics were used interchangeably.Bedsores: “For those healthcare providers who for, at most, three percent of the total number of insured to whom care is given suffer from bedsores, malnutrition, or dehydration, receive from our minister a modest bonus for the purpose of the workplace.” Outside government policy, the hospital mortality statistic is used for ‘internal quality improvement in hospitals’. The government stimulates improving the transparency and credibility of the statistics. In the studied texts, the managerial use of hospital mortality statistics to drive policy action was discussed. In an intended managerial use of a mortality figure, a higher risk of mortality in the weekend was used to request the government to act. Nevertheless, the debate does not prompt action, but focuses on the credibility of the figure. This discussion is illustrated in the following section.Some statistics are intended to be used managerially by the policy-maker such as the bedsores statistics and hospital mortality rate. However, in the studied documents, the application of these statistics for practical decisions was rejected. In an exchange between government and parliament, a member of parliament proposed to introduce a financial reward for those who keep the bedsore rates below a certain benchmark; however, the statistics were not considered sufficiently reliable by the minister to implement this idea (see quote).The need for scientific research is repeatedly mentioned in the different debates. Policy-makers discussed the reliability and credibility of statistics, especially when the statistic was used managerially. In the studied debates, when used rhetorically, the construction of the statistics was not questioned.In the debate on hospital mortality and bedsores, policy-makers did not consider the statistics to be solid enough for decision-making. Here, they adopted arguments used by the scientific community . The discussion on the statistic itself was illustrated by a question posed in parliament on higher hospital mortality during the weekends. The statistic was used to identify a possible healthcare problem, namely that of higher mortality in hospitals during the weekend, implying that care during the weekend might be substandard. The Minister of Health addressed the issue by providing an explanation on how the statistic was constructed, using argumentation provided by the scientific community on case-mix adjustment (adjusting to a differing mix of patients with regard to illness severity) to explain that statistic. Consequently, the discussion focused on the uncertainty of what the statistic indicates, rather than how to address possible problems related to the quality of hospital care during the weekends.Hospital mortality: “Do you share the opinion that a 20% higher mortality risk in the weekends is so shocking that something needs to be done about this immediately? If yes, what do you propose?” Parliament member.From the [Monitor adverse events in Dutch hospitals 2011/2012], that EMGO/NIVEL carried out on my request [ … ]. “A possible explanation for this – against the background of the risk of healthcare-related damage found – is that the so-called ‘case mix’ of patients admitted on the weekend means that these patients are, on average, sicker.” In the debate on dementia, the prevalence figure was used managerially as a basis for the evaluation of Deltaplan Dementia. In the quote below, two statistics are compared to clarify the use of the figure. Nevertheless, as opposed to other statistics that are used managerially, this statistic is neither exact nor the result of routine data collection, but is constructed through modelling, representing an exception to our observations regarding the use of exact statistics related to the managerial use of statistics.Dementia: “The estimation of 230,000 to 250,000 people with dementia in the Netherlands, on which the analysis of the Deltaplan Dementia is also based, is somewhat similar to international studies providing statistics for Western Europe. The RIVM bases the statistic of 80,000 on a sample from the GP registration database. The RIVM, however, mentioned that this does not provide a complete overview because it concerns a sample and also because GPs lack a complete registration of people with dementia.” The quote below illustrates how a parliament member asked a question about higher hospital mortality on the weekend. The answer by the Minister refers to published research, explaining that a ‘case mix’ causes this statistic to be higher. Thus, the Minister used the uncertainty of the methodology as an argument not to address the issue at hand.In the debates on breast cancer, healthcare expenditure, mobility in children and bedsores, statistics were used to managerially evaluate the effectiveness of the policies set by the government. We consider the use of statistics as a ‘managerial evaluation’ when the research was conducted with the explicit aim to evaluate a specific policy. These evaluations are intended to inform the managerial use of statistics.Breast cancer: “The conclusion is that the population screening yields considerable health benefits and the Health Council recommends continuing and further improving population screening. [ … ] A total of 6,975 cases of breast cancer have been detected and the detection rate has increased to 6.9 per 1000 women tested.” For example, statistics on breast cancer incidence and prevalence are used to evaluate established programmes and treatment of breast cancer. As such, the use of the screening programme was evaluated and confirmed to be effective.The type of data collection and evaluation of specific policy appears to be connected. All statistics used for managerial evaluation of policy were constructed through routine or standardised data collection. Statistics on national healthcare expenditure, mobility in children and breast cancer were either constructed through standardised or routine data collection.The statistics on dementia, costs of smoking and alcohol use among pregnant women were not used for specific policy evaluation. It seems that no defined method of constructing statistics on the costs of smoking was determined, and no effort was made on a policy level to strengthen these statistics. In the debate on alcohol use among women, measurements were conducted through questionnaires and, since 2007, have been repeated twice. The methodology behind these statistics is not questioned when used; however, they are not used for the evaluation of a specific policy.In the studied debates, the discussion on the methodology behind bedsores and hospital mortality statistics was taken up in the policy debates with a managerial function. Nevertheless, the policy-makers using these statistics did not consider them to be adequate to be used for implementation and evaluation.We explored how different types of statistics are used in a variety of ongoing policy debates on health and healthcare. Statistics used were mostly derived from research directly commissioned by the government, or produced by government organisations. The main sources of the statistics were reports, websites and  scientific studies. We distinguished two distinct functions of policy debate – rhetorical and managerial use of statistics. If the debate’s function is rhetorical, statistics were used as an argumentation tool to show the success of (or need for) a certain policy, to recruit support and to place/maintain issues on the policy agenda. The debate’s function is managerial when statistics were used to determine how specific policy measures are planned, monitored or evaluated. Statistics that are used managerially are primarily exact, expressed in tables or visualised, while rounded statistics are primarily used for rhetorical functions. When evaluating specific policy, statistics are exclusively the result of routine or standardised data collection. Furthermore, when statistics are used (or intended) for a managerial function, the debate within policy mirrors the debate on the construction of these statistics in the scientific community.n = 72), while other cases included fewer documents, e.g. alcohol use by pregnant women (n = 7) and costs of smoking (n = 5). The larger number of documents within the healthcare expenditure case allowed for a broader comparison of managerial and rhetorical use of these statistics within the same context. Nevertheless, the insights gained were not dominated by one single case , as valuable insights of the use of statistics were retrieved throughout all cases by observing the use of statistics in different contexts. A wider selection of cases would have resulted in a more comprehensive insight into how statistics are used across different topics. Simultaneously, an analysis of each single policy debate case and even every single text would provide a deeper understanding of how these statistics are used in their respective contexts.We explored the use of statistics in the Dutch debate on health and healthcare based on eight case studies. The debate on health and healthcare consists of numerous types of statistics and topics. A large part of the included documents was connected to one case, i.e. healthcare expenditure  rather than to achieve a change in regulation .Our results represent only those cases that were studied and cannot be generalised to all debates on healthcare involving the use of statistics in the Dutch government and parliament. Nevertheless, our results provide insight into how statistics are used in these debates and what might be expected in others.Most of the sources included in the policy debate were related to the government, as also found by an earlier study on ex ante policy studies in the Netherlands . This coIn the studied documents, policy-makers used arguments in which the scientific terms ‘case mix’ and ‘significance’ were mentioned, mirroring the language used in scientific debates. By using scientific language, the policy-makers and scientific institutions may gain more authority over the policy process. However, scientific language may also be a means to shift attention from societal problems to scientific/methodological problems. Then, methodological arguments could be used to discredit the evidence if it does not align with a certain political agenda. Conversely, if a statistic is trusted to be valid and accurate , the actIn the debates, only a few scientific publications were used as a source. The statistics used were published in reports or derived from websites. It seems that the usability of statistics for the evaluation of policy increases when data are collected routinely or through standardised methods. To embed statistics in the managerial policy debate, it appears worthwhile to invest in routine or standardised measurements. The results of this study support Cairney and Oliver , who proFurther research on evidence-based policy could focus on the use of statistics in policy debate in other countries. It would be interesting to establish whether the connection between the managerial use of statistics, scientific discussion and the routine data collection of statistics is similar to those in the debates we studied in the Netherlands. Moreover, the relation between the current debates and change in debates over different time periods might provide useful insight into the managerial and rhetorical use of statistics over time. Additionally, to improve understanding of the role of managerial and rhetorical use of statistics in the decision-making process, future research could address how these functions are applied to guide choices between particular policy interventions.It has been argued that policy-makers lack the knowledge and time to critically evaluate the statistics they apply , 39. StaMoreover, the number of government-related sources used indicates that the statistics applied in the policy are mainly government driven. While this co-production of evidence is considered a strong feature of Dutch policy-making and could support effective implementation of evidence in policy , governmOur results indicate a rational process of integration of statistics as evidence in the policy process when used for decision-making. Whereas the statistics used for rhetorical functions do not seem to invite critical reflection, when the goal of the debate is managerial, i.e. to plan, monitor or evaluate healthcare, the construction of the statistics receives consideration by parliament. Considering the current role of statistics as a rhetorical and managerial argumentation tool, there is a need to be cautious of too much reliance on statistics for all policy decisions in exchange for a balanced democratic debate in evidence-based policy-making.Additional file 1:Documents included in the analyses. (DOCX 22 kb)