To provide appropriate and sensitive care for lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) youth, providers must learn specific skills and guidelines. Most medical schools lack formal education on LGBTQ health, particularly for adolescent patients.We developed an Introduction to LGBTQ Health course for fourth-year medical students as part of a monthlong Ready for Residency curriculum in March and April of their graduating year. The course addressed guidelines recommended in the care of LGBTQ individuals utilizing problem-based learning methodology. Through learner-led discussion, students worked in small groups to research case-based scenarios and reported their findings to the larger group, followed by teaching points from a facilitator. The course was evaluated on curricular perception using a 5-point Likert scale and open-ended feedback.One hundred forty-six students participated in the curriculum; 103 completed the session evaluation. Mean total scores were 4.6 out of 5 in March and 4.7 out of 5 in April after changes were made based on student feedback, namely, increasing the session from 50 to 80 minutes and decreasing session size from 72 students to 36. Students felt the session was well planned and run, engaging, and relevant; appropriately integrated evidence-based medicine; and taught them what they hoped to learn.Many medical schools lack curricula dedicated to LGBTQ health care. Implementing this mandatory LGBTQ health course was well received and highly rated by almost all students regardless of anticipated specialty. The session could be easily replicated at medical schools across the country. The Association of American Medical Colleges (AAMC) has provided recommendations for implementing curricular changes to improve health care for LGBTQ individuals, but few specific topic guidelines or curricula have been published.4 The few educational materials that have been published are often focused solely on history taking for sexual and gender minority patients8 or eliminating implicit biases.9 To the best of our knowledge, there have been no published curricula that provide an overview of best practices in the clinical care of LGBTQ individuals mandatory for all students. We aimed to develop an Introduction to LGBTQ Health course dedicated to preparing fourth-year medical students to care for this unique population, with the goal of ultimately improving resident provider skills, knowledge, and awareness about the health and social issues that impact LGBTQ adolescents. We aimed to create a course that uniquely prepared students for the clinical care of LGBTQ individuals in addition to providing them the tools to continue self-directed learning on a topic that is constantly evolving.Despite the unique and specific health care needs of LGBTQ patients, the majority of medical schools and residency programs lack formal education on LGBTQ health. In a study of 176 U.S. and Canadian medical schools, a median of only 5 hours was spent on LGBTQ-specific content, and one-third of schools reported no time spent at all.10 A systematic analysis of PBL in UME showed moderate to strong evidence for physician competencies after graduation in social and cognitive domains, particularly communication skills, appreciation of legal and ethical aspects of health care, and self-directed continuing learning.11 We felt that PBL would be the most appropriate method to fulfill our aims of improving provider comfort, addressing barriers to care and psychosocial concerns, and providing students a framework for using evidence in real time to address questions about clinical cases.In order to reach all students regardless of future specialty, we developed this course as part of a larger mandatory residency-preparation curriculum for fourth-year medical students entitled Ready for Residency. For the conceptual framework, we decided on a case-based approach using problem-based learning (PBL) methodology to make the sessions interactive, encourage involvement of all students, and develop skills for self-directed, lifelong learning.12 We performed a general needs assessment based on literature review and a targeted needs assessment via survey of medical students to identify specific gaps in the UME curriculum on LGBTQ health. This survey highlighted many topics in which students felt they lacked significant knowledge, including gender dysphoria, puberty blockade, hormonal and surgical transitioning, mental health concerns, sexually transmitted infection (STI) testing and treatment guidelines, and general community resources. Based on these results, we defined our goals and objectives. Our primary objective was to develop a session that involved an evidence-based, interactive, and engaging method of teaching future physicians the current best practices in the care of LGBTQ individuals. We researched various educational strategies to best disseminate this information, and we piloted the session for content clarity and relevance. The session was initially piloted with the pediatric residency program (76 residents) in small groups of four to eight residents during their continuity clinic. This was an interactive case-based session but did not use formal PBL techniques. Based on resident feedback, we tailored the content of the course to ensure the material would be relevant for fourth-year medical students and restructured the session to utilize formal PBL methodology. We continued to revise and refine the course based on quantitative and qualitative evaluations.We designed the Introduction to LGBTQ Health course utilizing Kern's six-step approach to curriculum development for medical education.13 While some sessions were optional or specialty specific, we determined that the Introduction to LGBTQ Health course would be one of the mandatory sessions for all students.Based on the global interest from students and the clear gap in the literature and at our institution, we made this a mandatory course for all students. We decided to focus on the fourth-year medical students, who already had some baseline medical knowledge and could apply what they knew to focus on a specific patient population. At the end of their final year of medical school, our fourth-year students already had to complete the mandatory Ready for Residency curriculum, which was an ideal place to include the Introduction to LGBTQ Health course. Ready for Residency was a monthlong curriculum consisting of educational sessions devoted to specific topics deemed relevant in the preparation for residency, regardless of future specialty. The curriculum utilized a flipped, blended learning model including both mandatory and optional classroom sessions, online modules, simulations, skills workshops, and other novel learning techniques.All fourth-year medical students were assigned to participate in the Ready for Residency curriculum in either March or April before the end of the academic year to prepare them for residency beginning in July. The Introduction to LGBTQ Health course was one of 53 sessions within the Ready for Residency curriculum. Approximately half of these courses were optional, allowing students to choose one of two or three sessions that occurred at the same time. The curriculum was held 5 days a week for 1 month, and sessions ranged from 50 to 120 minutes. Out of the 146 students in the graduating class, 74 students were assigned to the March session, and 72 students were assigned to the April session. The Introduction to LGBTQ Health course was initially planned as a 50-minute session for all students. Based on feedback from the March group, changes were made prior to the April session, including increasing the time allotted from 50 to 80 minutes and dividing the session into two separate groups of 36 students each.Per PBL methodology, groups of students were provided dedicated time to work independently and then reported their findings to the larger group. Students were divided into groups of five or six, and each group was assigned one patient case with associated questions . For theThe facilitators were residents or faculty members with particular interest or expertise in the topic. They were brought in specifically to lead this session and did not need to have a prior relationship with the students, nor did they evaluate the students. This enabled the session to be a safe space for open discussion. The facilitator's role was to help engage the group, encouraging active participation from all learners, and to offer additional expertise and practical experiences. Learners did not require any prior fund of knowledge or preparation prior to the course. They were allowed to use electronics or any resources available to research the questions they were assigned prior to reporting back to the larger group. The specific case topics and learning objectives can be found in Feedback was elicited from all participating students after the session. The feedback form  was the Out of the 146 students who participated in the course, 103 completed formal evaluations. The total mean score was 4.6 out of 5 for the March session and 4.7 out of 5 for the April session. As depicted in When asked for open-ended comments, student responses included many recurring themes: (1) session format, (2) relevance/importance of material, (3) specific topics learned, (4) organization of session, (5) inclusion of evidence-based medicine, (6) improved comfort, and (7) other gratitude/positive feedback . Out of Students who evaluated the session were also asked to provide any suggestions for changes to the curriculum in the future. The majority of the recommendations were for smaller groups, increased time for the session, providing handouts or extra resources, and including this material in the preclinical curriculum. Many of these changes were made following the March session, making the April session longer (80 minutes instead of 50), and smaller (two groups of 36 instead of one larger group). We also added further resources for students to use and made the material publicly available for students to refer back to later in their career.3 Implementing a residency-preparation course devoted to educating students on barriers to care, medical risks and psychosocial concerns, state laws regarding confidentiality, terminology and definitions regarding gender identity and gender dysphoria, and the common steps in gender transition was well received and highly rated by almost all students regardless of their anticipated specialty. These topics were specifically chosen based on the AAMC's recommendations4 as well as a needs assessment at our institution.There are many unique and specific health care needs of LGBTQ patients, yet the majority of medical schools lack a dedicated LGBTQ curriculum.16 Additionally, studies have shown that PBL methodology can improve multiple physician competencies after graduation in social and cognitive domains,11 which we believe supports the efficacy of our curriculum and will lead to improved clinical competence for our students in residency and beyond. While many students have familiarity with this method of teaching, it is often utilized in the context of material that has been well studied and has straightforward guidelines. We believe that using PBL to teach a topic that is constantly evolving will provide students with the framework to continue learning and adapting to new guidelines on LGBTQ health care, including changing terminology and practice recommendations. This course required no background knowledge or advance preparation by students or facilitators, making it easy to replicate at any other medical institution or educational setting.Particular highlights of the session included the case-based and PBL format, the breadth of topics, the importance of the material, and the inclusion of evidence-based medicine. This course was particularly innovative in that it taught material frequently lacking in UME curricula through patient cases and PBL methodology, making the material feel more relevant and applicable to patient care. It was also unique in that it was mandatory to all students and was part of a residency-preparation course. Students felt that the PBL format was particularly engaging, and a majority of them commented on this as a highlight of the session, which is consistent with the literature on PBL showing that both students and educators prefer this method to conventional teaching.17 In the future, the course would benefit from evaluating learning via long-term content-based posttests and overall impact on patient care. Because the session was incorporated into the larger Ready for Residency curriculum with the goal of purely educating in preparation for residency without the stress of evaluation, we were unable to perform knowledge or skills-based assessments. Although we do not have these data for this group of students, we did perform pre- and posttests with the resident pilot group. The session significantly improved residents' perceived knowledge and comfort in caring for LGBTQ individuals in addition to increasing objective knowledge scores based on pre- and postcurriculum multiple-choice assessments. We can extrapolate that fourth-year medical students would similarly increase their knowledge and comfort, and we intend to formally study this in the future.One limitation of the course is that it was restricted to fourth-year medical students who had no prior exposure in their preclinical courses, so they may have already developed many clinical skills and practices without considering how these might be different in the context of LGBTQ patients. Ideally, this course will be expanded and integrated within the existing UME curriculum across all 4 years, making the material better engrained in students' clinical acumen. An additional limitation is our method of evaluation. The feedback tool adapted from the Academic Pediatric Association includes vague questions and does not have descriptors for each response in the Likert scale. The feedback form could be made better by utilizing a more precise and detailed scale and by improving the question stems. For example, the first question is confounded by asking about two separate aspects of the session: “Was the session well planned and run?” This could be improved by asking two distinct questions regarding the session's plan or organization and how well the session has been led. Particularly since this is a residency-preparation session, the scaled and open-ended questions should more specifically focus on whether the session is relevant and makes students feel prepared for internship and clinical practice. Additionally, the assessment tool elicits feedback that is subjective and mostly based on teaching strategy as opposed to improved knowledge, skills, or attitudes. Students rated the session based on how well planned and run, engaging, and relevant it was; how appropriately it integrated evidence-based medicine; and how much it taught them what they hoped to learn; thus, we evaluated only the first level of the Kirkpatrick's pyramid: reactions/perceptions.Performing this session multiple times with different groups of students allowed us to learn many lessons and adapt the course accordingly. We were initially limited by time constraints and sizes of the groups per session. Many students suggested the course could be improved by increasing the time allotted and conducting the sessions in smaller, more intimate group settings to increase discussion. The March course was a 50-minute session with 72 students. Based on this feedback, we split the April course into two separate sessions of 36 students each, allowing for smaller groups to promote more active discussion. With smaller groups, more students ended up speaking out loud and engaging with the material. We also extended the session to 80 minutes, which provided extra time for individual research in the beginning of the session as well as time for the facilitator to answer questions at the end of the session. As seen in the evaluations, these small changes had a significant impact on the average quantitative scores for the course.Overall, this curriculum was highly rated by students anticipating careers in all specialties. Students were highly engaged, felt they learned a significant amount, and were grateful for the incorporation of this topic in their curriculum. Future aims include evaluating clinical impact in the care of LGBTQ patients and expanding the curriculum to the preclinical years. This course should be a staple across UME given the unique needs and risks of LGBTQ patients and could be easily adapted to any medical school curriculum across the country.Cases and Questions.docxReady for Residency LGBTQ Health PowerPoint.pptxFacilitator Guide.docxCase Topics and Objectives.docxFeedback Form.docxAll appendices are peer reviewed as integral parts of the Original Publication.


When a new infectious disease emerges as an epidemic or pandemic, strict and appropriate mitigation strategies are critical. Appropriate steps that facilitate defining of cases, carrying out accurate clinical diagnoses, and forming a powerful health surveillance that addresses public health policies and procedures are necessary. Tracking the number of COVID-19 cases over time and flattening the curve is another important element to establish research settings and identify therapeutic components to expedite and develop effective interventions. Addressing the various sections of the society in a philanthropic way is crucial to acquiring the public cooperation that is essential to controlling a disease like COVID-19. In this study, we discuss various strategies and measures adopted by Kerala, an Indian state, to combat the COVID-19 outbreak. Regular and timely updates by government public relations and health departments were used in many of the adopted strategies. The engagement of health information systems, together with the application of decentralized governance and community engagement, has contributed to effective population health management and surveillance of the pandemic. Asymptomatic transmission of SARS-CoV-2 is another barrier for effective COVID-19 pandemic control because traditional public health strategies rely primarily on symptom-based disease detection to contain the spread.2 Currently, no therapeutic options or vaccines are available for the disease and hence prophylactic measures aimed at reducing community spread are critical. Health organizations have been working tirelessly hand in hand with governments to coordinate information flows and issue directives and guidelines to best mitigate the impact of the threat.A pandemic that has affected all sections, nationalities, and genders is ruling society with its fierce claws reaching out to the well-being of the entire world. The novel coronavirus named Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) has claimed 1,088,515 precious lives across the world, including 110,588 in India and 742 in Kerala. The ongoing, explosive spread of SARS-CoV-2 throughout the world represents a critical challenge for all countries. COVID-19 primarily spreads through the respiratory tract, by droplets, respiratory secretions, and direct contact3 That outbreak, characterized by the key epidemiological feature of person-to-person transmission with a high mortality rate, was successfully contained by case isolation, early initiation of barrier nursing, infection control practices, contact surveillance, and home quarantine.4The first case of COVID-19 in India was an imported case from Wuhan that was reported January 30, 2020, from Kerala, a small southern state popularly known as “God’s own country.” Kerala has been effective in its strategic preparedness and response plan to fight COVID-19. This is not quite unexpected because the state had previously faced a crucial test of its substantial public health care system while combating the Nipah virus outbreak in 2018.Kerala’s success story can be attributed primarily to 3 factors: the excellent public health care system in the state, functioning grassroot bodies, and the high level of literacy in the population. Here we discuss the strategies adopted by Kerala Government, now widely acclaimed as the Kerala Model, for mitigating the pandemic spread and executing the comprehensive preparedness at various levels of the administration for the outbreak.Ever since COVID-19 created an unprecedented social crisis touching all walks of life in Kerala, the governance mechanism could promptly discern that in a densely populated state, the casualty would be great. The Health Minister of the State immediately requested that citizens who had symptoms report or go into home quarantine. The management strategies planned and adopted by the administration conformed closely to the Global Humanitarian Response Plan launched by the United Nations on March 23, 2020, which for the global community to come to the aid of the ultra-vulnerable – people who are least able to protect themselves – which is essential for combating the viral infection.Here, we summarize the existing preparedness and response strategies in Kerala to make decisions to establish a state-wide taskforce and response plan to prevent the spread of the pandemic.Proper handwashing protocols as stipulated by the World Health Organization were publicized at the onset of the pandemic through various social media and audiovisual platforms. Medical experts and police department were asked to share the awareness campaign.Isolation wards were set up in hospitals, and people with doubtful health situations and contacts were kept under home quarantine. Kerala started stabilizing its health situation by implementing practices of social distancing and personal hygiene. Medical and paramedical students who had just passed their courses were appointed and trained properly to increase health care manpower as part of boosting up the machinery to meet the impending crisis. Some hospitals that had been nonfunctioning were sanitized and made ready to function.https://breakcorona.in/). Campaigns were made to familiarize the population with the new health care learnings and, for the same purpose, on March 15, the Government of Kerala introduced a new initiative (“Break the Chain”). The campaign aims to educate people about the importance of public and personal hygiene. Under this campaign, the government has installed water taps with handwash bottles at public locations, such as at the entry and exit gates of railway stations. Faculty from educational institutions ventured out to train the public and students on mass making of masks and sanitizers. All institutions and spaces such as educational institutions, cultural spaces, cinema halls, swimming pools, gymnasiums, etc., where there is a great possibility for people to come into contact, were closed. Work-from-home policies were implemented to the greatest extent possible. Mass gatherings such as marriages, festivals, religious congregations, etc., were prohibited. Strict restrictions were imposed on domestic and international travel.The government initiated a mission calling for innovative ideas and solutions from students, innovators, and startups to defend against the pandemic (see 5 and open-source public utilities came into the picture to express solidarity with the fight against the pandemic (see https://coronasafe.network/).Civil society organizations, along with Accredited Social Health Activists , made sure that people who were infected continued to self-isolate to prevent community spread. The Kudumbashree , a women’s cooperative/community wing of local government, was used to address the acute shortage of hand sanitizers and face masks that occurred in many regions, and prisoners were also tasked with mask production. Citizen science initiativesBy March 23, 2020, as the count of COVID-19-positive cases in the state shot up to 91, the chief minister of the state declared a health emergency and a complete lockdown. This was indeed a bold step in the endeavor to control the situation at a very early stage. The lockdown policy implemented by Kerala was later adopted by India as a whole.The police personnel were used to enforce lockdown instructions and drones were used to monitor mass gatherings. The intention of the state government was to test the maximum number of people by rapid test and to isolate and treat them so that conditions remained under control. For this, the government had to take care of the well-being of the entire population, irrespective of who and what they were. The government had to take into consideration the multitude of social problems that existed, such as inequality, unemployment, preexisting health issues, disability, gender issues, violence, poverty, a significant proportion of migrant laborers, etc. The various mitigation measures adopted to establish the lockdown mode and the various steps taken to make it more conducive are listed in Kerala’s success story should be credited primarily to effective dissemination of health-related information, guidelines, and awareness using both traditional and new media. Public awareness was continuously created through trolls and memes, often produced and shared by various official platforms of the state government. Various social media platforms were wisely used to convey the message with a wider reach. Preparing route maps for contact tracing of infected people was another concern, and publicizing these maps over social media proved to be highly successful. The media also started recording and sharing the experiences of people who were in isolation and quarantine and then recovered from the infection.A 24-hour helpline, Disha, that was set up by the Directorate of Health Services was effectively used in the management of COVID-19, providing a platform for the public to interact with and ask questions of health care experts. This was very helpful in creating awareness and removing fear and stigma among the public.The Health Department of the state also launched a WhatsApp Chatbot to check the spread of fake news through social media. Telemedicine facilities were also initiated by the government.GoK was launched by the Government of Kerala to provide verified and authentic information from authorities directly to the general public. The information was periodically updated and made available in different languages, which made it very popular among the multilingual population.A mobile application Considering the extremely high mobile and internet penetration of the state, the creative and efficient use of digital campaigns to communicate updates about the disease to the public needs special mention. In addition, the chief minister’s regular press briefings touched on a range of issues affecting the daily lives of people during the lockdown. The approach was so compassionate that even starvation of animals was taken into consideration, when he called upon the public to feed the stray dogs and monkeys that were living on temple premises.Various cultural organizations and artists started online performances to entertain people during lockdown, helping to alleviate boredom and motivating them to engage themselves in creative ventures.Migrant laborers, known as “guest workers,” form the major sector of the workforce that lost work and were uncertain whether to return to their respective homelands. Soon after Kerala announced the lockdown, however, the country as a whole went on a complete lockdown that prevented migrant laborers from traveling because rail and air transport were stopped. The government immediately took welfare measures to provide them with food and, in some cases, accommodation.In the case of non-resident Keralites who live in the West and the Middle East, the situation grew alarming day by day. But the state government provided timely help to thousands of Keralites who wanted to come back to their homeland, and Norka-Roots, the official body of diaspora, provided online registration for people who wanted to return to Kerala. The state government made arrangements to test and quarantine nonresidents as they arrived at any of the 4 international airports in the state.Women were disproportionately affected by COVID-19 because they faced several issues as soon as lockdown was implemented. These issues included domestic violence, issues related to an alcoholic spouse or head of the household, psychological issues related to fear regarding the health of themselves and family members, difficulty in facing unrest of family members who were forced to stay at home, etc. The government adopted several measures to address these issues. A 24-hour helpline number was provided to help needy women. A counseling team facilitated by district authorities catered to the various psychological needs of women in distress.An important factor to note is the role of women in the caregiving machinery established during COVID-19. The health care system – comprising administrators, decision-makers, cleaning staff, technicians, and others – is mostly female. The same is true of personnel such as Anganwadi  teachers and Accredited Social Health Activists workers, not to mention the Kudumbashree members who played pivotal roles in the community kitchens where food was prepared and delivered to needy individuals and those under home quarantine.6 The recovery of an elderly couple, aged 93 and 88, has brought a ray of hope to other COVID-19 patients. Some experts commented on it as the “rarest of the rare” case. This shows that recovery is possible when there is proper care.Because it was known that age is a risk factor for COVID-19 as far as infectivity and associated morbidity are concerned, special attention was given from the beginning to the people of the state who are above 60 years of age, those having comorbidities, and the immunocompromised. This is particularly significant because Kerala has a large elderly population, which is predicted to grow to 8.3 million by 2026.http://www.planningcommission.nic.in/plans/planrel/fiveyr/welcome.html).7 Thus it is apparent that more than a medical/health activity, dealing with COVID-19 is a sociopolitical activity. The strong public health system, containing a network of primary health centers, along with overall literacy have had a significant impact on the health literacy of the population. Moreover, decentralized governance gave people the ability to make decisions about their health care needs. The Navakeralam Model, which is the second phase of decentralization in Kerala, has played a significant role in refurbishing the health care system through its Ardram Mission, which aims at creating a “people-friendly” health delivery system . Through the efforts of this model, it has been proven that contagious diseases and epidemics could be contained effectively. It was the absence of such a public health model that devastated the health care system in developed nations during the pandemic.The health gains made in Kerala can be attributed to several factors, including strong emphasis from the state government on public health and primary health care, health infrastructure, decentralized governance, financial planning, girls’ education, community participation, and a willingness to improve systems in response to identified gaps – for example, in the Twelfth 5-Year Plan 2012–2017 created by the Government of India Planning Commission. Despite this investment in expanded infrastructure, by the early 1980s, there were reports of reduced access to medicine, lab supplies, and adequate sanitation (including drinking water and latrines) in public health centers in Kerala (Government of India Planning Commission. Twelfth 5-Year Plan 2012–2017. Available from: 8 They urged people to take care of themselves following the strict instructions given by the team dealing with COVID-19. There was rigorous monitoring of the daily activities of the community. Tests, early detection, quarantine of those who had contact with positive cases, isolation of positive cases, strict implementation of the mitigation protocol, and shielding of the vulnerable were given the utmost priority. Along with the infrastructure of the government machinery, the community also partook in prevention activities as volunteers. The majority of people who returned from abroad went into self-isolation/quarantine after screening at airports and followed government rules and regulations as part of the preventive measures. These positive attempts from the public are crucial to contain any pandemic situation and helped in Kerala’s efforts to reduce fatality rates.The governance machinery, led by the chief minister and the health minister, trusted the community with efforts to contain the disease.Lockdown in Kerala has made it possible to limit the number of positive cases down to less than 8,000, which would otherwise have risen up to 8 lakhs. Kerala has flattened the curve by virtue of its strategic planning, community participation, and interdepartmental coordination. Along with the network of institutions under the health department, the departments of medical education, police, fire and rescue, woman and child development, food and civil supplies, and legal metrology, together with research institutions and agencies, worked in a coordinated fashion to achieve this.In addition to the health department, special appreciation is due for the police department. Kerala police have made effective efforts using memes and movie dialogues in the local and vernacular style to provide awareness about social distancing and washing hands. The social media page of the Kerala police, which is one of the most followed police department pages in the world with more than 1.5 million followers, was used to execute this strategy.Our results show that varied, appropriate preventive measures adopted and implemented by the Kerala state aimed to maintain strict social distancing that would be effective in reducing the magnitude of disease transmission and in delaying the peak of the disease outbreak to a certain extent. The state quickly rose to the occasion by stepping up the number of tests using the existing infrastructure and available resources. The quick and successful response should definitely be attributed to lessons learned from the Nipah experience, which can be rightly called the “dress rehearsal” for COVID-19 that shook the state in 2018 and helped the state gain confidence to handle epidemics from unfamiliar pathogens. The lessons to be learned from the community-oriented, cautiously aggressive, inclusive approach that the small state of Kerala opted for should definitely be a guidance in shaping public health policies and mitigation strategies for fighting not only this pandemic, but also infectious diseases that may arise in the future.


This paper presents the design and validation of a traceability system, based on radio frequency identification (RFID) technology and Internet of Things (IoT) services, intended to address the interconnection and cost-implementation problems typical in traceability systems. The RFID layer integrates temperature sensors into RFID tags, to track and trace food conditions during transportation. The IoT paradigm makes it possible to connect multiple systems to the same platform, addressing interconnection problems between different technology providers. The cost-implementation issues are addressed following the Data as a Service (DaaS) billing scheme, where users pay for the data they consume and not the installed equipment, avoiding the big initial investment that these high-tech solutions commonly require. The developed system is validated in two case scenarios, one carried out in controlled laboratory conditions, monitoring chopped pumpkin. Another case, carried out in a real scenario, monitors oranges sent from Valencia, Spain to Cork, Ireland. Salmonella and Escherichia coli in fresh fruit, or the horsemeat scandal in precooked food [The current global economy has changed the food industry by increasing the distance that food travels from producer to final consumer, bringing many challenges related to food traceability. Scandals such as genetically modified (GM) crops and foods, the outbreak of ‘chickengate’ in feedstuff, ked food ,2,3 haveked food .Laws, policies, and standards have been developed attempting to regulate these issues. The International Organization for Standardization ISO 22005 Food Safety Standard attempts to ensure that there are no weak links in the supply chain, requiring that each company know their suppliers and customers. The ISO 22005:2007 gives codes and specifies the basic requirements for the design and implementation of a food and feed traceability system that can be applied by any organization operating at any step in the food chain. The traceability system is a technical instrument to assist an organization in conforming with its defined objectives and is applicable when necessary to determine the history or location of a product or its relevant components . Within In the European Union, the food law General Requirements are based on the safety of food because consumers must have confidence and assurance that the food they buy will not harm them or have an adverse effect. Thus, it establishes that only safe food and feed can be placed on the Union market or fed to food-producing animals. Besides, these requirements deal with the traceability of products throughout the food chain. The General Food Law Regulation defines traceability as the ability to trace and follow food, feed, and ingredients through all stages of production, processing, and distribution ,7.In the USA, the Food and Drug Administration (FDA) is adding regulations for the Current Good Manufacturing Practice, Hazard Analysis, and Risk Based Preventive Controls for Food for Animals. These regulations will, for the first time, establish requirements for the Current Good Manufacturing Practice (CGMP) for food for animals. In addition, the FDA is taking actions to provide greater assurance that animal food is safe and will not cause illness or injury to humans and animals. Nevertheless, the FDA Food Safety Modernization Act (FSMA) implements new rules intended to build an animal food safety system for the future that makes modern, science- and risk-based preventive controls the norm across all sectors of the animal food system .Ensuring compliance of the traceability standards requires robust and reliable technological solutions able to track, trace, and notify about any problem along the supply chain, guaranteeing the safety of the food and consumer.Emerging new technologies, such as smartphones, Internet of Things (IoT) or cloud computing, are changing rapidly the food industry. Access to the Internet through smartphones has made the food industry become more customer-oriented, as consumers can easily access product information. Customer complaints can also go viral through social networks, affecting a firm’s image. Regulations established by governments have forced companies to provide information about genetically modified (GM) products or its sources as customers are more aware of the origins and handling of their food . To facePaper-based labeling systems are still being used by many small and big companies to keep control over their products. Barcodes are a cheap technology that provides identification and can be found within systems operating across the whole food chain. However, it does not provide any extra value, like automation or information storing. Many small companies in the food industry use this technology as they do not perceive any return on investment in high-tech systems that also require skilled personnel for maintaining ,13.Going beyond labeling and sensing systems, other techniques have been developed focusing the analysis of the chemical composition of the food. These techniques include stable isotope analysis, DNA barcoding, near infrared spectroscopy (NIRS), or chemometric methods . These techniques have proven to be enormously successful in detecting food origins when applied in conjunction . HoweverRFID is a widely used technology in food logistics. This technology emerged in the 1950s and was made possible thanks to technological advances during the Second World War . It consNear field communication (NFC) is another common technology in the food industry. NFC is a special case of RFID technology oriented to the near field exchange of information. It is widely used in payments and has been recently boosted thanks to the compatibility with some smartphones. This fact has turned NFC into a more customer-oriented technology. In the food industry, these labels are attached to products storing information relevant to the customer, and this data can be easily extracted using an NFC-compatible smartphone. Other authors  present Wireless sensor networks (WSNs) are an active research line that counts many successful IoT applications ,27,28,29Although these technologies have managed to solve many of the problems, there is still a lack of studies that show an effective implementation of these systems. Some of their strongest barriers are economic, as no return of investment is perceived, and interconnection problems, as different technology providers create different systems incompatible with each other. The goal of this paper is to show a practical implementation of a cost-effective traceability system, based on ISO 18000-6C RFID technology  with addThe Internet of Things (IoT) involves the integration and interaction between the physical/real and the digital/virtual worlds, where through the use of smart technologies  the Things will be interconnected at any time, any place, and in any application . AlthougThe current deployment of IoT relies on multiple technologies that can be applied depending on the application and its constraints. Some technologies like Wi-Fi and Bluetooth have been widely used for smart home applications taking advantage of the Internet network infrastructure already deployed in homes . Some otIn , a revieThe conceptual framework has been mainly developed by the industry seeking to fulfill the standards and policies established by governments, dividing traceability into different entities, and focusing on the extracted valuable information more than the technology itself . The FooAs the case study focuses on identification and cold-chain monitoring, a survey about the commercial solutions available for temperature monitoring was carried out. As can be seen in Although several approaches have been proposed to overcome interconnection and cost-implementation problems in traceability ,16,39,40The implementation and operation of a traceability system is a complex and overwhelming task carried out by small companies whose business focus is food not technology. These small organizations mostly lack the financial capacity and trained personnel to implement it. Also, its implementation must comply with legislation and policies, guaranteeing food quality and information systems for all the stakeholders . The devThe Orbis Traceability System is based on RFID technology with sensing capabilities because RFID is the leading technology in the supply chain  and one The Orbis Traceability System is divided into two main subsystems: the RFID subsystem and the information and processing subsystem . The RFIThe IoT platform  is a cloThe cloud-based computing platform that uses RFID technology for the public transportation monitoring described in  is a patGoogle App Engine is a Platform as a Service (PaaS) that provides auto-scalability, so the system can be developed and tested at small scale, and when the massive deployment comes in, the system can grow flexibly, without the need of a redesign or performing any load balancing. PaaS is operating expenditures (OPEX) oriented, and its billing scheme is “pay as you go”, which means that the development phase is affordable and sometimes free, and during the operational phase the costs increase along with its use.The IoT platform is composed of two main middleware subsystems, the IoT and DaaS middleware. The function of the IoT middleware is to handle all the incoming posts and queries from the sensing systems, while the DaaS middleware handles the sending of information to the external consulting applications. The scheme of DaaS is a key point for this system, as the billing of the whole IoT solution relies on it. The interaction with both middlewares is made possible by its application programming interface (API) that establishes standardized JavaScript Object Notation (JSON) forms for exchanging information. The DaaS middleware exchanges information with previously registered and authenticated applications that can process the data and provide further services, such as data mining for business intelligence or data analysis. These external apps are application specific and can be developed using any technology, platform, and language.Receiving and verifying information sent by previously registered gateways and sensors, using Rivest, Shamir y Adleman (RSA) authentication keys.Providing services to manage  data sources .Interpreting, classifying, and storing incoming information.Ensuring privacy and integrity of the data as well as the auto-scalability of its databases, achieved through the use of the data storage model Google Datastore—BigTable.Avoiding Structured Query Language (SQL) injection attacks and denial of service attacks.Providing services to manage  systems to use the services of the DaaS and IoT middleware.The main functionalities of the IoT platform can be summarized as:As described in RFID tags enhanced with sensing capabilities are not a new concept, and several implementations have been already carried out in many applications. In , RFID taTypical data loggers for these applications often have several kilobytes of memory space. Nevertheless, the RFID chip just has 416 bytes available to the user, which is not enough for saving historical records during the cold-chain transportation, that often lasts weeks. However, if information about the timestamp on each sample is discarded, an account of the total time that the sensor was exposed to certain temperature values can fit, without any problems, into the small-Tag’s memory. Following this scheme, an effective method of sensing certain ranges can be implemented, storing into the RFID chip memory as much information as can be collected in one year. As will be seen in Traceability systems are recognized as tools for guaranteeing food quality and safety, providing tracking and tracing along the whole supply chain, ensuring safer supplies and connecting producers and consumers in a transparent way . TraceabAdvances in traceability systems can be divided into two approaches, the technology and the concepts. The technological approach focuses on the physical layer and through the implementation of leading technologies seeks to extract and control information about the product and its sources. On the other hand, the conceptual approach addresses the problem from the application layer, and it has been mainly developed by the industry seeking to fulfill the standards and policies established by governments, dividing traceability into different entities and focusing on the extracted valuable information more than the technology itself . These tThis study presents the design and validation of a traceability system, based on RFID technology and IoT services, intended to address the interconnection and cost-implementation problems typical in traceability systems.To validate the behavior of the whole system, we designed two case studies: local market pumpkin cold-chain monitoring and long-distance orange delivering.Cucurbita moschata) is a vegetable native to South Asia, and it belongs to the Cucurbitaceae family. It is a very important group of plants, not only from the economic point of view, but also due to its medical properties. In this sense, it has important compounds such as carotenoids with antioxidant properties [Pumpkin  was purchased in a local commercial market in Valencia, Spain. Fruits were selected for their uniformity in shape, weight and color in autumnal harvest. In this experiment, a pumpkin ) was cut into cubes, and then 150 g of pumpkin cubes were placed on four plastic trays and then sealed. The white plastic trays  and the film  used to seal the trays are compatible with food packaging. The sealing conditions were 165 °C for 3.5 s with compressed air without vacuum. The experiment was carried out in collaboration with the Institute of Food Engineering for Development (IUIAD) of the Universitat Politècnica de València, specifically, in the Fruit and Vegetable Postharvest and Conservation Laboratory.Fresh pumpkin  belong to the Rutaceae family, and they have many beneficial properties due to their high content of vitamins, fiber, minerals, ascorbic acid and very high content of antioxidant compounds, such as flavonoids, carotenoids and phenolic compounds [On the other hand, the orange is also a fruit native to Asia. Citrus fruits such as orange  to Cork (Ireland). Citrus sinensis, Navelate var.) were provided by Naranjas de Cullera, S.L., a small company specialized in direct harvesting and delivery to customers. Fruits were selected for their uniformity in shape, weight and color in winter harvest. In this experiment, the oranges presented Category I, caliber: 6 (60/80 mm/unit), total weight: 7 kg, origin: Valencia (Spain). They were boxed in cardboard for transport during the late winter without specific cooling conditions, only the typical winter environmental conditions. Fruits should not be frozen, and the recommended temperatures for storage are in the range of 2 to 8 °C [Fresh oranges  to overcome with the design of this framework, it shows the versatility of the IoT system, being able to store information from different types of systems. In the case of the Testo data logger information, it was obtained using a CSV format and, through the IoT middleware, the data was transformed and sent to the IoT platform.From this graph, information regarding temperature monitoring and therefore conditions during the food cold chain can be extracted. Regarding pumpkins temperature ramps , it is nConsidering this table we can conclude that, for 3.68 days the oranges were kept at good temperature conditions. But, during 4.25 days, there was an exposure to a range (9–22 °C) higher than the suitable. However, even though this temperature was not optimal the product arrived in good conditions to its destination, thanks to the roughness of its skin, oranges can support a variety of climate conditions typical to its transport process. Moreover, the lowest temperature registered was 1 °C, and the lower breakpoint was never reached (below −5 °C), so no cold chain break was detected for this product.The IoT platform solves the integration problems by receiving data from different providers and making it available to different customers.In this case, data was obtained by using two different technologies: the smart-Tag system and the Testo data logger system. In the case of the smart-Tags, the application that translates data into the format received by the IoT platform is already integrated into the RFID gateway. In the case of the Testo data logger, it is a standalone product, that uses a Windows application and, with a USB interface, stored data can be downloaded in a CSV file format. This data were processed by an application developed in Python , able to read all the data from the CVS and transform it into the JSON format accepted by the IoT platform. Once data is on the cloud, it is consulted by the external application shown in Compared with typical temperature monitoring solutions, which use robust and expensive wireless hardware, as it takes advantage of the scalability and low prices point of the RFID technology. As the ones described in Assuming that only temperature measurement is required, the mass production cost of this smart-Tag should be less than 2 Eur. If we consider the commercial margins, this type of solution would be suitable for those goods where the balance between the cost of the intelligent labelling and the product is adequate.In the fruit and vegetable market, consumer safety has become one of the most critical and priority issues in the food chain. Despite the efforts from members of the food chain for fresh products, food security problems cannot be eliminated easily. Vegetables, fruits, and food in general, require a comprehensive, integrated, and effective control system to warranty good conditions during the whole food chain. Therefore, an effective and cost-efficient traceability system can significantly improve tracking accuracy and speed access to information about food production and destination. The RFID technology used by the developed framework allows wireless immediate identification, without vision line with the reader, since the information is transmitted by radio frequency waves. This technology enables to do the traceability of the products while at the same time allows to save extra data in the RFID tags memory. Therefore, it brings great value to the consumer while guaranteeing the good conditions on the products, since a large part of the nutritional and vitamin characteristics will depend on the time that passes from its collection to its consumption. From a public health perspective, by improving the speed and accuracy of the tracking and location of the food items involved, it can help reduce risks related to food safety. Moreover, the tracking of food items can help public health services and industrial operators to determine the potential causes of a problem with integrated traceability from the origin, thereby providing the necessary individual information to identify and minimize health risks . With the data extracted by the traceability system described in this paper, and some information regarding logistics of the products, it was possible to reconstruct the cold chain and detect the compliance of temperature conditions. However, it was not possible to obtain information about the time when the cold chain break actually occurred, nor its recurrence. Due to the low-memory typically available in RFID chips, information regarding timestamps had to be sacrificed, but if we consider that the monitoring of most of the food-products should comply just with certain ranges, we could manage a different schema for mapping the events in memory, giving more details on timestamps and less granularity for the measured values. Therefore, as future work and an evolution of this framework, it will be considered customizable memory-mapping schemas depending on the product to monitor, which will allow us to record timestamps and be able to reconstruct the cold chain break events including timestamps, at the expense of less granularity in the measures, which at the end is not critical for this application. Also, in case of long periods for a cold chain break, the smart-Tag could emit a visual or audible signal, in order to warn consumers on the state of the product.


Sub-Saharan Africa is home to about 15 million children with varying developmental disorders. Services for children with developmental disorders are scarce in Africa. The few available services are limited to the capital cities and are in the private sector, with the cost beyond the reach of most families. In 2016, the Centre for Early Development, Learning and Care was established in Ibadan, South-west, Nigeria. The centre provide services for children with developmental disorders is a one-stop, multidisciplinary team approach. Children are assessed on both structured and unstructured interviews. A total of 584 children were assessed between December 2016 and December 2019. One third (32.4%) of the children assessed within this period met diagnostic criteria for ASD, 29.1% had intellectual disability and 27.6% had cerebral palsy. The remaining clients (10.9%) had other disorders including ADHD, Down’s syndrome, hearing impairment and visual impairment. Parents tend to downplay the severity of their children’s disability. There are many challenges that are associated with the establishment of a service centre in a low resource setting. These and other experiences are discussed. The Sustainable Development Goals (SDGs) call for an end to preventable deaths of new-borns and children by 2030, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births, and under-5 mortality to at least as low as 25 per 1000 live births . As a reet al. reported that the number of children younger than 5 years with epilepsy, intellectual disability, sensory impairments, autism spectrum disorder, and attention-deficit hyperactivity disorder in SSA rose from 8.6 million in 1990 to 14.7 million in 2016. The highest YLDs for all disabilities except for ASD were reported in sub-Saharan Africa [Early childhood, commonly defined as the first 5 years of life, is the fastest period of growth and the period in which the developing brain is most sensitive to stimulation and nurturing . Interven Africa . The fewn Africa .The situation and pathway to care for individuals with developmental disorders in Ibadan Nigeria before the centre: Ibadan is the largest city in West Africa. It has a population of about 3,532,400 [2. The first University in Nigeria is situated in the city with the teaching hospital arm known as the University College Hospital (UCH). Mental health services are provided by the university teaching hospital with child and adolescent mental health services, which became a stand-alone service about 10 years ago. There are five Child and Adolescent Psychiatrists in the city, about five people working as speech and language therapists , three occupational therapists and no psychologist with child and adolescent mental health (CAMH) training. There is no documented community prevalence of developmental disorders in Nigeria. However, there are reports from studies done among high risk groups that showed that the prevalence could be as high as 40% among children in institutions and clinics [,532,400  and appr clinics . MajoritThe pathway to care for most children in south-west, Nigeria is usually through faith-based organisations and mainstream schools, with a tiny fraction of them getting formal assessment at the UCH. The primary and secondary health care system is almost non-functional in terms of service provision for developmental disabilities. Families often recognise signs of developmental delays early but do not seek care due to unavailability of appropriate services. This often continues until the children start elementary school at about 6 years and are noticed by their teachers. Sometimes they are referred by teachers to health professionals. However, developmental disorders are often missed, even by health professionals who are not specialists. Many people with developmental disorders have co-morbid mental health problems like anxiety, depression and psychosis and therefore come into contact with mental health services. It is usually at this presentation that their developmental disorders are diagnosed for the first time. Unfortunately, diagnosis in most part of Africa does not necessarily translate to adequate treatment due to lack of appropriate care and therapy centres for developmental disorders.Starting the centre: one of the authors, YCA, who is also the lead clinician, had an initial training as a psychiatrist (Fellow of West African College of Physicians) and later trained as a Child and Adolescent Psychiatrist through a 2-year sub-specialty program under the National Postgraduate Medical College of Nigeria after which she was awarded the Advanced Certificate in Child and Adolescent Psychiatry. She is one of the only two with this qualification in the entire country. During this sub-specialty training, she was working in the outpatient and inpatient services of the Department of Child and Adolescent Psychiatry, UCH. She was also volunteering in homes and institutions that take care of children with developmental disorders and other mental health issues across the city. Her Master of Science work was also among children with intellectual disability [sability . During clinical and biomedical services: to provide a well-coordinated, multidisciplinary, and affordable care to persons with developmental disabilities and their families; training: to provide training for capacity building; Research: to conduct innovative and culturally-sensitive research and mental health promotion and policy: to partner with stakeholders to impact mental health promotion, policy and advocacy.The key step in establishing a child development centre is to gather a group of like-minded people who are passionate about the cause. In December 2016, YCA, a Child and Adolescent Psychiatrist, a physiotherapist (AFA), two Special Education teachers, a speech and language therapist, a secretary, two support staff and a guard began the centre. There was just enough fund to rent a space and purchase the initial items and equipment needed for the centre. The mission, vision and core values of the centre were established. Our vision is for every child with developmental disability to reach his/her full potential and live a meaningful life. It is our mission to bring out the best in every child living with developmental disabilities and support their families through evidence based and affordable programs. We set out to achieve this through our four-part mission: Some of our core values are: person and family-oriented services, cultural competence and diversity, community inclusion, early intervention, Evidence-based practice and collaboration, Building capacity through training and culture-sensitive research. As at March 2020, the team has enlarged and consisted of the following with their usual time allocation: clinical lead and director: consultant child and adolescent psychiatrist-4 hours daily; professor and head of physiotherapy-3 hours daily; physiotherapist-4 days; speech therapist-full time; speech therapist-part time; occupational therapist-full time; 8 special education tutors-full time; music and art tutor-full time; hostel supervisor-full time; administrator and head of operations-full time; 13 support staff-full time; 3 security guards-full time and volunteer-4 hours weekly.As the centre has become more established, it has been a popular destination for individuals and professionals with interest in developmental disorders. The Centre has received visitors and undertaken trainee placements from both undergraduate and postgraduate students, and doctors from the United Kingdom, United States of America, Australia, Canada, South Africa and many African countries. Prior to commencement of operations at the centre, the accreditation team from the Ministry of Women Affair and Social Inclusion visited the centre. The centre was subsequently approved to commence full operation, with an approval letter from the commissioner in charge of the ministry.Physical space and equipment: the plan was to provide core therapy for children with developmental disorders including boarding and respite care. For ease of coordination, we had to get an apartment that will accommodate both the therapy sessions and hostels. A storey building apartment was rented for a year at the start, and it´s been renewed yearly since 2016. We had to carry out lots of structural partitioning of the apartment to accommodate the different therapy units. Due to limited funds, we bought the most needed equipment at the beginning. These were sourced locally and we gradually update as the need arises.Referrals: we accept referrals from many sources. But most of our referrals came from: the teaching hospitals and other government hospitals in town; from NGOs, faith-based organisations and other outfits that work with children within the community; mainstream schools; snowballing of referrals based on testimonials from parents who already have children in the centre. This constitutes over 50% of referrals to the centre and self-referrals through social media, sign posts and various awareness programs . This is usually done during the first appointment. The MCHAT, Conners Rating Scale, SDQ and PHQ are administered at this visit. The speech and language pathologist and a special education teacher will also carry out appropriate assessments. The physiotherapist assesses the clients with physical disabilities.Developmental assessment: the primary caregiver, usually the mother is interviewed on pregnancy, delivery, neonatal and childhood history. Other history includes family, past medical and previous intervention, or care. The Bayley´s screening tool and WISC-IV are used at this stage. This usually lasts about 90 minutes on the average. We sometimes interview other family members like the grandparents and teachers, and this is usually done through phone calls if they did not accompany the parents. School report and medical reports are also reviewed where available. After the assessment, the team will meet to compare findings and take a decision about diagnosis, admission, and placement. Further interview is needed if the family is considering boarding facility. Reason for the choice of boarding, financial implications, and the need for continuous interaction between the centre and family while the child is in the hostel is discussed.Placement: after the assessment, children are either placed in the day or boarding  program based majorly on the family´s preferences. The day program involves that the children are brought to the centre every morning from Monday to Friday between 8am and 5pm. During this time, the children receive different interventions based on their needs.Available intervention and services at the centre: we offer core services such as speech and language therapy, occupational therapy and physiotherapy. Others are shown in Some other services provided by the centre: biomedical service: the centre provides basic medical services for the children at the centre, especially those in the boarding house. About 80% of the students have one or more comorbidities that require medications. The commonest comorbidity is epilepsy accounting for about 70% of the cases, and others include ADHD and sleep problems. Medications are administered and reviewed for students in the centre. Referrals are made to the teaching hospital for specialists care in some cases, for example, poorly controlled epilepsy is often referred for the neurologist´s review.Residential care: the centre provides residential services to students especially children outside the city of Ibadan, where the centre is located. The boarders stay in the hostel for average of 12 weeks after which the centre goes on a few weeks break necessitating that the children go home to their families. They are fed and cared for at the hostel by trained caregivers with supervision from the therapists. The boarders also join the day program from 8am to receive therapy and return to the hostel in the evening. They also continue to receive interventions especially behavioural and self-help skills in the hostel.Education and training: one of our mission is to provide structured training facilities for students and professionals working with children and adolescents. Students from Universities and tertiary institutions come for observership programs. In addition, family education and training aimed at improving understanding of relevant health issues to aid long-term compliance with treatment is organised periodically. The centre also provides continuous in-service training for staff of the centre.Research: one of the objectives of the centre is to conduct research on developmental disorders with emphasis on developing countries. This started with cross sectional studies with a plan to subsequently recruit patients into clinical trials and facilitate follow up of patients in long-term trials.As at December, 2019, the centre has assessed 584 clients. One third (32.4%) of them met diagnostic criteria for ASD, 29.1% had intellectual disability and 27.6% had cerebral palsy. The remaining clients (10.9%) had other disorders including ADHD, Down´s syndrome, hearing impairment and visual impairment. See Students´ progress in the centre are monitored by the therapists in charge and therapists give weekly report of the students to the Head of Therapy. A 3-monthly comprehensive report is provided for parents, the report often include response to the different interventions, difficulties encountered and recommendations. The centre collaborates with mainstream schools in the city to allow for smooth transition of children from the centre to the mainstream education for inclusion. We provide a summary of activities and interventions the child had gone through, a summary of improvements and recommendations to support the child in the inclusive setting .An important part of our objective is to provide education and awareness on developmental disorders, and drive advocacy. This objective is being achieved through several channels including: production and distribution of educational materials to members of the community in the form of leaflets written in clear and simple language. These leaflets provide information on common developmental disorders, symptoms, causes, and interventions. Since inception, the centre has distributed over 30,000 pamphlets;Television and radio: there has been tremendous effort from the centre on public awareness through the local television and radio stations. Some of the slots were paid for by the centre, but most of the slots were by invitation from the television and radio stations. People in the community had opportunities to phone-in during some of the programs to ask questions and make necessary enquiry about developmental disorders. Some of these programs were in local dialects, providing opportunities for non-English speaking population;Social media: our social media handles have served as sources of information to the general public on developmental disorders. This is especially more elaborate during the public awareness days that are relevant to developmental disorders like the Autism Awareness Day.Public talk in religious and social groups: as a result of the important role the centre is playing in advocacy and awareness, we have received numerous invitations to speak at different social gatherings on issues relating to developmental disorders and other programs like community outreach to provide free developmental assessment and medical advice to children with developmental disorders and their families.Strengths of the centre: the centre provides appropriate mental health support for both the child and family members through counselling, psychotherapy, assessment, and management of different mental illnesses for caregivers.One stop: burden of health care in Nigeria and most African countries rest totally on the family. Families pay out of pocket for services. Services are scarce and poorly coordinated. The Centre provides well-coordinated services for children with special needs.Serves as a model centre: the centre´s multidisciplinary assembly of staff, with multilevel professional training and experience in addition to a wide network of collaborations and partnerships and one-stop setting, makes it a model for others in the region.Challenges: one of the recurrent challenges has to do with availability of qualified professionals. Professionals working in the field of disabilities are scarce in countries like Nigeria. The few ones are constantly looking for greener pasture, hence the personnel turnover rate is remarkably high. We have had to hire ad hoc staff to meet up with services because of sudden resignation or exit of therapists. The need for re-training and continuous medical education of staff. The centre is a private establishment with initial funding solely from the founders. The initial rent, furniture, therapy materials and initial salary came from the founders of the centre. Subsequent funding came from the fee paid by the parents. Students are billed based on their need for therapy, with quite a number of the families not able to pay for all the required therapy.Feedback and evaluation: parents are encouraged to evaluate the different segments of our services through a feedback form. Evaluation follows both process-based and outcome-based. Some of the feedback from the parents are in Annex 1. We also ask our visitors to evaluate the setting and structures during their visits, and some of their comments are in Annex 2.A little over three years of commencement, the Centre has continued to grow and in the process, we have learnt a lot of lessons to help us improve our services. The number of families we serve, the number of regions we cover has progressively increased over the years. We have continued to evaluate our services and get feedback from users and partners. We are grateful to the community in which we operate as they have accepted and supported us in no small measure. We are indebted to the friends and partners of the centre for their advice, feedback, criticisms, and support to improve our services. With a clear vision, we are poised to continue to provide evidence-based, affordable, and culturally acceptable services to the children with developmental disabilities and their families.


The Israeli National Health Insurance Law provides permanent residents with a basket of healthcare services through non-profit public health insurance plans, independently of the individual’s ability to pay. Since 2015, several reforms and programs have been initiated that were aimed at reinforcing public healthcare and redressing negative aspects of the health system, and specifically the constant rise in private health expenditure. These include the “From Reimbursement-to-Networks Arrangement”, the “Cooling-off Period” program and the program to shorten waiting times. The objectives of this study were to identify, describe, and analyze changes in private hospitals in 1) the volume of publicly and privately funded elective surgical procedures; and 2) private health expenditure on surgical procedures.Data on the volume and funding of surgical procedures during 2013–2018 were obtained from Assuta Medical Center, Hertzelia Medical Center, the Israeli Ministry of Health and the Central Bureau of Statistics. The changes in the volume and financing sources of surgical activities in private hospitals, in the wake of the reforms were analyzed using aggregate descriptive statistics.Between 2013 and 2018 the volume of surgical activities in private for-profit hospitals increased by 7%. Between 2013 and 2017, the distribution of financing sources of surgical procedures in private hospitals remained stable, with most surgical procedures (75–77%) financed by the voluntary health insurance programs of the health plans (HP-VHI). In 2018, following the regulatory reforms, a significant change in the distribution of financing sources was observed: there was a sharp decline in the volume of HP-VHI-funded surgical procedures to 26%.Concurrently, the share of publicly-funded surgical procedures performed in private hospitals increased to 56% in 2018.,. During the study period, private spending on elective surgical procedures in private hospitals declined by 53% while public funding for them increased by 51%.In the wake of the reforms, there was a substantial shift from private to public financing of elective surgical activity in private hospitals.Private for-profit hospitals have become important providers of publicly-funded procedures. It is likely that the reforms affected the public-private mix in the financing of elective surgical procedures in those hospitals, but due to the absence of a control group, causality cannot be proven. It is also unclear whether waiting times were shortened. Health reforms must be accompanied by a clear and comprehensive set of indicators for measuring their success.The online version contains supplementary material available at 10.1186/s13584-021-00455-z. The Israeli National Health Insurance (NHI) Law, which went into effect in 1995, provides permanent residents with a basket of healthcare services through non-profit health plans (HPs), independently of the individual’s ability to pay. The HPs provide health services in HP clinics or through the purchase of services from external suppliers, primarily hospitals, which account for the main expenditures of HPs.Since 2015, the Government of Israel has introduced numerous health system reforms and programs that aimed to reinforce public healthcare, and whose effect has been the restructuring of the health system. These reforms have introduced fundamental changes through legislation (the Economic Arrangements Law), regulations, guidelines, regulatory directives, and new arrangements designed to redress negative aspects of the health system, and specifically the constant rise in private health expenditure.Based on the CBS data, between 1995 and 2018, the share of public financing for national health expenses declined from 68.2 to 63.8%. This decrease in public financing was apparently due in part to budgetary erosion and limited investments in the public healthcare system while at the same period of time, an increase in private spending was reported. The growth in health expenditure per capita during this period was approximately 1.7% a year, on average, but only 0.9% per age-adjusted standardized person, when considering changes in healthcare prices relative to the Consumer Price Index and increased needs due to changes in the age structure of the population [Concurrent with the decline in the share of public financing, a consistent rise in private expenditure on health has been documented over the years through voluntary health insurance (VHI) purchased either through the health plans - policies known as supplementary insurance (HP-VHI) - or through commercial insurance companies (C-VHI). The share of private expenditure on VHI out of total healthcare expenditure increased from 8.2% in 2010 to 11.1% in 2018; about 75% of this increase is attributed to the purchase of commercial insurance [For our discussion here, it is important to distinguish between two distinct, yet interrelated, facets of every health system: healthcare financing and healthcare delivery. According to Article 3 of the NHI Law, the state assumed the obligation of financing the basic governmentally guaranteed health benefits package, while the delivery of most of these services is the responsibility of the (non-profit) HPs. Health services are delivered either directly by HPs or through various external service providers that receive most of their funding by selling services to HPs. These service providers may be owned by the government, by a non-profit organization or a private company.An important example is the issue of elective surgeries. Prior to the 2015 reforms, elective surgical procedures performed in private for-profit hospitals were covered by a mix of commercial insurance, supplemental insurance, and out-of-pocket payments. Patients could choose the surgeon, the anesthesiologist and even the medical equipment to be used. HPs did not purchase elective operations  from for-profit hospitals. Additionally, the vast majority of public hospitals were not allowed to provide privately financed services that are included in the healthcare services basket; the hospitals located in Jerusalem are an exception for historical reasons. Consequently, at that time, concerns were raised that public hospitals would lose patients and staff to private hospitals due to growing patient interest in securing the benefits of privately-financed care.The blurring of the lines between health services provider and funding and between private and public health services in Israel is reflected in public and private/semi-private medical services  provided by private not-for-profit hospitals in which patients can choose their physician by paying an additional fee. Throughout time, the private-public mix in Israel was the possible origin for concerns that patients receiving care through the public system are deprioritized in terms of access, waiting times, and seniority of the attending specialist in comparison to patients who received the same services but paid for the service through the private system , 5.In view of the vast changes in the health system in recent years, it has become extremely important to track, measure, and identify the effects of the governmental reforms on the health system from their inception . It is equally important to examine whether these reforms achieve the desired results as defined in the official goals of the Ministry of Health (MoH) and Ministry of Finance (MoF), or whether additional/different steps are necessary to align outcomes with goals. In the section that follows, we briefly review the three main health reforms that were introduced between 2015 and 2018: the “from reimbursement to networks” arrangement, the “cooling-off period,” and the programs to shorten waiting times. Additional details can be found in the appendix.For many years HP-VHI and C-VHI plans offered their members two main tracks for surgical procedures and medical consultations, allowing members to choose between a monetary reimbursement track and a network-limited benefits track . This kiIn this track, individuals could receive reimbursement for the cost of surgical fees and medical consultations performed by physicians who were not part of the insurer’s network . In geneThe reimbursement track was less cost beneficial because the ability of HP members to choose any physician they desire and to receive reimbursement for their expenses created a negative incentive for physicians to join insurers’ networks. In addition, HPs had very little or no control over their spending on this track. Consequently, VHI expenditures on surgical procedures and consultations soared, especially in HP-VHI plans whose reimbursement track was an integral part of their organizational concept.(A) The network trackIn this track, when elective procedures and consultations are performed by a physician affiliated with an HP-VHI or C-VHI, the insured individual is charged a co-pay, which may vary from one C-VHI to another and from one VHI plan to another under the same HP. Co-pays are determined according to a range of parameters, for example, the type of surgery, its location  and the surgeon. In the past, HP-VHI plans could offer coverage with no co-pay for surgical procedures performed in private facilities; however, following the government’s decision within the Economic Arrangements Law of 2008, it was determined that VHI plans would not include coverage of choice of surgeon with no co-pay . This deIn response to the recommendations of the “Committee for Strengthening the Public Health System”, headed by then Minister of Health, Yael German , the MoHOn November 8, 2015, the Knesset Finance Committee approved the regulatory rule that prohibits HP-VHI and C-VHI plans from offering reimbursement for a surgical procedure or medical consultation. Instead, the insured individual must select the service provider from the insurer’s network and will be charged no fee other than a co-pay.Of note is that concurrently with the changes above, another regulatory rule prohibited insurers and physicians from entering agreements with senior physicians and specialists in unique fields that inevitably drive increased fees for these physicians. Additionally, under this regulatory arrangement there is a limit to the number of services each insured individual can obtain per calendar year.The Health Chapter of the Economic Program Law, including the transition from the reimbursement track to the network track, went into effect on July 1, 2016 despite harsh criticism voiced mainly by the Israel Medical Association.The transition to the network track was intended to improve HPs’ control over their expenses, especially for those HPs that had a high percentage of members who chose the reimbursement track.By promoting competition among HPs over the size and quality of their networks, the reform sought to achieve the NHI Law’s fundamental aim to promote competition among HPs over accessibility, availability, and service quality.B. The “cooling-off period” regulations.Concurrently with the transition from reimbursement to network arrangement described above, the Public Health Regulations were amended (effective November 2017) to include a “cooling-off period” . These rAn analysis of the MoF and MoH’s explanatory notes to the legislation indicates that the regulations were designed to create a limited-period barrier between the public and private health systems, especially with respect to financing. The official aim of the separation was to limit physicians’ ability to divert patients from the public to the private system based on the physicians’ financial interests. The separation is also intended to be used as an additional regulatory tool to restrain the increase in private health financing that stemmed from the relatively high co-pays on surgical and elective procedures performed in the private health system (through VHI plans).From its outset, the “cooling-off period” regulations attracted fierce criticism from the medical profession. In a petition filed with the High Court of Justice , the petC. The program to shorten waiting times.The program to shorten waiting times was launched in September 2016 in order to: 1) address the problem of lengthy waiting times for elective procedures in the public health system by increasing the number of procedures (regardless of the identity of the provider - private/public), and 2) reduce private health expenditure in the component of co-payments for surgeries and procedures by allocating additional budget to the healthcare system so that more operations may be performed. Unlike the previous two steps, which were only regulatory rules, the program to shorten waiting times is a budgetary program, that was accompanied by an additional government allocation of NIS 870 million (250 million USD) for direct support to HPs and NIS 180 million to public hospitals . The MOH stipulates participation in the program by providing a full report comprising information on the funding body, actions and diagnoses according to ICD9 codes, MOH price list codes, and approval of the completeness of the report .According to the MoH and MoF, the success of the program to shorten waiting times depends, among other things, on the success of corresponding regulatory arrangements, and especially the “cooling-off period” program. In November 2017 criteria for direct public support to HPs were published. These included increased volume of publicly funded operations and other procedures, a decline in activities funded by VHI plans, and criteria for diverting surgical procedures whose fees were under NIS 6000 to public funding. On September 23, 2019, a list of 115 authorized public and private providers in the program was published .Notably, as no specific targets or measures for assessing waiting times were defined, this lacuna naturally affected the regulator’s ability to evaluate the program’s success and the extent to which it achieved its official aim.In light of all of the legislative changes and regulatory arrangements described above, we aimed to identify, describe, and analyze 1a) the volume of publicly and privately funded elective surgical procedures, 1b) the distribution of financing sources of surgical procedures in the health system, 1c) private health expenditure on surgical procedures and 2) the extent to which the reforms’ aims were met.Data on the volume of elective surgical procedures performed between 2013 and 2018 in private hospitals were obtained from Herzliya Medical Center and Assuta Medical Centers . Data representing all hospitals in Israel  were obtained from the MoH.Financial data was obtained from The Summary Report of the Division for Supervision and Control on Health Funds and Additional Health Services  and fromAs it was not possible to discriminate among the outcomes of the three reforms, the analysis examined their outcomes together and compared data before and after the reforms. It is notable that the authors performed in-depth interviews with health policy leaders in Israel in order to distinguish between the different reforms. These findings will be elaborated in a future study.Between 2013 and 2018 the volume of surgical activities in private for-profit hospitals increased by 6.8%  were financed by HP-VHI plans. There was a gradual increase in the share financed by C-VHI plan, from 14 to 20%. The rest was financed by the NHI basic healthcare package, private insurance plans and medical tourism. In 2018, however, after the new regulatory arrangements regarding the public-private mix went into effect and the budget for the program to shorten waiting times was transferred to the health system, there was a significant change in the distribution of financing sources: the volume of publicly funded  surgical procedures performed in private hospitals increased dramatically from a single-digit share in previous years to 56%. Concurrently, there was a sharp decline in the volume of HP-VHI-funded surgical procedures - from > 70% in previous years to 26% in 2018 . Our analysis suggest that the regulatory arrangements, and in particular the program to shorten waiting times, probably strengthened private hospitals’ roles as service providers for HPs. That is reflected in the increased activity of publicly funded healthcare services delivered by private providers. In the wake of the reforms, there was an increase in the production infrastructure of publicly funded procedures and surgeries in parallel to a decrease in funding of procedures and surgeries through the HP-VHI (SHABAN) complementary health service programs.The allocation of resources for publicly funded surgeries routed surgeries to private providers. Among other things, the reasons for this diversion probably includes these providers’ higher capacity and higher utilization of operating rooms  and due The findings of this study illustrate how the components of the health system function in an integrated manner, whereby each movement affects the existing balance and influences a broad range of indicators both directly and indirectly. Occasionally, the true and significant impact of a change is manifested only months or years later, and in the meantime existing distortions in the system might be sustained, new distortions might be created, or the ability to correct long-established adverse effects might be compromised. For this reason it is extremely important to identify how - in the wake of new arrangements in the health system - key parameters change at various points in time, and to compare achievements to the desired goals and targets.In Israeli public discourse there are often claims that the public is moving rapidly and excessively toward the use of private medical care and the purchase of private insurance. In contrast, the findings of this study indicate that between 2013 and 2018, the rate of surgical activities in private for-profit hospitals increased by 7% only. This is a reasonable rate of increase, considering that the population’s annual growth rate was approximately 2% during this period and the population is also aging [Our findings also suggest that the new regulatory arrangements have affected the distribution of private hospital use by financing source. However, due to the absence of a control group, we were unable to assess whether a causal relationship exists. In addition, due to problems in measuring waiting times in the health system, and the absence of a reliable and relevant database for waiting times, it is not possible to assess whether waiting times decreased, in accord with the program’s official aims. It is even possible that in some cases, waiting times may have increased due to the growth of the eligible group (everyone covered under the NHI and not only HP-VHI members) and the materialization of latent demand . Even though publicly funded activities in the health system increased and a certain drop in private spending on health occurred, waiting times were not necessarily shortened.After many years of structurally and operationally blurred boundaries in HPs between publicly funded and privately funded activities, the “cooling-off period” regulations apparently had a significant effect by creating structurally distinct and separate tracks (public or HP-VHI plans) that allow HPs to identify and prevent diversion of members from the public to the private health system.These findings and conclusions are also reflected in the financial data published annually by the MoH, which indicate that the HP-VHI plans accumulated a surplus of NIS 189,142 thousand after the new regulatory arrangements and the reforms went into effect in 2016. This surplus led, among other things, to the decision in June 2018 to reduce the monthly premiums for HP-VHI plans.Similar to our findings, which showed an increase in publicly-funded activity in private hospitals, a similar pattern is presented by an MOH analysis related to all hospitals. According to an MoH report dealing with the government-allocated budget for the program to shorten waiting times - only 35% of the money went to the public hospitals (NIS 362 million) while 65% was transferred through the HPs to private hospitals (NIS 686 million). The MOH report demonstrated an increase in public funding (1.3 billion NIS) and a decrease in private funding (865 million NIS) among all four HPs during 2018 compared to 2015 . AccordiThe findings of this study and MoH data suggest that the regulatory arrangements led to an increase in the volume of activities in the publicly-funded health system while private out-of-pocket spending on health (co-pays for surgeries and other procedures) declined. Hence, these regulatory reforms, specifically, the reduced waiting times program, apparently strengthened private for-profit hospitals’ role as service providers to HPs. This expanded the infrastructure used for public health system-funded surgical and other procedures, apparently contributing to a concurrent decline in the use of HP-VHI-funded procedures and in private health spending. Notably, the findings of the study indicate that most of the additional budget was allocated to private for-profit hospitals. Therefore, HPs’ implementation of the new regulatory arrangements apparently led to the referral of a significant volume of members to private hospitals for their public health system-funded procedures.To what extent did this increase in publicly-funded operations in private hospitals coincide with the objectives of the reforms? The answer to this question is not simple, as the reform had multiple objectives. One objective was to decrease private financing of operations, and that was achieved. But it is unclear whether other objectives were obtained: there are no evidence for shroter wating period for elective surgeries. Another objective was to empower and strenghn the public healthcare system and this goal was only partly achieved.This finding speaks to the criticism voiced by the directors of public hospitals and MoH executives in the government hospital division, who argued against the unfair competition between public and private hospitals, and that public funds are being diverted to private hospitals by HPs.Moreover, our analysis distinguishes between supply (ownership) and financing of health services. Instead of being excluded, the private system should work together and alongside the public system in order to release bottlenecks, shorten waiting times and thus improve the quality of care. Reducing private funding can serve as a tool to reduce disparities and inequalities in healthcare, weakening the link between the ability to pay and the receipt of health services and leading to a fairer distribution of the system’s limited resources. Continuing the trend of reducing private spending will help make health services accessible to all and will contribute to health equality.The data presented in the study is limited to Assuta Medical Centers and Herzliya Medical Center, and did not include data for SHARAP services  which are public and private medical/semi-private services in which patients can choose their physician in a public hospital by paying an additional fee. However, Assuta Medical Centers and Herzliya Medical Center are the two largest private providers of surgeries and procedures in Israel. It is likely that the corporate connection between these hospitals and the HPs has helped to increase the activity of these hospitals.1It should be noted that the extent to which the changes can be attributed to the reforms described above is limited due to other changes that took place in the Israeli healthcare system during the study period, and the absence of a control group. Since all changes occurred at the same time, it is hard to differentiate among the relative contribution of each reform.It is notable that our findings, indicating a decrease in private funding and increase in public funding on surgeries are in correlation with the central bureau of statistics, which demonstrated an overall decrease in private healthcare expenditure and an increase in public funding .The findings of the current study indicate that private for-profit hospitals have become important providers of publicly-funded procedures. The reforms strongly affected the distribution of health expenditure by financing source, but it is unclear if waiting times were shortened.Additional file 1.