Equity, efficiency, sustainability, acceptability to clients and providers, and quality are the cornerstones of universal health coverage (UHC). No country has a single way to achieve efficient UHC. In this study, we documented the Iranian health insurance reforms, focusing on how and why certain policies were introduced and implemented, and which challenges remain to keep a sustainable UHC.This retrospective policy analysis used three sources of data: a comprehensive and chronological scoping review of literature, interviews with Iran health insurance policy actors and stakeholders, and a review of published and unpublished official documents and local media. All data were analysed using thematic content analysis.Health insurance reforms, especially health transformation plan (HTP) in 2014, helped to progress towards UHC and health equity by expanding population coverage, a benefits package, and enhancing financial protection. However, several challenges can jeopardize sustaining this progress. There is a lack of suitable mechanisms to collect contributions from those without a regular income. The compulsory health insurance coverage law is not implemented in full. A substantial gap between private and public medical tariffs leads to high out-of-pocket health expenditure. Moreover, controlling the total health care expenditures is not the main priority to make keeping UHC more sustainable.To achieve UHC in Iran, the Ministry of Health and Medical Education and health insurance schemes should devise and follow the policies to control health care expenditures. Working mechanisms should be implemented to extend free health insurance coverage for those in need. More studies are needed to evaluate the impact of health insurance reforms in terms of health equity, sustainability, coverage, and access. The Sustainable Development Goals (SDGs) Summit during the opening week of the 74th session of the United Nations General Assembly gave a clear message that many countries are off-track to achieve many of the SDGs by 2030. Universal health coverage (UHC) is no exception , 2. SomeMany LMICs contemplate adopting SHI as it is one of the essential routes towards achieving UHC, besides general tax revenue as the primary source of financing health services. SHI can provide a stable source of revenues by combining risk pooling and mutual support with the visible flow of funds into the healthcare sector . Since SDuring the past nine decades, numerous reforms took place in the Iranian health insurance system intending to achieve UHC. However, despite several major attempts to extend health insurance coverage to the entire population, there are still several challenges to reach and keep a sustainable UHC. Evidence suggests that despite the introduction of the universal basic benefits package under the SHI fund in Iran, inequalities in health financing indicators and access to health care services continue to exist, particularly for low-income groups and rural residents , 11. SomHealth policymaking is a complex process and suffers from limited uptake of research evidence, particularly in the Eastern Mediterranean Region. This study, aimed at generating insights about how health insurance policies were made over 90 years, identifies factors influencing policymaking and assesses to what extent these policies contributed to achieving UHC in Iran. Lessons learned from this study can be useful for informing future policymaking in health systems and provides insights for structuring the evidence-informed decision-making process, particularly in LMICs.2. The median age in Iran is 30.1 years, of which more than 70% are urban dwellers .Until 1997, as health insurance coverage was not mandatory for the rural residents, less than 1% of 23 million rural residents were covered by the Rural Residents’ Fund. In 1997, the insurance plan for the rural and nomadic population was instigated, and 23 million people received free health insurance cards , 36. It To solve a part of problems resulting from fragmentation in health insurance funds, the Organizing Healthcare Act (OHA) was passed in December 2002 . The OHAIn 2004, a new ministry called Ministry of Welfare and Social Security (MWSS) was established to administer the three layers of the social security system including the insurance section , financial support and empowerment services for the very poor, and relief services and rescue operations in disasters. By the creation of MWSS, health insurance funds, as well as the HCHI that were operating within MoHME were transferred to the MWSS. A purchaser-provider split occurred to boost strategic purchasing of health care services and encourage competition among providers , 41.In clause 91 of the fourth five-year development plan, it was determined that in order to increase the efficiency of the country’s health care system and expand and strengthen the health insurance system up to the end of 2010, the HCHI was assigned to prepare the prerequisites for the implementation of health insurance within the framework of family physician (FP) program and the referral system. The villagers’ health budget was increased fivefold with the cooperation of the Parliamentary Health Committee and Management and Planning Organization in 2005 for the development of health insurance for the rural population. This budget was given to the MSIO. MoHME seized this opportunity to implement a referral system relying on FP program for the rural residents, which had not previously been possible due to budget shortage , 42. It MSIO to a great extent depends on the public budget. It makes the financial resources more unpredictable, which in turn makes it more difficult for us to revise the BHIBPs.” [MSIO manager]. In 2011, MWSS once again converted into the Ministry of Cooperation, Labour and Social Welfare (MoCLSW) as a part of government downsizing project.When MWSS was established, it also took over from the MoHME the responsibility of defining the content of the BHIBPs. In 2008, MWSS released a new version of BHIBP formally known as a “Blue Book”. It was the first time that the contents of all BHIBPs were compiled systematically. In this book, all BHIBPs health services were categorised into nine categories: dentistry, medicine, inpatient services, outpatient services, medical equipment, medical supplies, laboratory, radiology, and physiotherapy. However, the definition of the BHIBPs content did not seem to be based on the evidence-based process or real prioritisation. Instead, BHIBPs content expansion was determined mainly by politics and the negotiations among the policy actors . For exaOverall, evidence suggests that there was financial instability of the basic health insurance schemes in all three main financing functions  , 44. ForDifficulties in reaching UHC because of unreliable and unclear information regarding population coverage and per capita health insurance expenditure, resulting from remaining fragmented health insurance system and overlapping population statistics, and a failure to implement policy integration among insurance schemes, despite several laws being passed in this regard, led policymakers and lawmakers to put the merging of the health insurance funds on the agenda of the fifth national development plan (2010–2015) , 49. It In the fifth national development plan, the method of health insurance contribution rates for IHIO beneficiaries changed from a fixed amount to 6% of salary up to 2-fold of the minimum wage.” [A senior health insurance policymaker].As the first step in merging the SHI schemes, the charter of the IHIO was approved by the Cabinet in 2012, and the MSIO was renamed into IHIO in 2012. However, the IHIO’s establishment came to a halt at this point. The creation of a real single national insurance scheme failed due to political resistance from some of the main actors, such as the SSO and other insurance organisations, a lack of some prerequisite infrastructure, and operational challenges caused by key differences in some insurance aspects, such as financing methods, benefits packages, health service delivery, and organisational structures . “In theDespite passing several major polices over previous decades, progress towards achieving UHC was not satisfactory in all three dimensions . Despite the repeated emphasis in the upstream documents ) on the need to extend health insurance coverage to all Iranians, reduce OOP health expenditure, and provide equitable access to health care services, self-employed continued to lack health insurance coverage and had to pay OOP for all health expenses.According to the Statistical Centre of Iran, about 20% of Iran’s economy is informal . In mostTo overhaul the health system and also address the health financing challenges , a series of policy interventions called Health Transformation Plan (HTP) was implemented in May 2014 mainly by increasing the share of public budget for the health sector , 46. The“In HTP, health authorities decided to cover those people without coverage freely. To our surprise, in the 2016 census, 10.3 % of the population stated that they have no health insurance. That is why in the sixth national development plan, it was stipulated again that health insurance coverage should be mandatory.” [A senior health insurance manager].Free Universal Health Coverage Fund expanded the basic health insurance coverage to include the 11 million previously uninsured Iranian people (mainly self-employed) which increased the overall population coverage up to 96% , 53. By Apart from the free Universal Health Coverage Fund, another program was implemented by HTP so-called “Financial support for patients in hospitals”. It aimed to reduce the OOP expenditures in public hospitals . This program which is managed directly by the MoHME provides more financial protection for patients by covering balance billing which patients paid OOP before the HTP or covering health services which are not under the coverage of existing health insurance schemes. To fund the HTP plan, the government announced that 10% of the total net of implementation of targeted subsidies law and also 1% of the value-added tax, is allocated to the health system . This prFurther improvements were made by revising medical tariffs and content of the BHIBP as the third phase of the HTP to improve financial protection and health equity for patients . For insOverall, the HTP implementation led to a sharp increase in health care utilisation due to improved financial accessibility. In deprived areas of Iran, many more hospitals and health facilities were built, and others were renovated. In the remote areas, the number of hospital beds and health care staff  was increased . These i“One of the obstacles facing reaching UHC was free coverage for self-employed and rural citizens. The self-employed joined free Universal Health Coverage Fund in 2014 although a part of this population is rich enough to pay premiums. By launching means test for the rural citizens and the self-employed, we hope that it will enhance health equity and risk pooling by providing free coverage just for those who are extremely poor.” [A provincial general director for IHIO]. Since Aug 2018, a new joint electronic program was introduced by the MoHME and health insurance schemes aimed to check the state of health insurance coverage of patients online and remove the duplication in health insurance coverage for the patients who have several health insurance cards.Facing financial difficulties to keep free Universal Health Coverage Fund, the public budget of IHIO was diminished significantly in 2018, and the free health insurance coverage  was stopped in November 2018. New applicants were obliged to pay half of the contribution. The last project introduced in IHIO was in November 2019. According to this project, all groups enjoying free coverage  are obliged to pass a means test to assess their affordability to contribute in paying premiums or be entitled to free health insurance coverage. Those belonging to the three lowest income deciles are exempted from paying premiums, and the government will cover them, those from the fourth income decile should pay half the contribution rate for all family members, and the rest should pay the whole amount of premium out of their own OOP. Those who are eligible for free health insurance coverage will be only allowed to go to the public health sector to get health services that they need. According to the history of the health insurance system in Iran, and despite making great progress in all three aspects of UHC including population coverage, benefits package  and financial protection  as a result of health insurance reforms over the last decades especially by launching HTP to achieve UHC, there are still several unsolved challenges.Although health insurance coverage became compulsory in Iran since the fifth national development plan, still no effective and applicable mechanisms have been introduced yet to put into effect the law of compulsory health insurance coverage for rural residents and the self-employed. It makes keeping UHC more challenging. Although HTP expanded benefits package and increased financial protection for patients in the public health sector, people (mainly IHIO and SSO’ beneficiaries) still have to pay the gap between private and public medical tariffs in the case of getting health services in the private health sector which is prevailing for outpatient services. “Financial support for patients in hospitals” program still provides inspiring extra financial protection for patients using inpatient services in the public hospitals although it stopped providing financial support for outpatient services since May 2019. Currently, it does not support those who have no insurance coverage, which can reduce health equity as, unfortunately, a considerable part of these people are from disadvantaged groups. This program also does not support patients receiving their health care services from the private health sector.From 1972 until now, the Iranian health system has witnessed critical changes in medical tariffs. In 1992, by splitting medical tariffs into public and private sectors, the gap between the public- and private-sector tariffs and insurance coverage became more prominent. Since 2003 that Iranian Medical Council set medical tariffs for the private health sector, the private medical tariffs increased by ten times more than public health sectors and basic health insurance funds especially IHIO and SSO failed to cover this gap. This reduced the access to health care services and increased OOP expenditures in private health sector . Health For decades, the main focus of health insurance reforms was on extending population coverage rather than increasing health services coverage or enhancing financial protection . Apart fEven though the physical integration of the existing health insurance funds and the formation of a single national insurance scheme were legislated in 2010, they were never implemented in practice. Reducing fragmentation by creating a single national scheme could have facilitated moving toward reaching UHC and improving health equity by controlling total health care expenditures, implementing strategic purchasing, better supervision of health care providers by centralizing their profiles in a single database, reducing fraud and controlling the volume of provided health care services, improving the health financing equity by setting the same coinsurance rates for different population groups and boosting risk pooling for the whole population, eliminating duplication in population coverage, centralizing health profiles and health expenditure profiles of beneficiaries in a single database . It is wProviding UHC for the self-employed is still a major challenge in Iran, even 26 years after the passing of the UHI law. The fact that insurance coverage is non-compulsory, the large scale of the informal economy in Iran (about 20%), the financial inability of people to pay the premiums, the shortages and instability of government financial support for the constant development of insurance coverage for villagers and the self-employed, as well as not devising reliable methods to engage rural people and self-employed in paying at least a part of premiums are among the main reasons for not achieving extending coverage for all self-employed. Apart from poor people, providing free health insurance coverage for about 23 million rural citizens and 11 million self-employed persons have imposed a high financial burden on the government and jeopardise the sustainability of UIC in Iran. By launching free Universal Health Coverage Fund in 2014, those who were participating in paying health insurance premiums including the self-employed and a part of SSO beneficiaries with voluntarily based coverage moved to IHIO to enjoy free health insurance coverage. In reality, just a part of 11 million persons covered by this project was new and did not have previous insurance coverage. This harmed moving towards reaching UHC and health equity, as those who got used to paying premiums shifted to free coverage again, and no distinguishing method was applied to extend health insurance coverage just for real underprivileged groups. Introduction of the means-testing project by IHIO in November 2019, can improve health equity by targeting those people in need although according to the current results of the means-testing project, majority of rural dwellers and self-employed still should be covered freely by the government. This program is at its beginning, and how it is going to affect the UHC is not clear. Although alongside the ability to pay, it should be mandatory for all to get health insurance coverage, which remains to be challenging.Lessons from South Korea show that a stable national economic growth has been an inseparable contributor for extension of health insurance coverage for the self-employed, the last group that joint national insurance coverage. Rapid considerable economic growth in late 1980 made it possible for the government, employers and the self-employed to invest in and pay for the health insurance , 60. In Joint work between two ministries of MoHME and MOCLSW to control total health care expenditures is vital if reaching and keeping UHC is a priority for both. By curbing health care expenditure, it is possible to lower the health insurance premiums, which enables more people to buy health insurance coverage. It will also enable health insurance schemes to include more health services in their benefits package and provide more financial support for the services they cover. Moreover, it will allow the government to pay premiums for more people . Reaching UHC also needs working on supply-side  alongside reforms in the demand side  to control health care expenditures. The amount of money injected in the health system by the HTP was unprecedented and ambitious projects were implemented in both the health insurance side and also health care provision side. Governmental health expenditures per cent out of government budget increased from 11.4% in 2013 to 19% in 2016 . HoweverTo our knowledge, this is the first study conducted in Iran comprehensively explore the health insurance policy trends and milestones through multi methods. The main limitation of the study was lack of enough published documents and also low information of interviewees regarding first and second periods of the study to cover these periods in more details.There is no single way of providing universal health insurance coverage for all population. Providing access to health services and financial protection against health costs, for everyone, can be a long-term process. Countries should focus on creating a clear role for public revenues in the health system financing while understanding the limitations of relying on the ability of the population to afford to pay insurance premiums. We strongly believe that to reach and keep UHC in Iran, the two main players of the health insurance system (MoHME and MOCLSW) should devise and follow the same policies to control health care expenditures. To do so, they can implement policies, such as extending family physician programme to all population groups, implement and apply close-ended payment methods, use clinical guidelines, revise the content of the benefits packages by including the most cost-effective interventions, devise more restrictive regulations to rationalise the prescription of diagnostic services, control the price of pharmaceuticals and medical supplies, control the high technologies/population ratio, and control the moral hazards by setting more realistic coinsurance rates for the programs under the coverage of HTP.Without controlling total expenditure, government, and health insurance funds like IHIO have to abolish free coverage for segments of the population, omit some health care services from the benefits packages or impose more financial burden on the patients at the service utilisation point which can lead to higher OOP expenditures, reduce health equity and paralyse keeping UHC. Majority of outpatient and diagnostic health services in Iran is provided by the private health sector, which is not under the coverage of HTP and is one of the main sources of increasing OOP payments. The government should extend the capacity of providing outpatient and diagnostic health services in the public health sector and support patients financially in the deprived cities for necessary health services which are available just in the private sector. Working on the medical tariffs and closing the gap between private and public medical tariffs should be considered to make UHC in Iran more sustainable. The compulsory health insurance coverage law still needs to be implemented in full. Also, it would be necessary to assess and analyse the impacts of health insurance and health financing reforms in Iran in terms of improving financial equity indicators, financial sustainability, equity in utilisation and access to health care services for disadvantaged groups, technical and allocative efficiency. Finally, we should assess the short and long-term results of IHIO means-testing project on UHC. Paying health premiums and providing free health insurance coverage may be difficult for people  and government due to the current tough economic situation in Iran caused by the international sanctions and also by mass unemployment caused by COVID-19 pandemic.


A Zika virus (ZIKV) infection outbreak occurred in Brazil in 2015, accompanied by a marked increase in the number of newborns presenting with microcephaly and other neurological disorders. This characteristic set of birth defects was later termed congenital Zika syndrome (CZS). The therapeutic itinerary of mothers and children infected by ZIKV can be determined by several factors, including the relationship established with existing healthcare services. Here, we aimed to describe and analyze the extent to which children with CZS, born from 2015 to 2018 in the state of Mato Grosso do Sul, Brazil, and their mothers were treated according to the guidelines established by the Brazilian Ministry of Health.This was a descriptive cross-sectional study that considered all children (and respective mothers) with confirmed or suspected CZS born in Mato Grosso do Sul. Children and their mothers were identified based on all suspected or confirmed cases of congenital anomalies in Mato Grosso do Sul that were reported to the Registry of Public Health Events. We analyzed data on the epidemiological profile of mother-child pairs and the care received by them. Data were summarized using statistical descriptive analysis.We showed that most mothers were white women (57%) with low income. Among pregnant women, 73% had a diagnosis of fever caused by ZIKV infection at a primary health care institution (PHCI), but only 36% received the necessary information regarding the risk of CZS. Over a third (36%) of the mothers did not receive guidance about childcare follow-up and 73% did not receive guidance regarding the availability of social support after childbirth. Gaps in medical care were observed mainly in pregnant women treated at a PHCI. Specialized assistance for children was adequate in most cases. Psychosocial support was not made available to women throughout their therapeutic itineraries.Here, we identified gaps in the care of families and children with disabilities, which can have an important impact on their quality of life. Beyond protocols, practical interventions must cover all the needs that arise throughout the therapeutic itineraries not only of children but also of pregnant women and mothers. In 2015, a Zika virus (ZIKV) infection epidemic emerged in Latin America, with a high number of cases registered in Brazil . After tZIKV has tropism toward human neural progenitor cells , 8 and cThe rapid spread of the ZIKV through the population, along with the magnitude and severity of the disease caused by it, demanded the development of health surveillance and assistance frameworks to identify and follow-up pregnant women and their infants who had been exposed to ZIKV –15. EsseFamilies with a child with CZS have many non-medical issues, such as concerns about having a lifelong responsibility, anxiety derived from uncertainties about the development and future of their child, and stress from the increased amount of care that a child with CZS requires . TherefoIn Brazil, from November 2015 through July 2018, 16,348 suspected cases of CZS in children were reported. Among those, 3226 19.7%) were confirmed. Most of the cases occurred in the Northeast (59.3%), Southeast (24.7%), or Midwest (7.3%) regions .7% were .The evaluation of interventions or the implementation of public health policies should be supported by data on the health needs of the relevant population; further, these decision-making processes should also take into account gaps in the medical care of affected individuals. However, in the Center-West Region of Brazil, there is a lack of data about the quality of care provided to individuals with CZS and mothers with ZIKV infection. Thus, this study aimed to describe and analyze, for the first time, the extent to which children with CZS, born between 2015 and 2018 in the state of Mato Grosso do Sul, Brazil, and their mothers were treated and followed according to the guidelines established by the Brazilian Ministry of Health –15. FurtThis was a descriptive cross-sectional study that considered all live-borns (and their respective mothers) between 2015 and 2018 with confirmed or potential CZS. In Brazil, all suspected or confirmed cases of congenital anomalies related to ZIKV and syphilis, toxoplasmosis, other , and rubella (STORCH) are reported to the Registry of Public Health Events (RESP) – a public health record created during ZIKV epidemic. The patients with CZS in Mato Grosso do Sul and their mothers had previously been identified by us, and the detailed methodology that led to their identification has been described in detail elsewhere . BrieflyIn the present study, we only analyzed the variables of interest that are related to the epidemiological profiles of the women  and information related to the care received by them and their children . These data were obtained from interviews with the mothers using a structured research tool with closed and open questions and from three Brazilian health information systems: Information System for Notifiable Diseases (SINAN), Live Births Information System (SINASC), and RESP. If the patients could not be located or otherwise refused to participate in the interview, the analysis was restricted to data obtained from the aforementioned three systems.First, we performed descriptive analyses of the variables used to characterize the epidemiological profile of the women. For the analysis of the assistance received by these mothers and children, the following official protocols developed by the Brazilian Ministry of Health were used as standards for the quality of care that should have been provided: “Procedures for monitoring changes in growth and development from pregnancy to early childhood, related to Zika virus infection and other infectious etiologies,” “Protocol for the health care and response to microcephaly occurrence” , and the clinical guidelines for early stimulation in the care of children with CZS –15. A seData on the therapeutic itinerary of each of the women and children identified in the study were obtained during the interviews. Then, the extent to which each mother-child pair received the expected level of care (according to the aforementioned guidelines) was determined and described as frequencies for each aspect of the expected standard of care considered in this study.After analyzing the 71 reports found in the RESP, we identified 9 confirmed and 5 suspected cases of CZS in Mato Grosso do Sul, diagnosed between 2015 and 2018. The first live births diagnosed with CZS occurred in the first half of 2016. Among these 14 patients, 71.1% (10) were born in Campo Grande. There were 10 stillbirths, 4 of which were related to ZIKV infection, within the analyzed population of 71 children reported to the RESP. Table Among the 14 women identified, we were only able to interview 11. The remaining were not contactable or refused to participate in the study. The mean age of the women during pregnancy was 26.8 years . Regarding race and/or skin color, 57.1% (8) were white and 35.7% (5) were brown. Regarding education, most of them  had completed > 10 years of education, and 42.8% (6) had started or completed higher education. Half (7) of the women reported having an unpaid occupation (i.e. housewife). The mean and median incomes per capita were 442.10 and 433.34 Brazilian reals , respectively.Regarding marital status during pregnancy, 64.3% (9) of the women were married. It was only possible to assess the marital status after pregnancy for the 11 women who accepted to participate in the interview; the marital status of the majority of women was unchanged. However, 2 women who were married during their pregnancy reported being single at the time of the interview. In half (7) of the cases, the pregnancy was planned. All women received care in a Brazilian public health system institution.The care received by the 11 women and their children included in the study was compared to the recommended therapeutic measures for the assistance and follow-up of pregnant women with ZIKV infection and their children and summarized in Tables Over two thirds  had a diagnosis of ZIKV fever on their first contact with a basic health unit, after presenting with febrile rash illness. In one case, the ZIKV infection was asymptomatic and did not require medical care. In some cases , despite the presence of identified signs and symptoms consistent with a diagnosis of ZIKV fever, no symptomatic treatment was prescribed by the attending physician(s), and no biological material was collected for further examination.Regarding information about ZIKV infection and its consequences, only 36.4% (4) of the pregnant women received the necessary warnings about the risk of CZS and instructions on how to proceed in terms of follow-up of the child.In terms of prenatal care, most women  had at least 6 consultations, as recommended by the Ministry of Health, but only 36.4% (4) were referred for high-risk prenatal care and consultations with a specialist. Three (27.3%) women did not undergo imaging examinations during pregnancy and 2 of them were not diagnosed with ZIKV while being pregnant. None of the women were oriented or referred for social assistance or received social benefits or support for their situation. Similarly, none of the women whose fetuses had been diagnosed with CZS received any kind of psychological support.Regarding childbirth care, 72.7% (8) of the women stated that the birth of the child occurred according to what was planned with the health team during pregnancy. In one case, the mode of delivery differed from the plan; in two cases, no previous plan had been established; and in one case, the child was born at home. In one case, no maternal biological samples were collected for examination and no laboratory tests were performed.In Mato Grosso do Sul, there was low compliance with the measures designed to assist pregnant women with suspected or confirmed ZIKV infection. None of the women were treated exactly in accordance with the planned medical assistance protocols. In fact, more than half of women underwent less than half of the medical procedures recommended in the protocols, with one woman having received less than 10% of the predicted medical assistance measures.We identified 24 medical procedures and activities among the documents provided by the Ministry of Health that should have been performed from childbirth until the child was referred to a specialist. These include physical examinations and immediate collection of biological material for laboratory tests. In 1 of 11 women, physical examinations were not performed, since birth did not occur in a hospital. Furthermore, in 2 cases, there was no collection of biological material to perform laboratory tests.Among issues related to the care of the newborn, repeated head circumference measurements were performed in 91% of cases, nonspecific laboratory tests were performed in all cases, and ZIKV-specific laboratory tests were performed in all infants except the one born at home. All infants underwent brain imaging after birth, as well as auditory and ocular screening tests. In 36% of cases, the mothers did not receive guidance regarding follow-up for the children within the healthcare network, while in 73% of cases, no guidance was provided in terms of social support after childbirth. In one case, the mother sought the services of a specialized rehabilitation center by herself.During the follow-up stages, all but one infant had undergone head circumference measurement. All infants underwent (or were scheduled for) further auditory and ocular screening tests. Most of these children (91%) had specialized follow-up consultations with a physiotherapist, speech therapist, occupational therapist, and a neuropediatrician. In one case, the follow-up by these professionals was started, but the mother discontinued them due to difficulties in attending the medical appointments. In the remaining cases, the patients underwent all recommended evaluations for auditory and ocular function, motor function, manual function, cognitive and social skills, language, and orofacial motor skills. Requirements for assistive technologies were appropriately addressed in all cases. In 9 of 11 infants, early intervention was started before 5 months of age.The social issues that arose during follow-up were as follows: 45% of the mothers did not obtain a medical report (necessary to obtain assistance benefits) from the institution providing the specialized service. Accordingly, these families were not assisted by social assistance services nor instructed on how to apply for them. None of the relatives of the children with CZS were put in contact with the existing social support network to identify eventual vulnerabilities and/or the feasibility of receiving social benefits.The degree of compliance with planned childcare activities was higher than expected in pregnant women. In all cases, more than 50% of the anticipated needs were met, and in over 70% of cases, more than 75% of planned activities were performed.ZIKV infection has been causally linked to congenital malformations  and otheRegarding the education level, our data showed that most of the mothers had more than 10 years of education. This value was higher than what has been reported for other Brazilian states like Espírito Santo, where only 8% of the mothers of children with CZS had a higher education degree . EducatiThe national mean monthly income per capita in Brazil was 400.16 USD in 2016 . DespiteHalf of the women reported having an occupation focused on domestic and family care. This same finding was described by Freitas et al. , who repFrom our results, we observed an evident gap in the health care received by these women. Although most of them had ZIKV fever diagnosed at the first contact with the health care network, in most cases, their needs were not fulfilled. Strikingly, the woman in a more vulnerable socioeconomic situation  were fulfilled. All infants underwent all the planned laboratory tests, brain imaging, and sensory screening  recommended during the neonatal period. Since the time between suspicion and diagnosis is often stressful for parents, a rapid diagnosis and referral to a specialist are essential to minimize their concerns . After tFrom the interviews, we concluded that the majority of patients were adequately referred to specialized rehabilitation services. In contrast, there was an evident lack of guidance regarding the need to seek the services of primary health care institutions (PHCIs): most families were not advised about scheduling childcare consultations to monitor the growth and general health status of children in PHCIs. Taken together, this seems to indicate that the assistance provided to these children was mainly aimed at promoting sensory and neuromotor assessments and interventions. This rehabilitation-centered approach might have led the care network to underestimate other basic childcare needs, with two important consequences: first, the initiation of certain childcare services in PHCIs per se leads to the referral of mothers and children with CZS to other specialized services by the healthcare professionals responsible for their care. If these services are not started, recommendations will not be made, and mothers and children may be less likely to seek those services on their own. Second, the acquisition of different social benefits requires different reports from general practitioners who work in PHCIs. For example, during childcare follow-up at a PHCI, mothers usually receive the first guidance regarding the social care benefits which they are entitled to from primary care institutions. Therefore, the unsatisfactory (in most cases absent) social care outcomes observed in about half of the families in our study might be explained by the aforementioned situation. Early interventions should focus not only on promoting neurosensory motor development outcomes but also on the welfare of the entire family –33.Social and psychological support to mothers and their families is as important as clinical support to the child. It is important to note that the needs of mothers of children with CZS do not end after the child is born. The anxieties and uncertainties related to caring for the child are constant and can be aggravated by isolation, due to difficulty in interacting with others and to guilt related to the condition of their child . TherefoIt is known that the care directed to the disease caused by ZIKV also involves promotional and preventive actions. In this sense, data related to the previous knowledge that these women had about the disease and its consequences, as well as the individual and collective preventive measures, are important to characterize the relationship of these individuals with the health system. However, this study focused on the issues pertinent to women affected by the most serious consequences of ZIKV infection. Accordingly, we are aware that there is a larger group of women who were infected with ZIKV during pregnancy but whose children did not show clinical complications after birth. Even though it is important to know what kind of care they have received, this study focused on children with CZS and their mothers, since this is a more vulnerable group.As a limitation of our study, we cannot exclude the possibility of not having analyzed the totality of the cases with ZIKV infection. However, we estimate that this is unlikely, as the previous study carried out an extensive search for all possible CZS cases . FurtherThe CZS epidemic provided Brazil with the opportunity to revise its protocols for the care of children with disabilities. In a short period, the Ministry of Health was able to adapt and create documents with a set of recommendations focusing on the wellbeing of families and children with CZS-related demands. However, from our results, we observed that many of the measures suggested by these protocols were not performed in a comprehensive way in the state of Mato Grosso do Sul. Different levels of the healthcare system had different levels of discrepancies. While the clinical demands of children with CZS were, for the most part, correctly addressed, the care given to women during all stages of the childbearing process in PHCIs demonstrated many gaps. Psychosocial support, with a family-centered approach, was sparingly offered after childbirth in most of the observed cases. Considering that they are as important as clinical treatment, psychosocial aspects also need to be accounted for, in order to improve the quality of life of these families. Other factors such as the economic burden, limited spouse support, uncertainty about the child’s future, and lack of provided information represent an additional strain to these women. In this regard, the lack of psychosocial support could have a more negative impact on the lives of these women than the lack of medical support toward the management of the child’s CZS.Beyond protocols, it is necessary that practical interventions adequately cover all the needs that arise throughout the trajectories not only of children but also of pregnant women and mothers, contributing to their quality of life.


Background: Due to different social and physical environments across Africa, understanding how these environments differ in interacting with placental disorders will play an important role in developing effective interventions. Methods: A scoping review was conducted, to identify current knowledge on interactions between the physical and social environment and the incidence of placental disease in Africa. Results: Heavy metals were said to be harmful when environmental concentrations are beyond critical limits. Education level, maternal age, attendance of antenatal care and parity were the most investigated social determinants. Conclusions: More evidence is needed to determine the relationships between the environment and placental function in Africa. The results show that understanding the nature of the relationship between social determinants of health (SDH) and placental health outcomes plays a pivotal role in understanding the risk in the heterogenous communities in Africa. Complications arising from the ischaemic placental disorders   contribuMany organisations have taken the initiative to tackle the issue of social determinants of health (SDH) as a way of improving health. The emphasis is on creating healthy social and physical environments for all. The neighbourhood and built environment, social and community context and an individual’s education and stability are some of the key areas of SDHs . Social Tackling the SDHs may be important in preventing adverse health events related to placental disorders. To develop targeting interventions to reduce the impact of placental disorders, it is essential to identify the social, economic and physical determinants of maternal health, specifically placental function, and understand how the relationships may vary across social groups within and across countries in Africa. It is now a global health policy priority to implement policies and programmes responsive to socio-cultural, contextual, regional and national societal heterogeneity in Africa ,9,10,11.A scoping review approach is considered when the objective is to identify existing evidence in a specific field, clarify key concepts in the literature, examine how research is conducted on a specific topic, identify key factors related to a concept, identify and analyse gaps in the knowledge base and as a precursor to a systematic review . Our aimStage 1. Identifying the research questionStage 2. Identifying relevant studiesStage 3. Study selectionStage 4. Charting the dataStage 5. Collating, summarising and reporting the results.The York methodology of Arksey and O’Malley, 2005,  was adopA sample of the themes and search terms used is provided in Three authors independently reviewed abstracts and full articles. The final set of papers that met the criteria for the review were determined by consensus.The literature search and the subsequent abstract and full article review yielded 38 articles that met the inclusion criteria, whose distribution is shown in A total of 30 articles discussed the interactions between socioeconomic and demographic factors and placental disorders. Education level, parity and maternal age were the most investigated factors .Education level was found to be associated with stillbirths, low birth weight (LBW) and pre-eclampsia ,24,25,26Parity was found to be associated with stillbirths, abruptio placentae, LBW, placental abnormalities, hypertension and eclampsia ,33,34,35Antenatal care (ANC) booking status is associated with stillbirths and placenta previa ,22. Not The husband’s employment status, maternal birth season, paternal birth season, diet, type of union, maternal employment sector, socioeconomic status, season of birth, unstable income, unplanned pregnancy, place of delivery and wealth index are all socio-geographical factors associated with LBW ,39,40,41Maternal nutrition and drinking and smoking were investigated for their association with preterm birth . Poor nuIn one study from Dakar, Senegal, it was observed that the use of skin lightening cream is associated with LBW and placental weight . Our intIn a study spanning 23 sub-Saharan African countries, it has been reported that exposure to environmental tobacco smoke (ETS) by mothers during pregnancy causes low birth weight in new-borns, particularly of the male gender . EnvironThe key messages from this scoping review are highlighted in This scoping review identified current evidence related to physical and social environmental effects on pregnancy events related to placental disorders in Africa. The review has revealed the important role played by the social and physical environment in stratifying risk of placental health outcomes. A lot of research has been done to investigate sociodemographic factors and their influence on placental health outcomes.The physical environment has been found to affect obstetric outcomes, even though not much has been reported, and its interaction with placental health outcomes, as compared to the social environment. More studies have investigated the influence of the social environment, especially at an individual level, on placental function compared to the physical environment. More has been done on this subject in the more developed parts of the world than in Africa. The review revealed that not much is known about the leading outcomes associated with the placental function, that is, pre-eclampsia (hypertension), IUGR and stillbirths.The existing evidence used the mother’s season of birth as the measure of her own early life environment. Upon validation of this measure and investigating the association between maternal birth season and placental function, there is a need to determine if effects of foetal undernourishment of mothers can be countered by proper nourishment during pregnancy. Knowledge of the mother’s foetal nourishment will play a big role in determining her baby’s risk, thus informing decision makers on the required nourishment during her pregnancy. This determinant is crucial because if not addressed, the cycle of underweight infants will not be broken until a generation is properly nourished.The association between sex of the baby and LBW leads to the question, “Can then the population structure of a community be used to determine the risk of LBW, hence inform policy makers or researchers on which areas require more interventions to reduce risk of LBW?” More research needs to be done to determine the association between the sex of the baby and placental disorders as such knowledge will play a role in determining risk of LBW in babies.Although existing evidence showed that booking for pregnancy care at health facility improves outcomes, there still exists the question of whether early booking will play a bigger role in improving these maternal outcomes. Women’s autonomy plays a big role in their health care seeking behaviour . DecisioFrom the evidence that exists, conflicting results, on the nature of the relationships between the environment and placental health outcomes, exist for some factors across the studies. More evidence is needed to determine the relationships between the environment and placental function. Most of the existing literature showed that these studies were done in referral facilities where cases are critical. Most, if not all women who were referred to the study facilities were in critical conditions. There is a need to investigate the interactions from within the communities.The regional variations in the impact of identified environmental factors on outcomes related to placental disorders in Africa is less clear. Only one study investigated the effect of place of delivery as a function of distance, and only in relation to LBW. Less is known about the influence of geographical access to care on outcomes related to placental disorders. Travel time (dependent on mode of transport and road infrastructure) is a known measure for physical access to care that models risk better than distance . The seaThere is great potential for the use of Geographical Information Systems (GIS) and Geographical Information Science (GISc) tools and methods in collecting and manipulating data for use as measures for social and physical environmental indicators. There are studies that have used geographical methods to measure social indicators, for example using walking distance to major roads as a measure for a community’s isolation  and acceMore research on the effects of the social and physical environment will expose how the growing industrialisation, globalisation and migration into cities in Africa is affecting changes in maternal health inequalities, increasing the need to investigate how this change is affecting the placental function. This review has shown that SDHs play a role in determining the nature of placental health outcomes in Africa. What is already known, from existing literature, has shown that there is potential for more research on SDHs relating to placental health in Africa, to further understand the extent of the influence the environment  has on placental health.


The COVID-19 is disproportionally affecting the poor, minorities and a broad range of vulnerable populations, due to its inequitable spread in areas of dense population and limited mitigation capacity due to high prevalence of chronic conditions or poor access to high quality public health and medical care. Moreover, the collateral effects of the pandemic due to the global economic downturn, and social isolation and movement restriction measures, are unequally affecting those in the lowest power strata of societies. To address the challenges to health equity and describe some of the approaches taken by governments and local organizations, we have compiled 13 country case studies from various regions around the world: China, Brazil, Thailand, Sub Saharan Africa, Nicaragua, Armenia, India, Guatemala, United States of America (USA), Israel, Australia, Colombia, and Belgium. This compilation is by no-means representative or all inclusive, and we encourage researchers to continue advancing global knowledge on COVID-19 health equity related issues, through rigorous research and generation of a strong evidence base of new empirical studies in this field. With the continuous rise in the global death toll from COVID-19 there is a growing realization that mortality for the SARS-COV-2 virus is inequitably distributed among vulnerable populations. These vulnerable populations may include older adults, people living in densely populated areas, people with lower socioeconomic status, migrants and minorities. These groups have higher rates of comorbid chronic conditions, putting them at high-risk for infection and for severe consequences of the disease [A recent commentary about the COVID-19 response in Iran  exemplifIt is of increasing concern that the current COVID-19 death toll fails to capture the devastating collateral effects on health equity. This includes the loss of health insurance, jobs and homes, which increases risk for mental and physical morbidity and all-cause mortality. Social isolation and movement restrictions also jeopardize health and access to basic needs, and point to the need for human rights protection and the development of public health and social measures that are rolled out in a comprehensive manner and without discrimination against vulnerable populations, including refugees, undocumented immigrants and people in detainment and correctional facilities , 7. Thushttps://analysis.covid19healthsystem.org/).To address the effects of the current pandemic on global health equity we have compiled 13 country case studies highlighting the unique needs of vulnerable populations and some of the measures taken to address these needs by each country. As information on the global public health response and consequences of COVID-19 is yet to be systematically collected and reported, the case studies presented here provide an interim account of challenges and some emerging solutions, which can potentially be more widely disseminated as countries realize the need to address COVID-19 related health equity issues even after containment of the outbreak. Our team of authors represent expert research and public health professionals in the topics they cover. For a more comprehensive account of publicly reported country data  readers are encouraged to turn to the WHO situation and country reports, and to resources such as cross country analysis provided by the Health System Response Monitoring initiative  declared the existence of community transmission in the entire territory. On May 13th, the country had accumulated 177,589 confirmed cases of COVID-19 (84.5 cases/100.000 inhabitants) and 12,400 COVID-19-related deaths - fatality rate of 7.0%. A week later, almost 60.000 cases were estimated, One of the highest transmission rates of the virus in the world [The coronavirus arrived in Brazil by plane, brought by people from the upper classes from Europe, mostly white and highly educated. Once landed, it contaminated domestic workers, generally black and less educated people who, then, disseminated the infection to their poor communities. Given this pattern, the rates of infection and case fatality recorded in China and Italy may not be adequate parameters to anticipate the trajectory of COVID-19 in Brazil, the 9th most unequal country in the world .On March 11th, the MoH published guidelines on the isolation of those infected with or under clinical or laboratory investigation for COVID-19. Recommendations of quarantine were first made by state governments with worst scenarios, and later became a MoH recommendation for the whole country. Although the MoH has also recommended quarantine measures, the country’s President, Jair Bolsonaro, has insisted on a denialist approach, making public announcements contrary to the scientific evidence existing so far. He has publicly insisted that there is not a public health emergency in place, and has encouraged people to not respect quarantine orientations, alleging that it is necessary to preserve the economy.The COVID-19 pandemic placed health services under considerable strain and this situation can be worsened in developing countries. Brazil has a public, universal health system known as Sistema Único de Saúde (SUS) established as a universal right of citizens, and a responsibility of the state, under the Federal Constitution, enacted in 1988. SUS is at the forefront of the response to the pandemic. The system, however, has been historically underfunded and particularly harmed by austerity measures implemented in 2016, when public investments in social areas were frozen for 20 years [In general, Brazil has a high number of ICU beds , even comparable to that of developed countries. The distribution of beds between the public and private systems, however, reveals, social inequalities. While, SUS has 1.3 ICU beds for 10 thousand inhabitants, the private sector offers 4.45 for 10 thousand beneficiaries . In viewConsidering that 30 million Brazilians do not have basic sanitation , it is eFurthermore, this economically disadvantaged population is the one with the highest prevalence of chronic conditions such as diabetes, hypertension, cardiovascular and respiratory diseases. In fact, the National Health Survey (2013) revealed that the proportion of people with one or more of these conditions represents 54% from the group that only attended elementary school versus 28% from the group that attended high school and 34% from the best-educated group . And it Racial inequality is also an important issue in Brazil as the majority of poor people are black. Moreover, it is already playing a role during the pandemic as the higher case fatality rate by COVID-19 is among blacks. Although Blacks represent 23.1% of hospitalized Brazilians with COVID-19, 32% of them died, and among whites, the situation is reversed, as the proportion of hospitalized cases is 73.9 and 64.5% died [Indigenous people are also a group of those most vulnerable to the COVID-19 pandemic due to worse social, economic and health conditions than non-Indigenous, which can increase the risk of the disease. In addition, barriers to access health services due to geographic distance or the unavailability of health services represents yet another disadvantage of this population.Two other sub-groups of the population in a situation of vulnerability are noteworthy: prisoners and homeless people. Brazil has the third-largest prison population in the world, 773,000 prisoners. It is estimated that 80% of the prison population will be infected with the virus, of which 20% may need hospitalization and 10,000 (8%) may need an ICU bed . So far,Finally yet importantly, Brazil may face difficulties in responding to other health problems, such as those related to sexual health during the pandemic. Experience from past outbreaks indicates the need to pay attention to the potential effects of the COVID-19 pandemic on sexual health outcomes, both at immediate and long terms . MoreoveIn sum, the social, racial and regional inequalities present in Brazil are revealing themselves in rates of infection and lethality, as well as in the possibilities of conforming to quarantine and other preventive measures, and in access to intensive care health services.With the ongoing global challenges posed by COVID-19, Thailand health systems seem to be in good control of the situation considering disease containment and medical care responses. As of 18th May, the Ministry of Public Health reported 3028 confirmed cases or less than 50 cases per million population, and 56 deaths . InitialThailand’s relatively strong health care delivery system and its near universal coverage of health insurance in the country have contributed to such achievement . It is cThe COVID-19 pandemic is in its initial months and it is still a long way to go. Nevertheless, the experience in Thailand already revealed several areas for improvement of our health care systems. One vulnerable population is the overseas migrant workers which Thailand has over four million of them , many enThe bigger challenge to health equity will likely stem from the social and economic implications from the pandemic and its policy responses such as partial lockdown restrictions. Potential delay in treatment may result in an increase in complications and severity of diseases, particularly for chronic disease sufferers of the poor and marginalized populations. Inadequate social protection coupled with inadequate social support from the government to mitigate the impacts of economic recession and rising unemployment means more households and children will be pushed into poverty. From the World Social Protection Report 2017–2019, the level of allowance for old age pension was very low and inadequate despite its universal coverage, and nearly four million children were still not covered by any social protection such as child support grant . A rapidThe news media started reporting on long queues of people lining up for food and necessity donations in various communities in the country. It is a demonstration of social solidarity but charity alone will not be able to solve the upcoming social and health problems especially during the challenging times. Thailand has made good systematic progress towards universal health coverage. The current crisis can serve as an important opportunity to mobilize public support to narrow the gaps and strengthen national policies to address social determinants of health and universal social protection, an imperative for better equity in health and social justice.The burden of deaths from covid-19 has been unequally borne by old people and those with pre-existing chronic conditions . Faced wFirst, poor households, who constitute the largest proportion of the population in SSA, are likely to be hit the hardest by covid-19 because the celebrated interventions of social distancing and staying at home are unlikely to be effective . This isSecond, supply and demand for other health services is also likely to be affected , dispropThird, although primary health services are said to be free at the point of use in Zambia, like many other SSA countries, there are other costs that must be borne by patients who want to access health services. These include transport cost as well as costs of medicines and diagnostics that are not provided in health facilities. These costs are likely to rise as covid-19 spreads and poor households in urban slums and rural areas will likely constitute a disproportionately higher share of the financial risk as they attempt to seek treatment or self-medicate. This will raise the risk of catastrophic spending and impoverishment, driving them deeper into poverty.Fourth, and last, inequalities in nutrition as well as access to food and other services are likely to be reinforced by lockdowns which restrict business activity of the majority of the population . More thWhile the rest of the world is receiving warnings about the coronavirus, the Nicaraguan government has not been imposing measures to prevent spread of the virus. Considered the second poorest country in Latin America, the health system is a big problem not only because of the conditions of the public hospitals, but also because of the catastrophic of the public health system response. Knowing that prevention could help mitigate impact of the pandemic, the government ignored this, risking the health of people by promoting Easter celebrations and gatherings on beaches.According to official figures Nicaragua has 25 confirmed cases of the COVID-19 (May 19th), but the government reports have been criticized from different institutions, including PAHO and Human rights organizations. Criticism stems from the acknowledgement of how rapidly COVID-19 can spread, especially if people are not taking precautions, and from comparison to neighboring countries, which closed the borders since the first cases were detected in Central America.Besides the negligent actions of the government and the poverty, the public have been taking their own safety measures, by fabricating facemasks, promoting hand washing, staying at home and not sending children to school -- all individual decisions based on recommendations spreading especially from social media.Armenia is a small country with a population of three million; it allocates around 1.5% of its GDP as tax-based public expenditure on health. However, public health efforts, primary health care, emergency care, and care for infectious diseases is currently fully covered by the government from general taxes.The Armenian government started working on this issue in January creating a special government intersectoral commission to develop and implement strategies to address the situation with SARS-CoV2. On March 16, the Armenian Government declared a state of emergency, a week or so later a complete lockdown. A major public awareness raising campaign started about the virus, how to prevent the spread of the virus, about what is lockdown, self-isolation, quarantine, etc. The majority of citizens trust the current government in Armenia and it helps to manage the pandemic situation much better. Government is very transparent about the situation in the country. Different branches of the government continuously have press conferences to inform the public about the current situation and 18 different programs that the government developed to help socially vulnerable households, daily wage earners, those who lost their job because of the pandemic, and small and medium size businesses, particularly those who did not lay down their employees. The Committee and all government agencies have widely shared their hot line numbers to be accessible to the citizens.Moreover, the Government, in collaboration with the IT sector, developed an Application on COVID 19 symptoms for self-diagnosing and giving advice to those who seem to be at risk on how to contact primary healthcare providers, and sending an alert to the National Center for Disease Control and Prevention about a need to do testing. It also provides latest official news and advice on infection control. The Government is also using mobile phone tracking to strengthen the contact tracing efforts.Government organizes charter flights to ship newly purchased medical equipment, medical masks, PPE, PCR tests, and other necessary materials. Government is also supporting local production of medical masks and diagnostic tests to improve access to those goods.The Government, including the Ministry of Social Protection, has changed the way they distribute pension to make sure that the pensioners do not leave their house to get their monthly pension. Pension is being taken to their apartments/houses.The Ministry of Health (MOH) and the Government came up with different plans for different stages of the epidemic in Armenia. The MOH first changed the Infectious Disease Hospital to one accepting only COVID 19 patients. In parallel, nine other hospitals/clinic – five in Yerevan, the capital city, and four in the other regions of Armenia – were renovated, furnished, and equipped to accept only COVID 19 patients. One of the biggest state-owned multidisciplinary hospitals was also reprofiled for COVID 19 patients only providing an opportunity to have appropriate care for patients with multimorbidity. In addition to this, to be ready for a worst-case scenario, in Yerevan and the regions several big sports/concert halls are prepared to admit patients if the number of patients goes up disproportionately. The MOH has been expanding the lab capacity in the country to be able to do more testing per day without compromising safety of the staff.Algorithms have been prepared for the Primary Care Providers to be able to respond to the situation properly, making sure everyone has good access, but without putting others into danger. All the primary care facilities have been working extended hours with 24-h functioning hot-lines. The phone numbers of all facilities have been widely circulated among the citizens, so that they could contact primary care providers and check with them about appropriate steps. Primary care providers in consultation with the National Center for Disease Control and Prevention make decisions when a special ambulance service should transfer the patient to a specialized facility for diagnostics and care.Moreover, hot line numbers of the Ministry of Health and its National Center for Disease Control and Prevention have been widely circulated via TV and social media to make sure all citizens have equal access to the existing resources.So far, all the confirmed cases, even without symptoms or very mild symptoms have been put into either hospitals or special hotels to fully isolate them and prevent the spread of the virus. Armenia has a supply of all those medications that many countries have tried for treating particularly severe COVID 19 patients.The National Institute of Health of the Ministry of Health has been conducting large scale trainings of physicians, nurses, and lab technicians. In collaboration with the Diaspora High Commissioner’s Office continuous webinars are organized between Armenian and diaspora health professionals to share their experience with each other.Starting March 1, when the first case was identified, the Ministry of Health started rigorous contact tracing and quarantining all exposed persons, and later all travelers coming to Armenia from different countries. The Government of Armenia mobilized many hotels for these people under quarantine. The conditions, including food, and other amenities have been very good and safe equally for everyone. The staff organizing quarantine have done a lot to protect the dignity and mental health of people. Later, the Armenian Government organized charter flights to bring its citizens from neighboring countries, most of them were migratory workers who were left without housing and jobs because of the pandemic. Many of these citizens are now in Armenia, under 14 day quarantine that is fully supported by the government, at 0 cost to the citizens, in safe and good conditions.Social solidarity: during the pandemic the regular citizens made donations to a special account to get additional medical resources needed such as PPE, equipment, tests, and for making extra payment to the frontline health providers. Thousands of citizens and diaspora contributed financial resources for this purpose.Thousands of volunteers got together to offer help and support to older age citizens of Armenia who are at higher risk for COVID 19. They prepared packages with food and other necessary items for 1 month or 3 months, so that our older age people do not go to stores. The priority has been given to those older age people, who live alone.The international agencies have also mobilized resources to help Armenia. Several countries made donations of medical tests and other needed supplies.Concluding remark: In my judgement, the Armenian population did not face inequity in access to information, to safe and appropriate quarantine services, access to diagnostic tests and care for COVID 19. Given the available scarce resources, I think, the Armenian Ministry of Health and Government have done a tremendous amount of work with great commitment to protecting wellbeing of their citizens.My concerns are related to health consequences of economic downturn and widening income inequality in societies. Moreover, with major global disruptions in flights and transportation of goods, there might be disruptions of medical supplies, and those with multiple chronic conditions, one of the most vulnerable groups, could suffer the most because of these disruptions. The inequity between high-income vs. low- and middle-income countries will become even more concerning. I think, all the countries should collaborate and unite their efforts to mitigate the consequences of this pandemic.This pandemic demonstrates very vividly the need for universal health coverage, the benefits of having strong public health services, and the importance of social solidarity.https://www.covid19healthsystem.org/countries/armenia/countrypage.aspx?fbclid=IwAR01MvAuqMrRF2VOfW_mrFlW_7tzgE6a_2Km71X-Jb0I33aCLAQxoLY481MMore information about Armenia’s response is available at: COVID 19 Health System Response Monitor: Armenia India has experienced relatively lower levels of morbidity and mortality due to the COVID-19 pandemic, though both confirmed cases and deaths continue to increase. The population shutdown to control the Coronavirus disease (COVID-19) pandemic has had devastating effects on the livelihoods of economically vulnerable populations. In India, just after a national lockdown was announced on March 22nd, thousands of migrant workers in cities found themselves without an income source and unable to sustain themselves started returning to their villages. In general, unemployment has increased substantially, particularly among those in the informal sector. It is now increasingly clear that economically vulnerable individuals are being forced to sacrifice disproportionately more for public health measures that benefit all of society. Further, the lockdown has also made it difficult for sick individuals to access health services.Population lockdown and the associated loss of economic activity has affected employment and livelihoods on a massive scale globally. India has the largest number of people under lockdown anywhere. By all accounts this lockdown has had a significant effect on movement of people, job losses and incomes. According to information provided by the Center for Monitoring the Indian Economy (CMIE), in mid-May the unemployment rate was 24, and 44% of households currently reporting a loss in income, up from around 10% in early-March. A recent telephonic survey carried out by National Council for Applied Economic Research (NCAER) in Delhi found that 84% of respondents reported loss of income, and nearly 30% experienced shortages of food, fuel, and medicines; these outcomes were concentrated among the poorer households and in rural areas. Historically, economic downturns are associated with the loss of livelihoods, decreases in dietary intake, poorer dietary quality, and health care consumption. The closing of schools due to the lockdown has deprived many children of their only nutritious meal through school-feeding programs. Moreover, children who experienced poor nutrition in utero or during their early years have long term effects on future cognition, educational achievement, and adult income.The Indian government, in recognition of the hardship imposed on economically vulnerable groups, has announced several relief measures. In mid-May the government announced a $260 billion rescue package for the economy, though its details are not clear. As part of this, the government said that it will provide free food grains to migrant workers for 2 months, as well as, subsidized loans to those in the informal sector and small farmers. Earlier, the government announced direct cash transfers (a one-time cash transfer of $13.31 to 30 million senior citizens and $6.65 a month to about 200 million poor women for next 3 months), as well as, make free food  available to them for the next 3 months.While the relief measures announced by the government are important and significant, it’s important to be cautious. The effectiveness of these safety nets will depend on the adequacy of the relief package, how well they reach the neediest groups, and efficiencies in delivery system. It is well known that safety net programs in India are generally inefficient and often miss the poorest. Secondly, it is important to note that these are one-off relief measures intended only for a short period of time. The economy will take some time to recover and the associated deprivation will linger long after the pandemic is over. Critically, the economic and health deprivation caused by COVID-19 will have long term effects. For example, pregnant women and young children who have experienced illness and/or poor nutrition in this period will likely suffer long term effects its terms of reduced cognition, educational achievement, and adult income.Epidemics have been particularly harsh on the economically vulnerable. One of the most powerful articulations of this was by Rudolf Carl Virchow, a prominent German biomedical scientist of the nineteenth century, who writing about Typhus outbreak in Upper Silesia (in Poland) remarked that the “population had no idea that the mental and material impoverishment to which it had been allowed to sink, were largely the cause of its hunger and disease, and that the adverse climatic conditions which contributed to … the sickness of its bodies, would not have caused such terrible ravages, if it had been free, educated and well-to-do.” Governments need to prioritize the economic security of those affected by corona virus control policies, as much as, ensuring that health systems are adequately resourced to manage the COVID-19 outbreak.The Guatemalan government has provided a weak and incoherent response to the threat of COVID-19 leaving, once again, the most vulnerable and marginalized populations even more unprotected. Although several weeks have passed since the first case of COVID-19 was identified, the government and public health authorities refuse to release detailed information about the numbers of cases, number of tests carried out, and their distribution. They are also unclear about the links between identified community cases, with negligible levels of contact tracing. Additionally, the Guatemalan army has been deployed to create barriers around communities that have a community case identified, and do not allow food or any resources inside. This will inevitably lead to the loss of human life among the most vulnerable and poor populations.Incoherent policies aimed at protecting the interest of the business interests of the Guatemalan chamber of commerce (CACIF) have caused much confusion over curfews, medicine, correct reporting behavior, and most importantly, how to treat those identified as testing positive for COVID-19. Neighbors stormed the house of a women and her five-year-old child in Escuintla, with the intent to lynch them for bringing the disease into their community .Weak health system responses have only increased the precarious situation of Guatemalans. With less than 400 intensive care beds, and fewer 50 respirators, the country is woefully unprepared for the wave of cases that will arise in the following weeks. Two reference hospitals had already collapsed in the first half of May, long before the pandemic hit its peak in the country. As a response, the president and physician Dr. Alejandro Giammattei, has alternatively referred to the virus as a simple flu, as something that would disappear as the country’s temperatures rose, and later as a matter of personal responsibility. It is unreal to believe that a Guatemalan citizen can maintain social distancing when the government forces essential businesses to open during very restricted hours, does not provide the social and economic support that is needed, and changes the policies and rules around the curfews almost daily.Despite strict rules, life in Guatemala City remains pretty much the same: long hours spent in traffic and crowded streets, with authorities being lenient with the curfew on pay days and reports of drunken congressmen and police officers disregarding social distancing orders.The presidential decree that closed down public transport left hundreds of thousands of Guatemalans that live in rural areas and small hamlets without communication to the outside world. With no trucks or busses, food has quickly become scarce and prices have hiked. In addition, the closing of the schools also limits the ability of many families to secure even one meal a day for themselves or the children. This is a country were 54% of the U5 children are chronically malnourished, and where almost 80% of indigenous people are poor. As of May 15, 2020, malnutrition had tripled among U-5 children.Guatemala agreed to become a “third safe country” for the United States, and the country is expected to host the asylum seekers that are fleeing the same conditions of violence, structural poverty, and exclusion that caused them to flee in the first place. In addition, the US has not stopped deportations and outside reports indicate that about 75% of deportees test positive for COVID-19 . Many haThe opposition has demanded explanations from the government and the Ministry of Health. During a hearing held before the identification of the first COVID-19 case in the country, MoH authorities were asked to present their strategy. In response, a vice-minister of health reported that there was no formal plan to deal with the COVID-19 threat because “Guatemala is a land loved by God”. When an openly gay congressman demanded explanations from the president, the non-practicing physician, Dr. Giammattei responded using vulgar and homophobic remarks, and declined to give more information. Since then, the MoH has reported that numbers are low because “God’s finger is on Guatemala”.A multimillion-dollar relief package was intended to help small businesses, individual families and people in the informal economy, which represents about 70% of the Guatemalan workforce. However, after the CACIF lobby, these measures where changed to benefit large businesses and banks, and the president vetoed the bill meant to provide relief from eviction and from basic services like water, internet and electricity being cut off. Municipal governments were asked to identify which informal workers are worthy of the government subsidy, and reports from human rights defenders show what was expected: these lists of workers are highly politized and only carried out in areas where the president has support from municipal authorities. This has great implications for local grassroots associations, many of which face considerable pushback from their local governments. The subsidy will be used as a political tool to benefit supporters and punish dissenters. In addition, only people with electricity in their homes will receive the family help.Guatemala, like the rest of the northern triangle in Central America, is set to become a killing field. With no health system resources, weak and incoherent government policies, and authorities interested in serving the economic elite over the poorest and most vulnerable of Guatemalans, there is little hope that the death toll will not be in the thousands.The high volume of coronavirus cases the U.S. is now facing, coupled with shortages in medical equipment and supplies, demonstrate the chilling consequences of neglecting public health and preparedness in fighting against pandemics such as COVID-19 and the disconnect between public health and healthcare delivery. Lack of preparation and lackadaisical attitude towards the outbreak led to an inability to take action early on. The U.S. is now the country with the most COVID-19 cases and deaths in the world, despite having weeks and even months to prepare.Ensuring the safety and well-being of vulnerable populations during the COVID-19 pandemic has presented a big challenge. These include the impoverished, the disabled, refugees, minorities, the uninsured, and other marginalized communities who have historically paid the highest prices in terms of health and welfare during infectious disease epidemics. They face significant challenges in gaining access to equitable care and staying economically and socially stable during a pandemic. Because of their higher rates of chronic disease, they are also at higher risk of developing severe symptoms if they contract the virus. Many vulnerable individuals do not receive paid sick leave or any type of paid leave that would make caring for a sick family member or a child home from school economically viable. Others may have lost their jobs as a consequence of the pandemic, making it more difficult to access quality, nutritional food, and safe, affordable housing .COVID-19 cases have skyrocketed among vulnerable populations. In Chicago, for instance, African Americans account for over 50% of all COVID-19 cases. The infection rate in predominantly black counties in the U.S. is also over three times that of predominantly white counties . The NatAdditionally, America’s homeless population faces major problems with regard to access to health care and an elevated risk of community transmission . The uniIn terms of testing and treatment costs, major insurance companies have waived copays for those insured . For theTo bridge the gap between public health and health care delivery, the federal government set up the COVID-19 Task Force headed by the Vice President. Along with FEMA  the Task Force is in charge of leading the nation’s public health response and securing resources to distribute to states . FEMA isTo enhance production of Personal Protective Equipment (PPE), the Trump administration has invoked the Defense Production Act (DPA), which allows the federal government to order the domestic production of necessary equipment in times of crises. The DPA has so far been used to command domestic companies to produce crucial equipment including ventilators, masks, and testing swabs. The Department of Defense has started handing out federal funding contracts to boost such production . To addrIsrael has universal health coverage through its National Health Insurance (NHI) law with four health funds operating as insurers and providers of services and a mix of government, public, private and health-fund owned and operated hospitals. A relatively quick governmental response to the COVID-19 threat, in terms of border closures and stay-at-home recommendations is considered to have helped Israel achieve relatively low confirmed cases and death rates to date (1901 cases/1 m population and 29 deaths/1 m population as of May 10th). Early on, the Israeli healthcare response has mainly relied on Magen David Adom  for performing testing, general hospitals which have almost all opened or built new designated COVID-19 units, and the four health plans which have all launched a primary care response for remote monitoring of low acuity patients. Health plans are charged with overseeing care to COVID-19 patients who are confined to their home or are transported (by the MDA) to designated hotels, currently constituting about 2/3 of all known cases. Such a widespread primary care response is called for especially given the limited hospitalization capacity, with a severe shortage of hospital beds (2.2/1000 compared to 3.6/1000 OECD average).Yet, despite universal healthcare coverage and a universal response coordinated by the Ministry of Health (MoH), a need for tailored approaches to population groups in the geographic and social periphery of Israel, is evident. One such group is that of religious Ultra-Orthodox Jewish populations. In some areas these groups have the highest infection rates due to a mix of risk factors, including low socio-economic status, crowded living conditions, minimal exposure to media platforms, and reliance on instructions from religious leaders who have not all conformed to governmental orders early on. Social distancing is anathema to the Orthodox Jewish communal way of life, and the government action of closing places of worship and study for the first time in the country’s history led to some early on opposition. Efforts to address COVID-19 among some of the ultra-religious populations require not only culturally tailored messaging but also culturally appropriate designated care facilities that can address religious needs such as dietary restrictions. Although a late response, the MoH together with other government authorities have invested great efforts to create the appropriate messaging as well as convene religious leaders and recruit their support by presenting data on contagion in synagogues for example. A recent commentary by Waitzberg and colleagues further details the unique needs of Ultra-Orthodox Jewish populations in Israel and the response to meet those needs .A unique approach is also required in order to meet the needs of people from Arab minority groups (constituting about 20% of the Israeli population). Main public health communication efforts have been slow in providing linguistically and culturally tailored messages addressing unique cultural phenomenon such as lack of taking tests due to the perception, by some, that contracting the virus is shameful. In Israel’s northern periphery, of which the Arab speaking communities constitute 54% of the population, efforts to educate and spread culturally tailored messaging have been led through a community-based coalition of municipalities and NGOs. These include creating a central emergency response center for the Arab sector, creating a linked-up network of health and social welfare platforms, and recruiting respected Arab healthcare professionals to assist in educating the public. The response center together with MoH and health funds, are increasing their educational efforts with the aim of preventing an outbreak among the Muslim communities with the current month of Ramadan. An additional consideration during COVID-19 in the Arab population is the markedly high prevalence of chronic morbidity, especially those which are already proven risk factors for serious COVID-19 morbidity such as diabetes, smoking, chronic lung disease, and autoimmune disease. This will require a response to assist the overstretched and challenged healthcare providers in their ability to provide care and support and presage an impending crisis of backlog neglected non-COVID-19 disease and social support.Other unique populations requiring specific consideration are those of non-citizens (mainly refugees and foreign workers), totaling about 250,000 people (~ 3% of the population in Israel). Non-citizens are not covered under the NHI law and therefore face significant barriers in access and provision of medical care (with the exception of some coverage to non-citizen children). These include financial, transportation, linguistic and cultural barriers, as well as fear of utilization of formal services due to suspicion of authorities. As part of the response to COVID-19, the Israeli MoH put together a team of representatives from non-citizen representative organizations and NGOs caring for non-citizens and issued clear instructions to all health funds and hospitals regarding the requirement to provide non-citizens COVID-19 tests and treatments at no point-of-care cost and without involving immigration officials. A COVID-19 test station was opened at a south Tel Aviv location, a concentrated living area of non-citizens. NGOs have also begun translating and distributing MoH COVID-19 messages in several languages, including Tigrinya and Thai.Finally, among the many types of unique populations suffering from the larger societal effects of COVID-19, in Israel and worldwide, are the societally marginalized people in prostitution. Amongst other restrictions, the current lockdown measures in Israel also included closure of two mobile clinics that since 2008 have been treating people in prostitution and providing specific medical and social responses regarding sexual health, sexually transmitted diseases and gynecological care. As prostitution in Israel is illegal, brothels operate under the radar and therefore are also not part of the awareness of COVID-19 transmission detection efforts, leaving the vulnerable sex worker populations at an even greater risk.During non-pandemic times, there are many drawbacks to living on an island that is remote from many of the major cities in the world. However, a combination of our remoteness, early border closures, and strict distancing measures, has meant that by mid-May Australia had only 6989 confirmed cases with 98 deaths . AustralAustralia has had universal healthcare since 1975  so testiAustralia’s pandemic response has had a strong focus on access to ongoing comprehensive primary care through telehealth. The Federal government introduced new payments for consultations conducted by telephone or video consultation. The earliest package mandated no out of pocket cost to the patient, but later versions of the legislation have allowed clinicians to charge a gap payment to patients deemed “not vulnerable” to the virus. Incentive payments have also been introduced for general practitioners who do not charge gap payments for vulnerable patients. While telehealth is an essential part of Australia’s COVID response to protect the healthcare workforce and patients, some of the equity issues associated with telehealth  are magnThe effects of ongoing colonisation of Aboriginal Torres Strait Islander populations is reflected in the higher rates of chronic disease and increased likelihood of living in overcrowded houses. The unique vulnerability of Indigenous communities has been recognised  and AustAccess to appropriate and quality housing is a significant equity issue in the Australian pandemic response. In recent years, there has been an increase in the numbers of people living in unstable housing situations due to rapidly increasing rental prices and low public housing stock . The fedThe unemployment rate in Australia will reach 10% due to the shutdown of businesses to control the spread of infection . The fedColombia is a High Middle-Income country that has invested steadily in the development and reach of its healthcare system, currently reaching over 96% of its legal residents with a comprehensive health insurance system . The sysWith a strong health system and a clear understanding of the COVID-19 circumstances as a both a health and an economic crisis, Colombia has embarked on innovative measures that aim to reduce the impact on inequality in the country. After initiating a national-level lockdown in the last week of March, the National Government began to implement key measures to reduce the economic impact on lower income and minority populations by distributing boxes of food supplies, targeting an income payment/subsidy of approximately US$20 per family, increasing the number of beneficiaries in the conditional cash transfer program and facilitating tax returns for small companies and self-employed tax payers. Along with the efforts to increase availability of hospital beds and testing facilities, the health sector has implemented innovative ideas such as the provision of home-based care and telemedicine for higher-risk groups, with the aim of reducing their unnecessary contact with the health system, the development of task-shifting strategies to allow lower cadre health workers to provide basic but essential primary health care services , the rapIt is too early to know what the impact of the economic/social and health sector policies will have on inequalities in Colombia, however, a few factors that have not been directly addressed by recent policies could prove to be continuing challenges. A first major challenge is the over 1 million poor Venezuelan migrants that have entered the country in the past years of which a large percentage have no access to formal ambulatory health services or insurance protection ; these mBelgium has a fee-for-service health care system with a complementary patient list system at the level of primary care , free choice of GP and direct access to secondary care. Primary health care plays an important role in the detection and the initial care of patients suspected of COVID-19. Patients with respiratory problems and/or fever are asked to contact their GP by phone. He/she does an intake interview and either reassures the patient when no COVID infection is suspected or gives advice on how to deal with the disease from home when a mild infection is suspected. Patients with more severe complaints are referred to a community-based triage point where general practitioners on-duty perform a physical examination and do technical investigations if the equipment to do so is provided in the triage facility: PO2 , CRP measurement , RX thorax (rarely possible). Patients who need more intense treatment are send to hospital, following a region-wide triage and referral protocol. Patients recovering at home are followed up by their GP trough online and/or phone consultations.Introducing this two-step primary care based approach allows not only for an efficient use of health care resources by decreasing importantly the burden of unnecessary use of the hospital emergency departments. It also reduces inequity in the detection of COVID patients, the initial care and the follow-up of the positive patients. Hence, all patients have access to the GP, to the triage centre and to the hospital. However, despite this universal accessible health care system some vulnerable groups experience major problems. First, the government communication on the measurements taken including this two-step procedure does not or hardly reach some vulnerable population groups: people not speaking one of the native languages, people with mental disorders or with limited health literacy, and homeless patients. Information is often focused on the white middle class and is too complex or does not take into account the difficult social circumstances in which some of these patients live. Because of lacking information in other languages than the national languages, some patients with a migration background turn to the available information from their home country resulting sometimes in behavioral patterns not conform the national guidelines regarding e.g. social distance but also health care use, making them vulnerable for social blaming. Some initiatives were therefore taken to translate health promotion materials and many practices actively reach out to vulnerable patients or invest in active follow-up procedures. This often time-consuming work is not remunerated in the fee-for-service system. Secondly, some patients, such as many of the homeless patients, do not have a fixed GP and experience therefor problems in accessing the health care system since direct access to the hospital is discouraged. Thirdly, although health care personnel is doing everything they can to provide health care to all who need it, it is unclear what the longterm financial consequences will be of hospitalization. Many patients, especially those without a voluntary hospitalization insurance and those who became jobless, fear personal bankruptcy. Even in a high income country with a strong welfare system such as Belgium the impact of becoming a COVID-19 patient might therefor largely contribute to inequity in health. Additionally, this gap might also be aggravated by the social differences in access to education (having access to computer at home to follow lessons …), in the ability to find a new job in a difficult economic context, and in the resilience to deal with multiple problems following the COVID pandemic on top of the already difficult social context in which many of our vulnerable population groups live.