Introduction: While close collaboration between general practitioners (GPs) and hospital specialists is considered important, the sharing of care responsibilities between GPs and oncologists during palliative chemotherapy has not been clearly defined.Objective: Evaluate the opinions of GPs and oncologists about who should provide different aspects of care for patients receiving palliative chemotherapy.Design: We conducted semi-structured interviews using six hypothetical scenarios with purposively sampled GPs (n = 12) and oncologists (n = 10) in the Netherlands. Each represented an example of a clinical problem requiring different aspects of care: problems likely, or not, related to cancer or chemotherapy, need for decision support, and end-of-life care.Results: GPs and oncologists agreed that GPs should provide end-of-life care and that they should be involved in decisions about palliative chemotherapy; however, for the other scenarios most participants considered themselves the most appropriate provider of care. Themes that emerged regarding who would provide the best care for the patients in the different scenarios were expertise, continuity of care, accessibility of care, doctor–patient relationship, and communication. Most participants mentioned improved communication between the GP and oncologist as being essential for a better coordination and quality of care.Conclusion: GPs and oncologists have different opinions about who should ideally provide different aspects of care during palliative chemotherapy. Findings raise awareness of the differences in reasoning and approaches and in current communication deficits between the two groups of health professionals. These findings could be used to improve coordination and collaboration and, ultimately, better patient care as results demonstrated that both disciplines can add value to the care for patients with advanced cancer.This study identified contrasting opinions of GPs and oncologists about who should provide different aspects of care for patients receiving palliative chemotherapy.Important themes that emerged were expertise, continuity of care, doctor-patient relations, accessibility of care, and communication.Although frequently using the same arguments, GPs and oncologists often considered themselves to be the most appropriate providers of palliative care. The aim of palliative care is to improve the quality of life of patients and their families . It is aIn the Netherlands, palliative chemotherapy is organized by hospital specialists, such as oncologists. Palliative chemotherapy is given in the non-curative setting to optimize symptom control, improve quality of life, and sometimes its given to improve survival. During this treatment phase, general practitioners (GPs) often lose contact with their patients and become involved again after chemotherapy has ended. This hampers the continuity and quality of care in the last phase of life . In addiClose collaboration between GPs and hospital specialists, with an increasingly greater role for GPs, is being promoted as a way to improve the quality of palliative care . HoweverTo date, there is a lack of agreement about the respective roles and responsibilities of primary and secondary care during palliative chemotherapy. To improve collaboration and clarity on who should provide care, more insight is needed into differences in the approach and reasoning of GPs and oncologists with respect to various clinical problems in the palliative care trajectory. For this reason, the present study evaluated the views of GPs and oncologists about who should provide which aspects of care for patients receiving palliative chemotherapy in the Netherlands.n = 12) and oncologists (n = 10) in the Netherlands. We followed the COREQ criteria, a guideline for reporting qualitative research interviews.We conducted a qualitative study with semi-structured in-depth interviews using six hypothetical scenarios with purposively sampled GPs (One researcher and GP in training (IN) conducted all semi-structured interviews. Respondents were presented with six scenarios see , each reGPs were recruited through the network of the department of General Practice of the Academic Medical Centre (AMC) in Amsterdam. All selected GPs worked in cities and villages of three provinces around Amsterdam, in the Netherlands. Oncologist were recruited from the hospitals in the working area of the participating GPs. The authors were not familiar with the participants. First, GPs and oncologists were invited by email with information about the study. Subsequently, they were informed by one researcher  by phone on details about the study and asked for agreement to participate. During recruitment, we used purposive sampling to achieve a wide sample of participants with respect to gender, age, years of experience, for GPs area of occupation  and for oncologist description of the hospital (i.e. academic vs non-academic). Details of the participants are shown in The semi-structured interviews were conducted face-to-face. The interview was pilot tested by IN (GP trainee). Inclusion continued until data saturation was achieved, defined as the situation in which no new codes appeared in three consecutive transcripts.Data were analysed using the six phases of thematic analysis described by Braun and Clarke . One resDemographic information on the 22 participants is provided in When discussing the scenarios, nearly all participants mentioned the importance of the cancer-specific knowledge of oncologists, and especially their knowledge of when and how to adjust chemotherapy, in contrast to GPs. This was mentioned more frequently when the participants thought that the patient’s symptoms and complaints were associated with chemotherapy. When this association was less obvious, as seen in scenario 2, predominantly GPs mentioned the lack of generalist knowledge of oncologists.The participants, more often GPs than oncologists, repeatedly stated having sufficient trust in the knowledge and expertise of GPs. However, if a patient consultation was cancer related, fewer participants thought GPs would be sufficiently competent. In scenario 3, a third of the GPs said they lacked cancer-specific knowledge but they still wanted to remain in contact with the patient. In scenario 5, which was about decision support, all participants felt that GPs lacked expertise about chemotherapy, expected side effects, and influence on survival. In the last scenario about end-of-life care, only two GPs mentioned feeling not competent.Continuity of care was considered important. Oncologists, but not GPs, mentioned that staying in charge helps them retain an overview of the patient in order to provide best care. For example, by staying informed about their medication use (scenario 3).Mainly GPs mentioned that the continuity of care provided by GPs was essential, so that they can remain in contact with the patient throughout the cancer trajectory and during end-of-life care. The GPs also argued that they, unlike oncologists, could evaluate, coordinate, and adjust care to the patient’s home situation. In the last two scenarios about decision support and end-of-life care, particularly oncologists mentioned the advantages of the patient seeing their GP, such as seeing the patient ‘in real life’, involving family members in decision-making, and facilitating death at the preferred place (including euthanasia).GPs and oncologists mentioned that oncologists have easier access to additional diagnostic testing. This was mostly mentioned in the context of the first three scenarios. However, the GPs argued that easier access could lead to overdiagnosis and overtreatment. Half of the GPs and oncologists emphasized that GPs should provide first-contact care and perform triage. GPs and oncologists frequently mentioned the better accessibility  and approachability of GPs, in contrast to oncologists. These arguments were mostly made in the context of the first two scenarios. Also both doctor groups mention that only the GP can perform home visits. This is a major advantage in the late stages of the disease. But also to provide first-contact and perform triage in patients who are not able to visit the GPs office or the oncologist in the hospital.Some oncologists mentioned that patients sometimes need the authority of a specialist to reassure them that their problems are not cancer related (scenario 2). In scenario 6 about end-of-life care, most of the oncologists and one GP mentioned it would be good for patients if they could still be in contact with their oncologist, so that oncologists could ensure a good transfer of care to the GP. Furthermore, remaining in contact with the oncologist might lower the threshold for going to the hospital, for example, if a blood transfusion is needed. This did not imply that oncologists should be the preferred doctor to consult.Arguments for choosing GPs as preferred health professional included seeing the GP as a mentor, especially in scenario 5 about decision support. Participants emphasized that, in general, patients have a better and longer relationship with their GP. This makes it worthwhile to consult a GP when it comes to making difficult choices. Nevertheless, no remarks were made in the interviews on the influence of the length of the enlistment in the GPs office on the above mentioned aspects.All participants stated there were no protocols or agreements between oncologists and GPs regarding care provision and coordination. An issue that came up in all interviews was the poor communication between oncologists and GPs. Most participants emphasized that improving communication between colleagues is essential to improve the quality of care, especially in palliative care. The main topic addressed was the need to keep each other up-to-date about patient management, such as adjustment of medication (scenarios 3 and 4) and the transfer of care in the terminal phase (scenario 6). The most-mentioned barrier to communication was the number of doctors involved, sometimes in several hospitals, which could lead to essential knowledge and data being missed, for example, if the oncologist is not aware that the GP has increased pain medication. Some oncologists mentioned a lack of time for getting in touch with colleagues and the poor accessibility of GPs, especially during out of office hours.GPs and oncologists emphasized that knowing which doctor is responsible for which patient and how to contact each other would improve communication. Participants frequently mentioned the importance of telephone contact, because that ensures that the person has received the information. Two oncologists mentioned email communication and working with electronic patient files, which they thought would create opportunities to obtain information without delay.GPs and oncologists have different opinions about who should ideally provide different aspects of care during palliative chemotherapy. Although frequently using the same arguments, GPs and oncologists often considered themselves to be the most appropriate providers of palliative care issues. Important themes that emerged were expertise, continuity of care, doctor-patient relations, accessibility of care, and communication. Findings raise awareness of the differences in reasoning and approaches, and in current communication deficits between the two groups of health professionals. This could lead to better coordination and collaboration and, ultimately, better patient care as results demonstrated that both doctor groups are clearly needed.This study identified partially contrasting opinions of GPs and oncologists about who should provide different aspects of care for patients receiving palliative chemotherapy. This was best seen in scenarios about physical complaints during treatment, which might be related to the anti-cancer treatment, the cancer, or to neither. It would be helpful if doctors could agree on how to coordinate patient care in these types of scenarios.Although frequently using the same arguments, GPs and oncologists often considered themselves to be the most appropriate providers of palliative care. This is in line with a recent study of psychosocial care in cancer survivors, in which both GPs and oncologists saw themselves as the main care provider . We founIn recent years, there has been growing interest in the role of GPs in the care of cancer patients. Studies have shown that, when using guidelines, GP-led care is not inferior to specialist-led care concerning quality of life and detecting recurrence ,16. AlsoAlso, it is important to contemplate the needs of the patient – to what extent do they prefer a specific health professional, for example a GP, for the different aspects of care. We did not address this in our study. However, a systematic review reported that patients consider that GPs provide good care, especially when they take time to listen and discuss matters fully . AdditioSimilarly, our study indicates that most participants emphasized that poor communication between oncologists and GPs hinders the provision of good-quality care. But to optimally use the skills and competencies of both oncologists and GPs, communication between the two groups of health professionals is essential. Previous research has also highlighted the deficits in communication and information transfer between health professionals in primary and secondary care . When doThe strengths and limitations of this study need to be considered. The use of scenarios covering the different stages of cancer enabled us to interpret the results in a structured way and to create more robust key themes. On the other hand, a limitation of the use of specific scenarios may include that the crises were all around reactive care, but less about the ongoing review process which is also vital. Also, there were no real acute or out of hours scenarios highlighted. Furthermore, a scenario were a patient is currently not, or no longer fit to receive chemotherapy and is referred to the GP by the oncologist is missing. GPs often complain about unclear treatment decisions by oncologists. It would have been interesting to ask both GPs and oncologists who is responsible for a patient in this scenario. Finally, we did not vary the complexity of the systemic treatment in our scenario’s, which could have affected the findings.Another limitation is that the interviewer works in primary care, which might have prompted participants, especially GPs to express socially desirable opinions. However, the observation that the participants mentioned both positive and negative arguments for both groups of health professionals suggests that they felt at ease discussing these issues. Another limitation is that we used quantitative data in order to visualize the differences between the opinions of the GPs and oncologists about who should be the ideal care provider in the six scenarios discussed . FurtherThis study provides insight into the views of GPs and oncologists about current practice in care for patients receiving palliative chemotherapy. It shows partially contrasting perspectives on who ideally should provide different aspects of care. The findings raise awareness about differences in the reasoning of GPs and oncologists and in their approach to specific aspects of palliative care. In general, oncologists put more emphasis on topics such as understanding the prognosis and treatment options, whereas GPs focused more on the social network around the patient, knowledge of their past medical history, and their ability to keep an eye on the situation at home, which creates continuity of care. Awareness of these different points of view and of current communication and information transfer deficits between GPs and oncologist, should help to provide better individualized care for patients. Future research should look for methods to clarify the role distribution, to optimize interdisciplinary communication and jointly improve the quality of care for patients with advanced cancer.


Intermittent claudication is a symptom of atherosclerosis of the lower limbs ) and is characterized by pain and cramps of lower limb muscles during exercise. Claudication leads to a reduction in physical activity of patients. PAD is a systemic disease. Atherosclerotic lesions located in the arteries of the lower limbs not only pose the risk of the ischemic limb loss, but above all, they are an important prognostic factor. Patients with claudication are at significant risk of cardiovascular complications such as infarcts or strokes. Comprehensive rehabilitation of patients with intermittent claudication based on the current TASC II  guidelines, ESC (European Society of Cardiology) guidelines, and AHA (American Heart Association) guidelines includes supervised treadmill training, training on a bicycle ergometer, Nordic Walking, resistance exercises of lower limb muscles, and exercises of upper limbs. A trained, educated, and motivated patient has a chance to improve life quality as well as life expectancy. One of the most common causes of disease and death in the Western world is atherosclerosis. The process is characterized by the formation of atherosclerotic plaques that narrow the lumen of the arteries, and its clinical symptoms depend on the location of the lesions. PAD prevalence varies widely between countries, increases sharply with age, and has a relation to ethnicity . AtherosPAD often manifests as intermittent claudication. It is characterized by cramp and pain of a given muscle group. Discomfort occurs only during exercise and intensifies gradually as one continues to walk until it forces complete stop. Effort-related lower limb muscle pain is associated with transient ischemia (IIa and IIb degrees of Fontaine classification). The patient with intermittent claudication does not feel any discomfort at rest because the blood flow and oxygen supply in the limb are then replenished. During exercise, narrowed or occluded arteries supplying the muscles of the lower limbs limit the necessary increase in blood flow, which results in disproportions between metabolic demand and oxygen supply and is associated with the occurrence of claudication . As a reIntermittent claudication limits the locomotive abilities and also makes it difficult for the patient to actively participate in personal, social, and professional life and is one of the causes of disability of middle-aged and elderly people . FontainThe basic examination of patients with PAD consists of palpation of the pulse in the typical sites on the lower limb, i.e., in the inguinal and popliteal regions and dorsal region of the foot and medial ankle. The lack of a palpable pulse indicates a significant narrowing or occlusion in the arterial system proximally to the examined area .There are two determinants of the patient's ability to ambulate. The maximal claudication distance (MCD) is defined as the distance after which the patient is forced to stop because of severe pain and muscle cramps. Another one, i.e., pain-free walking distance (PFWD), is the distance traveled before any pain occurs. A correctly estimated distance is an important element in the decision of a vascular surgeon or angiologist regarding further medical or surgical treatment. A distance of about 100 m and below prequalifies the patient for invasive treatment .The degree of impairment of blood supply to the limb is assessed by measurement of the ABI . The ABI is expressed as the ratio of the systolic pressure measured in the area of the ankle and the systolic pressure measured in the arm. Under physiological conditions, the ABI in the supine position is close to 0.9–1.4. In patients with PAD, ABI values fall below 0.9, and below 0.4, it correlates with critical limb ischemia . It shouThe latest findings of the European Society for Vascular Medicine in May 2019 contained in the Second European Agreement prove that classic PAD classifications are not complete and evidence-based. The need to define patients with a high risk of amputation and to categorize the patients whose prognosis improves owing to revascularization was indicated. Measurement of systolic toe pressure (STP), with a value below 30 mmHg suggesting the need for revascularization, appears to be an important factor. Patients with STP above 30 mmHg and suspected PAD should be treated conservatively in specialized centers, and the need for revascularization should be considered individually .In physical examination, attention should be paid to changes in the color of the skin, especially to the paleness which increases after lifting the limb up. Long-lasting chronic ischemia is indicated by hair loss, especially in the case of unilateral ischemia as opposed to the healthy limb. Additional features include thickened, deformed, slow-growing nails with a tendency to fungal infections. Chronic ischemia of the lower limbs is also characterized by muscular atrophies affecting the muscles of the feet and shins. The Ratschow test is a useful adjunct to routine peripheral vascular assessment and, if positive, suggests more severe ischemia with distal limb artery involvement .Location of the pain described by a patient may be useful for determining the anatomical area of the lesion, which may later facilitate diagnostic and therapeutic decisions. Claudication affecting the buttocks and thighs, sometimes combined with impotence, may be associated with stenosis or occlusion within the bifurcation of the abdominal aorta (Leriche's syndrome). The most frequent localization of PAD is the superficial femoral artery, and its narrowing is manifested by claudication within the calf. Exercise pain in the foot usually indicates impairment of the calf arteries—tibial anterior, tibial posterior, or sagittal (at least 2 of 3). Lesions may also occur in multiple sections of the arterial system, and it usually follows more advanced stage of atherosclerosis .Physiotherapists can start working with the patient with lower extremity PAD only if physical therapy is indicated by the angiologist or vascular surgeon after the patient has been diagnosed with lower extremity PAD; the location of the stenosis causing lower extremity ischemia has been detected; the stage of chronic ischemia, the initial and absolute claudication distances, and the type of treatment  are determined; and coexisting diseases and contraindications to specific rehabilitation methods are known. An individual personalized outpatient rehabilitation program should be designed for each patient.The current principles of atherosclerotic treatment of lower limb ischemia are based on the 2007 TASC II  guidelines and the 2017 ESC (European Society of Cardiology) guidelines, prepared in collaboration with the ESVS (European Society for Vascular Surgery) , 20. TreThe walking training is a very important element in the conservative treatment of PAD, apart from pharmacotherapy and the modification of risk factors, which include smoking, lipid disorders, hypertension, diabetes, obesity, and stress. In accordance with the ESC and TASC II guidelines, the supervised training on a treadmill should be a primary procedure in all patients with intermittent claudication . TraininTraining on the treadmill can be gradually modified by extending the duration from 30 to 60 minutes as well as the speed from 3.2 to 4.8 km/h . AtherosIt should be noted that atherosclerosis is a systemic problem and cardiac rehabilitation is refunded by the national health services. At the same time, rehabilitation of patients with PAD in many countries is not eligible for refund.Physical activity in patients with intermittent claudication is an integral part of general treatment. Since 69% of eligible PAD patients refuse to participate in supervised exercises 3 times a week because they are too burdensome for them, it is extremely important both to convince them about the purpose of walking exercises and to skillfully introduce training in their everyday activities . In the On the contrary, it would also be a mistake to limit the patient's physical effort since the mere exchange of 10 minutes of a sedentary lifestyle for 10 minutes of low-intensity physical activity reduces mortality by as much as 9% . The totIn the rehabilitation of patients with PAD, cycling and exercises on a bicycle ergometer (stationary bike) or a rehabilitation rotor, i.e., a device for exercising the lower limb muscles in a sitting position, are also used. These activities are particularly useful for patients who for some reason have limitations in conducting walking training, for example, degenerative joint changes in the lower limbs, neurological disorders, or excessive body weight. Because exercises on a bicycle ergometer with a comparable load increase the activity of the proximal muscle groups of the limb, while the march causes the load on the distal muscles—mainly calves, it is important that the patient places his forefoot, instead of the midfoot or the heel, on the pedal, which will allow for greater crural muscle involvement during exercise. If a patient is riding a bicycle or pressing the rotor pedals, it is not meant to make him or her breathless or evoke pain in the ischemic muscles of the lower limbs. Safe training on painless distances or until a small pain sensation interspersed with a few minutes of rest is recommended instead. The patient will benefit the most if the training is run every day and if the total distance covered about 10 km. The appropriately chosen load should be based on the result of an exercise test with CTK, CAS, and ECG recording, prior to the rehabilitation , 47.− age). This range is considered to be the target heart rate during exercise. Exceeding this limit might pose a risk to the myocardium [Training of upper arms (arm cranking) can be a highly beneficial procedure in patients with lower limb claudication according to some papers. It is suggested that improvement of cardiovascular endurance may contribute to improving gait. It has been demonstrated that exercises of upper limbs increase the antioxidant potential and lead to the extension of painless and maximum distance of claudication. Certainly, it can also be expected that this form of training contributes to strengthening the muscles of the upper limbs, possible blood pressure normalization, and improvements in the circulatory system as a whole –50. The ocardium –53. PatiPhysical therapy is also used in the treatment of patients with intermittent claudication. It is not an isolated form of therapy but rather an accessory element of therapeutic regimen with primarily hyperemic, vasodilating, and analgesic and anti-inflammatory effects. This applies particularly to patients' concomitant conditions such as degenerative changes of the joints of the lower limbs, in which the ability of walking is deteriorated. These methods can also provide the patients with a preparatory element for muscle and joint kinesitherapy, as they result in tissue relaxation . PreviouThe vasodilatation is achieved through the use of magnetotherapy, galvanic current, iontophoresis, Bernard's diadynamic currents, TENS, Träbert currents, and interference currents. The effect can also be obtained using infrared radiation, ultrasounds, and therapeutic baths, preferably carbon acid, radium, sulfide and hydrogen-sulfide, or brine .The beneficial effect of tissue overheating on patients with obliterative atherosclerosis of the lower limb arteries is associated with an increase in blood flow. It can be achieved by means of infrared radiation of the Sollux lamp. These treatments also lead to relaxation of contractured muscles, joints, ligaments, and tendons.In order to induce contraction of specific muscles, electrostimulation with electric impulses or Wadit high-frequency therapy is used for their stimulation. This type of electrogymnastics can be used in the treatment of muscular atrophy and muscular weakness, for example, in patients with short claudication distance .The effect of biostimulation of microcirculation leading to restoration of the network of damaged blood vessels, improvement of the rheological properties of blood, and increased production of collagen by fibroblasts is observed during polarized light therapy. This speaks for the potential use of this physiotherapeutic method in the treatment of patients with intermittent claudication .Analgesic and anti-inflammatory effects on muscles, joints, tendons, and nerves are obtained, thanks to the use of electrotherapy, including galvanic current and iontophoresis, diadynamic currents, interference currents, TENS, short-wave diathermy, and magnetotherapy. Light therapy with analgesic effects includes laser therapy, piler polarized light, and infrared radiation—Sollux lamp. Ultrasounds give a similar therapeutic effect .The Kneipp method is used to reduce the activity of the vasomotor nerves resulting from regulation of the autonomic nervous system centers. This particular form of balneotherapeutic treatment in the case of atherosclerosis of the lower limbs is based on the comprehensive use of hydrotherapy (mainly Hauffe showers and baths), therapeutic use of physical activity, learning health-related lifestyle, phytotherapy, and mental hygiene. Exercises in water, in particular swimming, have a beneficial effect on the function of the heart and peripheral vessels. Faster circulation of blood contributes to better supply of tissues and organs with oxygen and nutrients and increases the exercise tolerance of the human body , 61.Endovascular or surgical invasive treatment is indicated only in a subgroup of patients with atherosclerotic lower limb ischemia, in whom motor rehabilitation and conservative treatment did not bring the expected improvement and in the subjects with critical limb ischemia due to the risk of amputation and even death. Generally, it is assumed that invasive treatment is undertaken when the distance of claudication is 100 m and below, as well as in the patients with resting pain and necrotic changes (III and IV degrees of Fontaine classification). The degree of impairment of the patient's mobility and quality of life, the anatomical location of atherosclerotic lesions, the expected immediate and remote benefits of treatment, and the risk of complications are the most important factors in the choice of therapeutic modality . There aPercutaneous transluminal angioplasty (PTA) is an intravascular procedure and involves the widening of the narrowed or even occluded artery lumen. Very often, the stent implantation or the introduction of a specific “scaffolding” is an extension of balloon angioplasty. It is used to prolong the patency of the vessel after angioplasty and “hold” the atherosclerotic plaque or treat the dissection of the artery following ballooning.Respiratory and antithrombotic exercises of lower legs, consisting in activation of the calf muscle pump, are a routine element of prophylaxis for hospitalized patients and constitute a valuable supplement to the rehabilitation of patients after endovascular procedures. Initially, the exercises involving the hip joint or the area of the puncture site  are avoided so that the hematoma does not develop . After tin vivo. A popular product rich in nitrates is beet juice. It can be assumed that the combination of beet juice intake and walking training would bring the greatest benefit to patients with PAD [Proper education of patients with atherosclerosis of the lower limbs should be a professional and individualized action and cannot be based solely on spreading of the old Housley's principle “stop smoking and keep walking” .The patiwith PAD .Diabetes is an important risk factor for the development and progression of PAD. Among diabetic patients, intermittent claudication occurs 4 times more frequently, whereas gangrene and limb amputation as a consequence peripheral atherosclerosis occur 15 times more often than in nondiabetic subjects , 72. ThePAD is a systemic disease. Symptomatic PAD not only poses the risk to ischemic extremity, but above all, it is an important prognostic factor of general cardiovascular complications. Rehabilitation of patients with intermittent claudication should be a comprehensive, long-term action, initiated from the moment of diagnosis. It should be individually matched to the patient's capability. A trained and motivated patient has a chance to improve both the life quality and expectancy, which is why education of patients with PAD is extremely important. Effective education should be conducted not only by angiologists or vascular surgeons but also by physiotherapists and nurses.


The main experienced symptoms and diseases were thirst , excessive sweating , exhaustion  and headache . The most common way to reduce heat stress was drinking more water . Among the informed workers, the prevalent source of information was discussions. Therefore, educational campaigns are recommended, together with the testing of the efficiency of mitigation measures that will be proposed on the Heat-Shield project portal.Changing patterns of heat waves are part of the global warming effect and the importance of changes is reinforced by their negative impact on society. Firstly, heat waves were analyzed in Brnik (Slovenia) and Larisa (Greece) in the period 1981–2017 to reflect the environment which workers are exposed to. Secondly, outdoor workers  provided a self-assessment of heat stress. The heat wave timeline is presented as an effective way of illustrating long-term changes in heat waves’ characteristics for various stakeholders. In both countries, workers assessed as significant the heat stress impact on productivity (Greece 69%, Slovenia 71%;  Heat waves are typically known as prolonged periods of excessive heat or “summertime episodes with extremely high surface air temperatures and lasting for several days or longer” . SeveralThe Intergovernmental Panel on Climate Change  classifiThe number of vulnerable people exposed to heat waves around the world increased by about 125 million between 2000 and 2015. In the same period, the productivity of the outdoor working population decreased by 5.3% worldwide . Hot worThe successful design and implementation of a prevention plan require an effective and complete heat warning system based on critical thresholds . AccordiIn this light, the purpose of the study was, first, to analyze the climatological background of heat waves and outdoor working conditions in two climate-heterogeneous European countries, Slovenia and Greece. Additionally, we obtained Slovenian and Greek outdoor workers’ self-assessments of their heat stress symptoms, heat-induced diseases, and their own capacity to reduce their exposure to heat stress. Our aim was to compare both countries to identify the main differences and similarities between them with respect to the occurrence of heat waves, their impacts, and workers’ perceptions of heat stress.The impact and the perception of a heat wave vary considerably from region to region. For example, multi-day air temperatures above 30 °C in summer in Central or even North Europe would be expected to create more problems than similar temperatures in South Europe . For thiTmean): In the continental part of Slovenia, a heat wave occurs when Tmean is equal to or exceeds 24 °C for at least three days )The first part of the study showed the main differences in the climates of Brnik and Larisa in terms of heat waves. Daily mean air temperatures were much higher in Larisa and heat waves were already present in the earlier years of the period 1981–2017. Although the definition of a heat wave is still an unresolved issue within the scientific community e.g., ,8,24,27),2724,27]The second part provides an important insight into how wide the common range of experienced health problems already is, and shows that productivity loss due to heat stress was noted. Working people are particularly affected by high heat exposures in occupational settings , and thiAlthough the climates of both cities differ in heat intensity, the results showed that workers from both countries assessed heat stress impact on productivity as significant. Additionally, a slightly higher percentage of Greek workers  assessed the loss of productivity due to heat stress to be higher than 30%. The majority of respondents considered heat stress to have no impact on concentration, but to significantly affect well-being. Symptoms and diseases are mainly the same as described by Luther et al.  to be thConsidering the stated high impacts on the productivity and well-being of workers, it is urgent to provide measures or guidelines to mitigate the impacts of heat stress. First of all, there is still room for improvement in the provision of information, as more than half of the workers have not yet been informed about possible impacts and actions during heat waves. At a later stage, even when the knowledge level of individuals is good, there can be a misconception of people’s own risk  or abiliDespite our best intentions, it is important to note that the results obtained in this study should be considered through the prism of certain limitations. For instance, the results are not necessarily representative for Greece and Slovenia as only two stations were included in the analysis of heat waves and due to the small size of the samples. However, the research gives a first indication of the heat stress perception in these countries. Also, the workers’ self-assessments may be too subjective or misinterpreted, but the majority is consistent with the already detected impacts of heat stress.Our study showed the significance of heat stress impacts on outdoor workers, bearing in mind that the data is limited to two stations in Greece and Slovenia. The assessed high negative impact on productivity and well-being, endangering health, is consistent with the other findings of the Heat-Shield project, where we aim to improve both health and productivity. An exchange of experiences and lessons learned can substantially accelerate and improve the process of ensuring more heat resilient working conditions in Europe. In communication with health institutions, policymakers, employers, workers or others outside of the scientific field, it is of great importance to find out how to communicate results in a clear and easy to understand way. Here, the representation of heat waves used in this paper can be a good example, illustrating the increase in the frequency, intensity, duration and time span of heat waves to the point.The comparison of two stations in Greece and Slovenia showed higher temperatures and more heat waves in Greece, but more noticeable changes in this field in Slovenia. Therefore, the lower degree of acclimatization among Slovenian outdoor workers may be one of the main reasons they have more often described conditions as very hot and perceived more heat stress symptoms and heat-induced diseases than Greek workers. On the other hand, much higher temperature extremes in Greece could be the reason higher productivity loss was perceived in Greece and why some heavier diseases were experienced mainly there. As workers in both locations share a similar level of knowledge about heat stress, educational campaigns are needed and further research of the problem, which includes the testing of the efficiency of several mitigation measures, will be proposed on the Heat-Shield project portal.


The ongoing load-shedding and energy crises due to mismanagement of energy produced by different sources in Pakistan and increasing dependency on those sources which produce energy using expensive fuels have contributed to rise in load shedding and price of energy per kilo watt hour. In this paper, we have presented the linear programming model of 95 energy production systems in Pakistan. An improved multiverse optimizer is implemented to generate a dataset of 100000 different solutions, which are suggesting to fulfill the overall demand of energy in the country ranging from 9587 MW to 27208 MW. We found that, if some of the power-generating systems are down due to some technical problems, still we can get our demand by following another solution from the dataset, which is partially utilizing the particular faulty power system. According to different case studies, taken in the present study, based on the reports about the electricity short falls been published in news from time to time, we have presented our solutions, respectively, for each case. It is interesting to note that it is easy to reduce the load shedding in the country, by following the solutions presented in our dataset. Graphical analysis is presented to further elaborate our findings. By comparing our results with state-of-the-art algorithms, it is interesting to note that an improved multiverse optimizer is better in getting solutions with lower power generation costs. Proper management and finding out optimal solutions to utilize the available power production sources is an important optimization problem in Pakistan, which is the main theme of this paper –11. AccoAccording to a report published by National Electric Power Regulatory Authority (NEPRA) in 2016 , the totX1 to X5. They have fixed the per unit price to estimate the overall mathematical model. We have extended the model and included 95 production sources, which generates electricity using different means . We have implemented per unit price according to the actual price of fuel used to run these sources. The production capacities of each source are given in In this study, we have explored a scientific decision-making approach in terms of mathematical programming for providing a strategy to utilize the available production sources of Pakistan to meet the demand of energy in different seasons. However, in , a generIn the last few years, evolutionary algorithms (EAs) are implemented to solve different real-world optimization problems. EAs simulate social behavior or natural procedures in order to handle optimization problems with best solution. Among the popular EAs are the Bat algorithm , 24, graThe multiverse optimization algorithm (MVO) is a nature-inspired optimization technique given in . The keyCurrently, as can be seen in the former review, there are limited works on improving the performance of MVO. This work presents a new method of initialization with the MVO algorithm called improved multiverse optimization algorithm (IMVO). The experimental results on mathematical model of economic dispatch problem of electricity generation system in Pakistan and its three case studies show that IMVO is very competitive over FA, Bat algorithm, and GOA.Furthermore, we have presented solutions to five case studies for proper management and production by all the 95 energy producers in the country. Our model can be implemented to reduce the load shedding and distribute the burden of production on respective power production units.This work is organized as follows: The probability of having the white holes is directly proportional to the inflation rate.Individuals (universes) having higher inflation rate send objects through white holes with higher probability.Individuals (universes) having higher inflation rate send objects through white holes with higher probability.Individuals (universes) having lower rate of inflation send objects through black holes with higher probability.The objects present in all universes are moved randomly towards the current best individual (universe) through wormholes. This random process occurs without taking into account the inflation rate. A sketch of this algorithm is shown in The MVO algorithm simulates the theory of multiverse, where three verses play main part in the whole algorithmic procedure: these are white holes, black holes, and wormholes. This is a population-based algorithm, where the population is searched in two phases: exploration in which the search space is visited very well and exploitation performs the search in neighborhood of a solution extensively. White hole and black hole, in the theory of multiverses, are used as exploration agents, and wormhole is acting as exploitation agent in this algorithm. In U represents the matrix of candidate solutions, d is the dimensions of the problem, and n is the number of universes (population of solutions) which can be represented as follows:xij is the jth parameter of ith universe, Ui denotes the ith universe, NI (Ui) is the scaled inflation rate of the ith universe, r1 ∈ (01), and xkj is the jth parameter of kth universe selected by a roulette wheel selection mechanism. The objects are changed among the universes without perturbation. To maintain the balance between exploration and exploitation during the searching process in MVO, each universe is randomly treated to have wormholes to transport its objects through space. In order to ensure the exploitation around the current best solutions, particular wormhole tunnels are always established between a universe and the best universe formed so far, which can be represented mathematically as follows:Xj is the jth parameter of best universe formed so far, TDR (travelling distance rate) and WEP (wormhole existence probability) are coefficients, lbj and ubj are the lower bound and upper bound of jth variable, respectively, xij is the jth parameter of ith universe and r2, r3, and r4 are random numbers between 0 and 1. WEP and TDR are treated as adaptive formula as follows:Wmin is the minimum , Wmax is the maximum , l is the current iteration, L is the maximum iterations, and p is the exploitation accuracy over the iterations . Higher the value of p, the sooner and more accurate exploitation/local search is performed [The initialization phase of MVO can be written as follows:erformed . It is werformed .According to the trend in stochastic techniques, random initialization in each generation is the frequently used method to initialize algorithms without knowing any priory information about the problem in hand. The idea of random initialization is often pushing the algorithm to explore the given domain very well, while the exploitation around best solutions is not carried out by this type of initialization. We have used an initialization strategy in which IMVO is balanced in terms of exploration and exploitation. We have designed a two-stage initialization strategy: in the first stage, the algorithm is initialized randomly for a certain number of scattered solutions in the whole search domain. In stage two, after the algorithm completes a certain number of iterations and collects best points in the search domain, we initialize the IMVO with population of these best solutions to concentrate the algorithm on exploitation around the best solutions in the space. Hence, in current studies, we have assigned the function evaluations, fixed to solve a problem, in two parts. The first part initializes with random populations and collects the best solutions of each iteration by using the following equation:In the second phase, the algorithm is directed to search in the neighborhood of the best solutions obtained in the first part and exploits the search space around the population of these best solutions.xi,  i=1, 2,…, 95 and ui,  i=1, 2, 3,…, 95 represent different costs per kWh for each source. The objective function represents the total cost (C) incurred to meet the demand of energy in different situations. Mathematically,ui represents the cost per MWh and xi are the different sources given in nomenclature. The objective of this study is to produce a data set of solutions so that we can select the required optimal solution fulfilling the given demand with lowest cost per kWh as compared to other solutions in the data set. For more details, about the data set generated, the reader may refer to [In this paper, we have presented an optimal mixture of energy production system as a linear programming (LP) model consisting of different decision variables, representing different electricity production sources of Pakistan, see Nomenclature . Each varefer to . The proTotal demand constraint:x1 are producing higher demand which are overburdened and could be relaxed by installing or expanding alternate sources. In 4Table 2We have implemented IMVO which is coded in Matlab R2016 . The maiIn this paper, an improved multiverse optimization algorithm is implemented for solving a linear programming model for proper management of electricity production sources in Pakistan. To address the proper management of power production sources, several bound constraints, such as constraint for total demand, and bounds on all variables are considered. The objective function is linear with 95 decision variables and different coefficients. The IMVO algorithm is easy to implement with few parameters. We have found solutions for five different case studies and analyzed all solutions graphically. A link to the data set of 100000 different solutions is provided in this paper. In our results, we have obtained better solutions to meet the power demand in summer. It is recommended that current resources can produce the required power demand but some of the resources are required to be expanded in capacity along with installation of new sources. In future, we intend to include other factors, like power loss, in our model.


To analyze the perception of the relevance of introducing bilingual(Portuguese-English) musculoskeletal imaging education into radiology anddiagnostic imaging residency programs, describing the method used.To evaluate the relevance of incorporating the bilingual study ofmusculoskeletal imaging into medical residency programs, we administered aquestionnaire, consisting of several multiple-choice questions and onesubjective question, to 21 radiology residents at a private tertiaryhospital. The residents completed the questionnaire voluntarily andanonymously.Integrating English teaching into radiology training was considered importantby 95.2% of the residents. Approximately 90% of residents believe that themethod applied at their institution is suitable for learning.The introduction of the English language into the teaching of musculoskeletalimaging in the radiology residency program was perceived positively by theresidents, and the preceptors effectively supported those activities. Since English is the major language in medicalsciences(2). Japan has also inserted English into many areasof study, and in 2003 presented guidelines to improve the quality of Englishinstruction for professional training, thereby better preparing their graduates forthe labor market(3).Currently, bilingual study for medical students is a routine method in severalcountries around the world, notably in China, where policies were implemented in2001 to achieve that objectiveThere are few studies on bilingual education in medical radiology, especially inmusculoskeletal imaging. Therefore, this article aims to evaluate the perception ofthe relevance of integrating English instruction into the training of radiologyresidents, as well as to describe and discuss the available literature on otherbilingual education initiatives.This study, conducted between February 2015 and February 2016, involved radiologyresidents at a private tertiary hospital in Fortaleza, a Brazilian city in the stateof Ceará. During the study period, classroom sessions, case studies, andpresentations of articles were conducted in English on a weekly basis. Thepresentations were organized in a manner that the first presentation of the monthwas performed by a trained attending in musculoskeletal radiology residency program(preceptor) or by the medical English professor of the institution. The remainderclasses during the month were presented by residents or fellows.The first presentation of each month (that given by a preceptor or professor) had asmain goal the demonstration to residents how to create a well-developedpresentation, providing models, as well as to address the questions and difficultiesthat are more common in the group, such as pronunciation and the ability to discussthe content in the foreign language. Recent articles on relevant musculoskeletalimaging themes, published in the main international journals, were used as referencematerial.In the following weeks of each month, first- to fourth-year residents and fellowsproduced lectures totally in English, initially presented only to the professor ofmedical English, who provided guidance and corrections of pronunciation, as well asof the written content. After correction, the material was presented to the wholegroup. At the end, the preceptor of the musculoskeletal radiology residency programmade comments on the topic. After each presentation, the English teacher provided aone-to-one feedback to the resident who taught the class, to avoid personalembarrassment or insecurity.After the above-described teaching procedure had been employed for one year, aquestionnaire was given to 21 resident physicians, to find out their opinions. Theresidents completed the questionnaire voluntarily and anonymously. The questionnaireincluded the following inquiries:Do you consider a relevant issue to integrate English into your radiologyinstruction?How do you evaluate this method of radiology and English in the residencyprogram?How do you evaluate your performance in this integrated teachingactivity?To what degree are the preceptors, in general, committed to thisactivity?Were the chosen teaching methods adequate for learning?Do you have any comments or suggestions in regards to the teachingactivity?With the exemption of the final question, which allowed subjective answers, thequestionnaire comprised multiple choice questions, with the following possibleresponses: yes or no; excellent, good, satisfactory, or poor; and completely agree,partially agree, partially disagree, or completely disagree.All 21 of the first- to fourth-year resident physicians or fellow volunteerscompleted the forms. Of the total (21), 20 (95.2%) considered important to integrateEnglish into radiology instruction, whereas one (4.8%) did not.Nineteen (90.5%) of the volunteers agreed that the method applied for bilingualinstruction in musculoskeletal imaging is adequate for learning and only two (9.5%)disagreed. Neither of them disagreed completely. Nine volunteers (42.9%) evaluatedtheir performance in this integrated bilingual education activity as good orexcellent, eleven (52.4%) evaluated as satisfactory, and only one (4.8%) evaluatedas poor. Regarding the statement if the preceptors were dedicated and committed tothis activity, 20 volunteers (95.2%) agreed, only one (4.8%) disagreedpartially.The final question was optional and solicited observations or suggestions from theresidents about this teaching activity. One participant submitted the followingcomments: "I believe that bilingual study is relevant but should not be exclusivelybilingual. Studies in English should be intercalated with studies in the students'mother tongue. Thus, we would have a theoretical basis for more effective learning."Another volunteer commented, "I consider the integration of English intomusculoskeletal radiology instruction important because it allows the resident tostay updated through reading international articles in areas where there is agreater demand.", as well asparticipation in international conferences and meetings. In this context, the mainradiology journal in Brazil accepts and had published articles inEnglish(6-12). Given the lack of studies on bilingual educationin radiology, especially musculoskeletal imaging, we were motivated to analyze theintegration method of English into radiology instruction.English proficiency is crucial for the professional growth of physicians, since itallows adequate access to updated medical information(13).In order to better train professionals for their career, the Japanese Society forMedical Education developed guidelines aimed at proficiency in reading andunderstanding books and articles in English, as well as the ability to use Englishin conducting medical interviews and making presentations at scientificmeetings(1). Teachers can use survey questionnaires, fieldobservations, and interviews for such analyses and thus understand what type oflearning barriers their students confront(2).English for a specific purpose (ESP) has been gaining considerable prominence inrecent decades for the teaching of English. The ESP method is based on the analysisof the real needs of each student, from their level of knowledge of the language tothe learning methods in which they have already exposed, along with theirmotivations and aspirations(1). This method advocates the inclusion of threeelements of language in the medical English classes: functional language, whichrefers to specific medical skills, such as dialogues used in a consultation or inthe discussion of clinical cases; linguistic competence, linked to the ability tounderstand the language and express verbal fluency; and the system of language,directed to words that express sympathy with the patient and are of extremeimportance in professional practice(14).Teaching English for medical purposes is based on the idea of a practicalperspective. The goal is to prepare students for specific situations they willencounter in their work environment. The ESP method is focused on the context oflanguage, along with the acquisition of specific vocabulary, giving impetus to trainstudents in specific fieldsIn our study, we used scientific articles, classes, and clinical cases, simulatingreal-life situations and thereby promoting familiarity not only with medicalvocabulary, especially in the area of musculoskeletal imaging, but also with formalvocabulary. The command of English was categorized as basic (fewer than two years ofprevious study) in 10% of the residents, intermediate (approximately four years ofprevious study) in approximately 70%, and advanced (six or more years of previousstudy) in 20%. We also emphasize that the only resident who felt that theintegration of instruction in English into the curriculum was irrelevant was one ofthose with only the most basic knowledge of the language. That same resident wasalso the only one who reported having performed poorly on the activity, as well asbeing the only one to disagree  with the statement that thepreceptors were dedicated and committed to the activity. We also found that the tworespondents who partially disagreed with the method employed were the ones with amore basic knowledge of English. Analyzing this information, we can infer that alack of previous knowledge of English can be an obstacle, limiting residentadherence to the method employed, and requiring personalized attention to each caseto maintain their motivation and participation in the activity. In our study, wearranged, with the medical English professor, a distinguished attention and guidanceschedule for the residents who demonstrated more difficulties in preparing theirlectures in English.We emphasize that the method adopted here is easily applicable to residents withintermediate or advanced English language skills, who accounted for approximately90% of the sample. Over the course of the year, the progress in performance of theresidents and their their presentations in English was evident. In general, theywere motivated and confident. Even when making minor errors in pronunciation orsyntax, they were able to adequately convey the message of their presentations,promoting good understanding among the listeners.(1). Our groups had an average of 15 people perpresentation, thereby keeping the residents free to expose their difficulties andarticulate their questions. The professor of medical English, in addition to havinga good knowledge of the language, must be have a good communication and should alsobe familiar with the main technical terms and medical nomenclature used in thespecialty, although a medical degree is not a prerequisite(14).One of the most important strategies to better understand the English language is theformation of small study groups, since they allow the customization of the studyapproach for each student(4).The professor of medical English at our facility is course-certified by the leadinglanguage schools in Brazil and is the coordinator of a language center specializingin physicians and other health professionals. The internet has become a great allyin this learning experience. The easy access to websites that provide a phoneticquery for each word and the possibility of hearing the correct pronunciationfacilitates understanding and memorizationThe contemporary method of bilingual education for the medical field, in mostcountries, is carried out using problem-solving strategies and simulations ofreal-life situations. This method contributes to the training of professionals withgreater confidence and ability to cope with the adversities they will encounterthroughout their careers. Radiology residents and fellows also benefit from theimplementation of the bilingual study of musculoskeletal imaging, since thisactivity provides them with new sources of knowledge and makes them better preparedto work in their chosen specialty.We conclude, based on a review of the literature and our experience, that theintegration of bilingual education into radiology and diagnostic imaging residencyprograms is useful for training skilled professionals, enabling those professionalsto perform their functions in a confident and up-to-date manner. The introduction ofthe English language into the teaching of musculoskeletal imaging in radiologyresidency was positively evaluated by the physicians surveyed in this study, andtheir preceptors effectively supported the activities.


Background: A special health fund was established in Nigeria in 2014 and is known as the Basic Health Care Provision Fund (BHCPF). The fund is equivalent to at least 1% of the Consolidated Revenue of the Federation. The BHCPF will provide additional revenue to fund primary healthcare services and help Nigeria to achieve universal health coverage (UHC). This fund is to be matched with counterpart funds from states and local government areas (LGAs), and is expected to provide at least a basic benefit health package that will cover maternal and child health (MCH) services for pregnant women and under-five children.Objective: To determine the financial feasibility of using the BHCPF to provide a minimum benefit package to cover all pregnant women and under-five children in Nigeria.Methods: The study focused on three states in Nigeria: Imo, Kaduna, and Niger. The feasibility analysis was performed using 3 scenarios but the main analysis was Scenario 1, which was based on the funding of drugs and consumables only. All the costs and revenues were in 2015 levels. The standard costs of a minimum benefit package for the different states were multiplied by the number of target beneficiaries to determine the amount required for the year. Financial feasibility is determined by the excess or otherwise of revenue over costs.Findings: It was found that in the best case funding scenario of using 95% of the CRF with 25% counterpart funding from states and LGAs, the entire available funds were not adequate to cover the benefit package for all the pregnant women and under-five children in the three states. The funds were also inadequate to cover the target beneficiaries that live below the poverty line in two of the states.Conclusion: The BHCPF is a good step toward providing essential MCH services, but the current level of funding will not assure UHC for all the target beneficiaries. However, the available funds should be used immediately to target priority mothers and children such as vulnerable groups, whilst sourcing for additional funds to ensure universal coverage of MCH services. Nigeria has a maternal mortality ratio of 576 per 10,000 live birth and Infant and under-5 mortality rates of 69 and 128 deaths per 1,000 live births, respectively  office in the Nigerian presidency, using funds from the Debt Relief Gains (DRG), funded the National Health Insurance Scheme (NHIS) to implement a free Maternal and under-five children's healthcare program in some states in the country. The program, which was titled the “NHIS-MDG Maternal and Child Health Project,” was implemented between 2008 and 2015. The project was an exemption scheme for Maternal and under-five Child Health services at the primary healthcare level. The participating states were expected to provide counterpart funding to expand coverage. The benefit package of the Free MCH program included primary health services for children <5 years, basic antenatal services and secondary care for pregnant women  in the Act thus provide an opportunity to achieve this.The possibility to reactivate and scale-up the Free MCH program has been provided with the passage of the National Health Act in 2014 of Nigeria and the legal creation of a Basic Health Care Provision Fund (BHCPF) in the Act. The BHCPF is equivalent to at least 1% of the Consolidated Revenue Fund (CRF) of the Federation and it will be used to provide an essential package of health services to citizens, and to improve the infrastructure, drugs and consumables in primary healthcare facilities in Nigeria. This fund is to be matched with counterpart funds from states and local governments, and will be allocated through the National Health Insurance Scheme (NHIS [50%]), the National Primary Health Care Development Agency (NPHCDA [45%]) and the Federal Ministry of Health (FMOH [5%]). Hence, the BHCPF will provide additional revenue to support primary healthcare services and achievement of universal health coverage in the country when appropriated and released.However, a financial feasibility analysis is required to provide needed information on how viable the fund will be in providing a thin or basic benefit health package of MCH services. The World Health Organization Centre for Health Development  defines Financial feasibility has been used more in developed countries. Fiedler et al.  examinedIt is noted that financial feasibility analysis has commonly been used in non-health contexts . For insFinancial feasibility analysis, though more prevalent in the developed countries, has been equally utilized by various governments and organizations in less developed economies to assess the viability of public health services before undertaking them. In 2008, the World Health Organization assessed the financial feasibility of a Social Health Insurance scheme in Swaziland and found that universal health coverage for all citizens was feasible as long as government funding was maintained and increased in line with inflation and GDP growth . ManjunaThis paper presents evidence on the financial feasibility of using the BHCPF to provide a basic benefit package of maternal and child health services, which are considered the minimum set of services that such funds should provide. It also determined the unit costs of the MCH services in three states in Nigeria; and examined the potentials of additional funding options for extending coverage with a basic maternal and child health package.A financial feasibility assessment involves a comparison of all revenue sources to anticipated costs or expenditure, such that an excess of income over expenditure confirms viability. Hence, two components are required: “a costing of the service and an analysis of the revenue that will be used to provide the service at the stated costs. Financial feasibility is a study on whether a project is viable after taking into consideration its total costs and probable revenues. If the revenues cover the costs of the project, then the project is viable”Assumptions may be made about different factors which could affect income sources and expenditures, and such assumptions can be varied to show different scenarios; the essence being to anticipate all possible outcomes. For example, the impact on administrative costs of utilizing middlemen or other intermediaries in the service delivery chain can be assessed by varying the fees paid to them or seeing what the expenditure profile looks like when these fees are excluded. The accuracy of the data used for a feasibility analysis determines how precise and reliable the output is. In order to perform the financial feasibility assessment therefore, two major components required are, (a) a costing of the MCH services to be provided and (b) an analysis of the revenue used to provide the services at the stated costs. These are illustrated in Figure The study focused primarily on three states: Imo (southeast), Kaduna (northwest), and Niger , Nigeria. In each state, two local government areas (LGAs)–one urban and one rural, were purposively chosen for facility and LGA level data collection. Within each state, two primary healthcare (PHC) facilities were visited in each of the two LGAs, to allow for the performance of financial feasibility based on different contexts.Information was collected between April and June 2016 from staff of health facilities, local government councils, and from the state ministries of health. Key documents such as state and LGA budgets, Joint Annual Review Reports, State Strategic Health Development Plans, State HMIS reports and facility attendance, immunization, delivery, pharmacy and revenue registers were examined and relevant information collected from them.The study team comprised health economists, public health specialists and financial analysts. Information was collected between April and June 2016 from staff of health facilities, local government councils, and from the state ministries of health. Key documents such as state and LGA budgets, Joint Annual Review Reports, State Strategic Health Development Plans, State HMIS reports and facility attendance, immunization, delivery, pharmacy and revenue registers were examined and relevant information collected from them. Cost data was collected at the PHC, LGA and State levels in the three states for the year 2015. Cost data included both costs of delivering MCH services , and administrative costs  administration fees and other administrative costs). Capital items at the facilities were categorized into building, transport, medical equipment, available at the facility as long as they were listed in the NPHCDA requirements for a standard PHC facility . FacilitRevenue data was collected at the PHC, LGA and State levels as well as at the National level for the year 2015. The revenue from the national level was the BHCPF. This amounted to about 38,555,000,000 Naira (1% of CRF). At the facility level, actual revenue data for 2015 were scaled up to the state level based on an estimate of the number of standard PHC facilities in each state. Other sources of revenue were State counterpart funding, State PHC budgets for each of the three states, and LGA PHC budgets as well as Internally Generated Revenue (IGR) from the PHC facilities in the States, which were scaled up to state level. Counterpart funding was computed as 25% of the NPHCDA (45%) component of the BHCPF.A basic benefit package, divided into maternal and child services was used for the purpose of the analysis. The services in the benefit package included antenatal care (ANC), delivery, post-natal care (PNC), family planning (FP), treatment of malaria, pneumonia, diarrhea, and routine immunization. Other routine services such as health education and growth promotion services, provided alongside earlier mentioned services, are assumed to be included in the personnel, capital and overhead expenditures for the services within the specific benefit package. The total service cost for drugs and consumables were based on the provision of MCH services constituting a standard benefit package for a pregnant woman and a child under 5 years. Where several visits are needed  capital, personnel and overhead costs were allocated for each of the required minimum of four visits. The standard package of MCH services are to be purchased from PHC facilities in the states.Tables Table A coverage and funding gap analysis is performed to show the impact of different levels of revenue when only drugs and consumables are provided under maternal and child care services. The standard costs of a thin benefit package for the different states are multiplied by the number of target beneficiaries to determine the amount required for the year. Only revenue components are varied in the different options to enable a sensitivity analysis of the adequacy of coverage for the target beneficiaries. Financial feasibility is determined by the excess or otherwise of revenue over costs. Finally, the additional funding requirement needed is computed to assist future planning.So many scenarios were examined in the study. The different scenarios are based on different assumptions of the costs that will be incurred in the MCH program and the sources of revenue. Scenario one assumes that only costs of drug and consumables will be borne by the program, Scenario 2 is based on the funding of drugs, consumables, and overheads only, while Scenario 3 focuses on the funding of all cost items . All the costs and revenues were in 2015 levels.However, the main feasibility analysis was the Scenario one, where it is assumed that only drugs and consumables are provided under maternal and child care services. The scenario also reflects the situation in the defunct NHIS-MDG Free MCH program. Table An assumption was made that since 63% of Nigerians  live below the poverty line and that the BHCPF could be used to cover just this population. Hence, the free MCH benefit package that will be covered by the BHCPF will be used to cover just 61% of the potential beneficiaries.The target MCH population figures for 2015 were 1,306,143 (Imo), 1,994,184 (Kaduna), 1,334,287 (Niger). The target number of health facilities were 418, 255, and 274 for Imo, Kaduna, and Niger states respectively. Based on the facility outpatient attendance records, the utilization weights for MCH services in facilities in each state were 0.83 (Imo), 0.85 (Kaduna), and 0.9 (Niger). The average utilization of maternal services in 2015 was 817 (Imo), 4,690 (Kaduna), and 2,623 (Niger). For child services, average utilization for this same period was 3,658 (Imo), 8,671 (Kaduna), and 5,555 (Niger).The cost of delivering these services for 2015 were categorized into capital  costs, and recurrent  costs. The total capital cost attributable to MCH services for the states for 2015 were − 248,852,530 Naira (Imo), 149,420,695 Naira (Kaduna), and 182,132,833 Naira. The total cost for providing drugs and consumables for 2015 at the PHC facilities were − 454,991,616 Naira (Imo), 913,922,222 Naira (Kaduna), and 925,283,827 Naira (Niger). The total personnel costs at the PHC facilities for 2015 were 149,889,054 (Imo), 2,304,646,474 Naira (Kaduna), and 3,916,955,570 Naira (Niger). Total overhead costs for the PHC facilities for 2015 were − 149,889,054 Naira (Imo), 32,910,644 Naira (Kaduna), and 44,514,106 Naira (Niger). The average unit capital costs for the states were 133.1 Naira (Imo), 43.9 Naira (Kaduna), and 81.3 Naira (Niger). Average unit personnel costs were 2,506.6 Naira (Imo), 676.5 Naira (Kaduna), and 1,748.0 Naira (Niger). Average unit overhead costs were 80.1 Naira (Imo), 9.7 Naira (Kaduna), and 19.9 Naira (Niger).Table To provide a standard package of MCH services, it cost 21,145.5 Naira (Imo), 9,153.6 Naira (Kaduna), and 8,729.6 Naira (Niger) for a woman, and 8,544.8 Naira (Imo), 2,534.0 Naira (Kaduna), and 4,709.0 Naira (Niger) for a child in 2015.Each state would receive 521,013,514 Naira and 468,912,162 Naira as shares of the BHCPF from the NHIS (50%) and NPHCDA (45%) components respectively. Counterpart funding for each state was also 24,481,419 Naira. Based on the different revenue sources earlier identified, the total revenue for each state is − 7,013,884,907 Naira (Imo), 9,968,254,995 Naira (Kaduna), and 5,202,936,421 Naira (Niger).Table Table Table Table An example of Scenario 2 is 2f (moderate and unlikely), which involves three types of costs  and the revenue is 95% of BHCPF and state counterpart fund (0.25 of 95%BHCPF). In this case, all the revenue sources will not be able to cover the costs of maternal services in the three states, but will cover child health services in the three states. However, the revenue will not be able to cover a combination of MCH services in the three states.An example of Scenario 3 is 3f (extreme and unlikely), which involves all the costs  and the revenue is 95% of BHCPF and state counterpart fund (0.25 of 95%BHCPF) plus state and LGA budgets and internally generated revenue. In this case, all the revenue sources will be able to cover maternal services in the three states, child health services in Kaduna and Niger states and a combination of MCH services in only Kaduna state.The findings show that allocating just 1% of consolidated revenue fund of the federation as the BHCPF will not be enough to assure universal financial protection of a basic health benefit package needs of all pregnant women and children under five in the states based on the most optimistic and realistic Scenario 1. The various funding scenarios that were examined show the inadequacy of available funds to meet the needs of the target beneficiaries. The only feasible options are funding of child services only utilizing at least 70% of the CRF in addition to other revenue sources with counterpart funding from the states and local governments. It is also feasible to cover a limited percentage of vulnerable pregnant women and under-five children. Hence budgetary constraints will constrain the achievement of UHC for MCH based solely on the BHCPF. This is similar to findings in another context in by Hendriks et al.  who arguThe available funds from the BHCPF should be used immediately to cover the maximum numbers of mothers and children that it can, whilst sourcing for additional funds to ensure universal coverage of services. The available funds could for instance be used to target high priority population groups such as the like the poor and high risks pregnancies, whilst the state governments source for additional funds to cover all the targeted beneficiaries. The states and LGAs should also budget and pay counterpart funding for the BHCPF to cover an appreciable numbers of the target beneficiaries. The findings could also serve as a basis for incentivizing beneficiaries to utilize the services as was fund in a study in Pakistan that was used to provide information on a cost package for services .The study highlights the importance of undertaking a financial feasibility analysis to provide the evidence-base of what MCH services and population groups that the BHCPF can realistically cover. It is noted that financial feasibility analysis is now being used in different contexts in the health sector . The metThe funding gap analysis shows that states would require more funds in order to provide MCH services to target beneficiaries. However, it will not be feasible to devote all the state health revenue (Scenario 3) to only MCH services. More than half of those who need these services cannot access them in the States. Even when other cost components such as overheads and capital are removed from the benefit package, available funds from the BHCPF and State counterpart are inadequate to meet the required level of coverage. Personnel costs constituted the largest cost component. The results from a study in Tajikistan  was usedIt could be argued that the unit costs of the services could be smaller if the status quo is used to cover for capital and personnel costs, whilst the BHCPF is used to provide only commodities. However, a counter argument is that the health facilities rarely receive overhead budgets from the government and the BHCPF is expected to bridge the gap in funding for overheads budgets, which are needed to effectively run the health facilities. Also, many health facilities currently have insufficient staff complement when compared to the minimum standards specified by the NPHCDA. The basic benefit package for both mothers and children provides an initial minimum package to which further services could be added as funding increases. Hence, in order to meet the stated target of providing units of a basic benefit package and meet up with the minimum standards of health staff, additional funds from the BHCPF are also needed to engage more staff.The BHCPF is potentially a good step toward providing affordable healthcare for pregnant women and children under five years, but the current level of funding will not assure UHC for all the target beneficiaries. This highlights the importance of undertaking a financial feasibility analysis before program implementation so as to be aware of what the funds can cover . In a stIn recognition that BHCPF is insufficient to fund services for the target group. There is a need to re-evaluate the level of funds to be allocated as BHCPF and the analysis shows that at least 4% of CRF is the minimum that will cover the all target beneficiaries within the state based on just 50% of the BHCPF to the NHIS. Counterpart funding must be entrenched in the design and implementation of the program, so as to ensure that more beneficiaries are covered. There is also the need to explore funding from different sources such as from budget allocations, development partners, health insurance schemes at the national, state, and community levels as well as internally generated revenue at state and LGA levels. For instance, basket funds can be utilized to increase funding from the state and local government level. Meghani et al.  describeThe study limitations are related to the major challenges in data collection. There were significant variations in the costs of drugs at the facility levels and costs indicated at the state Central Medical Stores for drugs used in the facilities. In some cases, there was reluctance to provide the actual costs/prices of drugs. A uniform price list obtained from the functional Central Medical Store in Enugu State which was closest to the actual market prices of drugs was used for all computations. Also, there are several shortcomings with data summarization in the health facilities and the state HMIS system. In addition, it was not possible to obtain data on actual utilization of the NHIS/MDG programme from any of the parties involved . The accountability mechanisms and reporting systems for any future programme must be well laid out and appropriate sanctions for defaults clearly specified.The State Ministries of Health should be encouraged to utilize a similar feasibility analysis tool for budget negotiations. This would show in clear and quantitative terms the potential impact of revenue and expenditure decisions on health sector objectives and engender policy level support for improved budgetary allocation to the sector. Finally, in order to increase coverage with some services, the BHCPF could be channeled to provide only drugs and consumables, with states expected to continue their funding of other cost elements such as personnel and overhead costs. However, adequate steps should be taken to ensure that personnel and overheads are sufficiently provided by states.This study was carried out in accordance with the recommendations of the guidelines of the University of Nigeria research policy and the University of Nigeria Senate Research Grants Committee. The protocol was approved by the University of Nigeria teaching Hospital Ethics Committee. All subjects gave written informed consent in accordance with the Declaration of Helsinki.OO and HW conceptualized the study; OO, CO, IN, HI, and BU collected the data; OO, CO, HW, and HI undertook the data analysis; OO drafted the first draft of the paper, which was revised by all the co-authors. All the co-authors approved the final draft of the paper.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.