Active tourism improves human health and well-being regardless of age or disabilities. The paper analyses and describes current issues concerning the tourism of people with disabilities. The starting point is the currently insufficient availability of tourist offers for individuals with considerable motor dysfunctions. One of the causes for these limitations stems from deficiencies in transport means for people with disabilities. It was found that for a disabled passenger using public transport, it is crucial to consider its accessibility in the context of the entire transport system. Another cause is the limited popularity of innovative, atypical assistive equipment for people with disabilities. Those insights point out that novel assistive technologies need to be developed, as it is necessary to more effectively support the activity of people with disabilities in all areas of life, including tourism, as this enhances their social rehabilitation. This paper indicates the needs and describes and analyses examples of own original, innovative devices supporting the areas mentioned above of activity for people with disabilities. These analyses resulted in developing an algorithm to design innovative equipment, considerably expanding the tourism potential of people with motor disabilities. This design process focuses on the needs of people with disabilities and facilitates the development of novel classes of assistive technologies, thus promoting new areas of activity for all. According to the World Health Organization (WHO), there are 1 billion people with disabilities worldwide, representing 15% of the global population. Among them, 2 to 4% experience considerable problems with daily functioning. Additionally, it must be remembered that the number of people with disabilities is growing continuously, and as indicated by the WHO, this trend is associated, among other things, with population aging and the rapid increase in the prevalence of chronic diseases  to ensurAccording to the model proposed by professor Wiktor Dega, medical rehabilitation needs to be common, early, comprehensive, and continuous. In 1970, the WHO accepted and recommended the model developed by W. Dega . The rehNumerous studies have shown that physical impairments are the most common cause of disabilities. For example, investigations made by Okoro et al.  show thaThe group of people with motor disabilities is not homogeneous, and its diversity is derived from the character and underlying causes of these impairments. Generally, mobility impairments are caused by innate developmental defects, disease, unhealthy lifestyle , and biomechanical overload in the case of manual workers. A disability may also be caused by various accidents, the risk of which increases with population aging , or it mTourism is a form of physical and social activity performed outdoors. Tourism requires mobility and therefore supports physical activity. Movement improves human health regardless of the age or potential disabilities of individuals. Exercise associated with tourism, particularly when it is moderate, in combination with other factors that affect the human organism, has a beneficial influence on human physiology ,20. PhysIn addition, it increases the aerobic fitness of the organism and the efficiency of the circulatory system, while it also improves smooth muscle fitness, the function of abdominal organs, and the pelvis, which in turn prevents gait and balance disorders. Physical activity improves blood flow efficiency, reduces the risk of blood density and clotting in blood vessels, normalizes blood glucose levels, reduces the concentration of low-density lipoproteins (LDL), and increases the concentration of high-density lipoproteins (HDL), which improves the immune system function, accelerates metabolism, promotes mental well-being, as well as enhances physical fitness . These pPhysical activity, in combination with rehabilitation training, promotes greater daily life fitness, i.e., capacity to perform various activities of daily living (ADLs)  even at such extensive disabilities such as paraplegia or tetraplegia. Systematic rehabilitation training as part of rehabilitation was implemented in various countries many years ago when promoting the concept of the so-called active rehabilitation (in Sweden in 1976 and in Poland in 1988 ). The acActivities requiring practically no movement or exercise: reading, watching TV, listening to the radio, and other similar activities;Moderate physical activity: walking, gymnastics, or other forms of relatively moderate exercise;Considerable physical activity: swimming, other recreational sports, seasonal gardening, and other outdoor leisure activity;Sports activity: intensive training  or competitive sports.Unfortunately, physical activity is not very common among people with motor dysfunctions. Analyses by the Central Statistical Office (Statistics Poland)  provide It results from the data given in This paper aims to propose an algorithm that supports the design process of innovative assistive technology devices, expanding the areas of participation of individuals with motor disabilities in active tourism.According to the Polish Tourist and Sightseeing Society PTTK, the concept of tourism for people with disabilities is defined as: “intentional, purposeful physical activity adapted to individual needs, performed in various forms, closely related to sightseeing activity. It is a form of social rehabilitation for people with disabilities. This activity aims to maximize physical, mental, social, and occupational fitness as well as adaptation to normal life. Tourism for people with various disabilities is a recreation and a means of therapy and education” .The presentation of specific information on travel for people with disabilities is impeded by a lack of available statistics , while sThe PTTK report shows that the share of people with disabilities in tourism is 1.8%. In comparison to able-bodied tourists, this number is extremely low. Among the various forms of active tourism of people with disabilities, mountain and lowland hiking predominates (64% share in the entire activity of people with disabilities), followed by cycling and kayaking (approx. 14%). Horse riding (4%), sailing (1.7%), motorsports (1.6%), skiing (0.3%), and diving (0.02%) are rarely practiced ,26.Bauer indicated four factors that hinder the development of tourism for people with disabilities: intrapersonal, interpersonal, economic, physical, and attitudinal barriers . IntrapeTransport is an indispensable element of every tourist enterprise. Individuals with mobility impairment are at risk of being discriminated against in terms of public transport accessibility, especially when the journey takes place in a new, unfamiliar area, and it is logistically complicated when, for example, it requires a transfer to another means of transport, e.g., from a railway to a road or an air transport. Discrimination refers not only to the lack of adaptation of specific means of transport to special needs but also to the complexity of regulations and detailed rules of transport use. The movement of disabled people within the entire public transport system is considerably hindered by the continuing need to search for information on the availability of adapted transport means and regulations concerning the transport of individuals with significant disabilities, moving in wheelchairs. Frequently the intention to travel on a train or airplane needs to be reported much earlier, as a result, it is difficult to make flexible travel plans or introduce impromptu changes to the itinerary. This hinders the accessibility of the public transport system as a whole. Passengers typically use the entire system rather than only one means of transport and when a section of the itinerary may not be covered or when finding information required when traveling is too time-consuming, they simply either decide not to travel or choose an individual means of transport (a car) .For most people with disabilities, inaccessible transport harms their everyday life. Problems with accessibility, particularly in the case of public transport systems, may considerably reduce their employability and limit the potential for social inclusion of disabled people , while pThe needs related to mobility and transport for people with disabilities change with age . Many soDesign in rehabilitation engineering ,34 is thGolf carts ;Wheelchairs adapted to travel on the beach and in the forest, equipped with electric engines and stabilized using electronic gyroscopes with multiaxial suspension, moving on cross-country tires or caterpillar tracks;Wheelchairs for mountain tourism, with an adequately reinforced frame and wheels, a low seat, with an electric or hybrid engine—a combination of the strength of human muscles and an electric drive—, with widely spaced wheels, frequently with additional handles facilitating pushing, pulling or carrying by assisting individuals). An example of such a vehicle is a special wheelchair designed for a mountain trekking trip to the Himalayas for “Michał Woroch—Himalayas Challenge_2021” ;Equipment designed to facilitate sliding into the water when diving , speciaAlternative drive systems for manual wheelchairs enhancing their functionality  ;Adapted powered hang gliders—ultralight trikes and adaptations of planes with hand controls;Adapted sports cars for disabled drivers;Adaptations of cabin cruisers and sports yachts, e.g., specialist seats  and steeAt present, thanks to the application of specialist technical solutions, many forms of tourism may be practiced by people with almost all types and degrees of disabilities. An example in this respect may be given by Hilary Lister, disabled due to muscular dystrophy, who in 2009 singlehandedly sailed around the British Isles. This was made possible thanks to applying a unique steering system using the sailor’s breath . AnotherDespite the dynamic development of assistive and rehabilitation technology solutions for various leisure time activities, it is still necessary to search for similar solutions assisting in tourism, including the use in the urbanized space . These nThe selection of cases of original practical and theoretical solutions is based on the decision to present innovative solutions, i.e., those that are far from obvious while being positive and novel, introducing new opportunities or expanding the functionality of previously known solutions. Such solutions include a self-propelled carriage platform with adjustable functionality, a drive mechanism for a wheelchair based on a completely novel principle of operation, and a yacht for disabled people and senior citizens and its selected equipment elements. They are examples of original concepts and equipment designs that meet the needs of mobility and tourism and rehabilitation of people with motor disabilities.The necessity to support daily functions in various environments (the closed space of buildings and frequently non-adapted tourist spaces) requires the used means of rehabilitation engineering to exhibit an extensive and thus universal functionality (understood as a set of offered functions). To ensure functional mobility in all areas of life, a person with disabilities is forced to use a set of many specialized devices with limited and specialist uses . The use of a specialist device outside its designed area of application may cause problems in the functioning, e.g., the drive of a wheelchair being of limited effectiveness outdoors, overloading of upper limbs and the shoulder girdle, the risk of injury, and problems with moving an all-terrain wheelchair in narrow and small spaces.The need for excessive development of functionality in the case of a specific assistive technology device may lead to a deterioration of its function in many areas of its operation. An alternative may be provided by using an increasing number of various assistive means. However, their excessive number and the necessity to repeatedly select them to fit a specific situation is also far from advantageous.An uncontrolled overload of the wheelchair structure (attachments mounted at elements of the wheelchair structure at points that are not dedicated to such a solution);Damage to lacquer coating or at points of attachment mounting or damage to other elements;A lack of appropriate operation of combined elements or a lack of potential to combine them;Loss of performance properties of used products ;Increased risk of injury.It may also be assumed that a combination of various structural modules of currently produced devices, such as, e.g., a manual wheelchair and hand-bike attachments with electric drives , while dSince expectations of potential wheelchair users are so diverse, it was assumed that designers need to consider developing designs for devices ensuring the simultaneous application of many functions. For this reason, a concept has been proposed for a family of transport or rehabilitation vehicles, which are structurally based on a common self-propelled carriage platform.An electric wheeled transporter for a person with disabilities sitting in an active manual wheelchair d for indAn electric wheeled transporter with a study or work table for a disabled person sitting in a wheelchair e;An electric wheeled transporter adapted to transport a disabled person by an assistant f;An electric wheeled transporter with an additional lifting system for the manual wheelchair to increase the reach of the user’s arms in the workspace g;An electric wheeled transporter with a comfortable armchair securely supporting the body position, e.g., in the car, used for transport both outdoors and indoors h;An electric wheeled transporter with an electrically lifted comfortable armchair with an increased range of manipulation for shopping in supermarkets, residential and public buildings, and in urbanized areas i;An electric wheeled transporter, with a standing device to verticalization body position, which is especially needed by people sitting in wheelchairs j;An electric caterpillar track transporter with a comfortable seat providing secure support for the body using seatbelts for driving in non-urbanized areas for tourism and recreation k.It was decided that the main structural element of the system will be the so-called self-propelled carriage platform used for independent transport of a sitting person indoors or outdoors without the need to use the muscle power of the human user. The platform has an alternative wheel or caterpillar track mechanism. It is adapted to the attachment of replaceable modules, e.g., aiding in standing upright, raising the seat, or providing specialist seats. The developed design  is a novAs a result of The structural design of the platform and three selected designed representative types of the designed family are shown in The presented solution is based on a typical modular approach used in technology . Designing modular structures requires high structural and economic inputs. However, the rationalization effect results from a combination of pre-manufactured modules (parts or assemblies) providing the desired variant of a technical function. The modular segment structure is a system of assemblies and parts, which are modular segments that perform various general functions of the system . In thisSuch a solution is advantageous compared to a set of many single-function AT devices while simultaneously answering the demand for products characterized by atypical functionality. The basic structure of the transport platform facilitates the manufacture of vehicles of different functions at reduced production costs. The simple structure is provided, among other things, by applying the produced drive and steering systems. The solution has universal applications, both outdoors and indoors. It is operated with no assistance needed.This solution makes it possible to participate in various forms of activity in urban and adapted non-urban areas. At the application of the caterpillar tack transport system, it may be used in a non-adapted terrain and allow the user to involve in tourism. The application of the structure may promote increased physical activity, thus promoting rehabilitation. Despite the use of an electric drive , it expands the range of travel in the therapeutic sense. At the same time, within the scope of rehabilitation, it results in mobilization to rest in non-urbanized surroundings and the transfer, balance, and stabilization of the body while scaling terrain obstacles such as elevations and slopes, traversing obstacles, or promoting more active interactions with the surroundings as well as easier transport and performance of daily life functions.A typical drive for wheelchairs using drive rings is very simple and intuitive although burdened by several drawbacks. One of them is permanent, determined by the wheelchair structure, a trajectory of the drive motion of upper limbs ,53. The Wheels with the additional cam-thread drive may be mounted using a unified quick coupler to any manual wheelchair to replace typical drive wheels with drive rings. The application of cams with “progressive” characteristics  makes it possible to obtain a changing gear ratio for the wheelchair drive. When the wheelchair starts moving, a large motion of the string causes a small rotation of the wheel with large torque; next, the rotational speed of the wheel increases, facilitating faster travel. Driving the wheelchair only using short motions performed with high frequency slows the speed of travel and makes it possible to traverse a slope; in contrast, driving the wheelchair applying long motions of lesser frequency leads to a faster speed of travel. This type of drive works well over longer distances covered outdoors. Indoor mobility is slightly more difficult ; howeverThe size of the yacht ensures simultaneous long-distance travel for 10–16 people, including a maximum of 4 people moving on wheelchairs;The potential for unassisted sailing by senior citizens and people with disabilities independent of non-disabled people;Sailing by people with diverse disabilities ;Minimization of yacht size/length ;People with disabilities may perform sailing operations ;Large, safe, easily accessible open surfaces, e.g., the upper deck superstructure;The yacht is equipped with means supporting accessibility for people with disabilities first of all when walking, standing, sitting down, grasping, holding, orientation and identification of space, and receiving information.Various attempts have been made to adapt vessels for the needs of people with disabilities and senior citizens. Despite the superficially similar structure resembling conventional yachts, such vessels are considerably more varied in terms of their design and structure. The first problems with the adaptation of the hull of a traditional motorsailer for the needs of people moving on wheelchairs are experienced already at the designing stage. The deck needs to be widened, thus changing the geometric proportions of the yacht to facilitate the movement of disabled people in wheelchairs. A separate, huge design task when producing a yacht for disabled sailors is connected with considering different types of disabilities. Basic assumptions for the vessel design include the following:Developing a set of requirements for a yacht intended for people with disabilities is difficult because of the design and structure complexity. For example, the large surface area of the yacht promotes the comfort of operations and staying and moving inside the yacht. However, it is not advisable to considerably enlarge the yacht. Minimizing the size of the yacht results from the need to reduce the maintenance and servicing costs of the vessel. Frequently, an excessively large surface, e.g., of the Kingston valve, may lead to a risk of instability and bumping into the device or a fall in the case of disabled sailors. In turn, a too-small yacht may prevent the application of all required accessibility and safety measures. Negotiating the requirements and optimizing the multiple criteria determining the yacht size is necessary. A yacht for people with disabilities needs to include several different technical solutions compared to conventional vessels. Adopted technical solutions should ensure the potential for unassisted sailing independent of non-disabled people. An important aspect when assuring safety on the yacht is to apply various safety systems and to develop procedures for the performance of operations under different weather conditions and in various situations. The yacht should be equipped with special devices such as yacht wheelchairs for individuals whose mobility limitations (not necessarily paraparesis) may increase the risk of accidents under changing sailing conditions. Designing a yacht wheelchair is a new task. A yacht wheelchair may be used as an alternative to personal wheelchairs by people with disabilities. It will provide enhanced functionality compared to personal wheelchairs.Lc: B ratio  of the yacht hull amounting to approx. 18:6 m, which are atypical proportions compared to conventional designs of marine sailing boats. These proportions, primarily the considerable width, ensure accessibility of decks for people with disabilities moving on wheelchairs and using other rehabilitation devices. The increased yacht width facilitates free movement and provides an increased area of facilities  and passageways/traffic routes as well as a functional superstructure of min. 2 m usable height. The provided yacht dimensions will be the requirements defined as obligatory when presenting further considerations for yacht accessibility.It is assumed that yacht proportions are approx. 3:1, and they determine the As mentioned above, despite the high potential health risk when practicing such a form of physical activity, yachting brings several benefits to disabled people, as mentioned above. It positively impacts the process of social rehabilitation, including elements of rehabilitation enhancing physical fitness. Adaptation of yacht elements to the needs of people with motor disabilities requires several alterations in terms of the procedures and technical means assisting in mooring, handling the sails, the steering wheel and the anchor, moving around the yacht, physiological needs, as well as main material aspects of living conditions .Currently, the authors are designing the described A-class (ocean-going) yacht (under the working name: Empatia 60 FD—For Disabled) adapted to the needs of people with all types of disabilities. Because of the increased interest in various leisure activities and active participation in sports by senior citizens and people with disabilities, an important problem has been observed in yachting with the adaptation of the pilothouse or the steering wheel station to the needs of people sitting in wheelchairs or other seats . In the case of a conventional steering wheel, it is a problem to reach the wheel when sitting down comfortably. The knees limit the access to the steering wheel, making the operation uncomfortable and causing strain in the long run . As a rule, a classical large-sized steering wheel has a handle in the form of a large ring. The large diameter of this ring results from the need to provide an adequate gear ratio in traditional solutions with a rudder gear. The large dimensions of the steering wheel are also justified by the historical reference of the steering wheel design to the sailing traditions, which even today has an impact on the use of such a structural element. However, these are solutions dedicated to able-bodied operators in standing positions.People sitting in a wheelchair can use a typical large steering wheel when positioned at a certain distance from the steering wheel; however, it is not an entirely satisfactory or ergonomic solution. Literature on the subject presents only scarce examples of solutions to improving the quality of use of a steering wheel by people with disabilities and senior citizens.Other solutions are available for small steering wheels for individuals when sitting down. The small-sized steering wheel (resembling the car steering wheel) is mounted similarly to that in cars  to gather a user-centered approach . DevelopThe proposed algorithm starts with the identification of needs (step 1). Adequate identification of needs for the object of design is the basis for initiating actions in the AT design process. It facilitates an appropriate identification of the design goal (step 2). Designing to meet the needs of disabled people or senior citizens needs to be a human-centered design of an optimum system consisting of “a person with disabilities—assistive technology—environment of its operation”. Human-centered design (HCD), also known as user-centered design (UCD), is a methodology for designing systems well-fitted to their users. According to ISO 9241-210:2019, human-centered design is a design philosophy and process in which the needs and limitations of users influence the different stages of the design process . At HCD,The next step is to parametrize individual tasks (step 4), i.e., to determine their boundary and expected parameters expressed in physical units, e.g., admissible dimensions of the designed device, its weight, velocity, range, etc. At this stage, technical discrepancies in the designed device are identified. This requires the selection of primary and auxiliary functions of the device (step 5). The set of these functions defines the overall functionality of the device. Not all device functions are equally important, as some functions may adversely affect others. For example, excessive parameters of the function of the user’s body stabilization in the wheelchair result in a deterioration of the wheelchair’s transport function. For this reason, it is necessary to order the importance of functions of the designed system of “a person with disabilities—assistive technology (AT)—environment of its operation” and to improve the quality of the AT primary functions even at the expense of elimination or deterioration of certain auxiliary functions. Simultaneously with the selection of primary and auxiliary functions for the designed AT device, the process of searching for optimum technical solutions takes place (step 6). Selection of the structural design variant makes it possible to design a system ergonomically well-fitting the designed system of devices to a human user (Step 7). Ergonomic design  is a framework for designing or arranging products and systems (workplaces) so that they are comfortable for the people who use them ,64. It iDetailed design solutions (step 8) comprise a thorough selection of specific structural design solutions. Limitations in this selection are connected with the production capacity, availability of standardized parts, and structural properties of used materials. Other types of specific requirements are also encountered. For example, when designing assistive technology solutions for tourism of people with disabilities, it is necessary to predict the impact on these products exerted by various atypical environmental conditions, such as seawater, considerable fluctuations in temperature, strong wind, swaying of the yacht deck, considerable vertical accelerations of the yacht deck at wave motion, or the impact of rain. Sea water causes significant problems in using durable structural materials; it may also lead to injury . In turn, wind and swaying may result in less stability for people moving around the yacht; thus, it is vital to eliminate the risk of being hit by designing, e.g., foot shields for people moving on wheelchairs , and thThe designed system requires evaluation (Step 9). Evaluation consists of the verification of the actual functionality of the designed system compared to that planned in the design. An obligatory element is to conduct verification of product consistency with legal regulations. These requirements refer to the set of specifications and technical standards applicable to a specific type of device. A frequent problem in the design of innovative devices is related to the lack of respective standards and regulations. It is necessary to assimilate and apply the requirements imposed on products with comparable functions or to develop their standards in such a situation. Before implementing the designed AT device or system, the final step consists of the risk analysis for their use. Risk analysis methods are well-standardized and described in literature on the subject .When reviewing known models of the engineering design process  measures comprises specialist equipment, facilitating participation in various leisure activities including active tourism. Innovative AT devices are frequently designed and manufactured in single units and commissioned to be custom-made to meet the needs of a small number of people. On the one hand, the development of rehabilitation engineering devices aims at improving the functionality of available equipment, which has been redesigned many times before  to improve the quality of their use in spaces adapted to their usage . However, the aim is to find solutions for the designed devices to expand the area of their applications (various forms of active tourism and sports). In the case of the first of the mentioned groups, the structural modifications are small changes introduced in the multi-stage design iterations, and as a result, their performance parameters are slightly upgraded; nevertheless, they are still very important. In the second group, we may expect innovative AT solutions with novel, frequently only partly verified applications. For example, in sports disciplines previously unavailable for people with disabilities, the newly developed technical means make it possible for such people to practice these sports.Nevertheless, they are typically based structurally on models of known solutions, e.g., the design of frames for typical wheelchairs used in adapted sports, fitness, or leisure activities or yachts for disabled people. The technical solutions presented in this paper are only selected examples of such designs. This field is and will continue to be the subject of further design works on innovations aiming at improving life in the integrated society.The presentation and analysis of original, innovative concepts for technical solutions dedicated to people with motor disabilities as well as the subjective evaluation of progress in the development of technologies for people with motor disabilities constitute the basis for the proposed design process algorithm focused on the needs of people with disabilities. The proposed algorithm makes it possible to create new classes of assistive technology devices and opens new areas of activity for people with significant disabilities, which supports the maintenance of mental and physical well-being in different groups of disabled people in the long-term perspective.


This brief aims to guide how to equitably implement and inclusively finance safe abortion in Indonesia—in and beyond the COVID-19 pandemic—to gain maximum socioeconomic benefit and leave no one behind.Abortion is common in Indonesia, with 79% being unsafe. Unsafe abortion is one of the top five causes of maternal deaths globally. Meanwhile, in Indonesia, the maternal mortality rate (MMR) is still high, with up to 30% of it being related to unsafe abortion. In the COVID-19 pandemic, the number of unsafe abortions is expected to increase along with a 15–30% increase in unintended pregnancies. This will add to the number of maternal deaths on top of direct deaths caused by COVID-19. In Indonesia, access to safe abortion is still limited based on grounds. There are also gaps in implementation and in the financing mechanism of legal safe abortion, especially in the era of the national health insurance scheme  Unsafe abortion is one of the five major contributors to maternal deaths worldwide . This buIn Indonesia, abortion is also common. It is estimated in 2015–2019 that 25 induced (including both safe and unsafe) abortions happen per 1,000 Indonesian women of reproductive age . It is sUnsafe abortion is defined as “a procedure for terminating a pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards or both .” In IndOn the other hand, the COVID-19 pandemic has been disrupting health systems worldwide with a significant impact on sexual and reproductive healthcare services such as family planning (FP), maternal and newborn healthcare (MNHC), and safe abortion, especially in LMICs—resulting in a significant rise in the number of unintended pregnancies, unsafe abortions, and subsequent maternal deaths on top of the deaths directly caused by COVID-19 , 14. OffThe Indonesian government currently only allows safe abortion based on certain legal grounds regulated by the Government Regulation Number 61 Year 2014 about Reproductive Health (PP 61/2014). Those grounds are to preserve the life and health of the mother , in case of severe fetal anomalies and in case of rape. It also regulates how safe abortion should be provided. An eligibility team consisting of at least two health professionals  should decide on the client's eligibility in the case of a medical emergency. In the case of rape, a legal expert, psychologist, or other experts should confirm there is indeed a suspicion of rape . An addiJaminan Kesehatan Nasional or JKN) in which primary healthcare (PHC) facilities serve as gatekeepers. This is a significant unaddressed gap in safe abortion policy in Indonesia. In the COVID-19 pandemic with limited mobility, access to care, information , and fear of infection, Indonesian women who seek abortion may rely even more on informal providers such as online drug sellers who often provide poor-quality service , since the 1960 s. Although the private PHC facilities have been available, their roles are significantly expanded after the establishment of the JKN. In the JKN era, PHC facilities  play an important role as the first level of contact for individuals, families, and communities, and as gatekeepers  . AlongsiThere are some implications and disadvantages of this policy option. Technical guidelines and training should be established for safe abortion, especially for FKTP. Resources should be made available for purchasing and stocking by FKTP, such as medications and vacuum aspirators. Misoprostol is not currently included in the latest National Essential Medicine List of 2019, although it is included in the 2019 WHO Model List of Essential Medicines , 40. It Safe abortion indications stated in the current regulation (PP 61/2014) should also be interpreted broadly to encompass health problems beyond life-threatening conditions. This is to enable FKTP providers to diagnose broader health-related indications according to their level of competence. A broad interpretation of the current safe abortion regulation is crucial to delivering safe abortion to the full extent of the current law and is also in line with the protection of women's right to be free from physical and mental suffering, as stated in the International Covenant on Civil and Political Rights (CCPR) that Indonesia has ratified in 2006 , 43. MeaAnother possible disadvantage is sociocultural barriers and/or conscientious objections by FKTP providers. To address this, guidelines and training should include value clarification to address HCWs' views on abortion. Safe abortion-specific value clarification work should be based on internationally recognized toolkits . AwareneThe nonprofit private sector in Indonesia have significant experiences in providing safe abortion-related services in the effort to fill the unmet need. These experiences include care such as pre-and post-procedure counseling, medical service provision, and remote-based services. They have developed technical guidelines according to the WHO guideline and trained providers. They also have extensive experiences in safe abortion advocacy in Indonesia and are aware of the policy development –49. ConsThis policy option has several advantages. First, there would be less sociocultural resistance from HCWs working with the nonprofit private sector, considering their experiences. Hence, there would be less needs to establish value clarification. Second, their existing guidelines could be adapted as national guidelines and implemented more quickly in the field. Third, the nonprofit private sector already have resources to access tools and consumables related to safe abortion, which would simplify purchasing mechanism.However, there are also several disadvantages. The nonprofit private sectors only have a limited scale of reach for medical services with limited geographical distribution. This limited distribution can be due to revenue-driven, funder-driven, or urban-preference reasons. Contracting them as sole providers would leave some regions, especially eastern and rural Indonesia, without services. There would also be extra costs related to contract development and administrative or overhead costs. Services provided by the nonprofit private sector are also not yet connected to the public MNCH and FP programs, or the public health program in general. This would separate safe abortion from MNHC and FP programs in general. Separate financing and reporting mechanism would also be needed, which can complicate the governance and monitoring of the services. Additionally, providing an essential service through a third party or outside the public health system might compromise sustainability in the future.Providing safe abortion is a significant cost-saving approach compared with the cost of unsafe abortion and management of its complication, especially in LMICs. It is estimated that the cost of abortion-related healthcare in LMICs (whose biggest bulk comes from the cost of managing abortion complications) will decrease by up to 78% if all abortions could be provided safely, coupled with expanding access to contraceptive services for women of reproductive age . TherefoThe Indonesian constitution (UUD'45), the Law Number 40 of 2004 about the National Social Security System (UU 40/2004), and the Law Number 24 of 2011 about the Social Security Administrator (UU 24/2011) have mandated the provision of social security and basic life needs for all Indonesians, including the provision of healthcare services and health security –54. FurtThere are several advantages of this policy option. First, it will improve financial access to services for those who are socioeconomically disadvantaged such as the poor (whose contribution toward the JKN scheme is paid for by the government). Poverty has been known as one of the drivers of poor SRHR outcomes. Poor women and girls in LMICs are at high risk of unintended pregnancy and more likely to be exposed to unsafe abortion , 55–57. Second, there will be no need to establish a parallel financing arrangement or a separate pooled fund dedicated to safe abortion. This would help make the national pooled funding for health less fragmented as fragmentation leads to less effectiveness and more inefficiency in the system. Reducing fragmentation and aiming for larger revenue pools to increase efficiency are also crucial for the achievement of UHC, including in SRHR , 63.There are several disadvantages and implications of this policy option. The MoH should include tools and consumables related to safe abortion in the National Formulary list of JKN-covered medications, especially for FKTP. There would also be the need to establish a purchasing mechanism for safe abortion in the JKN scheme. This could be done through capitation-based or procedure-related fixed reimbursement for FKTP , or through diagnostic-related payment (DRP) for higher levels of care in case of referral . Existing diagnostic lists and reporting mechanisms should also be adjusted to include safe abortion and its indications. In addition, there could be political and/or sociocultural resistance to this policy option as it involves the utilization of public funds. Political engagement, dispersion of information and awareness, and intersectoral/multi-stakeholder dialogue should be actively and continuously carried out to gain support and decrease resistance.In line with the policy options that have been presented in this brief, several recommendations are made for the Indonesian MoH and for the national government in general.These guidelines should include not only the clinical aspects but also pre- and post-abortion counseling, task-shifting mechanisms, and telemedicine approaches. Guidelines should be developed in line with the WHO's most updated recommendation and informed by best practices in other LMICs.Training should be established as soon as possible on a regular basis and with a proper accreditation mechanism. Training should include clinical aspects, counseling, broad interpretation of the law, and value clarification. Training can be done in partnership with the nonprofit private sector.Analysis should also include the plan for resource mobilization and allocation.Information and awareness have to be consistently and continuously dispersed to decrease resistance and improve cooperation among providers. As in training, engagement and advocacy can also be done in partnership with the nonprofit private sector. Engaging with health students and trainees through the curriculum of health education institutions should also be explored to address earlier the ethical consideration and value clarification aspects.Linking of the programs should have the provision of a continuum of care and decreasing maternal deaths and disabilities as common goals.Providing access to safe abortion services is a crucial public health intervention to decrease maternal deaths and disabilities by driving out unsafe abortion. It is also part of impactful and more cost-efficient investment packages in SRHR, especially in LMICs like Indonesia. As a country that still struggles to decrease its high MMR, Indonesia has taken an important step in establishing several legal grounds for safe abortion services. However, as Indonesia is progressing toward UHC through the establishment of JKN as the national health insurance scheme and amid the challenges brought by the COVID-19 pandemic, policy gaps remain in the form of the uncertainty on how services should be arranged and publicly financed. Making safe abortion services readily available and accessible through the established PHC network and funding the services through the JKN scheme are important to ensure that safe abortion can be equitably delivered to those in need—including the poor, the marginalized, and the most vulnerable—to the full extent of the law and to gain the most socioeconomic benefits for the country.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Enhancing teacher leadership is not only one of the approaches to improving teaching and learning, but it is also essential to the success of education reform. Based on leader-member exchange theory, 294 preschool teachers in China were surveyed, and a structural equation model was established to explore the relationship between the participating teachers' principal leadership style, teacher leadership and psychological capital. The findings revealed a significant positive correlation between transformational and transactional leadership styles and preschool teacher leadership. The laissez-faire leadership style had no correlation with preschool teacher leadership. The transformational leadership style and transactional leadership style were significantly and positively correlated with psychological capital, while the laissez-faire leadership style was significantly and negatively correlated with psychological capital. The transformational leadership style can positively influence preschool teacher leadership directly and indirectly through psychological capital; and the transactional leadership style can only positively influence preschool teacher leadership indirectly through the mediating role of psychological capital. Preschool teachers' leadership can neither be directly influenced by a laissez-faire leadership style nor be indirectly influenced through the mediating role of psychological capital. Since the 1980's, with the emergence of educational reform worldwide, many countries have started to recognize the cultivation and enhancement of teacher leadership as a way to achieve successful educational reform. Teacher leadership has become a key factor in driving change in schools. Scholars have come to realize that the model of relying solely on the school's top leader, the preschool principal, to promote school development is not working as well as expected  issued by China's Ministry of Education in 2001 states that preschool teachers should make practical work plans and implement them flexibly according to the practical situation of the children in the class. During the transformation phase of the curriculum, each local preschool has its own characteristics, and each teacher and child in each school is different. Preschool teachers, as implementers of the early childhood curriculum, are in a better position to develop and implement appropriate curricula because they are more aware of the physical and psychological characteristics of their own children and their curriculum practices , the latest paradigm in leadership style theory, there are three types of leadership styles: transformational, transactional, and laissez-faire. These three leadership styles basically cover the main aspects of modern leadership styles  provides a good theoretical perspective for studying and analyzing the relationship between preschool principal leadership styles, teacher leadership and psychological capital. The uniqueness of this theory lies in its research focus on the dynamic exchange relationship between the leader and the members of the organization and on the mechanisms by which this dynamic exchange relationship affects the work attitudes and behaviors of the members of the organization. LMX is based on social exchange theory, in which the interaction of interpersonal relationships is a central theme. LMX refers to the quality of the exchange relationship between leaders and followers based on trust, respect and obligation. In exchange for a comprehensive view of the leader's support and motivation, the employee will reward the leader with respect, trust, and adequate feedback, thus establishing a relationship with a high level of mutual esteem  developed by Chinese scholars Wang and Xia  to measuThe Multifactor Leadership Questionnaire (MLQ-5X) compiled by Avolio and Bass  and the The Psychological Capital Questionnaire (PCQ-24) prepared by Luthans et al.  was adopFirst of all, the single-factor ANOVA test was used to test the differences in preschool teacher leadership and teacher psychological capital in teachers' seniority and position. Secondly, the correlation and relationship among these three variables of preschool teacher leadership, preschool principal leadership styles and teacher psychological capital were tested. After the significant correlation and regression of the three variables were verified, finally, a structural equation model with Maximum Likelihood Estimation was used to verify the mediating role of psychological capital between different preschool principal leadership styles and preschool teacher leadership.SPSS(Version 25.0) and Mplus (Version 8.0) were used for data analysis.M), standard deviation (SD) of each variable and the correlation coefficient between variables are shown in M = 3.97, SD = 0.75) and transactional leadership style  are both higher than the theoretical median value of 3, indicating that the two kinds of leadership styles perceived by preschool teachers are at a high level. But the scores of laissez-faire leadership style  is lower than the theoretical median value of 3, indicating that the two kinds of leadership styles perceived by preschool teachers are at a low level. The score of teacher leadership  is higher than the theoretical median value of 3, indicating that the preschool teacher leadership is at a high level. The score of psychological capital  is higher than the theoretical median value of 3, indicating that the psychological capital of preschool teachers is at a high level.The mean  and transactional leadership style . There is no correlation between laissez-faire leadership style and preschool teacher leadership . Psychological capital of preschool teachers was positively correlated with transformational leadership style  and transactional leadership style , while the psychological capital of preschool teachers was negatively correlated with laissez-faire leadership style . There was a significant positive correlation between preschool teacher leadership and psychological capital .Preschool teacher leadership was positively correlated with transformational leadership style  was significantly lower than who with more than 4 years of seniority , and reaches the peak within the range of 11–15 years of seniority . There were significant differences for position, F = 3.216, p < 0.01. Post-hoc analysis showed that the score of assistant teachers  was significantly lower than that of teachers in more senior positions. The leadership level of administrative teachers was the highest among all the teachers .The mean difference test was conducted for the two variables . The results are shown in F = 5.569, p < 0.05. Post-hoc analysis showed that the score of preschool teachers with 11–15 years of seniority  was highest. There was significant difference for position, F = 3.508, p < 0.05. Post-hoc analysis indicated that score of assistant teachers  was significantly lower than that of teachers in more senior positions.In terms of psychological capital, there was significant difference for seniority, The purpose of this study is to explore the relationship between the principal leadership style, the preschool teacher leadership and the psychological capital of preschool teachers, which focusing on the mediating effect of psychological capital. On this basis, a structural equation model was constructed, and the model results are shown in 2/df ≤ 3, CFI ≥ 0.90, TLI ≥ 0.90, RMSEA ≤ 0.08 and SRMR ≤ 0.80, the model is considered to be a good fit. The fitting index of the model is x2 = 6359.37, df = 2332, RMSEA = 0.073, CFI = 0.905, TLI = 0.918, SRMR = 0.047. Transformational leadership style has a significant positive impact on psychological capital  and teacher leadership . Transactional leadership style has a significant positive impact on psychology capital . Psychological capital has a significant positive impact on teacher leadership . Transactional leadership style  has no significant impact on teacher leadership. Laissez-faire leadership style has no significant impact on teacher leadership  and psychology capital .According to  was 48.2% (0.204/0.423). Therefore, it can be assumed that psychological capital plays a significant intermediary role in transformational leadership style and teacher leadership. In the Hypothesis 4B pathway , the mediating effect quantity was 0.253, p < 0.001, the 95% confidence interval was , the association between transactional leadership style and teacher leadership is non-significant. Therefore, psychological capital fully mediated the relationship between transactional leadership style and teacher leadership. In the Hypothesis 4C pathway , all paths are not significant and there is no mediating effect.To examine the indirect effects of psychology capital, mediation analysis based on 5,000 bootstrapping samples was conducted. The results were shown in On the whole, preschool teacher leadership is at an above-average level. First, since comprehensive education reform was launched in most areas of China, teacher-related policies in early childhood education reform have been considered a decisive factor in improving the quality of early childhood education, among which improving preschool teacher leadership is one of the important factors for the success of education reform , clearly indicated that the government will gradually improve the treatment of equal pay for equal work for teachers in public preschools, integrate all preschool education workers into the social security system, and require preschools to buy endowment insurance for them. The state and government departments at all levels should guarantee the material needs of preschool teachers to meet their basic survival and developmental needs so that they can find their great social importance and see the bright prospects of their careers. Therefore, they would have more confidence and hope in this career and could also maintain an optimistic psychological state at work.In this study, the psychological capital of preschool teachers is generally above the average level, indicating that preschool teachers can have a positive psychological state at work, remain optimistic and believe that they can solve challenges and difficulties. This is consistent with the results of Fu , Cheng aThe transformational leadership style of preschool principals can directly and positively influence the leadership of preschool teachers, which is similar to the results of Leithwood and Jantzi  and Li aIt is worth noting that in this study, the direct effect between the transactional leadership style of principals and preschool teacher leadership is not significant, but the mediating effect through psychological capital is significant. This means that the transactional leadership style of principals indirectly affects the leadership of preschool teachers through the intermediary role of their psychological capital. This also echoes the point of view of Marshall et al.  and Li . As a leThere was no direct effect between laissez-faire leadership style and preschool teacher leadership, nor was there an indirect effect on preschool teacher leadership through the mediation of psychological capital. Analyzing the related reasons, we can draw the following conclusions. First, influenced by the hierarchical management structure in China, the management system of Chinese preschools is under the responsibility of the preschool principal (known as “Yuan Zhang” in Chinese), i.e., who is wholly responsible for handling the work of preschool. He or she is responsible for major issues and decisions such as the missions of preschool, training programs, and teachers' appointments (Jiang et al., As the manager and head of the preschool, the principal's own actions can influence the perceptions and practices of the organization's members. In addition, it may affect the organizational climate of the school as a whole. When the principal is able to actively engage in leadership practices that set an example for teachers, preschool teachers are influenced by the principal's positive behavioral practices and are able to look to the principal and learn from her or his own leadership practices. Therefore, in management and teaching, the principal should actively exert his or her unique charisma and leadership skills to influence preschool teachers' perceptions of leadership practices, to “practice what you preach” and to “teach by example” as management guidelines, and to strive to set an example for preschool teachers with his or her own leadership practices.When preschool teachers are leaders who have a positive, non-powerful influence on children, colleagues, and even other people in the preschool, they demonstrate the characteristics of leaders who can influence others and lead them to progress. In addition, each teacher is an individual and must shine differently from others in the group. As the manager of the whole team, the principal should be good at discovering the shining points of each teacher, tapping into his or her leadership talents, encouraging teachers to take on leadership roles other than teaching based on their specific situations and personality characteristics, and bringing their professional strengths and authority to bear on other teachers and lead the whole preschool to a higher level of development.Preschool teachers need to change their role and understanding in a timely manner. Preschool teachers often habitually think of themselves as just a teacher, a follower of the director and management, and do not yet have a clear understanding of the identity of a teacher leader. Wei and Cheng  suggestsTeacher leadership is essentially a job-embedded professional development that enables educational reform and instructional improvement through ongoing, site-based professional development Poekert, . PreschoIn addition to the above, preschool teachers need to maintain a positive mental state. It is inevitable that preschool teachers will encounter many teaching problems and challenges in their work, and sometimes it is difficult for their professionalism to be recognized by others, and they do not have the support and understanding of parents, or even the understanding and help of colleagues or principals. This requires teachers to adjust their mindset and work status in a timely manner, always have enough confidence and hope in the early childhood education, be able to put in some effort when facing various challenges and problems, believe that they are capable of accomplishing them, and be persistent.When interpreting the findings of this study, it is important to note its limitations. Firstly, to examine whether there is an effect of leadership style characteristics on the individual characteristics of subordinates in a given organization, the participants should include both individual leaders and all subordinates. The results would be more convincing if nested data between leaders and subordinates could be collected and the correlation between the two sides of the data could be demonstrated.Secondly, the sample size in this study was somewhat limited, and the findings could not be generalized to all the preschools in China. In order to determine whether different organizational structures or management models for preschools can moderate the relationship between leadership styles and teacher leadership, future research could broaden the scope of the participant to include various types of preschools in various regions of China.Finally, in terms of research content, the mechanism of principal leadership style's influence on preschool teacher leadership has not been studied deeply enough. This research only explores the mediating variable of psychological capital, and many other variables that may affect the principal leadership style and preschool teacher leadership are not mentioned. There may even be chain mediating or moderating variables between the principal leadership style and preschool teacher leadership, which need to be further analyzed in future studies.This research, based on leadership-membership exchange theory, took preschool teachers in Guangdong Province of China as participants and analyzed the relationship and the underlying mechanisms of action between preschool principal leadership styles, preschool teacher leadership and psychological capital by distributing a large-scale questionnaire. First of all, the results showed that preschool teacher leadership and psychological capital were at moderate to high levels, with significant differences in terms of seniority and position. The principal leadership styles of preschool are mainly transformational leadership style and transactional leadership style. Secondly, transformational leadership style and transactional leadership style showed significant positive correlations with preschool teacher leadership, and laissez-faire leadership style showed no correlation with preschool teacher leadership. Preschool teacher leadership was significantly and positively correlated with psychological capital. Transformational leadership style and transactional leadership style were significantly and positively correlated with psychological capital, while laissez-faire leadership style was significantly and negatively correlated with psychological capital. Finally, Transformational leadership style can positively influence preschool teacher leadership directly and indirectly through psychological capital; transactional leadership style can only positively influence preschool teacher leadership indirectly through the mediating role of psychological capital. Laissez-faire can neither directly influence preschool teacher leadership nor indirectly influence preschool teacher leadership through the mediating role of psychological capital.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.All procedures followed were in accordance with the ethical standards of the responsible Committee on Human Experimentation  and with the Helsinki Declaration of 1975, as revised in 2000. Written informed consent to participate in this study was provided by the participants.LZ designed the research and drafted the manuscript. TW and CL collected and extracted data for analysis. LL and PR provided important ideas and substantial feedback for the study and edited the manuscript. All authors have approved the final version of this article.This work was supported by the Project of Humanities and Social Sciences of Ministry of Education of the People's Republic of China [21YJC880092].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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


We used bibliometric methods to assess the global scientific output on the IRAEs for colorectal cancer and to explore the current status and trends in the field over the last three decades.Studies on immune-related adverse events for colorectal cancer published from 1996 to 2022 were retrieved from the Web of Science. For quantitative and qualitative assessments of publication outputs and author contributions, the R bibliometrix package was used. VOSviewer was used to construct networks based on the co-authorship of countries/institutions/authors, co-citation analysis of journals/references, citation analysis of documents, and co-occurrence of keywords.A total of 237 relevant articles were included in the final analysis. The number of publications has increased significantly over time. The countries and institutions that contributed most to the field were the USA and the University of Texas MD Anderson Cancer Center. Jefferey Schlom was the most productive author, ranking first in cited authors. The most cited document was Topalian et al. in The New England Journal of Medicine (2012). The journals with the highest number of selected articles and citations were The New England Journal of Medicine and the Journal of Clinical Oncology, respectively. Co-occurrence analysis showed that IRAEs for colorectal cancer were associated with immunotherapy, open-label, chemotherapy, nivolumab, and PD-1. Trend analysis showed that immune checkpoint inhibitors, gut-microbiota, inflammatory-bowel disease, and PD-1has been on the rise in recent years to IRAEs for colorectal cancer.Our bibliometric analysis showed that studying IRAEs for colorectal cancer is increasingly a hot topic. The focus of the research had evolved from traditional treatment modalities such as targeted therapy to gut microbiota. Inflammatory bowel disease may be a future research hotspot of IRAEs for colorectal cancer. Worldwide, colorectal cancer ranked third in terms of incidence but second in terms of mortality. In 2020, it was estimated that there would be over 1.9 million new colorectal cancer cases and 935,000 deaths, representing approximately 1% of every ten cancer cases and death . AlthougBibliometrics takes the global literature as the object of study. It used statistical and other methods to study the distribution patterns and keywords of the literature to explore current research characteristics and practices . ThroughAll data were retrieved from the Web of Science (WoS) core collection, including SCI-EXPANDED, on August 1, 2022. WOS is one of the most widely accepted and suitable databases for bibliometric analysis of subsequent scientific publications due to its rigorous evaluation process and the most impactful and credible information it can provide. The data for this study were collected from the core collection of the WOS. Documents were collected using the search formula “) AND  or TS=(side effects)) AND (TS=(immune))”. The article type filter was set to journals and conference articles, and the language filter was set to English. Collected articles with full records and cited references were saved as plain text for subsequent analysis. In addition, to get the correct number of citations per document We also cross-matched the number of citations for each document in the Scopus and Google Scholar databases.The bibliographic information of the selected publications was automatically converted and analyzed using the bibliometrix package  in R 4.2The flowchart for this bibliometric analysis was shown in Global contributions to research on the IRAEs for colorectal cancer were analyzed. They were represented on the blue-coded world map , followed by the Certified Tumor Registrar (15 studies) and the Kaohsiung Medical University (14 studies)  , open-label (156), chemotherapy (152), nivolumab (146) and PD-1 (132)  in Refractory Solid Tumors: Safety, Clinical Activity, Pharmacodynamics, and Immunologic Correlates” and “Nivolumab in patients with metastatic DNA mismatch repair-deficient or microsatellite instability-high colorectal cancer (CheckMate 142): an open-label, multicenter, phase 2 study” had over 1000 cited. A deeper analysis showed that all three of these highly cited papers are randomized controlled trials assessing the efficacy and safety of immunotherapy in the treatment of colorectal cancer as well as other solid tumors. In addition, all three articles were published in some of the world’s most prestigious journals. A co-authorship network involving academics contributing to the current field suggested that close cooperation existed between different research teams, with most researchers involved in multiple research teams. This is due to the fact that collaboration between scholars provided a number of benefits for data collection and research design.Gut microbiota and inflammatory bowel disease were one of the outstanding results achieved in this study. Our trend analysis concluded that the two topics mentioned above might be one of the hot spots for future research on IRAEs for colorectal cancer. Healthy gut microbiota is essential for developing the immune system and coordinating the immune response. At the same time, dysbiosis is associated with various diseases, including inflammatory bowel disease and colorectal cancer , 20. SubA bibliometric analysis will provide valuable references and recommendations, especially for studies of adverse events and side effects of cancer treatments, such as IRAEs in colorectal cancer. It may also provide us with a landscape of literature in the areas of interest to researchers. As a follow-up to this study, we will continue to follow the hot topics and their evolution in the IRAEs in colorectal cancer and plan to conduct updated bibliometric analyses when significant new data become available.Our results showed that the USA significantly contributes to the research on IRAEs in colorectal cancer. Most of the studies related to IRAEs in colorectal cancer have been published in high-quality journals, indicating the high attractiveness and impact of research advances in this field. We revealed that the most popular lines of research in this area are inflammatory bowel disease and gut microbiota, indicating that the bibliometric analysis of IRAEs in colorectal cancer has greatly guided future research hotspots as well as directions in colorectal cancer.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.JC, YX, and LL contributed to conception and design of the study. LZ organized the database. MS performed the statistical analysis. XH wrote the first draft of the manuscript.XG, LL, YL, and JC wrote sections of the manuscript. All authors contributed to the article and approved the submitted version.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The Clean Development Mechanism (CDM), a partnership tool founded under the Kyoto Protocol, grants potential opportunities to help developing countries achieve sustainable development. The present research examines the CDM projects in Eastern Europe . Although there were far fewer projects in this region than, for instance, China or India, it has some specific features that make it worth studying. Major findings are that most CDM projects in Eastern Europe involved a changing combination of two or more sources of financing, and the distribution of projects in the region was uneven. Moreover, although there was a small number of projects overall, they were all cost-effective, long-term and large-scale. The findings of the research call for improvements to be made to the governance of the CDM, by strengthening the international and national regulation of projects and by aggregating the scales of decision-making and actions so that real multi-scalar transnational governance — from the global level down to the local level — is implemented in a coherent manner. It is also recommended to carry out ex-post project evaluations, following which readjustments could be made. The Kyoto Protocol (KP) introduced a fundamentally new approach in the form of a cooperation tool aimed at reducing the costs associated with limiting greenhouse gas (GHG) emissions. Since climate change mitigation does not depend on where the emission reductions occur, a reasonable economic approach is to reduce them to the lowest possible level everywhere.Accordingly, the KP provided three market mechanisms to maximize emission reductions: international emissions trading, joint implementation (JI), and what is known as the Clean Development Mechanism (CDM). In particular, the protocol stated that the CDM should help industrialized countries (those listed in Annex 1 of KP) to reduce the cost of meeting their emission reduction targets by implementing measures in other countries at lower costs than potential domestic costs UNEP . The CDM1The significance of CDM projects has been raised by many researchers, including Hepburn , RuthnerThe CDM projects aim to promote sustainable development in the host countries. However, the final decision on whether a particular project meets sustainable development criteria lies with the host country government. Adopted in 2015, the Sustainable Development Goals (SDGs) established a set of goals and targets to work towards in order to achieve sustainable development, focusing on the three dimensions of sustainable development: social, economic and environmental. The SDGs include a set of specific indicators for each target, which allow progress to be monitored in each case (The Danish Institute for Human Rights n.d.). The screening of CDM projects according to sustainable development criteria has the same aim. Specifically, from an economic and environmental perspective, SDG 7 and SDG13 are similar to the primary aims of CDM projectsFrom SDG 7 and 13, the relevant indicators are 7.2.1 renewable energy share in the total final energy consumption, 7.3.1 energy intensity measured in terms of primary energy and GDP, 7.b.1 installed renewable energy-generating capacity in developing countries (in watts per capita), 13.1.1 number of deaths, missing persons and directly affected persons attributed to disasters per 100,000 population and 13.1.2 number of countries that adopt and implement national disaster risk reduction strategies in line with the Sendai Framework for Disaster Risk Reduction 2015–2030. However, assessing the impact of the CDM projects analysed in terms of these indicators goes beyond the scope of this paper.Notwithstanding a number of studies in the field of CDM projects and renewable energy sources (RES), there are few analyses of specific CDM projects in the countries under study here,In view of the lack of research focused on Eastern Europe, the main aim of this work is to contribute to bridging this gap in the knowledge by examining various CDM projects in these countries, specifically, Moldova, Serbia, Bosnia and Herzegovina, Montenegro, and Albania. The region under investigation in our study was not chosen by chance. These countries are home to a considerable number of RES projects. Due to the critical proximity of these countries to the European Union (EU), they have a direct impact on the energy system of the European continent and its energy security.The novelty of this paper lies in the methodological approach applied. The CDM projects are studied here not only from a financing perspective, but also taking into account the main economic and environmental features essential for the sustainable development of the host countries. To do so, the fundamentals of the projects and their goals are described in detail, the concept of “project efficiency” is analysed and the effectiveness of the projects is considered, including their economic and environmental efficiency. The analysis of the results of these projects in terms of economic and environmental efficiency is primarily based on statistical and financial data on the reduction of GHG emissions and quantitative indicators. Finally, this paper explores possible problems in the CDM decision-making process.To the best of our knowledge, no previous papers have focused on this issue. The recent conflict between Russia and Ukraine has shone a light on European countries’ dependence on Russian gas. Given that many of the projects analysed in this research consist of replacing fossil fuel technologies, such as natural gas, with RES, the research is also of geostrategic interest.The main findings show that most of the analysed CDM projects involved a changing combination of two or more sources of financing, and the distribution of projects in the region was uneven. Moreover, although there was a small number of projects overall, they were, without exception, all cost-effective, long-term and large-scale projects. The study highlights the contribution of these projects to sustainable development from an environmental and economic perspective.The paper is structured as follows: After this introduction, the second section presents the literature review. The third section describes the method while the fourth section explains the data. The results are analysed and discussed in the fifth section. The conclusions are explained in the sixth section, along with some policy implications.Studies of CDM projects tend to prioritize their temporal analysis and the interdependence between the result and the commencement date of the project  are assigned to a specially created project company. Nonetheless, it is worth noting that in recent years, the number of investments in the field of RES has been growing rapidly  technology ; (6) industrial processes , PFCs (fluorocarbons), SF6 (sulphur hexafluoride), NF3 (nitrogen trifluoride)); and (7) absorption projects (afforestation and reforestation only). To ensure the competitiveness of small-scale projects in comparison with large-scale projects, the Marrakesh Accords provide for a simplified procedure with less stringent acceptance criteria. The CDM also covers the use of RES up to 15 MW, or energy efficiency with a lower consumption (either on the production side or on the consumption side) up to 15 GWh/year, and other project activities that both help reduce emissions and directly emit less than 15 thousand tonnes of CO2 equivalent (CO2eq) per year.The CDM covers projects in the following seven sectors: (1) improving user-level energy efficiency; (2) improving energy efficiency in energy production; (3) RES; (4) fuel change; (5) agriculture , one delegate from small island developing countries, and two representatives from each Annex I country and each non-Annex I country. The Executive Council held its first meeting during the negotiations in Marrakech (November 2001), which marked the launch of the CDM.Figure An extensive literature review on the subject of CDM projects was carried out using the main databases of scientific documents, primarily official United Nations sources, in particular UNFCCC. An additional source was Web of Science for scientific publications on the topic, as well as topics related to the issue under analysis in this research. To the extent possible, aspects relating to the countries under analysis are explicitly highlighted whenever available data or information exists.We then identify and provide details on CDM projects conducted during the analysed period, which varies from country to country but may be defined as covering 30 years (2006–2036). It is worth noting that there is a limited amount of peer-reviewed literature about this topic.This research was conducted using a combination of approaches and scientific methods. The abstract-logical method was used to reveal the theoretical aspects of assessing the financial condition and financial stability of projects, in order to determine the main characteristics of the processes and phenomena in this area. The system-structural method was used to analyse the financial condition and identify structural changes.The financial appraisal process is a standard approach for assessing the economic viability and environmental efficiency of a project see Fig. . The finAlthough detailed financial data, such as monthly cash flow reports, provide the necessary information to evaluate project performance, some different indicators can also be used to summarize the situation. The relative importance of various indicators differs between debt and equity providers, although the basic principles are the same. The indicators commonly used are the following: (1) net present value (NPV) and internal rate of return (IRR); (2) IRR (equity); (3) earnings before interest, taxes, depreciation and amortization (EBITDA); (4) interest rate and (5) debt service cover ratio (DSCR). However, in our research, certain indicators were not used due to a lack of data and/or the fact they were not relevant to the studied projects. Thus, NPV and IRR and IRR (equity) were considered in the analysis, while EBITDA, interest rate and DSCR were not applicable to the projects under study here.It is important to emphasize the indispensable role of NPV and IRR when it comes to assessing CDM projects in general, and our analysed projects in particular. The aforementioned indicators are needed to ascertain the cost-effectiveness of investment projects. Moreover, they tell us the cost–benefit the project provides in comparison with other financing alternatives for a similar period. Detail on each country is presented in Annex B.The data used were sourced from the official UNFCCC database, UNdata, the Open SDG Data Hub, MBS, the UN Comtrade database, the National accounts – Analysis of Main Aggregates (AMA) and the UN Digital Library. After a systematic search of the whole set of aforementioned sources, the projects for analysis were hand-selected.As mentioned above, the main data source is the official UNFCCC database. The CDM page of the UNFCCC website has a “Project Search” tab. On this page, in the public domain, the search tool makes it possible to find specific CDM projects as well as general project types. The UNFCCC database contains all the projects that are at various stages of the registration process, as well as rejected projects.The search tool has a user-friendly interface, which offers various ways to search for a project: by name, for instance, or using the project classification. Furthermore, all projects are grouped by their size  and can be at any stage of adoption, which may be indicated. A search can also be conducted by reference number, if known. Another significant advantage of the system is the advanced search function, which enables the user to select or reject projects according to the methodology applied, as well as the host country. It also makes it possible to indicate the date of registration, and the amount of emission reductions. It is worth noting that the database includes a wide range of methodologies used for calculating and submitting projects, where the user can find a large amount of information regarding particular projects, as well as methodological recommendations in general. The register of CDM projects also provides information on the evaluation and status of existing as well as completed projects. Lastly, the UNFCCC database provides information on “Investor Interaction” to study current projects and trends in capital flow through CDM partnerships.Another essential source is UNdata. This is a search system that provides access to data from UN system databases. UNdata began operations in February 2008 and is the outcome of a partnership among the UN Statistics Division, the Swedish Statistical Office and the Swedish International Development Cooperation Agency. UNdata enables the user to explore and download data from many statistical resources, covering such subjects as energy, the environment, employment, food and agriculture, health, human development, industry, information and communication technologies, national accounts, population, refugees, commerce and tourism. On the official UNdata website, the user can find an enormous amount of statistical information, reports, paperwork, statements and infographics from all UN entities, providing genuine and unique data. The data are divided into datasets, sources and topics, which makes it easier to find the desired information. In addition, there is an “Update Calendar” section, which simplifies the separation of data into dataset, source, organization, last update and next update; this feature proves extremely useful for tracking down the needed information. Also helpful is the glossary, which provides the user with official definitions of key terms.Furthermore, it is worth highlighting the other databases used in our study: the Open SDG Data Hub, MBS (monthly bulletin of statistics online), the UN Comtrade database, the National accounts – Analysis of Main Aggregates (AMA) and the UN Digital Library.The CDM projects are studied here from a financing perspective, but we also take into account the main economic and environmental features. The results of this analysis allow us to discuss both the local and global relevance of these projects.From a financing perspective, there are usually three types that can be used to develop CDM projects: grants, loans (debt), and equity. However, most CDM projects will involve a changing combination of two or more sources of financing, due to the large number of necessary investments. While there are some typical models of project financing that were considered in this research, it should be noted that not all of them were applied to the specific projects here, due to certain characteristics of our chosen region. Thus, project financing (in a particular sense of this term), also known as limited recourse financing, corporate financing and leasing financing, was utilized in the projects in question.Although some less common financing types were not used , one of the most recent and relevant types was implemented — namely, Energy Service Company/Renewable Energy Service Company (ESCO/RESCO) . Most of the Albanian projects were handled in partnership with Austrian energy companies. All projects had fairly high investment inflows, as well as reasonably high annual emission reductions.The three Albanian projects were also carried in the field of hydropower. It should be noted that the HPP Ashta project had the greatest environmental cost-effectiveness of all the projects, with a ratio of 3106.27  , SDG8 (decent work and economic growth), SDG9 (industry innovation and infrastructure), and SDG17 . After all, one of the aims of the CDM is to provide a cheaper solution for developing countries to achieve their targets.Following the analysis of the studied projects, the initial purpose of the CDM to function as an effective climate finance tool can clearly be seen in the individual projects Olsen . By analMost projects conducted a sensitivity analysis considering various possible scenarios. Within the framework of its sensitivity analysis, each project justified its cost-effectiveness given its inherent uncertainty and risks. It has been shown that the projects under consideration have a relatively low sensitivity, which makes it easier to interpret the economic and environmental indicator of annual emission reductions.The last finding relates to an assessment of the environmental role of the projects. Each project was under the supervision of a national environmental review, which took into account legislative requirements in the field of environmental impact assessment. Each project (with the exception of three projects in Serbia) conducted an evaluation of the hypothetical damage and benefits, within the framework of the integrated environmental and economic effectiveness analysis.This research allows us to conclude that, in a short period of time, the CDM acted as a catalyst for a large number of project activities in Eastern Europe. All the selected projects supported decarbonization processes. Without this mechanism, it is difficult to imagine such a result would have been achieved. In spite of the overall progress driven by the CDM, the outcomes have not always been entirely clear or acknowledged by all actors. The benefits in terms of sustainable development (SDGs), technology transfer, additionality of funding and global emission reductions have been called into question, as has the fair distribution of the benefits (the CDM market has been dominated a few non-Annex 1 parties).The contribution to the sustainable development of host countries was one of the two main objectives of the CDM. It is therefore important to assess the impact of CDM projects in terms of sustainable development. This evaluation constitutes a prerequisite for the acceptance of projects by the Executive Council, but it must be said that the requirements in this area are extremely limited. In fact, to meet the requirements of the Executive Council, it is enough for the host country to certify that the project complies with its sustainable development policy. One might therefore argue that there is no reason to further question the principles and methods which should guide the ex-ante evaluation of CDM projects from the point of view of sustainable development. This would be to ignore the fact that, in the absence of an explicit national policy of sustainable development, host countries may be anxious to verify that the projects submitted to them nevertheless fall within this scope. Moreover, Annex 1 countries may wish to impose additional admissibility criteria on the projects presented to their National Authority, including in matters of local development.To ensure the success of CDM in the future, it is important to make prompt modifications to governance, market functioning and project scope. Adjustments performed in the short term are best done in the context of a strategic outlook with plainly defined goals. Such changes must be meaningful enough to produce continuity and to rebuild reliance on the UNFCCC’s ability to implement the mechanism. This will be especially challenging in light of developments in the negotiations over the medium term.It seems essential to improve the governance of the CDM by strengthening the international and national regulations of projects and by aggregating the scales of decision-making and actions, so that real multi-scalar transnational governance — from the global level (CDM Executive Council) down to the local level (places where projects are carried out) — is implemented in a coherent manner. It also crucial to improve the effectiveness of projects, by carrying out ex-post evaluations, following which readjustments could be made.Despite the shock caused by the SARS-CoV-2 pandemic, nations are still striving to reduce emissions, while overcoming the crisis and developing their economies in a sustainable way. An effective battle against climate change requires much more drastic emission reductions by the world’s top emitters. By drawing on these lessons from the past and involving civil society at the heart of CDM governance, it will surely be possible to produce a robust and adaptive institutional framework.