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Background Cardiovascular diseases are leading causes of death, globally, and health systems that deliver quality clinical care are needed to manage an increasing number of people with risk factors for these diseases. Indicators of preparedness of countries to manage cardiovascular disease risk factors (CVDRFs) are regularly collected by ministries of health and global health agencies. We aimed to assess whether these indicators are associated with patient receipt of quality clinical care. Methods and findings We did a secondary analysis of cross-sectional, nationally representative, individual-patient data from 187,552 people with hypertension (mean age 48.1 years, 53.5% female) living in 43 low- and middle-income countries (LMICs) and 40,795 people with diabetes (mean age 52.2 years, 57.7% female) living in 28 LMICs on progress through cascades of care (condition diagnosed, treated, or controlled) for diabetes or hypertension, to indicate outcomes of provision of quality clinical care. Data were extracted from national-level World Health Organization (WHO) Stepwise Approach to Surveillance (STEPS), or other similar household surveys, conducted between July 2005 and November 2016. We used mixed-effects logistic regression to estimate associations between each quality clinical care outcome and indicators of country development (gross domestic product [GDP] per capita or Human Development Index [HDI]); national capacity for the prevention and control of noncommunicable diseases (‘NCD readiness indicators’ from surveys done by WHO); health system finance (domestic government expenditure on health [as percentage of GDP], private, and out-of-pocket expenditure on health [both as percentage of current]); and health service readiness (number of physicians, nurses, or hospital beds per 1,000 people) and performance (neonatal mortality rate). All models were adjusted for individual-level predictors including age, sex, and education. In an exploratory analysis, we tested whether national-level data on facility preparedness for diabetes were positively associated with outcomes. Associations were inconsistent between indicators and quality clinical care outcomes. For hypertension, GDP and HDI were both positively associated with each outcome. Of the 33 relationships tested between NCD readiness indicators and outcomes, only two showed a significant positive association: presence of guidelines with being diagnosed (odds ratio [OR], 1.86 [95% CI 1.08–3.21], p = 0.03) and availability of funding with being controlled (OR, 2.26 [95% CI 1.09–4.69], p = 0.03). Hospital beds (OR, 1.14 [95% CI 1.02–1.27], p = 0.02), nurses/midwives (OR, 1.24 [95% CI 1.06–1.44], p = 0.006), and physicians (OR, 1.21 [95% CI 1.11–1.32], p < 0.001) per 1,000 people were positively associated with being diagnosed and, similarly, with being treated; and the number of physicians was additionally associated with being controlled (OR, 1.12 [95% CI 1.01–1.23], p = 0.03). For diabetes, no positive associations were seen between NCD readiness indicators and outcomes. There was no association between country development, health service finance, or health service performance and readiness indicators and any outcome, apart from GDP (OR, 1.70 [95% CI 1.12–2.59], p = 0.01), HDI (OR, 1.21 [95% CI 1.01–1.44], p = 0.04), and number of physicians per 1,000 people (OR, 1.28 [95% CI 1.09–1.51], p = 0.003), which were associated with being diagnosed. Six countries had data on cascades of care and nationwide-level data on facility preparedness. Of the 27 associations tested between facility preparedness indicators and outcomes, the only association that was significant was having metformin available, which was positively associated with treatment (OR, 1.35 [95% CI 1.01–1.81], p = 0.04). The main limitation was use of blood pressure measurement on a single occasion to diagnose hypertension and a single blood glucose measurement to diagnose diabetes. Conclusion In this study, we observed that indicators of country preparedness to deal with CVDRFs are poor proxies for quality clinical care received by patients for hypertension and diabetes. The major implication is that assessments of countries’ preparedness to manage CVDRFs should not rely on proxies; rather, it should involve direct assessment of quality clinical care.

Introduction Agenda Setting Theories Cases Selection and Methods CGH Cases for Analysis Discussion of the CGH Cases Conclusions and Recommendations ReferencesAbstract-Common goods such as air, water, climate, and other resources shared by all humanity are under increasing pressure from growing population and advancing globalization of the world economy. Safeguarding these resources is generally considered a government responsibility, as common goods are vulnerable to market failure. However, governments do not always fulfill this role, and face many challenges in doing so. This observation-that governments only sometimes address common goods problems-informs the central question of this paper: when do governments act in support of common goods? We structure our inquiry using a framework derived from three theories of agenda setting, emphasizing problem perception, the role of actors and collective action patterns, strategies and policies, and catalyzing circumstances. We used a poll of experts to identify important common goods for health: disease surveillance, environmental protection, and accountability. We then chose four historical cases for analysis: the establishment of the Epidemic Intelligence Service in the US, transport planning in London, road safety in Argentina, and air quality control in urban India. Our analysis of the collective evidence of these cases suggests that decisions to advance government action on common goods require a concisely articulated problem, a well-defined strategy for addressing the problem, and leadership backed by at least a few important groups willing to cooperate. Our cases reveal a variety of collective action patterns, suggesting that there are many routes to success. We consider that the timing of an intervention in support of common goods depends on favorable circumstances, which can include a catalyzing event but does not necessarily require one.

IntroductionThe Framework Convention on Tobacco Control (FCTC) offers guidance on evidence-based policies to reduce tobacco consumption and its burden of disease. Recently, it has provided guidance for alternative tobacco products, such as the waterpipe. Waterpipe tobacco smoking (WTS) is prevalent worldwide and policies to address it need to take into consideration its specificities as a mode of smoking. In parallel, a growing body of literature points to the potential of evidence-based tobacco control policies to increase health inequities. This paper updates a previous global review of waterpipe tobacco policies and adds an equity lens to assess their impact on health inequities.MethodsWe reviewed policies that address WTS in 90 countries, including 10 with state-owned tobacco companies; 47 were included in our final analysis. We relied primarily on the Tobacco-Free Kids organisation’s Tobacco Control Laws website, providing access to tobacco control laws globally. We categorised country tobacco policies by the clarity with which they defined and addressed waterpipe tobacco in relation to nine FCTC articles. We used the PROGRESS (Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status and Social capital) framework for the equity analysis, by reviewing equity considerations referenced in the policies of each country and including prevalence data disaggregated by equity axis and country where available.ResultsOur results revealed very limited attention to waterpipe policies overall, and to equity in such policies, and highlight the complexity of regulating WTS. We recommend that WTS policies and surveillance centre equity as a goal.ConclusionsOur recommendations can inform global policies to reduce WTS and its health consequences equitably across population groups.