H. Merdarion.

Hemoptysis and bloody sputum occur in less than a quarter of patients buy 100mcg cytotec mastercard, with the worst cases originating from lesions invading blood vessels discount cytotec 200mcg overnight delivery. Few crackles can be noticed on auscultation after deep inspiration and also ronchi and tubular sounds generic cytotec 200mcg overnight delivery. Such delays in diagnosis may be due to low diagnostic suspicion by the medical personnel, lack of access to health services, because the patient may not acknowledge being sick or may not seek medical help due to eco- nomic or cultural reasons. An early diagnosis is critical for controlling transmission of the disease in the community, especially in congregated institutions, such as hospitals, prisons, and shelters. It is crucial to perform the diagnosis in the initial phase of this type of presentation in patients with recent symptoms (less than four weeks) (Figure15-6). If diagnosis is delayed, the disease may evolve rapidly, destroying the pulmonary parenchyma (Figures 15-7 and 15-8). In the past, it was recognized as a sign of the tubercle bacilli seeking a route for air- borne dissemination (Figure 15-7). Tuberculosis disease 495 a b c Figure 15-6: Parenchymal infiltrate in the upper left lung, in posteroanterior (a and b) and lordotic position (c). After achieving cure, respiratory symptoms such as a productive cough persist in some patients for several years. When the patient refers to recurrent hemoptysis with elimination of more than 15-50 mL of sputum per day, bronchiectasis and/or a fungus ball may be present (Figure 15-10). Figure 15-10: Chest X-ray showing fibrotic infiltrate and cavity with a fungus ball in the upper left lobe. After this, tubercle bacilli can multiply at any time when there is a decrease in the host’s immune capacity to contain the bacilli in their implantation sites. The specific signs and symptoms will depend on the affected organ or system, and are characterized by inflammatory or obstructive phenomena. For this reason, the extrapulmonary disease gener- ally has an insidious presentation, a slow evolution and paucibacillary lesions and/or fluids. Access to the lesions through secretions and body fluids is not always possible, and for this reason, invasive techniques may be necessary in many cases, to obtain material for diagnostic investigation. Tissues and/or body fluids should be submitted to laboratory examination, in particular bacteriological culture for myco- bacteria and histopathological analysis. Nevertheless, the chest X-ray is mandatory for the evaluation of evidence of primary infection lesions, which provide a good verification to support the diag- nosis (Rottenberg 1996). Its onset may be either insidious or abrupt, depending on the bacillary load and/or the host immune situation, with unvacci- nated infants, elderly and immunodeficient patients being the most susceptible (Lester 1980, Thornton 1995). Other specific symptoms depend on the organs affected, and involvement of the central nervous system occurs in 30 % of cases. The physical examination is unspecific, and the patient can present 498 Tuberculosis in Adults with variable degrees of wasting, fever, tachycardia and toxemia. Chest X-ray shows a characteristic diffuse, bilateral and symmetrical micronodular infiltrate (Figure 15-8). The onset of the disease may be insidious or abrupt, with fever, systemic complaints, dyspnea, dry coughs, and pleuritic thoracic pain. The pleural effusion is generally unilateral and moderate, and can easily be de- tected by conventional chest X-ray examination (Figure 15-12). The differential diagnosis for pleural effusions includes para-pneumonic pleural effusions, mycoses, malignant diseases, and, especially in young women, collagen vascular diseases. Most of the time, the effusion is resolved, even if not treated, leaving minimal or no radiological sequelae. The preferential localization is the anterior cervical lymph node chain with little predominance of the right side chain. Patients mainly complain of fever and the increasing vol- ume of lymph nodes, but other symptoms may be absent. Renal disease occurs after a long latency period and is frequently secondary to hematogenous dissemination. The patient generally com- plains of dysuria, polacyuria, and lumbar pain, whereas systemic symptoms occur less frequently. Frequently, the disease presents as a urinary infection that does not respond to routine broad spectrum antimicrobial treatment. Excretory urography can either be normal or present a wide variety of alterations that include parenchymatous cavities, dilatation of the pyelocalicial system, renal calcifications of irregular contours, decreased capacity of the urinary bladder, and multiple ureter stenoses (Figure 15-15). In the cystoscopy, edema and diffuse hyperemia are observed, which are more intense around the orifice (golf hole sign), often accompanied by irregular ulcerations and/or infiltrates and vege- tations. Figure 15-15: Infertility patient hysterosalpingogram, revealing proximal dilatations of the fallopian tubes (“rigid pipe stem" appearance ) and distal enlargments/constrictions (“beaded" appearance). Culture of three to six specimens of first morning urine are together as reliable as the culture of a single 24-hour urine sample. Tuberculosis of the central nervous system The compromise of the central nervous system occurs in two basic forms: menin- goencephalitis and intracranial tuberculoma. The clinical manifestations are due to the inflammatory process induced by the mycobacterial infection, and the symptoms depend on the site and intensity of 15. Meningoencephalitis generally has an insidious onset and a slowly progressive course, with symptoms including apathy, lethargy, fever, and mental disturbances such as irritability, understanding difficulties, personality alterations, disorienta- tion, and progressive mental confusion. Findings on physical examination are related to the stage of the disease and the nd rd affected area, such as cranial nerve involvement (the most affected are the 2 , 3 , th th 4 , and 8 nerve pairs), focal neurological deficits, and signs of meningeal and cerebellar irritation. The cerebrospinal fluid is generally clear, with a predominance of lymphocytes, an increase in proteins and a decrease in glucose levels. In the differential diagnosis the following conditions should be considered: other infectious meningitis, vascular pathologies, the collagen vascular disease sarcoido- sis, metastatic carcinoma, acute hemorrhagic leucoencephalopathy, and lymphoma. In the case of intracranial tuberculoma, the clinical manifestations depend on the location of the lesion, which generally grows slowly. When there is no compromise of the sub-arachnoid space, the cerebrospinal fluid is normal and the computerized tomography exhibits a mass, which is generally difficult to differentiate from neo- plasia (Azambuja 1993, Kasik 1994, Norris 1995). Bone involvement consists of osteomyelitis, and arthritis can occur either by extension of the osseous lesion to the joint or by direct hematogenic inoculation. The most frequent sites of bone involvement are the vertebrae (Pott’s disease) and the proximal extremities of the long bones. With evolution, it presents a wedged flattening and gibbus formation that can be associated with a paravertebral cold abscess (Figure 15-17). Image on X-ray is characterized by erosion of the anterior vertebral body margins with no preservation of the intervertebral space. The definitive diagnosis should be obtained by biopsy for culture and histopathological analysis (Ridley 1998, Schle- singer 2005). The diagnosis is established by puncture, biopsy, histo- pathological examination, and culture (Zylbersztejn 1993, Davidson 1994, Ridley 1998, Schlesinger 2005). Other extrapulmonary localizations Tuberculous involvement of other tissues, such the eye, skin (lupus vulgaris), genital, and digestive tract, may also be the result of hematogenous dissemination, but there are other possible routes of infection. Tuberculosis disease 507 and appropriate invasive and non-invasive procedures should be employed to en- sure an early diagnosis (Moore 2002, John 2002, Erkoc 2004). Fever and sweating It is believed that bacillary multiplication increases in the afternoon, with the daily circadian rhythm cortisol peak, which is followed by the evening fever characteris- tic of the disease. However, when there is massive hema- togenous or endobronchial dissemination, peaks of high fever can occur at any time of the day and are accompanied by chills.

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Conversely discount generic cytotec uk, groups of athletes or intelligent students tend to reject substance consumption as a common element of leisure buy cytotec 200 mcg. They are small purchase generic cytotec, cohesive groups (five to ten members) of boys and/or girls who share attitudes, thoughts, and sometimes drug use. Within this group, pressure to conform to group norms is exercised by offering desirable rewards such as the position of status within the group and applying undesirable sanctions such as exclusion based on the acceptance of group norms. In the case of substance Family Context and Substance Consumption during Adolescence consumers said norms involve consumption. Similarly, a click in which sports, religious or artistic values predominate will base group member status on matters unrelated to substance consumption. The best friend (both same sex as well as opposite) is the major source of influence, even if you control for substance consumption of other friends and peers. Alcohol consumption by the best friend is the best predictor of alcohol consumption for both boys and girls. Debunking Certain Myths about the Influence of Peers on Substance Consumption Some years ago articles by Cohen (1977) and Kandel (1978) articulated how the three following concepts relate: behavioral homophily, active selection and reciprocal socialization. The term behavioral homophily refers to the trend towards similarity in various attributes among people affiliated with each other (friends, clique, crowd). The fact that boys and girls who are part of the same groups have similar habits (behavioral homophily) has traditionally been considered evidence that adolescence is a period of conformism. Even today there are studies that speak of conformity when similarities in the behavior of a group of adolescents are observed. However, a longitudinal study by Kandel (1978) showed two differentiated processes that cause the similarities that we have been describing to occur. In general, they select friends who share social characteristics congruent with their own identity; those with whom they best fit. Once a friendship is formed by those who from the beginning have characteristics in common, they mutually socialize or reciprocally influence each other through the relationship, such that with the passage of time, they grow increasingly similar. That is, similitude between individuals explained from the point of view of influence is the result of one or more persons (“the others”) having an influence on another (“the ego”). There is always a target person (“the ego”) who is being influenced by a friend or some friends (“the others”). But nevertheless, that “ego” is also capable of joining (“the others”) and vice versa, and therefore being the one who influences/pressures instead of the pressured. From the articles of Cohen and Kandel, the two processes: active selection, whereby individuals choose as friends those who are most similar to them in attributes considered important 16 and reciprocal socialization, whereby individuals influence one another regardless of initial similarities, have been steadily documented in scientific literature. For example, Mitchel and West (1996), in a study on smoking behavior and the influence of peers on it, boys between the ages of 12 and 14 who did not want to smoke chose friends who did not smoke, non-smoking social contexts and even left friends who started to smoke. Both Cohen (1977) as well as Kandel specify a third process: the deselection, or inclination to withdraw from friends whose attitudes and activities diverge from the path of similarity or if similarity weakens. Therefore, when looking for friends, adolescents look among those who look like them, and have attitudes towards life, values and norms that they find suitable. It is in the family where boys and girls learn norms; acquire moral values and more or less healthy habits. In the research study done by Miller et al (2001), they conclude that among all the indices analyzed on family relationships and the influence on consumption, the most effective protective factors against substance consumption are warm and positive parenting practices, adequate monitoring of behavior, communication about drugs, the existence of clear norms and a system of precise values against the use of such substances. Sims y Koh (2003) indicated that adolescent perception of the perniciousness or lack thereof of a conduct is one of the main factors that related to carrying out the conduct. In this manner, adolescent substance users may do so simply because the consumption is motivating in itself and they have not learned to perceive the harmful effects of the substance. The family that educates in a system of values contrary to substance use will give rise to its children mixing with friends who have value systems similar to their own, consider consumer behavior dangerous and, consequently, do not engage in it. Friends, on the other hand, do not always exert pressure towards negative behavior such as substance use. In general, it is more often that they exert pressure towards behaviors considered socially positive, like studying or good behavior in school (Berndt y Keefe, 1996). Thus, it is easier and more often that adolescents find themselves pressured to not consume alcohol on a weekend when they are on medication, to the contrary (Sánchez-Queija, 2007). In another empirical study on the consumption of harmful substances (Maxwell, 2001) it is shown that the influence of peers is exerted as much to begin Family Context and Substance Consumption during Adolescence chewing snuff or drinking alcohol, or to continue said behaviors, as to cease the mentioned conduct. In any case, we must not forget the risks entailed by allowing information about substances to come from the context of peers: although this group will exercise more positive than negative influence, we cannot forget that group mates have less and more distorted information than parents and adults in general. In the group of friends, myths such as the following abound: cannabis is not bad because it is a natural plant, that it helps get you “in the mood” before sex, or that a joint is less harmful than a cigarette. This information, based on being heard in different settings and, especially, if transmitted by a high status group mate, takes on an element of truth. For this reason, although it is well- proven that information alone does not reduce substance use, it becomes essential that it be parents and adults in general who provide truthful and verifiable information in a language and tone understandable to adolescents. Although, as previously stated, adolescents choose friends who are similar to them and the pressure the group exerts is more positive than negative, we must not forget that it is in the environment of the group of friends where there is access to consumption substances and, that it is in the group, emboldened by the heat of the moment or adapting to unwritten rules, where adolescents begin to experiment with different substances. It is not the role of a villain and several good guys, but rather company at the time of transit through the period that is growing up which we have named adolescence. Therefore, it becomes important that parents have created, prior to the arrival of adolescence, a climate of trust and mutual respect that will lead adolescents to share their fears and concerns with their parents, including those about substance consumption. Boys or girls may in such cases turn to a peer group which views the intake of alcohol or other substances as normative, a form of socialization and a hallmark of the group. Despite the general consensus around the idea that the group of friends is one aspect to consider in the prevention and study of drug use, it is quite clear that in general, their influence is outsized and is given greater value than it really has. Boys and girls will seek friends with whom they share an attitude toward life, and that attitude will have been learned in the family of origin. First, as we have already explained, many of the 18 problems that appear during adolescence have their origins in childhood, which highlights the vision of development as a continuous process, and of adolescence as a debtor stage to previous years. Secondly, some of the problems experienced by adolescents are transient and resolve themselves at the beginning of adulthood. This is true of drug use, which most boys and girls decrease upon starting a relationship, entering the labor force and adopting typically adult roles. Finally, it seems important to differentiate between occasional experimentation and frequent involvement in substance use situations. While the former is characteristic of sensation seeking typical of the adolescent years, the latter may be an expression in definite terms of serious problems with more damaging consequences for the adolescent. An appropriate family education involves good affective relationships, communication while setting norms (i. We also want to draw attention to an issue that has not emerged, nor has it appeared at any moment, but in everyday life is often related to substance consumption: the family structure. Research shows that divorce, single parenthood or living in extended families is unrelated to drug use. Family dynamics and not structure are what can lead to dysfunctional behavior in the different family members. Family protection factors from the consumption of substances A family intervention program from the school must take into account all these aspects, which as we can see; it must not only help families with respect to substance use behaviors of sons and daughters, but also in the positive and comprehensive education of adolescents. Recipes for the education in the responsible consumption of alcohol, tobacco, cannabis and other substances are no different than those for the positive education of children in general. But above all, an action plan run from the school should try to reach the parents of adolescent students, not just those who are more concerned about the education of their children and come to the center frequently – possibly, these are the ones who will least help the program since they are already involved in the education and positive development of their children – but also those who normally do not attend.

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The sacral canal contains the sacral spinal nerves purchase cytotec 200mcg on line, which exit via the anterior (ventral) and posterior (dorsal) sacral foramina 200 mcg cytotec visa. The supraspinous ligament is located on the posterior side buy generic cytotec from india, where it interconnects the thoracic and lumbar spinous processes. In the posterior neck, this ligament expands to become the nuchal ligament, which attaches to the cervical spinous processes and the base of the skull. It has a jugular (suprasternal) notch, a pair of clavicular notches for articulation with the clavicles, and receives the costal cartilage of the first rib. The manubrium is joined to the body of the sternum at the sternal angle, which is also the site for attachment of the second rib costal cartilages. The last false ribs (11–12) are also called floating (vertebral) ribs, because these ribs do not attach to the sternum at all. Instead, the ribs and their small costal cartilages terminate within the muscles of the lateral abdominal wall. This process begins with the localized accumulation of mesenchyme tissue at the sites of the future bones. The mesenchyme differentiates into hyaline cartilage, which forms a cartilage model of the future bone. Surgery can return the joint surface to its original smoothness, thus allowing for the return of normal function. At its lateral end, the clavicle articulates with the acromion of the scapula, which forms the bony tip of the shoulder. The acromion is continuous with the spine of the scapula, which can be palpated medially and posteriorly along its length. Together, the clavicle, acromion, and spine of the scapula form a V-shaped line that serves as an important area for muscle attachment. Forces will then pass through the midcarpal and radiocarpal joints into the radius and ulna bones of the forearm. These will pass the force through the elbow joint into the humerus of the arm, and then through the glenohumeral joint into the scapula. The force will travel through the acromioclavicular joint into the clavicle, and then through the sternoclavicular joint into the sternum, which is part of the axial skeleton. The auricular surfaces of each hip bone articulate with the auricular surface of the sacrum to form the sacroiliac joint. The right and left hip bones converge anteriorly, where the pubic bodies articulate with each other to form the pubic symphysis joint. The sacrum is also attached to the hip bone by the sacrospinous ligament, which spans the sacrum to the ischial spine, and the sacrotuberous ligament, which runs from the sacrum to the ischial tuberosity. The hip joint is formed by the articulation between the acetabulum of the hip bone and the head of the femur. The leg is the region between the knee and ankle joints, and contains the tibia (medially) and the fibula (laterally). The knee joint is formed by the articulations between the medial and lateral condyles of the femur, and the medial and lateral condyles of the tibia. Also associated with the knee is the patella, which articulates with the patellar surface of the distal femur. The ankle joint is formed by the articulations between the talus bone of the foot and the distal end of the tibia, the medial malleolus of the tibia, and the lateral malleolus of the fibula. The posterior foot contains the seven tarsal bones, which are the talus, calcaneus, navicular, cuboid, and the medial, intermediate, and lateral cuneiform bones. The anterior foot consists of the five metatarsal bones, which are numbered 1–5 starting on the medial side of the foot. The toes contain 14 phalanx bones, with the big toe (toe number 1) having a proximal and a distal phalanx, and the other toes having proximal, middle, and distal phalanges. These plates of hyaline cartilage will appear dark in comparison to the white imaging of the ossified bone. Since each epiphyseal plate appears and disappears at a different age, the presence or absence of these plates can be used to give an approximate age for the child. For example, the epiphyseal plate located at the base of the lesser trochanter of the femur appears at age 9–10 years and disappears at puberty (approximately 11 years of age). Thus, a child’s radiograph that shows the presence of the lesser trochanter epiphyseal plate indicates an approximate age of 10 years. Chapter 9 1 Although they are still growing, the carpal bones of the wrist area do not show an epiphyseal plate. This patient also had crystals that accumulated in the space next to his spinal cord, thus compressing the spinal cord and causing muscle weakness. This is important because it creates an elevated rim around the glenoid cavity, which creates a deeper socket for the head of the humerus to fit into. The sequence of injury would be the anterior talofibular ligament first, followed by the calcaneofibular ligament second, and finally, the posterior talofibular ligament third. An amphiarthrosis is a slightly moveable joint, such as the pubic symphysis or an intervertebral cartilaginous joint. A biaxial diarthrosis, such as the metacarpophalangeal joint, allows for movement along two planes or axes. A gomphosis is the fibrous joint that anchors each tooth to its bony socket within the upper or lower jaw. A narrow syndesmosis is found at the distal tibiofibular joint where the bones are united by fibrous connective tissue and ligaments. A syndesmosis can also form a wide fibrous joint where the shafts of two parallel bones are connected by a broad interosseous membrane. The radius and ulna bones of the forearm and the tibia and fibula bones of the leg are united by interosseous membranes. The epiphyseal plate of growing long bones and the first sternocostal joint that unites the first rib to the sternum are examples of synchondroses. Symphysis joints include the intervertebral symphysis between adjacent vertebrae and the pubic symphysis that joins the pubic portions of the right and left hip bones. The articulating surfaces of the bones are covered by articular cartilage, a thin layer of hyaline cartilage. These may be located outside of the articular capsule (extrinsic ligaments), incorporated or fused to the wall of the articular capsule (intrinsic ligaments), or found inside of the articular capsule (intracapsular ligaments). Ligaments hold the bones together and also serve to resist or prevent excessive or abnormal movements of the joint. These muscles serve as “dynamic ligaments” and thus can modulate their strengths of contraction as needed to hold the head of the humerus in position at the glenoid fossa. Additional but weaker support comes from the coracohumeral ligament, an intrinsic ligament that supports the superior aspect of the shoulder joint, and the glenohumeral ligaments, which are intrinsic ligaments that support the anterior side of the joint. An area called the joint interzone located between adjacent cartilage models will become a synovial joint. Endurance exercise can also increase the amount of myoglobin in a cell and formation of more extensive capillary networks around the fiber. Chapter 11 1 D 3 B 5 C 7 A 9 C 11 D 13 B 15 B 17 A 19 B 21 B 23 A 25 D 27 B 28 Fascicle arrangements determine what type of movement a muscle can make. Facial muscles are different in that they create facial movements and expressions by pulling on the skin—no bone movements are involved.

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When these studies are done prospectively (as opposed prevalence survey found that 75% of the smear-positive cases to retrospectively buy cytotec 200mcg lowest price, using electronic databases that are already detected had symptoms that met national screening criteria available) cytotec 100mcg lowest price, the mapping of providers that is required at the but had not been previously diagnosed discount cytotec 100mcg online, suggesting high beginning can subsequently help with eforts to engage all levels of underdiagnosis and a need to strengthen access to care providers, including in reporting (Box 4. Examples of mechanisms to ensure reporting of all detected 1 cases include linking reimbursement from health insurance For further details, see Box 2. To date, there have been few assessments of six of these countries (India, Kenya, Malawi, Mozambique, the implementation and outcomes of systematic screening Namibia and Swaziland) maintained coverage of at least 90% in both 2015 and 2016. This represents a more than of community-based activities in all basic management threefold increase in reporting since 2013, when data units. Further efort is needed to update the data were frst collected on the two core indicators (referrals recording systems in these countries to refect community and treatment support) used to monitor community contributions. In these 53 countries, 57% (30/53) reported nationwide coverage by all basic management units a Community health workers and community volunteers are defned of community engagement in referrals of cases (thus here: World Health Organization. These low percentages show that progress in detection largest burden, particularly China, India and Indonesia. Globally, the treatment This section summarizes the latest results of treatment for success rate for the 5. In Brazil (71% success), 21% of cases were either 1 For defnitions of treatment outcomes, see World Health Organization. South-East Asia Western Pacific The number of cases reported in annual cohorts has steadily increased over time, reaching 99 165 cases globally in the 2 2 2014 cohort. However, these national diagnostic practices for extrapulmonary or childhood fgures concealed wide geographical variation. In seven countries (Burkina Faso, Globally, in 2016, there were an estimated Colombia, Dominican Republic, Georgia, Lithuania, 1. As is challenging given the lack of standard systems for in previous years, South Africa accounted for recording and reporting data, and the involvement the largest share of the total (41%), followed by of multiple service providers. In some force in 2016, and the recommended indicators are shown in low-burden countries, reactivation accounts for about 80% of Table 5. The three main sections of this chapter present and discuss A total of 161 740 child household contacts were reported progress in provision of these services. Estimated rate Most of the increase occurred from 2009 to 2014, and has of reactivation of latent tuberculosis infection in the United States, overall and by population subgroup. These were Angola, Botswana, Brazil, Central African Republic, Chad, China, Congo, Ghana, Guinea-Bissau, Kenya, Lesotho, Pakistan, Papua New Guinea, Thailand, and Zambia. Estimates are shown to two signifcant fgures for numbers below 1 million, and to three signifcant fgures for numbers above 1 million. It As in previous years, South Africa accounted for the is hoped that the conference will galvanize greater political largest proportion (41%) of the global total in 2016 (Fig. Coverage was more than 50% in the four countries care facilities and congregate settings, a comprehensive set that reported denominators (i. Data for clinical risk groups – such as patients environmental and personal protection measures – should be implemented. Nosocomial transmission of extensively drug-resistant tuberculosis in a rural hospital in South Africa. However, Using an online dashboard, users can track indicators in systematic monitoring and evaluation of the programmatic real time. The dashboard The establishment of monitoring systems is particularly also provides geospatial data and allows users to visualize challenging when multiple health-care service providers the location of clients on a map. The latest data with the estimated requirement for this group of from the Organisation for Economic Co-operation countries in the Global Plan. Estimates treatment requires adequate funding sustained over many of the funding required to achieve these milestones have years. Domestic and donor fnancing for tuberculosis care and control in low-income and middle-income countries: an analysis of trends, 2002–11, and requirements to meet 2015 targets. Despite this growth in quality of health-care services or to remove fnancial barriers funding, amounts fall short of what is needed. Since many countries reported fnancing data and therefore data for detailed costing studies in a wide range of countries high-income countries are not featured in Chapter 6. In the group of six among countries in the share of funding from domestic and upper-middle-income countries, the proportion ranges from international sources (Fig. The countries are those listed in 3 Out-of-pocket expenditures are also not included in the fnancing data Fig. Disbursement data include both direct transfers to countries and the provision of goods and services, such as in-kind transfers or technical assistance. Also, government contributions to multilateral organizations are not attributed to the government of origin, only to the multilateral organization. The United Kingdom remaining funding came from the United Kingdom 200 World Bank Other (3%), the World Bank (1%), and other sources (6%), within which the largest contributing country was 0 Belgium. This pattern may refect the transition to a new funding model that started in 2013, and some associated delays in approving and disbursing funds. France, Germany, Japan and the United Kingdom also provided funding streams directly to countries in addition to their disbursements to the Global Fund. This trend is mostly explained by large reductions in the funding gaps reported by China, Kazakhstan 6. High programme costs relative to a smaller pool of patients also help to explain comparatively high per- patient costs in some countries (e. Monitoring of public expenditures as well as increased public of these indicators can be used to identify key health budgets are needed. By 2030, total average health spending would need proportion of the population with large household expenditures on health as a share of total household expenditure or income. Financing transformative health systems towards achievement of the health Sustainable 87 Development Goals: a model for projected resource needs in 67 low-income and 80 middle-income countries. Per person health costs are reported as 1219 population-weighted mean values per income group per year. Financing 500 transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and 0 middle-income countries. Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and middle-income countries. The latter is a population-based indicator that measures the share of the population incurring “catastrophic expenditures” on health, with a threshold defned based on household ability to pay. Signifcant predictors for experiencing catastrophic costs were being in the poorest or less poor household wealth Proportion of households that experienced 1 catastrophic costs quintiles. Subsequently, a stakeholders’ meeting The poorest households were the most afected, with costs to review survey results and refne the elements of the representing on average 347% of annual household income roadmap and the monitoring and evaluation framework was Costs experienced by households afected by held. Seven surveys had been social insurance, and labour programmes, and with particular completed, in Ghana, Kenya, Myanmar, the Philippines, attention to the needs of low-income populations. Data on adoption of new tools, while others indicate a need for social coverage levels are not easy to obtain, but coverage in many 5 assistance and other forms of social protection. However, increasing such pooled funding alone is patients, for example by providing food, cash, vouchers, or not sufcient; the funds must then be directed to priority other economic or psycho-social support. Both publications services and populations through the mechanisms used to also signaled the need to explore more efcient, systematic pay providers. Philippine Institute for Development patient must be an active PhilHealth member, meaning Studies; 2015.