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Background: Cancer is one of the leading causes of morbidity and mortality in the world. Its growing incidence and prevalence, as well as the advances in diagnostic and treatment tools, motivate an open debate about the economic burden it may place on health systems and have raised concerns about access to this technological innovation. There is a lack of information on the detailed costs of pharmacological treatment of cancer in our health setting. In this context, it is necessary to know the use of drugs in cancer treatment in conditions of real clinical practice. A real-word, evidence-based retrospective cohort study was conducted at Vall d’Hebron University Hospital (VHUH), the largest hospital complex in Catalonia, Spain, in order to determine the use of drugs and the associated cost in real clinical practice for the treatment of solid tumors in adult patients attended at this institution over 10 years (2010–2019). Methods: This was a single-center retrospective cohort study of adult cancer patients attended in clinical practice at the Medical Oncology Department of VHUH between 1 January 2010 and 31 December 2019. Data of prescription, preparation, and cost of antineoplastic treatments were analyzed by pharmacological class (cytotoxic drugs, immunotherapy, targeted therapy, radiopharmaceuticals, and others), by antineoplastic agent, and by type of tumor. The number of patients and the pharmaceutical expenditure corresponding to all these subgroups were recorded. The cost per patient in each tumor location was also calculated. Results: The study population included 13,209 patients with an overall pharmaceutical antineoplastic expenditure of EUR 120,396,097, increasing from 7.67% in relation to the total HUVH pharmaceutical expenditure in 2010 to 12.82% in 2019. By pharmacological class, the specific weight of the cost of targeted therapy is relevant (75.22% of pharmaceutical antineoplastic expenditure, 21.3% of patients) compared to the group of conventional cytotoxics (17.25% of pharmaceutical antineoplastic expenditure, 76.37% of patients), while immunotherapy has represented the largest relative increase, from 5% in 2014 to 12% in 2019. Eight targeted therapy drugs represented 50% of the costs of the targeted therapy drug class (palbociclib, trastuzumab, pertuzumab, bevacizumab, nivolumab, cetuximab, pembrolizumab, and trastuzumab emtansine). Eleven tumor sites accounted for 90% of the expenditure in 71% of all patients. Breast cancer had the highest expenditure during the study period (EUR 34,332,210) and at each individual year. Melanoma showed the highest increase, with 9.7% of total pharmaceutical antineoplastic expenditure in 2019 (2% of patients), representing a paradigm of the rising costs of cancer treatment due to the incorporation of new high-cost therapies. The average annual cost per patient was highly variable depending on the pathology. There was a growing increase in costs per patient in most tumor locations, particularly in patients with melanoma (from EUR 1922 in 2010 to EUR 37,020 in 2019), prostate cancer (from EUR 2992 in 2010 to EUR 14,118 in 2019), and non-small cell lung cancer (from EUR 3545 in 2010 to EUR 8371 in 2019). The relevance of the difference in monthly cost per patient that has been identified for the different intrinsic subtypes in breast cancer patients during 2019 (HER2+ EUR 2661/month, Luminal EUR 881/month, Triple negative EUR 386/month) makes us consider suggesting differentiated reimbursement rates for certain clinical conditions. Finally, support treatment with antiemetic drugs, erythropoietin stimulating agents, granulocyte-colony stimulating factor (G-CSF), and bone resorption inhibitors has involved a cost of EUR 5,751,910, which represents 4.6% of the overall pharmacological cost of cancer treatment. Conclusion: This study provides detailed insights on the oncological pharmaceutical expenditure for the treatment for solid tumors in the VHUH, based on real cost information from our hospital practice and for all antineoplastic therapies and types of solid tumors. This type of information on all the different types of cancer can be useful to better understand the economic burden of the disease and can be decisive for allocating public resources and funds for research, especially in those areas where information is scarce and therefore where further studies are needed. The contribution to knowledge of the cost of oncology therapy is of great value due to its realism and scope. Full article

Family caregivers and care providers are increasingly becoming more distressed and reaching a breaking point within current systems of care. First Nations family caregivers and the health and community providers employed in First Nations communities have to cope with colonial, discriminatory practices that have caused intergenerational trauma and a myriad of siloed, disconnected, and difficult-to-navigate federal-, provincial/territorial-, and community-level policies and programs. Indigenous participants in Alberta’s Health Advisory Councils described Indigenous family caregivers as having more difficulty accessing support than other Alberta caregivers. In this article, we report on family caregivers’, providers’, and leaders’ recommendations to support First Nations family caregivers and the health and community providers employed in First Nations. We used participatory action research methods in which we drew on Etuaptmumk (the understanding that being in the world is the gift of multiple perspectives) and that Indigenous and non-Indigenous views are complementary. Participants were from two First Nation communities in Alberta and included family caregivers (n = 6), health and community providers (n = 14), and healthcare and community leaders (n = 6). Participants advised that family caregivers needed four types of support: (1) recognize the family caregivers’ role and work; (2) enhance navigation and timely access to services, (3) improve home care support and respite, and (4) provide culturally safe care. Participants had four recommendations to support providers: (1) support community providers’ health and wellbeing; (2) recruit and retain health and community providers; (3) improve orientation for new providers; and (4) offer providers a comprehensive grounding in cultural awareness. While creating a program or department for family caregivers may be tempting to address caregivers’ immediate needs, improving the health of First Nations family caregivers requires a population-based public health approach that focuses on meaningful holistic system change to support family caregivers. Full article

Sri Lankan public services have a lingering colonial legacy, and there have been several efforts since the country’s independence to break away from the restraints of the past to align them with modern times and expectations. The drive for modernization of public services passed through several phases of experimentation without much success in the past. A significant attempt at the modernization of public services was made in the first decade of this millennium; we now notice substantial changes in public service delivery (PSD) in the country. In this paper, we assess the impact of an inside-outside-inside (IOI)-based open system innovation-related business process reengineering (BPR) regime adapted for reforms in the organization and the delivery of public services in the country. We carried out an input and output analysis of the BPR regime, adopted by various departments and ministries of the government of Sri Lanka to improve the PSD infrastructure. A broad-based ground survey on a five-point Likert scale was carried out, and performance data were collected. We collected a total of 290 responses—each questionnaire was composed of 40 questions regarding the inputs and the outputs of the regime’s implementation. Applying an ordered multivariate logistic regression model, we have attempted to estimate correlations amongst inputs, results, and overall perception of success or failure of the BPR regime across 29 departments and ministries (D&M). We have tabulated summary statistics and regression results to assess the relative significance of various regime inputs and their impact on the corresponding outcomes. The outcomes suggest that while all inputs and outputs are significantly correlated, some inputs have a more significant effect on the results expected from the BPR regime. We have used original data acquired through a survey carried out directly through the PSD organizations in the country, and this study is the first of its kind in this regard. We expect this study will be of high utility to the personnel engaged in the planning and implementation of PSD through systematic innovation and BPR, not only in Sri Lanka but also for many other professionals and researchers who are engaged in designing and execution of similar service improvements and reengineering strategies in different countries around the world. Full article

Sri Lankan public service apparatus has a long colonial heritage, and all of that has not been in line with the requirements of a 21st century public service expectations. However, the increasing societal pressure for the delivery of more modern public services has forced it to undergo a major overhaul of its business process. In this paper, we assess the impact of the recent efforts at business process reengineering (BPR) in public service. We estimate the overall as well as relative efficiency of public service delivery across various ministries and departments of the Sri Lankan government. A broad-based Likert scale field survey on a five-point scale was carried out and performance data were collected. We applied a non-parametric data envelopment analysis (DEA) to estimate the overall and relative efficiency of the public service delivery across 29 departments and ministries (D&Ms) and the departments of the government of Sri Lanka. Our results show that, save for a few, most D&Ms have a potential for improving the performance. The performance enhancement is desirable both from an input as well as output perspectives. Moreover, our results indicate significant scale inefficiencies associated with the performance of ministries and departments that are engaged in public service delivery (PSD) in the country. The authors have also indicated towards critical success factors for a wider deployment of the study’s findings in the conclusion. Full article

How did women architects shape a modern world in the late period of Portuguese colonial Africa, just before the Carnation Revolution? The specific role of women in Portugal working in colonial African architectural culture has now started to be addressed by Portuguese and Lusophone-African historiography. During the 1950s, the presence of women in the metropolitan schools of architecture was reduced. Of those who could graduate, few actually worked as architects. Most were absorbed by the commonly feminine roles, resulting from marriage and from the ideal of family promoted by the Estado Novo dictatorship. To the ones that risked prosecution for working outside the family, the option of jobs associated with the feminine universe, such as teaching, was privileged. Among those who were emancipated from this pattern, the majority worked in familiar partnerships, regarded as an extension of marriage. The women architects that follow the husbands in their African emigration often ended up having the opportunities to work in their professional field partly due to the lack of qualified technicians, and to the high demand of commissions. This paper not only seeks to outline a perspective on these women, but also tries to understand the context of their work by presenting two case-studies in the late in the late period of Portuguese Colonisation: Maria Carlota Quintanilha and Maria Emilia Caria. Full article

Drinking water supply and sanitation have had a strong association with military institutions in South Asia from the colonial period to the present. This paper shows how military-state-society relationships created spaces of differential water access and sanitation burdens in mid-19th-century cantonments in ways that involved complex gender relations. In comparison with previous research, we argue that privileged military enclaves were segregated but never fully separated from larger urban water and sanitation systems. We use historical geographic methods to review the evolving role of military sanitation regulations in cantonments from late-18th-century policies of the East India Company (EIC) through mid-19th-century rule by the British Crown, during which time military cantonments, regulations, and formal monitoring reports were established. Close reading of the British Army Medical Department’s Statistical, Sanitary, and Medical Reports (Sanitary Reports) in the 1860s then shows how military-state-society relations diverged from civilian public health programs in ways that persist to some extent to the present day. Health advisors, some of them women, pursued an ideology and tactics to “guard the sons of empire”, from what they perceived to be a disease-filled landscape of “lurking evils”, “choleric attacks”, and “native offensives”. We conclude with a discussion of both continuities and change in the relationships between military and civilian public health reforms beyond the barracks. Full article