Existing Health Systems Research Articles

Launch of Master’s program (M.Sc.) in Health Economics and Statistics in Taras Shevchenko National University of Kyiv

Health Economics has now evolved into a complex science that is based on related disciplines, including epidemiology, statistics, psychology, sociology, operations research, and mathematics. Thus, Health Economics is a set of economic and statistical disciplines that serve as the basis for decision-making by healthcare providers and governments. It also includes a set of analytical methods used in the analysis of the healthcare market.
 Health Economics and Statistics is a modern master’s program with the main objective to prepare statistics specialists who are able to solve complex problems, make appropriate analytical decisions in the field of clinical research and management decisions in the field of public health that involves conducting research and fostering innovation in the face of uncertainty. Studying statistical methods enables students to acquire up-to-date analytical skills applied to clinical research and healthcare management.
 The objectives of the Master’s program are focused on providing students with the necessary information about international clinical research experience, forming a critical understanding of the pricing process on the healthcare market, as well as the mechanism for reimbursement of medical expenses in the world. In addition, the program will provide students with an understanding of the organization of existing health systems and methods needed to analyze health policies.
 The advantages of the program are tied to the goals of the acquisition of applied statistical analysis skills, which is an indispensable requirement of high qualification of an analyst in clinical research and public health. This is ensured by: 1) integration of practice with academic training; 2) the opportunity to contribute to the development of one's own potential; 3) expanding the capacity for scientific research; 4) the opportunity to defend a master’s thesis, working on a real project; 5) providing real career perspectives.
 Thus, the implementation of this program will provide an opportunity to prepare highly qualified specialists – analysts in the field of clinical research and public health. Specialists who are in high demand in the private sector (clinical research market) on the national and international level, in the national, regional and local NGOs and institutions in positions related to the planning, collection, processing, and analysis of clinical and public health data, as well as evaluating the quality of managerial decisions in healthcare. All of this, in turn, will help to ensure the competitiveness of specialists and increase the prestige of the specialty.

Developing a community-based autism spectrum disorder management model: Results after 1-year pilot experience

ABSTRACT Background: To develop an official comprehensive management of Autism spectrum disorders (ASD) system nationwide, we conducted a pilot community-based ASD management model, developed based on participatory approach to empower parents, preschool teachers and health staff by conducting communication campaign, training and health system support in two Northern provinces of Vietnam in 2018. Objective: To explore the appropriateness and feasibility of this model in terms of cultural context, ease of operation, existing health system structure, human resources, infrastructure and finance after one-year piloting. Methods: A phenomenological qualitative study design was employed with 15 in-depth interviews including piloting coordinator and local policymakers, 14 focus group discussions with health staff and community, and 1 workshop with central stakeholders. Results: Our findings demonstrated that the model is appropriate and feasible with cultural context and existing resources. However, to replicate the model in other provinces, stigma towards families having children with ASD in the community, lack of electronic connection system between levels, and difficulties related to health insurance implementation at provincial level should be solved. Conclusion: Integrating ASD management into existing community mental health program; developing ASD intervention package that covered by health insurance; and continuing training for community and health staff should be implemented.

Designing a resource-stratified, phased implementation strategy for breast health care services in India.

Breast cancer is the most common cancer among women in India. Jhpiego, a not-for-profit health organization, is providing technical assistance for developing an evidence-based model of breast health care in the states of Uttar Pradesh and Jharkhand in India. A situational assessment of breast health care services using validated tools was conducted in the 2 states. Findings of the assessment were presented to the Breast Health Technical Advisory Committee comprised of subject experts and government functionaries. The committee, guided by Breast Health Global Initiative resource-stratified guidelines, developed a conceptual framework for integration of breast health services into the existing health system. This conceptual framework was presented to the Technical Advisory Groups (TAGs) of the respective state governments. Each TAG then developed an operationally feasible, contextually appropriate implementation plan in alignment with the national guidelines for noncommunicable diseases. This implementation plan guided the rollout of the breast health care program in the Lucknow (Uttar Pradesh) and Ranchi (Jharkhand) districts. Early results from the implementation suggest that it is feasible to integrate the breast health care pathway with the ongoing National Cancer Control Program of India.

Midwife Led Units: Transforming Maternity Care Globally.

Background:Midwifery-led care is a high-certainty, evidence-based strategy to improve maternity care. Midwife-led units (MLUs) are one example of how the midwifery model of care is being integrated into existing health systems to transform maternal health around the world.Purpose:To promote global investment in MLUs by describing the benefits, current advances and future directions of this model of care.MethodA viewpoint based on prevalent notions of midwifery, research findings, guidance from professional organizations and authors’ professional experience.Conclusion:Renewed commitment to research and the implementation of MLUs across a variety of settings is needed to address the practice, education and policy issues associated with this evidence-based strategy. The World Health Organization “Year of the Nurse and Midwife-2020” is an opportune time to invest in midwifery models of care that are fundamental to achieving core global health initiatives such as Universal Healthcare 2030.

Inflammatory Bowel Diseases and COVID-19: The Invisible Enemy

Inflammatory Bowel Diseases and COVID-19: The Invisible Enemy

Feasibility of implementing the World Health Organization case management guideline for possible serious bacterial infection among young infants in Ntcheu district, Malawi.

Neonatal sepsis is a leading cause of mortality, yet the recommended inpatient treatment options are inaccessible to most families in low-income settings. In 2015, the World Health Organization released a guideline for outpatient treatment of young infants (0-59 days of age) with possible serious bacterial infection (PSBI) with simplified antibiotic regimens when referral was not feasible. If implemented widely, this guideline could prevent many deaths. Our implementation research evaluated the feasibility and acceptability of implementing the WHO guideline through the existing health system in Malawi. A prospective cohort study was conducted in 12 first-level health facilities in Ntcheu district. Trained health workers identified and treated young infants with PSBI signs with injection gentamicin for 2 days and oral amoxicillin for 7 days, whereas those with only fast breathing were treated with oral amoxicillin for 7 days. Health Surveillance Assistants (HSAs) were trained to promote care-seeking and to conduct home visits on day 3 and 6 to assess infants under treatment, encourage treatment adherence and remind the caregiver to return for facility follow up. Infants receiving outpatient treatment were followed up at health facility on day 4 and 8. The primary outcome was proportion of outpatient cases completing treatment per protocol. A total of 358 infants received outpatient treatment (202 clinical severe infection, 156 only fast breathing) from February to September 2017. Of these, 92.7% (332/358) met criteria for treatment completion and 88.8% (318/358) completed the day 4 follow-up. Twelve (3.4%) young infants clinically failed treatment with no reported deaths in those treated at outpatient level. This treatment failure rate was lower than those reported for the simplified regimens tested in the SATT (8-10%) and AFRINEST (5-8%) equivalency trials. More than half of infants (58.1%; 208/358) received HSA follow-up visits on days 3 and 6. Study results demonstrate the feasibility of outpatient treatment for sick young infants when referral is not feasible in Malawi, which will inform scale-up in other parts of Malawi and countries with similar health system constraints.

Healthcare Access Inequity within a Social Health Insurance Setting: A Risk Faced by Indonesia’s Jaminan Kesehatan Nasional (JKN) Program

This paper is a literature review laying out empirical evidence of healthcare access inequity within an implementation of social health insurance (SHI) programs. The research question of this paper is: in what way, and how, inequity in healthcare access potentially happens, even if a type of SHI covers the whole, or most, of a society. This paper is mainly motivated by the implementation of Jaminan Kesehatan Nasional (JKN), an SHI program in Indonesia. Even though the program aims to create better equity in healthcare access, the existing health system and the program’s design may prevent the achievement of this goal. By laying out evidence on how healthcare access inequity in other countries remains within an SHI mechanism, this paper illuminates that JKN may face the same risk. In reviewing the papers, this study applied Goddard and Smith’s (2001) concept of healthcare access inequity in the area of availability, quality, cost, and information. The findings suggest that healthcare access inequity could happen despite the implementation of an SHI program. Four types of circumstances that might have led to healthcare access inequity include geographical disparities of health facilities; adequacy of insurance program’s reimbursement and healthcare providers’ financial motive; healthcare providers’ prejudices toward patients; and unequal personal advantages of health treatment seekers. When applied to the context of JKN implementation in Indonesia, the risks of healthcare access inequity are imminent, mostly due to the uneven concentration of health facilities, the program’s segmented tariff rates, and the socioeconomic diversity among JKN members. The findings imply that JKN members might be at risk of healthcare access inequity. While the risks are plausible, this study is limited to predicting the potential inequity within JKN, mirroring from the empirical evidence. This study signifies the need for further empirical research on this area, which will potentially inform policymakers to improve the program.

Managerial workarounds in three European DRG systems.

Attempts to transform health systems have in many countries involved starting to pay healthcare providers through a DRG system, but that has involved managerial workarounds. Managerial workarounds have seldom been analysed. This paper does so by extending and modifying existing knowledge of the causes and character of clinical and IT workarounds, to produce a conceptualisation of the managerial workaround. It further develops and revises this conceptualisation by comparing the practical management, at both provider and purchaser levels, of hospital DRG payment systems in England, Germany and Italy. We make a qualitative test of our initial assumptions about the antecedents, character and consequences of managerial workarounds by comparing them with a systematic comparison of case studies of the DRG hospital payment systems in England, Germany and Italy. The data collection through key informant interviews (N=154), analysis of policy documents (N=111) and an action learning set, began in 2010-12, with additional data collection from key informants and administrative documents continuing in 2018-19 to supplement and update our findings. Managers in all three countries developed very similar workarounds to contain healthcare costs to payers. To weaken DRG incentives to increase hospital activity, managers agreed to lower DRG payments for episodes of care above an agreed case-load 'ceiling' and reduced payments by less than the full DRG amounts when activity fell below an agreed 'floor' volume. Empirically this study is limited to three OECD health systems, but since our findings come from both Bismarckian (social-insurance) and Beveridge (tax-financed) systems, they are likely to be more widely applicable. In many countries, DRGs coexist with non-DRG or pre-DRG systems, so these findings may also reflect a specific, perhaps transient, stage in DRG-system development. Probably there are also other kinds of managerial workaround, yet to be researched. Doing so would doubtlessly refine and nuance the conceptualisation of the 'managerial workaround' still further. In the case of DRGs, the managerial workarounds were instances of 'constructive deviance' which enabled payers to reduce the adverse financial consequences, for them, arising from DRG incentives. The understanding of apparent failures or part-failures to transform a health system can be made more nuanced, balanced and diagnostic by using the concept of the 'managerial workaround'. Managerial workarounds also appear outside the health sector, so the present analysis of managerial workarounds may also have application to understanding attempts to transform such sectors as education, social care and environmental protection. So far as we are aware, no other study presents and tests the concept of a 'managerial workaround'. Pervasive, non-trivial managerial workarounds may be symptoms of mismatched policy objectives, or that existing health system structures cannot realise current policy objectives; but the workarounds themselves may also contain solutions to these problems.

Study protocol: CareAvenue program to improve unmet social risk factors and diabetes outcomes- A randomized controlled trial

Despite the burdens costs can place on adults with diabetes, few evidence-based, scalable interventions have been identified that address prevalent health-related financial burdens and unmet social risk factors that serve as major obstacles to effective diabetes management. In this study, we will test the effectiveness of CareAvenue – an automated e-health tool that screens for unmet social risk factors and informs and activates individuals to take steps to connect to resources and engage in self-care. We will determine the effectiveness of CareAvenue relative to standard care with respect to improving glycemic control and patient-centered outcomes such as cost-related non-adherence (CRN) behaviors and perceived financial burden. We will also examine the role of patient risk factors (moderators) and behavioral factors (mediators) on the effectiveness of CareAvenue in improving outcomes. We will recruit 720 patients in a large health system with uncontrolled Type 1 diabetes mellitus (T1DM) or Type 2 diabetes mellitus (T2DM) who engage in CRN or perceive financial burden. Participants will be randomized to one of two arms: 1) receipt of a 15–20 min web-based program with routine follow-up (CareAvenue); or 2) receipt of contact information for existing health system assistance services. Outcomes will be assessed at baseline and 6- and 12-month follow-up.Clinical Trial Registration: ClinicalTrials.gov ID NCT03950973, May 2019

COVID-19 pandemic: A global health burden.

Coronavirus disease 2019 (COVID-19) pandemic began in China with a group of severe pneumonia cases, later identified to be caused by the severe acute respiratory syndrome coronavirus 2 in December 2019. Thailand reported the first COVID-19 case outside of China on 13th January 2020, Africa reported its first case in Egypt on 14th February 2020 and Nigeria reported its index case of COVID-19 on 27th February 2020. Virtually, all countries in the world are affected, with over 5 million cases reported globally. A literature search was conducted using publications from academic databases and websites of relevant organisations. The disease is associated with typical and atypical signs and symptoms, mimicking other common illnesses. Nigeria is now in the phase of widespread community transmission as almost all the states have reported confirmed cases. The pandemic has shown a wide range of case-fatality rate (CFR) globally; this is postulated to be related to the demographics, existing health systems and probably other unidentified factors. There has been a steady increase in the burden caused by the disease in Nigeria with a relatively stable CFR, which is lower than the global CFR. Health systems have responded with the guidelines for prevention, management, and surveillance of the disease, while effort is being put in place to find a vaccine and a specific therapy for the cure of the disease. The pandemic has had a severe effect on health systems globally, including an unintended disruption in the service delivery of other diseases. It has the potential to disrupt the weak health system in Nigeria significantly. As such, a combination of non-pharmaceutical preventive measures that are cost-effective needs to be scaled up to prevent it from further weakening the existing health system.

Baseline Assessment of Primary Healthcare Delivery Through Subcenters of Northern India.

BackgroundOur study assessed the status of facilities and services available at the subcenter level and identified the gaps that deter the realization of universal health coverage.MethodsA cross-sectional observational study design was used for assessing the subcenters of the Ambala district, Haryana, India with a predesigned, semi-structured tool containing 88 items marked on an ordinal scale. The subcenters were assessed and scored as per their functioning and delivery of various services, their coverage, and quality in terms of various national health programs.ResultsWe found that the essential infrastructure of most of the buildings was average. The types of equipment for antenatal examination, vital medicines, and prominent display boards in the local language were present in all subcenters. The majority of the health workers (n = 27; 93%) successfully demonstrated proper handwashing techniques; 65% correctly measured blood pressure during an objective structured clinical examination (OSCE), and 48% could correctly estimate hemoglobin with a hemoglobinometer. Sound knowledge regarding maternal and child healthcare practices and guidelines was noted in 89% of the health workers.ConclusionsThe health system of Haryana has scope for improvement in terms of health centers. It is pertinent for the realization of universal health coverage. Therefore, internal audits similar to what we performed must be planned and executed as a regular activity within the framework of existing health systems.

PATIENT-CENTERED MEDICINE: BACKGROUND TO THE TRANSFORMATION AND COMPONENTS

Purpose of the study. To analyze the concept of creating patient-oriented medicine, the prerequisites for its emergence, the difficulties of introducing it into existing health systems based on foreign experience. Materials and methods. The main materials of the study were used sources of foreign literature, which presents the concept of patient-oriented medicine, analyzed the prerequisites for changing models of health care in the European Union, USA and Asia in accordance with the principles of patient-oriented medicine, as well as data on the components and levels of patient-oriented medicine in foreign countries Results. The analyzed literature quite fully describes the difficulties of introducing patient-oriented medicine into existing health care systems. Particular attention should be paid to a multidisciplinary approach, continuity at different levels of medical care and effective communication between the physician and the patient towards the integration of this model into clinical practice. The analysis of the availability of medical care in developed countries and its dependence on social status, ethnicity and disease of the patient. Conclusion. Patient-oriented medicine is a new model for planning, implementing and evaluating medical services, which is based on mutually beneficial partnerships between medical workers, patients and their families. Taking into account the current problems of domestic health care, the introduction of the patient-oriented model will significantly improve the quality of medical care provided to the population of our country. Globally, the implementation of the principles of this model is far from complete. In the Russian Federation, targeted work in this direction requires additional scientific research, systematization of available data, and development of new legal documents

\u2018Leaving no one behind\u2019: a scoping review on the provision of sexual and reproductive health care to nomadic populations

BackgrundMarginalized groups, such as nomadic populations across the world, have perhaps the least access to modern reproductive health (RH) services. This scoping review aims to identify barriers to access to RH services faced by nomadic populations from the existing literature and to highlight possible opportunities to address them.MethodsKey databases, including PubMed, Popline, Google Scholar, and Google Advanced were searched for relevant articles published between 2002 and 2019. A total 344 articles were identified through database online searches, and 31 were included in the review.ResultsNomadic people face complex barriers to healthcare access that can be broadly categorized as external (geographic isolation, socio-cultural dynamics, logistical and political factors) and internal (lifestyle, norms and practices, perceptions) factors. To effectively address the needs of nomadic populations, RH services must be available, accessible and acceptable through tailored and culturally sensitive approaches. A combination of fixed and mobile services has proven effective among mobile populations. Low awareness of modern RH services and their benefits is a major barrier to utilization. Partnership with communities through leveraging existing structures, networks and decision-making patterns can ensure that the programmes are effectively implemented.ConclusionFurther research is needed to better understand and address the RH needs of nomadic populations. Though existing evidence is limited, opportunities do exist and should be explored. Raising awareness and sensitization training among health providers about the specific needs of nomads is important. Improved education and access to information about the benefits of modern RH care among nomadic communities is needed. Ensuring community participation through involvement of nomadic women and girls, community leaders, male partners, and trained traditional birth attendants are key facilitators in reaching nomads. However, participatory programmes also need to be recognized and supported by governments and existing health systems.

Which delivery model innovations can support sustainable HIV treatment?

The rapid scale-up of antiretroviral treatment (ART) for HIV since the mid-2000s, mostly through disease-specific or “vertical” programmes, has been a highly successful undertaking, which averted millions of deaths and prevented many new infections. However, the dynamics of the HIV epidemic and changing political and financial commitment to fight the disease will likely require new models for the delivery of ART over the coming decades if the promises of universal treatment are to be met. Delivery model innovations for ART are intended to improve both the effectiveness and efficiency of the HIV treatment cascade, reaching new people who require ART and providing ART to more people without an increase in resources. We describe twelve models for ART delivery, which could be achieved through five categories of delivery innovations: integrating ART (“vertical ART plus”, “partially-integrated ART” and “fully-integrated ART”); modifying steps in the ART value chain (“professional task-shifted ART”, “people task-shifted ART” and “technology-supported ART”); eliminating steps in the ART value chain (“immediate ART” and “less frequent ART pick-up”); changing ART locations (“private-sector ART”, “traditional-sector ART” and “ART outside the health sector”); and keeping the status quo (“vertical ART”). The different delivery model innovations are not mutually exclusive and several could be combined, such as “vertical ART plus” with “task-shifted ART”. Suitability of the models will highly depend on local and national contexts, including existing health systems resources, available funding, and type of HIV epidemic. Future implementation research needs to identify which models are the best fit for different contexts.

The only way is up: priorities for implementing long-acting antiretrovirals for HIV prevention and treatment.

Purpose of reviewLong-acting HIV treatment and prevention (LAHTP) can address some of the achievement gaps of daily oral therapy to bring us closer to achieving Joint United Nations Programme on HIV/AIDS Fast-track goals. Implementing these new technologies presents individual-level, population-level, and health systems-level opportunities and challenges.Recent findingsTo optimize LAHTP implementation and impact, decision-makers should define and gather relevant data to inform their investment case within the existing health systems context. Programmatic observations from scale-up of antiretroviral therapy, oral preexposure prophylaxis, voluntary medical male circumcision, and family planning offer lessons as planning begins for implementation of LAHTP. Additional data intelligence should be derived from formative studies, pragmatic clinical trials, epidemiologic and economic modeling of LAHTP. Key implementation issues that need to be addressed include optimal communication strategies for demand creation; target setting; logistics and supply chain of commodities needed for LAHTP delivery; human resource planning; defining and operationalizing monitoring and evaluating metrics; integration into health systems.SummarySuccessful LAHTP implementation can bolster treatment and prevention coverage levels if implementation issues outlined above are proactively addressed in parallel with research and development so that health systems can more rapidly integrate new technologies as they gain regulatory approval.

PMTCT care cascade and factors associated with attrition in the first four years after Option B+ implementation in Mozambique.

To evaluate the effectiveness of the prevention of mother-to-child transmission (PMTCT) Option B+ programme in two provinces with high human immunodeficiency virus (HIV) burden in Mozambique over the first four years of programme implementation. We assessed the PMTCT cascade in antenatal care (ANC) from July 2013 to December 2017 using facility-level data and performed a retrospective cohort analysis with patient-level data. We compared the 12-month antiretroviral therapy (ART) retention rates between women with HIV infection who initiated ART under Option B+ ('B+ pregnant') and those who initiated ART for their own health ('own health'). A total of 916280 pregnant women enrolled in ANC. The proportion of women with a documented HIV status increased from 93% in 2013 to 96% in 2017. The proportion of those tested HIV-positive decreased from 8% to 6% while that of those HIV-positive on ART increased from 42% to 95%. Of the 44377 HIV-positive women included in the analysis, 35% were lost to care. 'B+ pregnant' women initiating ART in 2015 were less likely to have no follow-up (NFU) compared with 'own health' women starting ART during the same period (adjusted odds ratio: 0.77, 95% confidence interval [CI]: 0.64-0.94, P=0.01). There was no statistical difference between the two groups during the other years in which ART was initiated. Of those returning for care after their first visit (N=39801), the 'B+ pregnant' women showed a higher risk of non-retention than the other group (adjusted hazard ratio: 1.14, 95% CI: 1.03-1.25) when ART was initiated in 2013. The risk decreased during the subsequent years, with no difference observed between the groups. PMTCT Option B+ programme scale-up has yielded positive results, including the maintenance of high HIV testing and ART initiation rates in ANC. Challenges still remain, however, in improving immediate engagement in care and long-term retention. Seeking alternative service delivery models to support existing health systems and prevent defaulters is required to achieve the UNAIDS 95-95-95 targets for PMTCT in Mozambique.

Knowledge on leprosy and its management among primary healthcare providers in two districts of Bangladesh

BackgroundIn 2013, Lepra Bangladesh (a non-government organization) and the National Leprosy Programme of the Directorate General of Health Services under the Ministry of Health and Family Welfare, Bangladesh implemented a 3 years project entitled “2015 and Beyond: Poverty Reduction through Strengthened Health Systems”. The aims of this Health System Strengthening (HSS) project were to improve quality of leprosy services through service delivery, capacity development, curriculum development, improved collaboration, coordination, operational research and knowledge sharing to identify and treat leprosy in order to contribute to strengthen existing health systems. We evaluated the changes in knowledge of primary and community level healthcare providers about cardinal signs, course of leprosy treatment, and drug use for paucibacillary (PB) and multibacillary (MB) leprosy cases.MethodsWe conducted two surveys using purposive sampling technique in two pilot districts: Bogra and Moulvibazar. The first survey was conducted before implementing the HSS project from March to June 2014 among 98 providers. The end-line survey was conducted in November 2015 and included 49 providers. The interview was conducted using the same pre-tested structured questionnaire. Descriptive statistics followed by further analysis was done including proportions, 90% confidence intervals, and p values were calculated for the selected variables.ResultsThe primary and community level healthcare providers demonstrated significant increases in knowledge on one cardinal sign (definite loss of sensation in a pale -hypopigmented- or reddish skin patch), doses and courses for the adult PB and MB cases and duration of Multi-Drug Therapy (MDT) course at the end line compared to the beginning of the project. All the providers except TB and Leprosy Control Assistants demonstrated statistically significant decreases in knowledge at the end-line compared to the baseline about supportive counseling.ConclusionsHSS activities including training and capacity building of the providers recorded significant increase of knowledge on types of leprosy, one cardinal sign, courses of MDT and drug use for the adult PB and MB cases and use MDT for leprosy treatment among the service providers at the end-line. Any health systems strengthening project should incorporate a capacity building approach within the programme all through.

Perceptions of health professionals regarding minimally invasive tissue sampling (MITS) to identify the cause of death in stillbirths and neonates: results from a qualitative study

BackgroundPakistan is considered to be one of the riskiest places in the world for childbirth as measured by its high stillbirth and neonatal mortality rates. Complete diagnostic autopsy remains the gold standard to determine the cause of death (CoD); however, it is not routinely implemented due to religious objections, sociocultural beliefs, limited resources and low demand from physicians and families. Recently, minimally invasive tissue sampling (MITS) using needle biopsies of multiple tissues to obtain tissue for histological examination and organism identification with PCR has been developed and promoted to determine CoD in low-resource areas. To ensure successful implementation of MITS, it is important to understand health professionals’ attitudes and perceptions related to MITS.MethodsA qualitative study was conducted at the National Institute of Child Health (NICH), Karachi, Pakistan. Focus group discussions (FGDs) and Key-informant interviews (KIIs) were conducted with health professionals including doctors, nurses, trainees, clinicians, bioethics experts and public health experts to explore their perceptions and views on acceptability of MITS. Data were analyzed using NVivo 10 software.ResultsA total of 12 interviews (FGDs = 4; KIIs = 8) were conducted. Four overarching themes were identified: (I) acceptability of MITS; (II) perceived benefits of the MITS procedure; (III) factors facilitating the implementation of MITS; and (IV) health system requirements for implementing the MITS procedure. Generally, MITS was considered as a positive development for the health system. Diagnostic accuracy and identification of less common causes of death were highlighted as two main benefits of the MITS procedure. The study highlighted a number of facilitators for the acceptability of MITS including effective counseling, building trust with parents, fast procedure time, and approaching families within a few hours of death. In addition, lack of skilled staff, poorly equipped healthcare facilities and the potential high cost to conduct MITS were identified as challenges for the implementation of MITS.ConclusionsThis formative research provided a unique opportunity to explore health professionals’ views and attitudes towards the MITS procedure. Such insights are crucial to ensure successful implementation and integration of a new technique into the existing health system. The research identified the factors influencing the acceptability of MITS among health professionals in Pakistan. The study also informed factors that could help facilitate the implementation of the MITS procedures in the context of Pakistan and similar settings.

Offline: The mistakes we made over Ebola

Where did global health go wrong? The failures the global health community made collectively over Ebola, argued Caroline Voûte (Médecins Sans Frontières) at last week's Global Health Lab, held at the London School of Hygiene & Tropical Medicine (LSHTM), were not simply abstract errors in outbreak responses. They were errors that failed people. The actions in west Africa in 2014–16 and more recently in the Democratic Republic of the Congo (DRC) certainly evolved in their complexity and understanding. But the fundamental mistakes were the same. Systems were designed around the disease, not those affected. There was a surprising lack of urgency to deploy vaccines and treatments. Money was invested in global surveillance and response systems, but little attention was given to standards of care and the effects of the outbreak on families, communities, and health workers. The Ebola outbreak response was securitised and politicised. A security-based approach emphasised deterrence, compliance, and punishment, principles contrary to public health. Security concerns diverted attention from human-rights-based protections and violations. There were pervasive failures to apply best public health practices. Decision making was often slow. There was no continuity of care. Ebola responses were not integrated into existing health systems. Interventions, such as new vaccines, can never be substitutes for building trust and cooperation with local populations. Wider health and humanitarian needs were neglected. There was little transparency and almost no accountability regarding the massive financial resources mobilised to address Ebola. Together with colleagues in Africa, Melissa Parker (LSHTM) established the Ebola Response Anthropology Platform in 2014. Technical solutions were insufficient in the face of communities afflicted by precipitous losses of trust. Community engagement often meant little more than issuing instructions. Existing inequities were elided. And those affected saw that their lives were valued differently from the lives of those living in western nations. What went right? Gillian McKay (LSHTM) offered a different assessment based on her work during west Africa's and DRC's Ebola outbreaks. Lessons were learned. First, the importance of national and regional leadership was acknowledged and given. Second, evidence-based decision making was successfully implemented. Third, the value of high-quality medical treatment, especially supportive care, became outstandingly clear. Fourth, vaccination reached over 200 000 people. And finally, despite challenges, the critical value of humanising the response to Ebola was recognised. These “successes” surely do deserve appreciation. As Mo Koker, an NHS emergency medicine specialist deployed to Sierra Leone in 2014, observed, many people didn't believe that Ebola was Ebola. The response to this tragedy was therefore a remarkable story of international cooperation. Francesco Checchi (LSHTM), who oversaw Save the Children's response to Ebola in west Africa, underscored how the Ebola outbreak response revealed extraordinary levels of collaboration, courage, and empathy. But these unprecedented events also showed the astonishing bargain that was being negotiated between affected countries and the international community. Manage Ebola well, those counties were told, and the gates of heaven will open for you. Fail, and you will go to hell. The threat was palpable—and unconscionable. I sat in international conferences, convened after the west Africa outbreaks, where country leaders pleaded for the equivalent of a Marshall Plan, a west African recovery programme, to counter the de-development that Ebola had wreaked on their economies. Big promises were made. But the fact is that once Ebola withered away, the international community lost interest in Africa. The US and Europe were concerned about Ebola only in so far as it represented a threat to their own borders. Once that threat had dissipated, Africa was once again left to clear up the debris of a humanitarian catastrophe. Watching this betrayal unfold was not surprising. It was simply one more deception western nations have perpetrated on African peoples. Yes, a vast amount of money was invested in controlling Ebola. Yes, important lessons were learned. Yes, the global health community did sharpen its understanding of public health emergencies. But Ebola showed how western countries bequeathed one more chapter of duplicity and treachery on the history of Africa.

Assessment of Burden of Sickle Cell Trait and Disease Among Tribal Students of South Rajasthan

Background: Sickle cell disease, an inherited disorder of erythrocytes, is highly prevalent among the tribal population of India. However, the disease has not been well-illustrated and as the tribal population in India is approximately 100 million, it is necessary to identify the magnitude and characteristics of this problem. Also, the prevalence of the disease is unknown among the 5 million people of tribal provinces of Rajasthan. In this study we intended to determine the prevalence and characteristics of sickle cell disorder among the tribal students of South Rajasthan. This is the first large scale study conducted among the tribal population in the state of Rajasthan. Methods: This cross sectional study was conducted in the Maa Badi and Hostel students of the five tribal sub-plan districts of Rajasthan. Maa Badi Centres are situated in every village and one hostel for every four to five villages. A total of 36,752 students were screened from 1,006 Maa Badi centres and 243 hostels. The screening was done by solubility test and electrophoresis was used for confirmation. Findings: The prevalence of sickle cell disorder among the tribal students is 5.8%. The prevalence of the heterozygous and homozygous conditions is 5.61% and 0.17% respectively. Among the five sub-plan districts, highest prevalence was seen in Sirohi District (10.5%) followed by Banswara (7.42%), Udaipur (6.53%), Pratapgarh (5.51%) and Dungarpur (1.89%). Among the four major tribes belonging to these districts, highest prevalence was recorded in Garasia tribes (13.81%). Interpretation: The study carried out for the first time among large number of students, significantly revealed the existence of problem of sickle cell disorder in this region and it is recommended that a structured screening programme targeting the entire tribal population with appropriate counseling as well as treatment is needed through existing health system. Funding Statement: This study was funded by Government of Rajasthan, India. Declaration of Interests: The authors declare no competing interests. Ethical Approval Statement: The study was approved by the Institutional Committee for Research on Human Subjects, Desert Medicine Research Centre (ICMR)”, written informed consent and assent were obtained from all participants and all investigations were conducted according to the principles expressed in the Declaration of Helsinki.