Local Health System Research Articles

Access to HIV testing and factors associated among sexual minority women in a metropolitan region of the Brazilian Amazon

In Brazil, health policies implemented over the last three decades have enabled rapid testing for HIV to be made available in primary health care services. However, although these policies are national, the implementation of actions is not uniform, as they depend on the local management of local health systems. In this context, the study identified the proportion of women from sexual minorities who had never tested for HIV and the factors associated with access, in a Metropolitan Region of the Brazilian Amazon. This was an observational, cross-sectional study, conducted from data collected from July 21, 2022 to April 11, 2024, in the Brazilian Amazon. The study included women, aged 18 or over living in the study area who self-declare and self-identify as lesbian, bisexual, pansexual or asexual. The dependent variable: participants were asked if they had ever been tested for HIV in their lifetime. The independent variables were the access components: predisposing, facilitating and necessary. 301 women from sexual minorities participated in the study, 42.2% of whom had never tested for HIV. In the final model, multiple backward logistic regression was performed, the highest chances of never having been tested for HIV were participants aged 18 to 30 years (OR 2.99; p = 0.038); with income less than or equal to 1 minimum wage (OR 1.91; p = 0.026); participants who did not have children (OR 6.67; p = 0.012); and those who did not have an active sexual life (OR 4.73; p = 0.006). While the lowest chances of never having tested for HIV were among participants who used drugs OR 0.44; p = 0.008) and women who had already had an STI (OR 0.20; p = 0.044). Although the testing prevalence was below 50%, the study identified that the combined prevention strategy has reached the most vulnerable populations.

Threats Analysis and Control Strategies in Immunization Programs for Rural Communities in Nigeria

Vaccination is crucial for disease prevention, particularly in rural Nigeria, where access to healthcare is limited. This study examines the challenges to immunization programs, the impact of government policies and local health systems, and the effectiveness of control measures. Key challenges include logistical issues, such as inadequate health facilities, storage for vaccines, and equipment, as well as socio-cultural barriers like lack of knowledge, traditional beliefs, myths, and rumors. Government policies and health systems play a significant role in immunization efforts but are often hindered by resource shortages and inconsistent implementation. Effective strategies, such as mobile vaccination units, community health education, and integrating immunization with other health services, have shown promise in improving vaccination coverage. However, concerns about the sustainability of these interventions highlight the need for systemic strengthening, including community involvement and a reliable vaccine supply chain. This study emphasizes the importance of coordinated efforts by government, healthcare providers, and community leaders to address both structural and cultural barriers. Achieving 100% immunization coverage in rural areas requires inter-sectoral strategies that address social determinants of health. By tackling these underlying factors, sustainable improvements in immunization programs can be ensured, ultimately reducing the burden of vaccine-preventable diseases in hard-to-reach rural areas.

Strengthening local health systems and governance for Universal Health Coverage: experiences and lessons from the COVID-19 pandemic response in Quezon City, Philippines.

Strengthening local health systems and governance for Universal Health Coverage: experiences and lessons from the COVID-19 pandemic response in Quezon City, Philippines.

Toward Resilient Maternal, Neonatal and Child Health Care: A Qualitative Study Involving Afghan Refugee Women in Pakistan.

Afghan refugees in Pakistan, particularly in Quetta, Balochistan, encounter formidable barriers in accessing maternal, newborn, and child health (MNCH) services. These challenges have been intensified by the COVID-19 pandemic and entrenched systemic health inequities. This qualitative study, conducted from February to April 2023, aimed to assess the obstacles within health systems and community environments that hinder MNCH service access among Afghan refugees. The study involved 20 key informants through in-depth interviews and focus group discussions, including Afghan refugee women, community elders, health workers, and representatives from non-governmental organizations and government agencies. The research focused on experiences during the initial four waves of the COVID-19 pandemic (2020-2021), utilizing a conceptual framework integrating Health Emergency Disaster Risk Management (Health-EDRM) with primary health care. The study identified significant systemic barriers to accessing MNCH services, such as insufficient funding, inadequate health infrastructure, and discriminatory practices within the healthcare workforce. Additionally, community-level obstacles were prominent, including cultural and language differences, geographical isolation, and economic constraints. The integration of Health-EDRM into local health systems was minimal, with many stakeholders either needing to be made aware of or unengaged with the framework. The findings highlight a critical need for comprehensive policy reforms, infrastructure enhancement, and community-centered approaches to address Afghan refugees' health needs effectively. Strengthening the integration of health-EDRM into health systems is crucial for enhancing resilience and ensuring continuous care during health emergencies. The study calls for concerted efforts to implement culturally sensitive health interventions that include disaster risk management components to improve MNCH outcomes among Afghan refugees in crisis-affected settings. Addressing systemic and community-level barriers makes creating a more resilient and equitable health system for vulnerable populations possible.

Unexpected renal side effects of mRNA COVID-19 vaccines; a single-center experience and short review.

In late 2019, the World Health Organization declared Coronavirus disease 2019 a global emergency. Since then, many vaccines have been developed to combat the pandemic. Millions of people have received one of the approved COVID-19 vaccines; unfortunately, some adverse events also have been recorded. In the local health system, patients could get either mRNA vaccines (either Pfizer-BioNTech or Moderna), adenoviral vector vaccine (AstraZeneca), or the vaccine based on inactivated virus (Sinovac). We investigated what immune-mediated adverse events occurred in our department after the COVID-19 vaccination. We evaluated six patients from our center who received mRNA vaccines and developed suspected immune-mediated adverse events. The immune-mediated adverse events are characterized by de novo or relapsing glomerular diseases and are further confirmed with percutaneous kidney biopsies. During A follow-up of more than two years, remission occurred in five patients, and glomerulonephritis persisted in one of them. Vaccinations are pivotal in effectively protecting and preventing various epidemics. As such, it is essential to maintain a high level of vigilance concerning post-vaccination adverse events. This heightened level of suspicion leads to earlier detection, better understanding, and optimal prevention and management of these events. To this end, developing a specific vaccine/patient risk profile is necessary to categorize the target population selectively.

Barriers and facilitators for preventing mother-to-child transmission of Trypanosoma cruzi and hepatitis B in the Gran Chaco region: a qualitative analysis using the consolidated framework for implementation research (CFIR)

BackgroundMother-to-child transmission (MTCT) of Trypanosoma cruzi and hepatitis B virus (HBV) increases morbidity and disability in Latin America and the Caribbean. The tailormade comprehensive antenatal care based on the Framework for the elimination of MTCT of HIV, syphilis, hepatitis B virus (HBV), and Chagas disease (EMTCT Plus) has been implemented in the region since 2018 through a private-public partnership. This study aimed to estimate the effectiveness of the intervention in preparing MTCT of T. cruzi and hepatitis B. The study further attempted to identify the barriers to and facilitators for preventing MTCT of T. cruzi and HBV in the Gran Chaco region of Argentina and Paraguay.MethodsData on T. cruzi and HBV screening and treatment among pregnant women and infants were collected from antenatal care (ANC) registries between June 2018 and December 2022. A cascade-of-care analysis was applied to assess the intervention’s effectiveness and identify bottlenecks. Additionally, key informant interviews were conducted for both implementors and service recipients to identify barriers to and facilitators for accessing screening and treatment using the Consolidated Framework for Implementation Research.ResultsA total of 1,658 pregnant women were recruited, achieving 100% antenatal care coverage and screening for T. cruzi and HBV. The prevalence of T. cruzi among pregnant women was 3.3% (95%CI: 2.4-4.1%), while in newborns it was 14.0% (95% CI: 6.0–25.0). Treatment coverage for newborns infected with T. cruzi was 100%, whereas post-delivery treatment coverage among mothers was 67.3%. This achievement was likely attributed to strong community engagement, contributing to 100% ANC coverage. However, barriers such as a fragile local health system, long-term follow-up requirements, high mobile populations, cultural beliefs, and social trauma were identified in target areas.ConclusionImplementing the EMTCT Plus Framework improved access to quality ANC in the study area. Nevertheless, continuous follow-up for T. cruzi screening and treatment for post-delivery remains challenging. To improve access to healthcare and ensure the sustainability of the intervention, an intercultural approach that empowers the community, alongside efforts to strengthen the local health system, is recommended.

Resilience in local Finnish health systems: how are leaders’ approaches to change manifested in organisational crisis responses?

PurposeLocal health systems form the basis for health system resilience. Leaders’ standpoints are crucial in advancing resilience capacities and change. This study analysed how local health system leaders’ approaches to change reflect health system resilience capacities. Furthermore, we explored what triggers and hinders change during a crisis.Design/methodology/approachThe data consist of purposively sampled interviews with 14 local Finnish health system leaders during the COVID-19 pandemic. Using abductive content analysis, examples of resisting, absorbing, adapting and transforming were identified. Contextual triggers and hindrances for the initiation of change processes were analysed to support understanding of health system resilience capacities at the local level.FindingsResilience capacities were manifested by doing standard things faster (absorption), engaging in collaborative reflections (adaptation) and reforming organisational boundaries and services (transforming). “Resisting” leaned on varied levels of reflection, with mixed responses. Triggers and hindrances varied situationally and highlighted the roles of a changing operational environment, existing practices and the social dimension (e.g. building a shared understanding).Originality/valueLeaders’ standpoints and their approaches to change are rarely the focus of attention in system-centred conceptualisations of health system resilience. Leaders’ awareness of their approaches to change can affect organisational responses and health system resilience. This should be more clearly acknowledged in theoretical frameworks, leadership training, preparedness planning and crisis governance. Health system resilience capacities form intertwined, nonlinear processes that are reshaped throughout a crisis. Analysis of resistance can enrich the understanding of local-level processes.

Rethinking village malaria workers in Cambodia: Perspectives from the communities, programme managers, and international stakeholders.

Since the early 2000s, malaria cases in Cambodia have declined steadily. Village malaria workers (VMWs) have played a critical role in reducing malaria transmission and progress towards malaria elimination. To prevent malaria re-establishment, however, implementation strategies need to consider carefully the changing healthcare needs in the communities as well as challenges to, and opportunities for, programme adaptation. We conducted in-depth interviews with a diverse range of stakeholders involved in the planning or implementation of the VMW programme in Cambodia, to elicit their views and experiences about health priorities in the communities, the public health value of VMWs and community-based care, and prospects for future programme development. Respondents included managers and implementers involved in the VMW programme at the central and provincial level (n = 9), technical officers at international agencies in Cambodia (n = 7), international stakeholders in non-governmental and research organisations based in Cambodia or other countries in the region (n = 5), as well as VMWs (n = 10), and community members (n = 16) in six endemic communes of Kravanh District, Pursat Province. In Kravanh, we also conducted four focus group discussions with 19 community members who had previous experience of malaria. The qualitative dataset was analysed using a thematic approach. VMWs, particularly mobile malaria workers tasked with active case detection among forest workers, were deemed necessary to maintain effective malaria control. However, there was a clear demand in the communities for additional services including treatment for common illnesses, monitoring of blood pressure and blood sugar levels, and relief of general symptoms through medication, such as for fever, headache, and stomach pain. Programme managers and international stakeholders agreed that the VMW programme needs a rethinking of the current implementation model to ensure continued uptake, relevance, and motivation of VMWs. Suggestions for add-on activities included adoption of new tests for febrile illnesses such as dengue and chikungunya, and screening for the prevention and monitoring of non-communicable diseases. There was emphasis on the needs for more sustainable financing mechanisms and integration with the existing community health infrastructure. The potential expansion of VMW services will benefit from the continued involvement of external donors and partners for technical and financial support. However, the implementation strategy should consider since the outset opportunities for enhanced local ownership and health system integration. To maintain domestic political momentum and access new potential sources of domestic funding, further programme development should align with national health priorities and the ongoing process of administrative decentralisation, while being responsive to changing public health needs within the communities.

A heart failure program in low-income patients in Argentina(COMM-HF)

Objective. In low- and middle-income countries, heart failure (HF) is the leading cause of death and disability. Materials and methods. A feasibility study was conducted to assess the fidelity, reach, and adoption of an educational program led by non-medical staff to improve outpatient care for patients hospitalized with HF in the local public health system. Results. Thirty patients were included, with a mean age of 55.3 years (63.3% male). A total of 97.3% of planned home visits and 90% of scheduled phone calls were completed. Counselling modules were delivered during 90.4% of home visits, with no significant challenges reported during implementation. At the end of follow-up, there was a trend towards improved lifestyle habits, a reduction in mean heart rate (78.0 to 68.3 beats per minute; p = 0.016), a decrease in the proportion of patients in NYHA functional class III (20% to 7.4%; p = 0.041), and a slight reduction in mean body mass index (29.5 vs. 28.9; p = 0.042). Conclusions. A home-based educational program, designed to optimize outpatient management of heart failure and led by non-medical healthcare personnel, was well-received and demonstrated feasibility for implementation in low-income patients relying solely on the Argentine public health system.

The Use of Oral Phenobarbital Loading for the Management of Alcohol Withdrawal Syndrome in an Outpatient Setting: A Case Report.

Alcohol withdrawal syndrome is most frequently treated with benzodiazepines, but due to their short half-life, tapering prescriptions are frequently required for outpatients, which presents challenges to both clinicians and patients. Our local health system has had significant success treating alcohol withdrawal in the emergency department with phenobarbital loading doses. As patients also present in alcohol withdrawal to our outpatient addictions clinic, we have adapted our emergency department intravenous protocol to a staggered, oral loading protocol for the treatment of mild and moderate alcohol withdrawal syndrome in the community setting. In this case report, we successfully treat a 36-year-old man with mild alcohol withdrawal symptoms using this approach and without requiring a tapering sedative prescription.

Leveraging local health system resources to address quality healthcare gaps in sub-Saharan African: lessons from the SafeCare quality improvement programme in Ghana

IntroductionIn low- and-middle-income-countries (LMICs) like Ghana, universal access to quality healthcare remains a mirage and this undermines achievement of sustainable development goal (SDG) 3. The SafeCare Quality Improvement (QI) programme is an initiative of PharmAccess Foundation, a Netherlands-based non-governmental organisation (NGO). In 2009 SafeCare QI programme was launched in Ghana to help address gaps in healthcare quality standards, leveraging existing local resources. Over 600 private and public healthcare facilities are currently enrolled in the programme and is being adopted for nation-wide rollout by government of Ghana and implementing partners.ObjectiveThis paper explored views and experiences of frontline health staff and policy makers on the SafeCare quality improvement programme in Ghana and how local resources were leveraged in its implementation.MethodologyDesign/setting: The evaluation was conducted in 53 private and public healthcare facilities from seven administrative regions of Ghana across the coastal, middle, and northern geopolitical belts. The regions are Ashanti (n = 12), Bono East (n = 8), Bono (n = 3), Greater Accra (n = 12), Oti (n = 4), Savannah (n = 8) and Western (n = 9).Sampling: Quota and purposive sampling techniques were used to sample the healthcare facilities in accordance with the study eligibility criteria. Total of 45 focus group discussions (FGDs) and 47 individual in-depth interviews (IDIs) were conducted among frontline staff and policy makers from government and private local partner institutions.Analysis: Group and individual interviews were audio recorded, transcribed verbatim and thematic content analysis done using Nvivo (version 12.0) software.FindingsOverall, participants perceived the relevance and benefits of the SafeCare programme to be "very satisfactory" while the programme impact, rollout process and success were perceived to be "satisfactory". Quality healthcare standards were perceived to have improved in beneficiary health facilities due to participation in the SafeCare programme. Patient satisfaction, service utilisation and revenue generation in healthcare facilities were also attributed to the SafeCare programme. Proposals were made for harmonisation of existing QI assessment tools to mitigate duplications. Agreed data sharing protocols and interoperability with existing national database were also recommended to promote sustainability. Finally, low staff motivation, high workload, lack of financial and material resources were cited as potential impediments to full compliance with the SafeCare QI standards by healthcare facilities enrolled in the programme.ConclusionsSafeCare QI programme has contributed to QI and adherence to patient safety standards in Ghana. Sustainability is however dependent on continuous government commitment as the programme gets adopted as a national QI programme. Overlaps in content of QI assessment tools ought to be addressed to promote efficiency without compromising quality standards. The SafeCare programme demonstrates that health systems in LMICs have the potential to attain acceptable quality healthcare standards when they take advantage of existing local resources, including private-public partnership (PPP) and peer-learning opportunities.

Managing medicines in decentralisation: discrepancies between national policies and local practices in primary healthcare settings in Indonesia.

In Indonesia, primary health centres (PHCs) are mandated to provide essential medicines to ensure equal access to medication for all Indonesians, as stated in the national medicine policy. However, limited information is available regarding the actual practices of health workers within the context of decentralised governance. This paper investigates the discrepancies between national policies and local practices in two Indonesian districts, shedding light on coping mechanisms employed in each phase of medicine management within PHCs. The mixed-method study began by identifying pertinent policies addressing medicine management in PHCs. Subsequently, panel data on patient visits to tuberculosis, maternal and neonatal health (MNH) and non-communicable disease (NCD) services were collected from 2019 to 2022. After analysing the panel data, interviews were conducted with 56 health workers including physicians, nurses, pharmacists, midwives, and public health programme managers regarding their views on fluctuations in medicine stocks and the patient visits data. These participants included pharmacists and programme managers specialising in tuberculosis, MNH, and NCD care and were affiliated with PHCs and district health offices (DHO). Our findings highlight the occasional unavailability of essential medicines in PHCs, with stockouts being attributed to supplier shortages at provincial and national levels and to variations in the capacity of the local health system. Low-skilled pharmaceutical staff are a contributing factor in each phase of medicine management. Additionally, health workers employ coping mechanisms, such as deviating from policy on the use of capitation funds to purchase medicines, to manage temporary stockouts. To tackle systemic stockouts, central government should prioritise capacity-building among health workers, by establishing a continuous and easily accessible local learning system.

Delphi definition of general practice/family medicine specialty for a post-COVID world: in-person and remote care delivery.

The evolving landscape of general practice (GP)/family medicine (FM) in the post-COVID-19 era, focussing on integrating telemedicine and remote consultations requires a new definition for this specialty. Hence, a broader consensus-based definition of post-COVID-19 GP/FM is warranted. This study involved a modified electronic Delphi technique involving 27 specialists working in primary care recruited via convenient and snowball sampling. The Delphi survey was conducted online between August 2022 and April 2023, utilizing the Google Forms platform. Descriptive statistics were employed to analyse consensus across Delphi rounds. Twenty-six international experts participated in the survey. The retention rate through the second and third Delphi rounds was 96.2% (n = 25). The broader consensus definition emphasizes person-centred care, collaborative patient-physician partnerships, and a holistic approach to health, including managing acute and chronic conditions through in-person or remote access based on patient preferences, medical needs, and local health system organization. The study highlights the importance of continuity of care, prevention, and coordination with other healthcare professionals as core values of primary care. It also reflects the role of GP/FM in addressing new challenges post-pandemic, such as healthcare delivery beyond standard face-to-face care (e.g. remote consultations) and an increasingly important role in the prevention of infectious diseases. This underscores the need for ongoing research and patient involvement to continually refine and improve primary healthcare delivery in response to changing healthcare landscapes.

A Retrospective Analysis of Jordan's National COVID-19 Call Center: Operations, Effectiveness, and Lessons Learned.

Contact tracing has been a cornerstone of non-pharmaceutical interventions to control the COVID-19 epidemic, with highly mixed effectiveness internationally. In Jordan, the Ministry of Health (MOH) collaborated with the Jordan Nurses and Midwives Council and the USAID Local Health System Sustainability Project to set up a call center for contact tracing of COVID-19. This study described the operation and assessed the effectiveness of Jordan's COVID-19 call center activities in reaching COVID-19 cases and their contacts. A retrospective observational design was conducted using data from all calls made by the COVID-19 call center cases between November 2020 and April 2022. Data were collected from initial and follow-up calls to PCR-confirmed COVID-19 cases and their contacts. Data on socio-demographics, symptoms, and contact tracing activities were recorded. The study focused on key outcomes, including call success rates, the number of cases and contacts reached, and the role of different detection modes in identifying cases. During the study period, the call center attempted to contact 1,027,911 COVID-19 cases, successfully reaching 802,525 cases (78.1%). Follow-up calls were made to 1,126,334 cases, with a success rate of 74%. The call center appeared particularly valuable during the initial period of the pandemic until it was overwhelmed by the significantly more transmissible Omicron variant of the virus. Two weaknesses were identified: gaps in reaching non-Jordanian citizen cases and difficulty in keeping up with case volume during the Omicron wave of February-March 2022, when reported cases peaked at over 20,000 per day. One-third of all reached cases said that they had been referred for testing through contact tracing. Contact tracing activities led by the MOH were instrumental in identifying new cases, optimizing resource allocation, improving surveillance and data systems, targeting vulnerable population, and supporting mitigation strategies to combat the COVID-19 pandemic in Jordan.

The global health and economic burden of chikungunya from 2011 to 2020: a model-driven analysis on the impact of an emerging vector-borne disease

IntroductionChikungunya is a mosquito-borne arboviral disease posing an emerging global public health threat. Understanding the global burden of chikungunya is critical for designing effective prevention and control strategies. However, current...

Perspectives of cancer consumer representatives on their involvement in healthcare service improvement: a qualitative study

BackgroundConsumer involvement in healthcare service organisation and policy development is recognised globally as a vital strategy in improving the quality and patient-centredness of care. There are significant gaps in knowledge about consumer involvement in practice, including consumers’ engagement in the process of enhancing cancer services. This study aimed to explore consumers’ perspectives on their involvement in cancer service improvement.MethodsCancer consumer representatives were recruited through Victorian Integrated Cancer Services, Australia. Eligible consumers were, or had been, a member of a health service improvement-related committee or project and attended at least one meeting with health professionals. Semi-structured qualitative interviews were conducted online and transcribed verbatim. Data were analysed using inductive thematic analysis.ResultsSix experienced consumer representatives were interviewed. Perspectives on their involvement in improving cancer services were categorised into three major topics. The first addressed personal aspects of involvement, in which participants described personal motivations (e.g., having lived experience of cancer themselves or in their family), challenges encountered in committee involvement, experiences of received support in their role as a consumer representative, concerns about narrow representation, and their evolving identity as a consumer representative. The second discussed practical contributions made by consumer representatives to improve systems and services. Participants detailed their active engagement with committees and consumer-led projects, contributing both their cancer experiences and general or professional skills. The third topic focused on directions for improving consumer involvement in the health system. Suggestions highlighted widening consumer representation to include often marginalised voices to inform decision-making at local committee and health system levels.ConclusionsThis study enhances the real-world understanding of the role that consumer representatives play in improving cancer health services. The strategies suggested in our research provide the opportunity to enhance consumer involvement and pave the way for more effective cancer service planning and implementation across diverse healthcare settings.

Cancer prevention for homeless people: Qualitative evaluation of the Health Navigator Model

Abstract Background People experiencing homelessness (PEH) face significant barriers when accessing cancer preventive services. The Health Navigator Model (HNM) seeks to address these challenges by improving access and engagement with cancer preventive care through tailored navigation services. This study aimed to explore PEH’s and health navigators’ experiences with the HNM. Methods This qualitative evaluation involved semi-structured interviews with a total of 61 PEH receiving the HNM intervention and 11 health navigators across four pilot sites in Austria, Greece, Spain, and the UK. Data were analyzed thematically using a cross-national coding framework. Results Following overarching themes were identified: (1) State of health and perception of health of PEH; (2) Experiences and understanding of cancer prevention; (3) Perceived effects of the Health Navigation intervention; (4) Navigators’ experiences with the implementation of the Health Navigation intervention; and (5) Effects of the Health Navigation intervention from the navigator perspective and sustainability of the intervention. Participants reported a general lack of access to healthcare services and low cancer prevention literacy. The HNM intervention led to increased engagement in cancer prevention activities, such as screenings, facilitated by the personalized support from health navigators. Navigators played a crucial role in bridging the gap between PEH and healthcare systems, though challenges such as mistrust and logistical barriers persisted. Conclusions The HNM has shown potential in enhancing cancer preventive care access for PEH by providing personalized guidance and support. The navigators’ role was pivotal in overcoming systemic and individual barriers, suggesting the need for integrated services that cater specifically to PEH. Future implementations should consider continuous training for navigators and further integration into local health systems to expand the benefits of the intervention. Key messages • The Health Navigator Model effectively enhanced cancer prevention engagement among people experiencing homelessness and empowered them through tailored and person-centered support. • Health navigators bridged healthcare gaps for people experiencing homelessness, improving their access to cancer preventive care services in their local settings.

Preparedness and Public Health: an Italian Local Health Authority plan for a mass gathering in 2023

Abstract Issue Mass gatherings represent an important Public Health challenge. The increased number of people present in a specific area puts local health systems under stress (i.e.workload of emergency services, environmental health and food safety) and at the same time it rises the risks of a potential mass casualty incident. Effective planning and disaster preparedness have to be achieved through collaboration among local health authorities(LHA) and other stakeholders (event planners, law enforcement, local transportation services). Problem Every year, for 3 days, the Italian Alpine troops gather in a different city to remember First World War fallen. During those days, the city centre transit is not allowed to car (in specific areas even to emergency vehicles).In May 2023 this event occurred in Udine, a city in the North East of Italy with almost 100.000 inhabitants. For that year at least 300.000 participants were expected. LHA had to reorganize preparing itself to manage a temporary quadrupled catchment area. Results In the previous months, local authorities met local health representatives and other stakeholders in order to define a single emergency response plan. For healthcare services it was decided to: institute first aid points within the city; reorganise patients’ emergency transport system; increase hospitals’ treatment capacity (beds, life support equipment); increase healthcare professional availability; empower drugstores (opening times, drugs procurement); strengthen human and animal health surveillances;activate alternative communication systems. During the event, LHA updated other authorities involved three times a day about hospital and emergency system situation. At the end of the event,a multiprofessional debriefing meeting was held and no critical situations were reported. Lessons Preparedness requires a great commitment in terms of resources and time, but it is confirmed to be essential to guarantee adequate assistance even in extraordinary conditions. Key messages • Mass gathering s events put under stress all the main areas of public health system. • Public health preparedness cannot be effective without a strong involvement of other public and private stakeholders.

Expanded roles of community health workers beyond malaria in the Asia-Pacific: A systematic review.

In the Greater Mekong Subregion (GMS), community health workers (CHWs) are a key component of malaria elimination strategies. As malaria declines, support for, and uptake of, malaria services may also subsequently decrease. Expanding their roles beyond malaria has been proposed to sustain the services. A systematic review was conducted to identify and characterize programmes with CHWs providing services in addition to those for malaria in the Asia Pacific. This review describes the expanded roles, identifies evidence of impact or success of the programmes, and explores strategies to ensure sustainability and factors for effective implementation to inform the design of malaria CHW programmes. Searches were conducted in 6 databases, for grey literature, and in bibliographies of retrieved articles. Data were extracted from 38 published articles, 12 programme reports, and 4 programme briefs and analysed using thematic coding and descriptive analysis. Twenty-nine programmes were identified with CHWs performing both malaria and non-malaria roles in the Asia Pacific. There was evidence of impact on malaria incidence in 4 of these, none on malaria mortality, and 4 on other diseases. Monitoring and evaluation mechanisms, multi-sectoral stakeholder collaborations, and adequate training and consistent supervision of CHWs were key to effective programme implementation. Integration of programmes into broader health services, ongoing political and funding support, and engagement with local communities were found to contribute to sustaining provision of health services by CHWs. Expanding CHW roles depends on programme management and strengthening linkages with local health systems. To sustain malaria CHW services, countries need adequate policies and financing, and sufficiently strong health systems to deliver basic health services that are adapted to the health needs of the community which means transitioning away from vertical disease programs. Further research should explore programmes that have not been captured in this review and address gaps in measuring malaria outcomes.

Individual, community and health systems factors influencing time to notification of tuberculosis: situating software and hardware bottlenecks in local health systems

BackgroundDespite several global interventions, tuberculosis (TB) remains a leading cause of death affecting millions of people globally. Many TB patients either have no access to quality care or go undetected by national health systems. Several multilevel factors account for under-detection of persons with TB. This study sought to explore patient-related software, community and health systems software and hardware factors influencing time to notification of TB in Lusaka District, Zambia.MethodsThis was an exploratory qualitative case study that adopted a software and hardware lens of conceptualizing health systems. Data were collected from across three sites – urban and peri-urban areas: Chongwe, Kafue, and Lusaka – within Lusaka Province, Zambia. Sixteen key informants - TB corner nurses, community TB treatment supporters, and TB program managers - were interviewed. Six focus groups were held with TB patients. Data were analyzed using thematic analysis.ResultsThe study identified factors influencing timely TB notification, categorized into software and hardware elements.Patient-related software elements, including TB knowledge and awareness, and health-seeking behavior, are crucial for prompt notification among TB patients.In the community health system, software elements like social stigma and undesirable community attitudes towards contact tracing, and hardware elements such as unbalanced schedules, excessive workload and limited capacity of community TB treatment supporters contribute to delayed TB notification.In the formal health system, software elements like negative attitudes of health providers towards TB patients and demotivation of TB staff, and hardware elements such as high diagnostics and transportation costs, outdated diagnostics in primary care facilities, and slow referral mechanisms, can also delay TB notification.ConclusionDelays in time to TB notification are influenced by a combination of software (attitudinal and behavioral) and hardware (resource-related) elements across TB patients, community health systems, community TB treatment supporters, health providers, and TB staff. Addressing these factors, particularly social stigma, negative attitudes, and resource constraints, is crucial to improving timely TB detection and treatment.