The report on the reciprocal learning approach used for the Self-Management and Reciprocal learning for the prevention and management of Type 2 Diabetes (SMART2D) project is a valuable example of how interventions, specifically those improving the strength and equity of health systems, can be improved through partnerships across borders (1). The project emphasises the need to adapt interventions to local contexts, and share this learning among researchers and health workers. This report also alludes to the challenges that can stem from cultural and power differences both between researcher and participants, and between collaborating researchers. This indicates the importance of shared leadership and decision-making, as well as shared learning, throughout the process of intervention design.

The groundwork of the SMART2D project included a literature review of the role of community health workers (CHWs), and this has provided an insightful compass for future research (2). The vast majority of studies evaluating the role of the CHWs have been conducted in the US. CWHs in the US perform diverse tasks going beyond patient education and medication adherence, including connecting patients to community resources such as exercise groups, and advocating for them in a complex medical system. Despite patients' frequent contact with primary care, this system often fails to provide them with adequate understanding of their condition (3). Diabetes management in high-income countries could indeed benefit from learning processes that engage service providers with the needs of service users. A relatively small number of studies have investigated the effectiveness of diabetes interventions involving CHWs in low- and middle-income countries (LMICs). These indicated positive outcomes in self-management, glucose control, and body mass index; however, these studies often lacked detailed characterisation of the role played by CHWs (4). The burgeoning epidemic of diabetes in LMICs demands context-specific research to assess the position of CHWs, and to shape opportunities for developing their role in diabetes management.

Adaptation of health interventions at the local level is key to making them relevant and acceptable to the communities they serve. In this area, diabetes management programmes can learn reciprocally from HIV intervention programmes, which have developed beyond reducing transmission, to chronic infection management, community engagement, and raising global awareness. The double burden of diabetes and infectious diseases such as HIV and tuberculosis, known to have interactions at the physiological as well as societal level, demands stronger health systems that can provide joined-up care. Previous studies have shown the central role of community-based individuals for outreach and mobilization in HIV interventions. They furthermore provide guidance on how to adapt interventions to their implementation sites, including the involvement of local staff in the adaptation process (5). Patients must also be stakeholders in the learning and adaptation process. We can anticipate that reciprocal learning approaches to health service development, both internationally and between disease-specific health programmes, will enhance services and strengthen resource-limited health systems.

References

1. van Olmen J, Delobelle P, Guwatudde D, Absetz P, Sanders D, Mölsted Alvesson H, et al. Using a cross-contextual reciprocal learning approach in a multisite implementation research project to improve self-management for type 2 diabetes. BMJ Glob Heal. 2018 Nov 26;3(6):e001068.

2. Egbujie BA, Delobelle PA, Levitt N, Puoane T, Sanders D, van Wyk B. Role of community health workers in type 2 diabetes mellitus self-management: A scoping review. PLoS One 2018;13(6):e0198424.

3. Silverman J, Krieger J, Sayre G, Nelson K. The Value of Community Health Workers in Diabetes Management in Low-Income Populations: A Qualitative Study. J Community Health. 2018 Oct 1;43(5):842–7.

4. Alaofè H, Asaolu I, Ehiri J, Moretz H, Asuzu C, Balogun M, et al. Community Health Workers in Diabetes Prevention and Management in Developing Countries. Ann Glob Heal. 2017 May 1;83(3–4):661–75.

5. Kevany S, Khumalo-Sakutukwa G, Murima O, Chingono A, Modiba P, Gray G, et al. Health diplomacy and the adaptation of global health interventions to local needs in sub-Saharan Africa and Thailand: evaluating findings from Project Accept (HPTN 043). BMC Public Health. 2012 Jun 20;12:459.

Standardized packaging may be the way to go in terms reducing smoking prevalence (McNeill et al, 2017). Although plain packaging has reduced smoking and brand appeal in Australia, it did not restrict launching of new products and diminish tobaccos’ extensive, highly differentiated brand variant ranges, (Greenland S.J., 2016). As countries prepare to use this policy they should take into account the influence of the tobacco industry on both the economy and social life of people.

India is amongst few countries implementing healthy warning and in sharp contrast, it is also, as stated in the article, the largest producer and the second largest consumer of tobacco in the world. This presents a cross roads and this is illustrated by the delay seen between policy formation and implementation of the current tobacco control policy in India which stipulates health warning branding using(85%) space on all tobacco products. This has given enough time for the tobacco industry to fight back the policies and to make most sales out of the hesitancy. These strategies have been used in the legal frontiers citing international trade organization laws (Eckhardt et al 2016)

This is a challenge to World Health Organization (WHO) and its policies as they are challenged by laws governing trade and competition. In the interest of successful implementation of such policies there is need for more collaboration between WHO and World Trade Organization (WTO), as this can be the key to unlocking the potential of the plain packaging policy. The tobacco industry, which made almost a trillion dollars in 2016, in India alone (Statista, 2018), is a big forex earner for most low and middle income countries, and there is a need for future policies to focus on giving societies who provide labor for the system an alternative way of means.

References
McNeill A, Gravely S, Hitchman SC, Bauld L, Hammond D, Hartmann-Boyce J (2017). Tobacco packaging design for reducing tobacco use. Cochrane Database of Systematic Reviews 2017, Issue 4. Art. No.: CD011244.DOI: 10.1002/14651858.CD011244.pub2.
Steven J. G. (2016): The Australian experience following plain packaging: the impact on tobacco branding, Society for the study of addiction,
Eckhardt, J., Holden, C., & Callard, C. D. (2016) Tobacco Control and the World Trade Organization: Mapping Member States’ Positions after the Framework Convention on Tobacco Control. Tobacco Control. pp. 692-698. ISSN 1468-3318
Statista: tobacco industry statistics & facts. https://www.statista.com/topics/1593/tobacco/ 27 October 2018

Médecins Sans Frontières (MSF) welcomes the analysis of the cost of manufacturing of human and analogue insulins by Gotham and colleagues. This work provides a realistic estimate of significantly lower market prices that would be more affordable for both governments and individuals and should open the eyes of the global health community to the shameful reality of abusive pricing as well as the gross inequity in access to treatment for people living with diabetes.

In resource-limited settings, access to insulin is centralised and rarely free of charge within the public health system. For those who can access insulin, many must travel once or often twice daily to a clinic to receive their injections, due to fears around home storage of phials and self-injecting - particularly in conflict-affected or insecure settings.

Human insulin is the only type of insulin included on the WHO Essential Medicines List (EML), and when procured in phials, costs significantly less than analogue insulin or insulin within an adapted device (cartridge or pen) which may simplify delivery. Debates continue around the impact of analogue insulins on diabetes outcomes (HbA1c), but many experts recognise that access may make regimens safer, particularly in settings where MSF works.

The market dominance of and excessive pricing by the three major human and analogue insulin producing companies - along with the lack of competition from biosimilar manufacturers to challenge this dominance - has contributed to the reality that worldwide at least 50% of those in need of insulin are not able to access this life saving treatment. As Gotham and colleagues’ work clearly outlines, the cost differentials in manufacturing a phial of human insulin ($2.28 – $3.42) versus analogue insulin ($3.69 - $6.16) are not reflected in current market prices. Indeed, insulin prices around the world lie far above these ranges, with often excessively high price differentials between human and analogue. The abusive pricing strategies of pharmaceutical corporations must be challenged in light of the limited access globally, and in low income and humanitarian settings in particular.

The majority of insulin that MSF procures is human insulin in phials, from Lily and Novo Nordisk, two of the three insulin market dominators. Activism by people living with HIV, MSF and other advocates for affordable generic antiretrovirals (ARVs) and a coordinated donor response resulted in over 20 million people currently receiving treatment for HIV. The current lack of competitive biosimilar insulins – similar to the lack of generic ARVs 20 years ago – is a huge hurdle to overcome in ensuring access for people living with diabetes today. Regulatory pathways for biosimilars and lack of transparency across price negotiations are just two of the factors challenging competition in the insulin market.

People living with diabetes need insulin today, and the lack of access in 2018 is an outrage. MSF supports a coordinated global response to ensure quality, affordable human and analogue insulin formulations are available in adapted delivery devices for people in need of this life-saving treatment.

Dear Editor,
We read with interest the paper: ‘Geographic coverage of demographic surveillance systems for characterising the drivers of childhood mortality in sub-Saharan Africa’ (1). This paper raises a few points that we would like to discuss (1). We focus on the authors’ extrapolation of findings from their study on children’s under five mortality [U5M] rates to the entire sub-Saharan Africa region. Other determinants we discuss include urban-rural disparities, factors that affect accessibility to health care services and the effect of political conflict in the region on under five mortality rates.
Firstly, we discuss the use of data from the east and the west regions in Africa generalised to the entire Sub Saharan Africa [SSA] region (1). The regions covered in the analysis are represented in figure 1 of the original paper by Utazi et al. (1). They point out that civil and vital registration systems are incomplete and weak in SSA (1) which makes data derived from Health and Demographic Surveillance Systems [HDSS] more important to monitor trends and causes of under-five mortality in the region (1). Although many countries in SSA region have similar features and characteristics, analysis from a limited number of countries from either the east or the west of SSA should not be used to generalise to all countries in the SSA region (2). The disadvantages of using data generalised to the broad SSA region were discussed by Cooper et al (2). We believe the results of this study may have more impact if the study had included all countries in SSA.
The paper by Utazi et al mentions risk factors that influence under five mortality, these include the prevalence of preventable diseases, maternal risk factors, sanitation practices and prevalence of stunting (1). The protective factors mentioned in the paper include education of women, vaccination coverage and access to healthcare facilities (1). These authors discuss the similarities between Health and Demographic Surveillance Systems [HDSS] sites located in urban areas compared to rural areas (1). They determined that the urban areas had higher levels of protective factors and lower levels of risk factors (1). However, the level of infrastructure, urban-rural disparities and presence of intervention strategies in urban areas could be attributed to these findings (3, 4). As Urban areas are easily accessible and tend to have basic infrastructure in place (3), intervention strategies can be implemented with relative ease in urban areas. Similarities between countries in U5M rates in urban areas could be due to urban-rural disparities, infrastructure and accessibility of intervention strategies, which are common features in many low and middle income countries (3, 4).
In our last point we consider political conflict in a region as a determinant of U5M rates (5). A study based in South Sudan discussed the effect of conflict-related health inequities and inequitable conditions of daily living on U5M (5). Healthcare service delivery becomes a challenge in regions where violence and conflict remain (5). Furthermore, in the region of South Sudan, where conflict and displacement persists, children in urban areas were at greater risk of dying before their fifth birthday, than those living in rural areas (5).

We agree with the fact that HDSS sites are an important and comprehensive tool for monitoring child mortality and influencing policies related to child mortality. However, the geographical variation in the factors associated with mortality should not be confined to only risk and protective factors as highlighted in this paper (1). We suggest that the variations should also consider factors such as political conflict, displacement and urban rural disparities.
The implications for future research point to the need for an inclusion of all countries in SSA rather than selected countries that cluster on the east and west of SSA. We have highlighted the importance of considering underlying determinants of conflict and disparities, when analysing the relationship between under five mortality rates and geospatial variables.

Reference List:
1. Utazi CE, Sahu SK, Atkinson PM, Tejedor-Garavito N, Lloyd CT, Tatem AJ. Geographic coverage of demographic surveillance systems for characterising the drivers of childhood mortality in sub-Saharan Africa. BMJ Global Health. 2018;3(2).
2. Cooper RS, Osotimehin B, Kaufman JS, Forrester T. Disease burden in sub-Saharan Africa: what should we conclude in the absence of data? The Lancet. 1998;351(9097):208-10.
3. Mulholland E, Smith L, Carneiro I, Becher H, Lehmann D. Equity and child-survival strategies. Bulletin of the World Health Organization. 2008;86:399-407.
4. Beatriz ED, Molnar BE, Griffith JL, Salhi C. Urban-rural disparity and urban population growth: A multilevel analysis of under-5 mortality in 30 sub-Saharan African countries. Health & place. 2018;52:196-204.
5. Mugo NS, Agho KE, Zwi AB, Damundu EY, Dibley MJ. Determinants of neonatal, infant and under-five mortality in a war-affected country: analysis of the 2010 Household Health Survey in South Sudan. BMJ Global Health. 2018;3(1).