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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 co...
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.
Recently, Colbourn et al questioned the use of modelling to seek alternative trial results1. They cited a radio intervention study from Burkina Faso that based on mathematical modelling suggested that the radio intervention was associated with a 7.1% reduction in under-5 mortality, whereas the actual trial results suggested no effect (Rate ratio: 1.00 (95% CI: 0.82-1.22))1. Colbourn and colleagues raised the important point that modelled estimates should not take precedence over empirical mortality data.
We would like to support the point raised by Colbourn and colleagues with an example from the field of vaccinology.
The phase 3 trial of the RTS,S/AS01 malaria vaccine found a vaccine efficacy of 18-36% against clinical malaria2. The study was not powered to assess mortality endpoints, but the results suggested that RTS,S/AS01 was associated with 24% (95% CI: -3 – 58%) higher all-cause mortality3. This was obviously not what was expected; a vaccine that reduces clinical malaria would be expected to reduce all-cause mortality. However, based on our experience, it could indicate that the vaccine, like other non-live vaccines, could have negative non-specific effects4. If that was the case, we predicted that the negative effect would be strongest in females as seen for the other non-live vaccines3. Subsequent analyses indeed revealed that RTS,S/AS01 was associated with higher mortality in girls (Relative Risk of death for RTS,S/AS01 compared with control (RR): 1.9...
Recently, Colbourn et al questioned the use of modelling to seek alternative trial results1. They cited a radio intervention study from Burkina Faso that based on mathematical modelling suggested that the radio intervention was associated with a 7.1% reduction in under-5 mortality, whereas the actual trial results suggested no effect (Rate ratio: 1.00 (95% CI: 0.82-1.22))1. Colbourn and colleagues raised the important point that modelled estimates should not take precedence over empirical mortality data.
We would like to support the point raised by Colbourn and colleagues with an example from the field of vaccinology.
The phase 3 trial of the RTS,S/AS01 malaria vaccine found a vaccine efficacy of 18-36% against clinical malaria2. The study was not powered to assess mortality endpoints, but the results suggested that RTS,S/AS01 was associated with 24% (95% CI: -3 – 58%) higher all-cause mortality3. This was obviously not what was expected; a vaccine that reduces clinical malaria would be expected to reduce all-cause mortality. However, based on our experience, it could indicate that the vaccine, like other non-live vaccines, could have negative non-specific effects4. If that was the case, we predicted that the negative effect would be strongest in females as seen for the other non-live vaccines3. Subsequent analyses indeed revealed that RTS,S/AS01 was associated with higher mortality in girls (Relative Risk of death for RTS,S/AS01 compared with control (RR): 1.91 (1.30-2.79)), but not in boys (RR 0.84 (0.61-1.17))5.
WHO established a collaboration where four groups (the Institute for Disease Modelling, GSK Vaccines, Imperial College London and the Swiss Tropical and Public Health Institute) modelled the expected public health impact of introducing the RTS,S/AS01 vaccine. Based on the measured vaccine efficacy against clinical malaria, the models estimated that per 100,000 fully vaccinated children in a four-dose schedule, 484 deaths would be averted6. However, if the RTS,S/AS01 mortality results5 were representative, fully vaccinating 100,000 children in a four dose schedule would cause 464 additional deaths: Stratified by sex, 100,000 fully vaccinated boys would result in 252 fewer deaths, whereas 100,000 fully vaccinated girls would result in 1182 additional deaths.
The modelled results are in line with the general perception that vaccines only have one effect: prevention of the target disease. However, increasing evidence suggest that non-live vaccines may have negative non-specific effects despite protection against the target disease. The RTS,S/AS01 results fits the pattern previously observed perfectly: the negative non-specific effects of non-live vaccines are particularly pronounced in females.
Nonetheless, the RTS,S/AS01 vaccine is now being introduced as a four-dose schedule in Ghana, Kenya and Malawi as part of the WHO malaria vaccine pilot programme targeting 720,000 children. Policymakers may feel confident about this decision given the effect on clinical malaria and the modelled mortality data. However, based on the empirical mortality data, and the fact that they fit into an already established pattern of mortality effects on non-live vaccines, we fear that this introduction of RTS,S/AS01 may lead to unnecessary female deaths. Discrepancies between modelled and real-life data must be taken seriously. No model is better than the data and assumptions used. Therefore, empirical data should rank higher.
References
1. Colbourn T, Prost A, Seward N. Making the world a simpler place: the modeller’s temptation to seek alternative trial results. BMJ Global Health 2018;3(5) doi: 10.1136/bmjgh-2018-001194
2. RTS.S Clinical Trials Partnership. Efficacy and safety of RTS,S/AS01 malaria vaccine with or without a booster dose in infants and children in Africa: final results of a phase 3, individually randomised, controlled trial. Lancet 2015;386(9988):31-45. doi: 10.1016/S0140-6736(15)60721-8
3. Aaby P, Rodrigues A, Kofoed P-E, et al. RTS,S/AS01 malaria vaccine and child mortality. The Lancet 2015;386(10005):1735-36. doi: 10.1016/S0140-6736(15)00693-5
4. Benn CS, Netea MG, Selin LK, et al. A small jab - a big effect: nonspecific immunomodulation by vaccines. Trends in immunology 2013;34(9):431-9. doi: 10.1016/j.it.2013.04.004
5. Klein SL, Shann F, Moss WJ, et al. RTS,S Malaria Vaccine and Increased Mortality in Girls. mBio 2016;7(2) doi: 10.1128/mBio.00514-16
6. Penny MA, Verity R, Bever CA, et al. Public health impact and cost-effectiveness of the RTS,S/AS01 malaria vaccine: a systematic comparison of predictions from four mathematical models. The Lancet 2016;387(10016):367-75. doi: 10.1016/s0140-6736(15)00725-4
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...
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
Many countries in sub-Saharan African are implementing prevention of mother to child transmission (PMTCT) of HIV programs. In 2003, the World Health Organization (WHO launched a comprehensive four-pronged strategy to prevent HIV among infants and young children to combat mother to child transmission (MTCT). One of the elements in the strategy is prevention of unintended pregnancies particularly among those living with HIV.
There is also a significant unmet need for family planning among many including women living with HIV in Sub-Saharan Africa. The WHO states that 214 million women of reproductive age in developing countries who want to avoid pregnancy are not using a modern contraceptive method (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). According to WHO, citing a study by Ross & Winfrey 2001, 95% of women who are 0 to 12 months postpartum want to avoid pregnancy in the next 24 months, but 70% of them are not using contraception. The WHO indicates that ‘pregnancies in the postpartum period pose the greatest risk for women and their infants, and have increased risks of adverse health outcomes. Providing postpartum family planning is therefore crucial for ensuring the health, human rights and well-being of women and their babies’ (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). A study by John B. Casterline et al (2004) cited a number of salient factors contributing to the unmet need including poor access...
Many countries in sub-Saharan African are implementing prevention of mother to child transmission (PMTCT) of HIV programs. In 2003, the World Health Organization (WHO launched a comprehensive four-pronged strategy to prevent HIV among infants and young children to combat mother to child transmission (MTCT). One of the elements in the strategy is prevention of unintended pregnancies particularly among those living with HIV.
There is also a significant unmet need for family planning among many including women living with HIV in Sub-Saharan Africa. The WHO states that 214 million women of reproductive age in developing countries who want to avoid pregnancy are not using a modern contraceptive method (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). According to WHO, citing a study by Ross & Winfrey 2001, 95% of women who are 0 to 12 months postpartum want to avoid pregnancy in the next 24 months, but 70% of them are not using contraception. The WHO indicates that ‘pregnancies in the postpartum period pose the greatest risk for women and their infants, and have increased risks of adverse health outcomes. Providing postpartum family planning is therefore crucial for ensuring the health, human rights and well-being of women and their babies’ (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). A study by John B. Casterline et al (2004) cited a number of salient factors contributing to the unmet need including poor access to services, lack of necessary knowledge about contraceptive methods, social opposition to their use, and health concerns about possible side effects.
The finding that ‘providing a behavioral nudge in combination with a voucher for free postpartum contraceptive increases take- up of modern methods’ is, in my view, an important finding, particularly for program planners particularly in Sub-Saharan Africa and other developing countries where there is heavy burden of HIV.
It is key, therefore, to consider this study’s finding of providing both behavioral nudges and some promise of free modern contraceptive methods, especially for women living with HIV as a strategy to improve both PMTCT and the health, human rights and well-being of women.
References:
• John B. Casterline; Steven W. Sinding; Unmet Need for Family Planning in Developing Countries and Implications for Population Policy; wiley online library; (2004);
• Sexual and Reproductive Health, World Contraception Day 2018 report,WHO (http://www.who.int/reproductivehealth/topics/family_planning/world-contr... (retrieved, 3rd November 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 d...
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 have read with interest the paper ‘Accelerating Kenya’s progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015’ by Keats et. al (May, 2018). The authors discuss drivers of change in mortality of under five year old children in Kenya in relation to health systems, policies and financing. We believe that further discussion of conflict and governance is required in order to understand Kenya’s progress towards sustainable development. The Composite Coverage Index (CCI) calculates the coverage of preventive and curative interventions. The index looks at coverage of family planning, skilled birth attendance, skilled antenatal care, BCG-measles and DPT3 vaccinations, diarrhoea treatment and pneumonia care. We agree that increasing health workforce increases coverage of interventions and raises the CCI. In contrast, the CCI remains low in areas of conflict, displaced populations and refugee settlements despite existence of a high health workforce. For example, in the North Rift Valley and North Eastern counties (except Turkana) there is a lower CCI than in southern counties (such as Tana River, Narok, Kajiado and Kilifi) despite a larger workforce [2]. Although refugee settlement areas receive huge workforce support from humanitarian organisations and the government for coverage of interventions targeted towards health of children under five, a household and death survey carried out by Médecins Sans...
Dear Editor, We have read with interest the paper ‘Accelerating Kenya’s progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015’ by Keats et. al (May, 2018). The authors discuss drivers of change in mortality of under five year old children in Kenya in relation to health systems, policies and financing. We believe that further discussion of conflict and governance is required in order to understand Kenya’s progress towards sustainable development. The Composite Coverage Index (CCI) calculates the coverage of preventive and curative interventions. The index looks at coverage of family planning, skilled birth attendance, skilled antenatal care, BCG-measles and DPT3 vaccinations, diarrhoea treatment and pneumonia care. We agree that increasing health workforce increases coverage of interventions and raises the CCI. In contrast, the CCI remains low in areas of conflict, displaced populations and refugee settlements despite existence of a high health workforce. For example, in the North Rift Valley and North Eastern counties (except Turkana) there is a lower CCI than in southern counties (such as Tana River, Narok, Kajiado and Kilifi) despite a larger workforce [2]. Although refugee settlement areas receive huge workforce support from humanitarian organisations and the government for coverage of interventions targeted towards health of children under five, a household and death survey carried out by Médecins Sans Frontières showed measles and diarrhea (variables of the CCI) still contributed to the major causes of under five deaths in these areas [3]. There is a gap if coverage here is low despite there being a large workforce. Under usual circumstances when there is not conflict, a large workforce is associated with an increase in CCI. However, this situation does not exist when there is conflict and political upheavals notwithstanding the larger workforce as this does not mitigate against the ravages of internal conflict. Devolution is a type of decentralisation where central government transfers authority to the local government. Devolution occurred in Kenya where political and economic powers were transferred to 47 counties. As a result of this administrative change, decisions were made at the county level by local people rather than at a national level to fulfil their needs according to local factors. However, devolution to counties did not ensure that all citizens received services as some ethnic minorities were without proper services and unable to access benefits due to lack of support at the county level [1]. Table 1 shows that advantaged and disadvantaged groups under devolution have unequal access and distribution of resources. This raises the question: how does the role of decentralised governance justify equity? We believe that human resource capacity plays an important role in the performance of a devolved government. Around 200,000 displaced Somalis seek home in refugee camps in northern Kenya. Due to the large population of Somali people in the camps, outbreaks of diseases and delays in registration affecting provision of food are common. Clearly, the humanitarian as well as governmental actions to control the under-five deaths in refugee population have failed [3]. A review of early implementation of devolution in Kilifi county of Kenya carried out by Tsofa et. al (2017), showed that insufficient human resource capacity caused confusion over management roles, and political interference with management led to job dissatisfaction which resulted in a low retention of the workforce [4]. With these effects and workforce attrition, the county capacity will be inadequate to manage large refugee populations. We agree that decentralisation of governance has shown improved healthcare impacts in developing countries such as South Africa and Rwanda. However, contextual factors like political upheavals affect the maximum benefits that can be achieved through decentralisation. When planning healthcare services, policies and financing consideration should be given to the impact of conflict, refugees, ethnic minorities and displaced populations. Discussion and research focusing on governance in disadvantaged areas will help Kenya to further reduce under-five mortality by identifying if the current governance and its capacity works best within the given circumstances. References: 1. D'Arcy, M., & Cornell, A. (2016). Devolution and corruption in Kenya: Everyone's turn to eat? African Affairs, 115(459), 246-273. 2. Keats, E. C., Macharia, W., Singh, N. S., Akseer, N., Ravishankar, N., Ngugi, A. K., Rizvi, A., Khaemba, E. N., Tole, J., & Bhutta, Z. A. (2018). Accelerating Kenya’s progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015. BMJ global health, 3(3), e000655. 3. Polonsky, J. A., Ronsse, A., Ciglenecki, I., Rull, M., & Porten, K. (2013). High levels of mortality, malnutrition, and measles, among recently-displaced Somali refugees in Dagahaley camp, Dadaab refugee camp complex, Kenya, 2011. Conflict and health, 7(1), 1. 4. Tsofa, B., Goodman, C., Gilson, L., & Molyneux, S. (2017). Devolution and its effects on health workforce and commodities management–Early implementation experiences in Kilifi County, Kenya. International journal for equity in health, 16(1), 169.
Table 1
Winners and losers under devolution
Group members with a home county who live in their home county
Group members who live outside home county/ groups who lack a home county
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 resu...
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).
This article is a valuable addition to guide researches in planning and conducting implementation research (IR). As a complement to this paper we would like to draw attention to a paper on the ethical issues relating to IR, which deserve specific consideration by researchers and must be taken into account by research ethics committees reviewing IR as outlined in https://implementationscience.biomedcentral.com/articles/10.1186/s13012-.... Specifically community engagement, sustainability, scalability, identification of all stakeholders and research participants and monitoring to anticipate/avoid harm is crucial. All ethical considerations must be taken into account from the planning stage and throughout the research activity.
Massuda and colleagues have recently published at BMJ Global Health a paper entitled “The Brazilian health system at crossroads: progress, crisis and resilience” describing the Brazilian health system and its challenges in health system financing, coverage, resource allocation and the impact over the regional disparities in access to healthcare services and health outcomes.
Brazil is a large country with an estimated population of approximately 209 million inhabitants. The Universal Health Coverage provided by Brazilian Unified Health System (SUS) is a constitutional right of every citizen. According to the National Supplementary Health Agency (ANS) in May 2018 only 22.7% of Brazilians had private insurance plans, with a 12% decrease in relative numbers during the last 30 months due to the local political and economic crisis [1].
Every two years the Brazilian National Cancer Institute generates data on cancer. According to the last publication 600,000 new cases are expected for 2018 [2]. Currently cancer is the second most common cause of death in Brazil [2].
Since the middle of the last century, the scientific understanding of cancer began to rise. This enabled the development of novel therapeutic interventions, such as new surgical techniques, modern radiotherapy, cytotoxic agents and more recently, targeted therapy and immunotherapy, giving place to a growing number of oncological interventions to combat cancer, improving quality of life, overall survi...
Massuda and colleagues have recently published at BMJ Global Health a paper entitled “The Brazilian health system at crossroads: progress, crisis and resilience” describing the Brazilian health system and its challenges in health system financing, coverage, resource allocation and the impact over the regional disparities in access to healthcare services and health outcomes.
Brazil is a large country with an estimated population of approximately 209 million inhabitants. The Universal Health Coverage provided by Brazilian Unified Health System (SUS) is a constitutional right of every citizen. According to the National Supplementary Health Agency (ANS) in May 2018 only 22.7% of Brazilians had private insurance plans, with a 12% decrease in relative numbers during the last 30 months due to the local political and economic crisis [1].
Every two years the Brazilian National Cancer Institute generates data on cancer. According to the last publication 600,000 new cases are expected for 2018 [2]. Currently cancer is the second most common cause of death in Brazil [2].
Since the middle of the last century, the scientific understanding of cancer began to rise. This enabled the development of novel therapeutic interventions, such as new surgical techniques, modern radiotherapy, cytotoxic agents and more recently, targeted therapy and immunotherapy, giving place to a growing number of oncological interventions to combat cancer, improving quality of life, overall survival or even curing patients with advanced tumors.
On the other hand, the economic burden of cancer care is a worldwide debate, as cancer cost is not only a problem for the developing world. Healthcare resource utilization and economic outcomes in this field are themes under substantial discussion.
Despite conceptually having full-coverage at public health care, Brazilians diagnosed with cancer suffer with long waiting times, delays in scheduling medical appointments, shortage of chemotherapeutic agents, backwardness in pathological reports, paucity of human resources and radiotherapy machines and lately the lack of widespread availability of newer technologies in the public health system [3]. In the prevailing Brazilian public health care environment, most of the new drugs for cancer are not affordable and minor investments in equipment and infrastructure were performed over the last years, resulting in great inequities in cancer care and outcomes comparing to the Brazilians covered by private insurance plans which provides the entire cancer treatment approved by the regulatory agency for local use [4].
In this scenario of many competing health needs, limited resources and inequalities in health access, cancer care is a real challenge if the benefits of the remarkable advancements in oncology are planned for the entire Brazilian cancer population. At this rate, resilience could be the perfect word. However, the concept described by Nassim Taleb in his book Antifragile must be put in practice [5]. Antifragility goes beyond resilience. The resilient is able to resist, but the antifragile improves with stressors. This grim scenario in the public health care system can be an opportunity to discuss its inefficiencies, health-economics driven processes to incorporate new technologies, rational precision medicine-based patient selection, and even its financing. The bottom line is to improve a public health system that is indispensable in a country so unequal as Brazil.
References:
1 - http://www.ans.gov.br/perfil-do-setor/dados-gerais - accessed on July 2018
2 - http://www.inca.gov.br/estimativa/2018 - accessed on July 2018
3 - Paulino, E; de Melo, AC; Nogueira-Rodrigues, A; Thuler, LCS . Gynecologic cancer in Brazil and the law of sixty days. Journal of Gynecologic Oncology 2018;29(3):e44.
4 - Liedke, PER; Finkelstein, DM; Szymonifka, J; Barrios, CH; Chavarri-Guerra, Y; Bines, J; Vasconcelos, C; Simon, SD; Goss, PE. Outcomes of breast cancer in Brazil related to health care coverage: a retrospective cohort study. Cancer Epidemiology, Biomarkers & Prevention 2013; 23:126-33.
5 - Antifragile: Things that gain form disorder. Nassim Nicholas Taleb, Ed Random House, 2012
To an extent, poverty is the root cause of all illness (physical, social and psychological) and it also stands true to pregnancy-related complications. Both poverty and economic biases have been cited the strong cause of pregnancy-related deaths in India (1, 2). Inadequate healthcare infrastructures, lack of skilled attendance at the delivery site, un-optimized nursing care in maternity wards in post-delivery time, unprofessional attitude exhibited by hospital staffs, socioeconomic discriminations and marginalization, systemic corruption and improper dissemination of medical treatments are life-threatening to the pregnant women's and/or to their newborn (2).
Issues like post-partum hemorrhage (PPH) are quite manageable, but nothing pursued with effectiveness. Albeit Janani Suraksha Yojana is playing the crucial role in the promotion of institutional deliveries through availing incentives, but still, lots of uninstitutional delivers are in practice across India (3). In 2016, maternity mortality rate for India was reported as 174 deaths per 100,000 live births that counts to 5 death/hour or 45,000 deaths/year (4). The issue loudly states that Indian healthcare system is failing to achieve with sustainable development goals and the made signs of progress in the health care system are not sufficient enough to meet the standards. Moreover, the lawsuits and healthcare system do not have any accountabilities and catch holds on foul acts happening with whatever cited...
To an extent, poverty is the root cause of all illness (physical, social and psychological) and it also stands true to pregnancy-related complications. Both poverty and economic biases have been cited the strong cause of pregnancy-related deaths in India (1, 2). Inadequate healthcare infrastructures, lack of skilled attendance at the delivery site, un-optimized nursing care in maternity wards in post-delivery time, unprofessional attitude exhibited by hospital staffs, socioeconomic discriminations and marginalization, systemic corruption and improper dissemination of medical treatments are life-threatening to the pregnant women's and/or to their newborn (2).
Issues like post-partum hemorrhage (PPH) are quite manageable, but nothing pursued with effectiveness. Albeit Janani Suraksha Yojana is playing the crucial role in the promotion of institutional deliveries through availing incentives, but still, lots of uninstitutional delivers are in practice across India (3). In 2016, maternity mortality rate for India was reported as 174 deaths per 100,000 live births that counts to 5 death/hour or 45,000 deaths/year (4). The issue loudly states that Indian healthcare system is failing to achieve with sustainable development goals and the made signs of progress in the health care system are not sufficient enough to meet the standards. Moreover, the lawsuits and healthcare system do not have any accountabilities and catch holds on foul acts happening with whatever cited reasons (5). Since centuries, the burden of pregnancy-related sufferings is very high in African and Asian countries. With all said above, I strongly commend the authors (1) for the challenges they have taken towards estimation of the pregnancy-related health crisis in India, Pakistan, Kenya, and Malavi. Regularization, standardization, and effectiveness are warned in pregnancy cares. In summary, India needs to act fast and effective to achieve the set sustainable developmental goals for safeguarding women's health.
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 co...
Show MoreRecently, Colbourn et al questioned the use of modelling to seek alternative trial results1. They cited a radio intervention study from Burkina Faso that based on mathematical modelling suggested that the radio intervention was associated with a 7.1% reduction in under-5 mortality, whereas the actual trial results suggested no effect (Rate ratio: 1.00 (95% CI: 0.82-1.22))1. Colbourn and colleagues raised the important point that modelled estimates should not take precedence over empirical mortality data.
Show MoreWe would like to support the point raised by Colbourn and colleagues with an example from the field of vaccinology.
The phase 3 trial of the RTS,S/AS01 malaria vaccine found a vaccine efficacy of 18-36% against clinical malaria2. The study was not powered to assess mortality endpoints, but the results suggested that RTS,S/AS01 was associated with 24% (95% CI: -3 – 58%) higher all-cause mortality3. This was obviously not what was expected; a vaccine that reduces clinical malaria would be expected to reduce all-cause mortality. However, based on our experience, it could indicate that the vaccine, like other non-live vaccines, could have negative non-specific effects4. If that was the case, we predicted that the negative effect would be strongest in females as seen for the other non-live vaccines3. Subsequent analyses indeed revealed that RTS,S/AS01 was associated with higher mortality in girls (Relative Risk of death for RTS,S/AS01 compared with control (RR): 1.9...
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...
Show MoreMany countries in sub-Saharan African are implementing prevention of mother to child transmission (PMTCT) of HIV programs. In 2003, the World Health Organization (WHO launched a comprehensive four-pronged strategy to prevent HIV among infants and young children to combat mother to child transmission (MTCT). One of the elements in the strategy is prevention of unintended pregnancies particularly among those living with HIV.
Show MoreThere is also a significant unmet need for family planning among many including women living with HIV in Sub-Saharan Africa. The WHO states that 214 million women of reproductive age in developing countries who want to avoid pregnancy are not using a modern contraceptive method (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). According to WHO, citing a study by Ross & Winfrey 2001, 95% of women who are 0 to 12 months postpartum want to avoid pregnancy in the next 24 months, but 70% of them are not using contraception. The WHO indicates that ‘pregnancies in the postpartum period pose the greatest risk for women and their infants, and have increased risks of adverse health outcomes. Providing postpartum family planning is therefore crucial for ensuring the health, human rights and well-being of women and their babies’ (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). A study by John B. Casterline et al (2004) cited a number of salient factors contributing to the unmet need including poor access...
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 d...
Show MoreDear Editor, We have read with interest the paper ‘Accelerating Kenya’s progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015’ by Keats et. al (May, 2018). The authors discuss drivers of change in mortality of under five year old children in Kenya in relation to health systems, policies and financing. We believe that further discussion of conflict and governance is required in order to understand Kenya’s progress towards sustainable development. The Composite Coverage Index (CCI) calculates the coverage of preventive and curative interventions. The index looks at coverage of family planning, skilled birth attendance, skilled antenatal care, BCG-measles and DPT3 vaccinations, diarrhoea treatment and pneumonia care. We agree that increasing health workforce increases coverage of interventions and raises the CCI. In contrast, the CCI remains low in areas of conflict, displaced populations and refugee settlements despite existence of a high health workforce. For example, in the North Rift Valley and North Eastern counties (except Turkana) there is a lower CCI than in southern counties (such as Tana River, Narok, Kajiado and Kilifi) despite a larger workforce [2]. Although refugee settlement areas receive huge workforce support from humanitarian organisations and the government for coverage of interventions targeted towards health of children under five, a household and death survey carried out by Médecins Sans...
Show MoreDear Editor,
Show MoreWe 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 resu...
This article is a valuable addition to guide researches in planning and conducting implementation research (IR). As a complement to this paper we would like to draw attention to a paper on the ethical issues relating to IR, which deserve specific consideration by researchers and must be taken into account by research ethics committees reviewing IR as outlined in https://implementationscience.biomedcentral.com/articles/10.1186/s13012-.... Specifically community engagement, sustainability, scalability, identification of all stakeholders and research participants and monitoring to anticipate/avoid harm is crucial. All ethical considerations must be taken into account from the planning stage and throughout the research activity.
Massuda and colleagues have recently published at BMJ Global Health a paper entitled “The Brazilian health system at crossroads: progress, crisis and resilience” describing the Brazilian health system and its challenges in health system financing, coverage, resource allocation and the impact over the regional disparities in access to healthcare services and health outcomes.
Show MoreBrazil is a large country with an estimated population of approximately 209 million inhabitants. The Universal Health Coverage provided by Brazilian Unified Health System (SUS) is a constitutional right of every citizen. According to the National Supplementary Health Agency (ANS) in May 2018 only 22.7% of Brazilians had private insurance plans, with a 12% decrease in relative numbers during the last 30 months due to the local political and economic crisis [1].
Every two years the Brazilian National Cancer Institute generates data on cancer. According to the last publication 600,000 new cases are expected for 2018 [2]. Currently cancer is the second most common cause of death in Brazil [2].
Since the middle of the last century, the scientific understanding of cancer began to rise. This enabled the development of novel therapeutic interventions, such as new surgical techniques, modern radiotherapy, cytotoxic agents and more recently, targeted therapy and immunotherapy, giving place to a growing number of oncological interventions to combat cancer, improving quality of life, overall survi...
To an extent, poverty is the root cause of all illness (physical, social and psychological) and it also stands true to pregnancy-related complications. Both poverty and economic biases have been cited the strong cause of pregnancy-related deaths in India (1, 2). Inadequate healthcare infrastructures, lack of skilled attendance at the delivery site, un-optimized nursing care in maternity wards in post-delivery time, unprofessional attitude exhibited by hospital staffs, socioeconomic discriminations and marginalization, systemic corruption and improper dissemination of medical treatments are life-threatening to the pregnant women's and/or to their newborn (2).
Issues like post-partum hemorrhage (PPH) are quite manageable, but nothing pursued with effectiveness. Albeit Janani Suraksha Yojana is playing the crucial role in the promotion of institutional deliveries through availing incentives, but still, lots of uninstitutional delivers are in practice across India (3). In 2016, maternity mortality rate for India was reported as 174 deaths per 100,000 live births that counts to 5 death/hour or 45,000 deaths/year (4). The issue loudly states that Indian healthcare system is failing to achieve with sustainable development goals and the made signs of progress in the health care system are not sufficient enough to meet the standards. Moreover, the lawsuits and healthcare system do not have any accountabilities and catch holds on foul acts happening with whatever cited...
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