I congratulate the authors who successfully conducted a survey on the current provision of global health education (GHE) in United Kingdom (UK) medical schools.1 Their findings are in keeping with a recent cross-sectional study into the timetables of UK medical schools.2 In the methods section of the paper, the global health learning outcomes and competencies surveyed were listed. However, global surgery was neither surveyed nor discussed in this paper.
This occurred despite global surgery being added as a mandatory learning objective to the national undergraduate curriculum in surgery by the Royal College of England in 2015.3 Post 2015, GHE studies2 and study protocols4 have typically strived to ensure that global surgery is assessed within their study designs. This is particularly important as global surgery often becomes the ‘neglected stepchild of global health’.5 It is easy to see why given that approximately two-thirds of UK medical courses are reported not to cover this topic within their core curriculum.2 It is not in the best interests of the population for a subject of such importance to be ignored by global health researchers and educational institutions.
Therefore, whilst it is encouraging that a study has been done with the aim of identifying gaps in GHE teaching in UK medical schools, the study design in and of itself has resulted in the researchers missing gaps.2 This exemplifies the importance of having a diverse range of stakeholders involve...
I congratulate the authors who successfully conducted a survey on the current provision of global health education (GHE) in United Kingdom (UK) medical schools.1 Their findings are in keeping with a recent cross-sectional study into the timetables of UK medical schools.2 In the methods section of the paper, the global health learning outcomes and competencies surveyed were listed. However, global surgery was neither surveyed nor discussed in this paper.
This occurred despite global surgery being added as a mandatory learning objective to the national undergraduate curriculum in surgery by the Royal College of England in 2015.3 Post 2015, GHE studies2 and study protocols4 have typically strived to ensure that global surgery is assessed within their study designs. This is particularly important as global surgery often becomes the ‘neglected stepchild of global health’.5 It is easy to see why given that approximately two-thirds of UK medical courses are reported not to cover this topic within their core curriculum.2 It is not in the best interests of the population for a subject of such importance to be ignored by global health researchers and educational institutions.
Therefore, whilst it is encouraging that a study has been done with the aim of identifying gaps in GHE teaching in UK medical schools, the study design in and of itself has resulted in the researchers missing gaps.2 This exemplifies the importance of having a diverse range of stakeholders involved in GHE study designs. A more diverse panel of authors or a more complete patient and public involvement stage could have ensured the inclusion of global surgery into the survey or at least into the discussion section of this paper. For global surgery to truly get the attention it needs, it is critical that it features in global health research, particularly in studies such as this.
There now exists a need to conduct a survey study to better understand the perceived status of global surgery teaching within the UK medical curricula. This survey should evaluate whether medical students are exposed to global surgery during medical school, how they are exposed to global surgery, and whether the types of exposures meet the needs of students. It is equally essential to collect data on the opinions shaped by this experience; therefore, career aspirations and perceived barriers to joining the global surgery workforce must be elucidated also.
References
1 Matthews NR, Davies B, Ward H. Global health education in UK medical schools: a review of undergraduate university curricula. BMJ Glob Heal 2020; 5: e002801.
2 Collaborative IU. Global health education in medical schools (GHEMS): a national, collaborative study of medical curricula. BMC Med Educ 2020; 20: 389.
3 The Royal College of Surgeons England, (RCSENG). National undergraduate curriculum in surgery 2015. RCSENG – Prof Stand Regul 2015.
4 Bandyopadhyay S, Shortland T, Wadanamby SW, et al. Global Health Education in UK Medical Schools (GHEMS) study protocol. J Glob Heal Reports 2019; 3. DOI:10.29392/joghr.3.e2019052.
5 Farmer PE, Kim JY. Surgery and global health: A view from beyond the OR. World J. Surg. 2008; 32: 533–6.
Introduction and Brief Overview
The Global Health Security (GHS) Index is the first comprehensive assessment and benchmarking of health security and related capabilities across the 195 countries that make up the States Parties to the International Health Regulations (IHR [2005])1. The GHS Index takes into account countries’ capability to prevent, detect, and respond to public health emergencies while also assessing the robustness of the healthcare system in each country. This index is comprehensive since it has the ability to consider political and socioeconomic risks, as well as adherence to international norms, which can influence countries’ abilities to stop outbreaks1,2. The GHS Index has been the creation of Open Philanthropy Project, the Bill & Melinda Gates Foundation and the Robertson Foundation1.
The GHS Index treats biosafety and biosecurity as critical components of global health security. As such, the tool includes numerous indicators measuring country capacities and accounts for differences in priorities between high income and low/middle income countries. The GHS index is based on 6 categories, 34 indicators, and 85 sub-indicators. The six categories comprise prevention, detection and reporting, rapid response, health system, compliance with international norms, and risk environment5.
This article describes the practical value of the GHS Index and also explains how the methodology of assigning country ranks and scores is helpful in aidin...
Introduction and Brief Overview
The Global Health Security (GHS) Index is the first comprehensive assessment and benchmarking of health security and related capabilities across the 195 countries that make up the States Parties to the International Health Regulations (IHR [2005])1. The GHS Index takes into account countries’ capability to prevent, detect, and respond to public health emergencies while also assessing the robustness of the healthcare system in each country. This index is comprehensive since it has the ability to consider political and socioeconomic risks, as well as adherence to international norms, which can influence countries’ abilities to stop outbreaks1,2. The GHS Index has been the creation of Open Philanthropy Project, the Bill & Melinda Gates Foundation and the Robertson Foundation1.
The GHS Index treats biosafety and biosecurity as critical components of global health security. As such, the tool includes numerous indicators measuring country capacities and accounts for differences in priorities between high income and low/middle income countries. The GHS index is based on 6 categories, 34 indicators, and 85 sub-indicators. The six categories comprise prevention, detection and reporting, rapid response, health system, compliance with international norms, and risk environment5.
This article describes the practical value of the GHS Index and also explains how the methodology of assigning country ranks and scores is helpful in aiding decision making for different countries on their health system preparedness. This concept is especially very timely in the current COVID-19 pandemic in measuring global health security capacities and pointing out areas for improvement. The main learning from the GHS index is that national health security is fundamentally weak around the world. The average GHS Index score among all 195 countries was 40.2 of a possible score of 100.
Methodology
The GHS tool is effectively building on the World Health Organization’s (WHO) Joint External Evaluation (JEE) which results from a collaboration that countries can volunteer to undertake to assess their compliance with the standards that have been agreed upon by the international community. The intuitive technique of scoring and ranking is used for summarizing complex health system capacities across diverse contexts3,4.
Critique/Commentary
Due to the way the tool is structured, GHS Index may be prone to misinterpretation as a forecasting tool which it clearly is not. It is in fact a snapshot in time of a country’s preparedness in tackling infectious disease outbreaks given the prevailing socio economic and political conditions. It would have been fascinating to see Andersen’s Model of Healthcare Utilization being used in the development of this index since it encompasses predisposing, enabling and need factors driving healthcare resource use. Many commonly used indicators of health security capacity like GHS Index are somewhat a rigid framework of outbreak prevention, detection and response. This framing likely fails to account for socio- cultural determinants of health and broader aspects of population health management which are parts of Andersen Model of Healthcare Utilization. The overall GHS index scores summarize country capacities across all categories. However, countries with high overall scores may still have low category-level, indicator-level and sub-indicator- level scores that more strongly influence outbreak-associated outcomes. A startling inconsistency observed was the United States (US), United Kingdom (UK), Netherlands, Australia, and Canada ranked in the top 5 countries on the GHS index. However, the top 5 countries as ranked by the GHS index are among the worst-hit countries by COVID-19, with a high number of cases and mortalities6. What would make the GHS index more comprehensive is some more focus on access to healthcare as even in the US one of the key drivers of health inequity is disparity in access. Based on the way COVID-19 has been handled in an inept manner across the world, there should be more learnings around factors affecting decision making that led to this crisis so that we can be more prepared to handle the next pandemic or global disaster. Besides the metrics in the GHS index it looks like political leadership is the most decisive factor in determining success in dealing with epidemics. Based on other background reading it appears that the GHS index expert panel did not directly engage authorities responsible for emergency preparedness in their respective countries and other key stakeholders. Instead, the panel evaluated information provided by each country which caused methodology to be biased and obscured crucial weaknesses in a country's capacity to confront outbreaks. Thus the GHS index is a good start but needs incorporation of more public health measurement factors and political leadership as a factor to make it more representative and possible a predictive tool for future pandemics.
Reference
1. Ravi SJ, Warmbrod KL, Mullen L, et al. The value proposition of the Global Health Security Index. BMJ Global Health 2020;5:e003648. doi:10.1136/ bmjgh-2020-003648
2. Cameron E, Nuzzo J, Bell J, et al. Global health security index:building collective action and accountability, 2019. Available: https://www. ghsindex. org/ wp- content/ uploads/ 2020/ 04/ 2019- Global-Health- Security- Index. Pdf
3. Peters DH, Noor AA, Singh LP, et al. A balanced scorecard for health services in Afghanistan. Bull World Health Organ 2007;85:146–51.
4. Munda G, Nardo M. On the methodological foundations of composite indicators used for ranking countries. Barcelona, Spain Universitat Autonoma de Barcelona, European Commission; 2003. https:// pdfs. semanticscholar. org/ f308/ aae4 26de ca90 aa7e 0929 9561 bcfe 10e129b0. Pdf
5. 2019 Global Health Security Index. 324.
6. COVID-19 Map. Johns Hopkins Coronavirus Resource Center. Accessed May 31, 2020. https://coronavirus.jhu.edu/map.html
We have read this excellent article with interest. As physicians based in Pakistan: a low-middle income country and not having English as our first language, we could relate to the challenges mentioned in this manuscript. Authors have very rightly pointed out that the issue with most of the researchers based in the low-income (LIC) and middle-income countries (LMIC) is not of poor or low-quality science. We need data and experience sharing from all parts of the world in order to complete the bigger picture and understand the issues that we face today in health, environment, and social sciences. One of the main challenges authors based in the LIC and LMIC face is the issue of presentation of that data i a presentable form. Due to the lack of training opportunities, many authors are unable to write manuscripts that meet the high standards of global scientific journals. This deprives these authors of an opportunity to publish in journals with a global audience and the world misses out on reading a different perspective from the LIC or LMIC. In this context, the introduction of PREPSS is an excellent and welcome initiative that must be supported and promoted.
In this context, we would like to highlight the role of AuthorAID: a global platform of more than 17,000 researchers from all around the globe. We have been extensively using this platform for more than a decade to learn and now collaborate and teach other researchers based in the LIC and LMIC. AuthorAID also pr...
We have read this excellent article with interest. As physicians based in Pakistan: a low-middle income country and not having English as our first language, we could relate to the challenges mentioned in this manuscript. Authors have very rightly pointed out that the issue with most of the researchers based in the low-income (LIC) and middle-income countries (LMIC) is not of poor or low-quality science. We need data and experience sharing from all parts of the world in order to complete the bigger picture and understand the issues that we face today in health, environment, and social sciences. One of the main challenges authors based in the LIC and LMIC face is the issue of presentation of that data i a presentable form. Due to the lack of training opportunities, many authors are unable to write manuscripts that meet the high standards of global scientific journals. This deprives these authors of an opportunity to publish in journals with a global audience and the world misses out on reading a different perspective from the LIC or LMIC. In this context, the introduction of PREPSS is an excellent and welcome initiative that must be supported and promoted.
In this context, we would like to highlight the role of AuthorAID: a global platform of more than 17,000 researchers from all around the globe. We have been extensively using this platform for more than a decade to learn and now collaborate and teach other researchers based in the LIC and LMIC. AuthorAID also provides services related to the process of conducting, analyzing, and reporting research. However, the model of AuthorAID is different from the PREPSS. AuthorAID provides a platform for mutual collaboration among researchers based in different parts of the world by connecting them as mentors and mentees. The process entails free registration on the website and completing the profile including details of the collaboration and help one is seeking. The mentee has to identify the mentor from the list available and send a request for mentorship. Once the request is accepted, a formal online agreement has to be signed by both parties. The agreement clearly spells out the nature of the help requested ( formulating the research question, assistance with data analysis, help with the writing process, choosing a target journal, and responding to peer reviewers' comments) , time lines, mode, and frequency of communication planned.
We both have benefited immensely from the free services, resources and online courses offered by AuthorAID and now have progressed from mentees to mentors helping others.
The world has become a global stage open to all. It is very encouraging to see initiatives like PREPSS and AuthorAID which are primarily meant fro the authors and researchers based in the LIC and LMIC. These platforms not only foster global collaboration, create long-term professionals networks but also help researchers based in developing countries to share their rich experiences and publish in international journals with a global readership. This makes the world a better place
In relation to SAM terminology. No one could argue with the logic of acute v chronic. However, SAM is well understood at a policy level. It is however understood at above six months. The work that ENN and MAMI have done on identifying wasting at birth is a narrative change which can lay the foundation for the bridging language that the paper talks about.
Narrative is a story that people can understand.
As pointed out, consistency is important, but consistency must hover across the 1000 day window. Currently, our terminology for narrating fetal undernutrition is very weak. While simplistic, if children are being born wasted, then they are also wasted in utero. To fully open the curtains, we would suggest that the SAM terminology be adapted to include fetal malnutrition. The narrative neither stops nor begins at birth regardless of the terminology we use.
In relation to the false positives and visa versa. Given current programming capacity and coverage rates well below 20% for CMAM false negatives represent only a tiny fraction of those who need treatment and do not receive it. Focus on false positives takes away from the substantive issue of low coverage rates for Essential Nutrition Actions across the 1000 day window.
On a broader theme, it would be helpful to explore how the food system and the food system summit support people in immediate need.
A conversation starter
The food system belongs to...
In relation to SAM terminology. No one could argue with the logic of acute v chronic. However, SAM is well understood at a policy level. It is however understood at above six months. The work that ENN and MAMI have done on identifying wasting at birth is a narrative change which can lay the foundation for the bridging language that the paper talks about.
Narrative is a story that people can understand.
As pointed out, consistency is important, but consistency must hover across the 1000 day window. Currently, our terminology for narrating fetal undernutrition is very weak. While simplistic, if children are being born wasted, then they are also wasted in utero. To fully open the curtains, we would suggest that the SAM terminology be adapted to include fetal malnutrition. The narrative neither stops nor begins at birth regardless of the terminology we use.
In relation to the false positives and visa versa. Given current programming capacity and coverage rates well below 20% for CMAM false negatives represent only a tiny fraction of those who need treatment and do not receive it. Focus on false positives takes away from the substantive issue of low coverage rates for Essential Nutrition Actions across the 1000 day window.
On a broader theme, it would be helpful to explore how the food system and the food system summit support people in immediate need.
A conversation starter
The food system belongs to every one of us. The Food System and so the Food Systems Summit, at its cornerstone must aspire to meet all peoples immediate nutritional needs every day.
Editor, the commentary highlights the sad situation the Levant region in the middle east has reached. The Syrian healthcare workers are most needed in Syria and not in Germany. It is their very country which is in most need for their services. Syria now has shortage of trained doctors and nurses to help fellow country men and women recover from war injuries and myriad of infectious and non-communicable diseases. Integrating in Europe is never easy for a people from Muslim countries, even if the were professionals (https://www.dailymail.co.uk/news/article-8854519/Muslim-doctor-refused-s...). I have lived in London for over 30 years and still feel an outsider in the UK. How will these refugees cope with the threat of their children losing their Arabic language or Muslim identity. Careers are not everything. It just baffles me why the Syrians who came to Europe could not seek refuge in rich Arab nations. Something terribly wrong is going on in the middle east and coming to Germany is not the answer. Syrian refugees are looking for a quick fix, but they should go back to their own country and tough it out to rebuild what was demolished before someone else comes and takes their places! Britons and Germans did not run away from their countries during the two world wars! Did millions of Britons leave to America to escape WWII? Why have did almost...
Editor, the commentary highlights the sad situation the Levant region in the middle east has reached. The Syrian healthcare workers are most needed in Syria and not in Germany. It is their very country which is in most need for their services. Syria now has shortage of trained doctors and nurses to help fellow country men and women recover from war injuries and myriad of infectious and non-communicable diseases. Integrating in Europe is never easy for a people from Muslim countries, even if the were professionals (https://www.dailymail.co.uk/news/article-8854519/Muslim-doctor-refused-s...). I have lived in London for over 30 years and still feel an outsider in the UK. How will these refugees cope with the threat of their children losing their Arabic language or Muslim identity. Careers are not everything. It just baffles me why the Syrians who came to Europe could not seek refuge in rich Arab nations. Something terribly wrong is going on in the middle east and coming to Germany is not the answer. Syrian refugees are looking for a quick fix, but they should go back to their own country and tough it out to rebuild what was demolished before someone else comes and takes their places! Britons and Germans did not run away from their countries during the two world wars! Did millions of Britons leave to America to escape WWII? Why have did almost 6 million Syrians leave their country? My parents left Palestine to Lebanon in 1948 anticipating to return to Haifa after few weeks. More than 70 years on we, their children, are still wondering whether we will ever visit Palestine.
Candal-Pedreira and colleagues showed that for 304 retracted papers, overall citations increased not decreased following retraction, but citations did seem to decrease for retracted papers in higher impact journals and those with higher citation rates, although that decrease might have been temporary.1 It is disturbing that retracted papers continue to be cited.
We approached the issue of changes in citations rates after retraction in a different way. We assessed citation rates of retracted and unretracted publications from individuals with more than one retracted publication in the Retraction Watch database.2 Using this approach, we found that, overall, citations for 989 retracted publications declined after the retraction and citations for 9671 unretracted papers also declined after the author’s first retraction, but the decline was greater for retracted papers. For example, for retracted publications, 671 papers had 3566 citations in the 3rd year before their retraction and 831 papers had 1575 citations in the 3rd year after their retraction. In contrast, 5311 unretracted papers had 17935 citations in the 3rd year before the author’s first retraction, and 7388 papers had 17252 citations in the 3rd year after the author’s first retraction.
Part of the difficulty in conducting and interpreting such analyses is the different lengths of time pre-and post-retraction for different papers. To try to address that issue, we calculated the slope of the citations/yea...
Candal-Pedreira and colleagues showed that for 304 retracted papers, overall citations increased not decreased following retraction, but citations did seem to decrease for retracted papers in higher impact journals and those with higher citation rates, although that decrease might have been temporary.1 It is disturbing that retracted papers continue to be cited.
We approached the issue of changes in citations rates after retraction in a different way. We assessed citation rates of retracted and unretracted publications from individuals with more than one retracted publication in the Retraction Watch database.2 Using this approach, we found that, overall, citations for 989 retracted publications declined after the retraction and citations for 9671 unretracted papers also declined after the author’s first retraction, but the decline was greater for retracted papers. For example, for retracted publications, 671 papers had 3566 citations in the 3rd year before their retraction and 831 papers had 1575 citations in the 3rd year after their retraction. In contrast, 5311 unretracted papers had 17935 citations in the 3rd year before the author’s first retraction, and 7388 papers had 17252 citations in the 3rd year after the author’s first retraction.
Part of the difficulty in conducting and interpreting such analyses is the different lengths of time pre-and post-retraction for different papers. To try to address that issue, we calculated the slope of the citations/year for individual papers for up to 5 years immediately prior to the year of the retraction (or the year of the author’s first retraction for unretracted papers) and for up to 5 years following first retraction. The median change in this slope was greater for retracted publications (−0.3, 95% CI −11.8 to 1.6) than for unretracted papers (0.0, 95% CI −6.3 to 1.7: P < 0.001).2
We agree with the Candal-Pedreira and colleagues that improvements are needed: there is no longer any excuse for citation of retracted publications. Publishers need to ensure that all retractions are clearly categorised on all commonly used bibliographic databases, and authors and journals need to ensure that papers cited have not been retracted, for example by using reference management tools such as Zotero that automatically update references when a retraction occurs.
1. Candal-Pedreira C, Ruano-Ravina A, Fernandez E, et al. Does retraction after misconduct have an impact on citations? A pre-post study. BMJ Glob Health 2020;5(11).
2. Mistry V, Grey A, Bolland MJ. Publication rates after the first retraction for biomedical researchers with multiple retracted publications. Account Res 2019;26(5):277-87.
Title: An integrated primary health care response to COVID-19 in Siaya, Kenya
Authors: Neema Kaseje, Andy Haines, Kennedy Oruenjo, Dan Kaseje, and Marcel Tanner.
We note that the article makes a strong case for the critical role of community health workers (CHWs) in pandemics, and we would like to outline the experience of rapid scale up of a programme to support CHWs in Siaya, Western Kenya.
On November 6th 2020, the Kenya Ministry of Health (MOH) reported a total of 59’595 COVID-19 cases and 1072 deaths due to COVID-19 (1).
In the last 4 months, to respond to the COVID-19 pandemic, we deployed CHWs, equipped with mobile technology, and accompanied by young university graduates under 30 years old. They visited households door to door and screened community members for symptoms of COVID-19. They isolated, tested, and managed suspected cases of COVID-19. Symptomatic testing was performed at home (by the Siaya rapid response team) and in health facilities (by clinicians). Youth were included to build their capacity in health interventions and provide them with practical experience during the lockdown period in Kenya. They were selected based on their academic credentials, their interest in working with CHWs, and their ability to use digital tools. CHWs and youth educated households about preventive measures including frequent handwashing, universal mask wearing (indoors when visitors are present and outdoors), and home management of mild case...
Title: An integrated primary health care response to COVID-19 in Siaya, Kenya
Authors: Neema Kaseje, Andy Haines, Kennedy Oruenjo, Dan Kaseje, and Marcel Tanner.
We note that the article makes a strong case for the critical role of community health workers (CHWs) in pandemics, and we would like to outline the experience of rapid scale up of a programme to support CHWs in Siaya, Western Kenya.
On November 6th 2020, the Kenya Ministry of Health (MOH) reported a total of 59’595 COVID-19 cases and 1072 deaths due to COVID-19 (1).
In the last 4 months, to respond to the COVID-19 pandemic, we deployed CHWs, equipped with mobile technology, and accompanied by young university graduates under 30 years old. They visited households door to door and screened community members for symptoms of COVID-19. They isolated, tested, and managed suspected cases of COVID-19. Symptomatic testing was performed at home (by the Siaya rapid response team) and in health facilities (by clinicians). Youth were included to build their capacity in health interventions and provide them with practical experience during the lockdown period in Kenya. They were selected based on their academic credentials, their interest in working with CHWs, and their ability to use digital tools. CHWs and youth educated households about preventive measures including frequent handwashing, universal mask wearing (indoors when visitors are present and outdoors), and home management of mild cases. Simultaneously, we worked with nurses and doctors to build their capacity in infection prevention and control measures, and the care of severe cases of COVID-19 in health facilities.
So far, we have trained 1359 CHWs (68% of CHWs in Siaya) and reached 412’005 people in 82’401 households. In addition, we have built the capacity of 54 clinicians from 27 facilities with oxygen capacity. We provided pulse oximeters to all 27 facilities improving the pulse oximeter coverage from 3.7% to 100%. We improved the diagnostic and referral capacity of CHWs with contactless thermometers and for the first time pulse oximeters. With the Siaya MOH, we ensured essential maternal and child health services coverage and utilization.
To date, Siaya with a population of 993’000, has had 224 confirmed cases of COVID-19 and 6 deaths since the pandemic was declared on March 11th 2020 (2,3). These figures represent a small proportion of the total number of COVID-19 cases and deaths in the country (Figure 1: Source: Siaya MOH -3).
Our approach has been unique in its comprehensiveness, its integration of activities from the community to the health system, its responsiveness in addressing needs of Siaya communities, CHWs and clinicians, and in the true partnership that has developed with the Siaya county MOH with systems integration.
In the coming months, we will continue to reinforce critical components of the intervention and follow key indicators in preparation for a potential surge in cases as schools reopen and movements between hotspots and Siaya continue.
We thank Hanson and colleagues for their editorial response1 to our paper, Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap2. Reassessment of care models for childbirth in low-income countries is urgently needed to change stubbornly flat trajectories of maternal and newborn mortality. The central point of our paper is that the current childbirth care model that sends one-third or more of pregnant women to deliver in under-equipped, understaffed, low-volume health clinics in the highest mortality countries is not evidence-based, ethical or equitable and that convergence with global best practice—delivery in highly skilled facilities—is long overdue.
Hanson and colleagues note that primary care facilities might perform better if they were “staffed and equipped to standard”, but evidence does not support this strategy3. For example, the most rigorous randomized study in this field, the Better Birth Study, showed that despite extensive coaching and support, primary care facilities in India failed to reduce mortality over control facilities4. High and middle-income countries have long determined that low birth volumes and lack of surgical and advanced care make primary care delivery unadvisable. This clinical reality is no different in low-income settings.
Other points that Hanson and colleagues make align with the core arguments we offer for health system redesign. We agree that redesign should focus...
We thank Hanson and colleagues for their editorial response1 to our paper, Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap2. Reassessment of care models for childbirth in low-income countries is urgently needed to change stubbornly flat trajectories of maternal and newborn mortality. The central point of our paper is that the current childbirth care model that sends one-third or more of pregnant women to deliver in under-equipped, understaffed, low-volume health clinics in the highest mortality countries is not evidence-based, ethical or equitable and that convergence with global best practice—delivery in highly skilled facilities—is long overdue.
Hanson and colleagues note that primary care facilities might perform better if they were “staffed and equipped to standard”, but evidence does not support this strategy3. For example, the most rigorous randomized study in this field, the Better Birth Study, showed that despite extensive coaching and support, primary care facilities in India failed to reduce mortality over control facilities4. High and middle-income countries have long determined that low birth volumes and lack of surgical and advanced care make primary care delivery unadvisable. This clinical reality is no different in low-income settings.
Other points that Hanson and colleagues make align with the core arguments we offer for health system redesign. We agree that redesign should focus on highly skilled providers and not just facilities. Hanson et al highlight the importance of midwifery-led care and we concur: we call midwifery a potential “cornerstone” of health system redesign and address midwifery-led models in detail in Table 1. However, even the most competent midwife would not be able to save a woman’s life in a remote primary care facility if she needs an emergency hysterectomy or blood transfusion. Anyone who has managed a severe post-partum hemorrhage or an asphyxiated newborn knows that it takes a system to save a life. Our central arguments for redesigning maternity care include eliminating the need to find emergency transport and having unstable patients travel long distances on poor roads. The majority of neonatal deaths occur in the first three days of life 5 and any major effort to reduce neonatal mortality must address these challenges.
We concur with Hanson that hospitals are not the only places for delivery; freestanding maternity centers proximate to advanced care can provide excellent services. Ultimately, the decision on the best configuration of delivery facilities will be made by countries to fit local health systems and resources. We agree that no single approach will fit all settings, even within a single country, and we do not propose any such model. As we say in the paper, governments will lead the charge for system redesign and reforms need to be pursued with full consultation of leaders from multiple sectors, the population, providers, and managers and carefully tracked and evaluated.
Hanson et al argue that our claim that the majority of women are now living relatively close to hospitals is overly optimistic. While multiple studies have documented this6,7, any particular woman’s access clearly depends on the local context, which is why we propose that regions contemplating redesign conduct feasibility assessments that measure access to care and consults women and health workers, as the government of Kakamega County in Kenya is doing now.
We recognize that our paper challenges the status quo and we thank Hanson and colleagues as well as the paper’s reviewers, other maternal and newborn health experts, and national policymakers for their careful analysis of redesign; their input has unquestionably improved the concept. We acknowledge that reorganizing health systems is daunting and that many details remain to be worked out. But as COVID-19 has forced the world to take a fresh look at how health systems are working for people and the clamor for universal health coverage is growing, let’s be bold in demanding higher standards for the world’s poorest families.
Margaret E. Kruk
Sanam Roder-DeWan
Kojo Nimako
Nana AY Twum-Danso
Ana Langer
Archana Amatya
References
1. Hanson C, Waiswa P, Pembe A, Sandall J, Schellenberg J. Health system redesign for equity in maternal and newborn health must be codesigned, country led, adapted to context and fit for purpose. BMJ Global Health 2020; 5(10): e003748.
2. Roder-DeWan S, Nimako K, Twum-Danso NAY, Amatya A, Langer A, Kruk M. Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap. BMJ Global Health 2020; 5(10): e002539.
3. Larson E, Gage AD, Mbaruku GM, Mbatia R, Haneuse S, Kruk ME. Effect of a maternal and newborn health system quality improvement project on the use of facilities for childbirth: a cluster-randomised study in rural Tanzania. Tropical medicine & international health : TM & IH 2019; 24(5): 636-46.
4. Semrau KEA, Hirschhorn LR, Marx Delaney M, et al. Outcomes of a Coaching-Based WHO Safe Childbirth Checklist Program in India. New England Journal of Medicine 2017; 377(24): 2313-24.
5. Sankar MJ, Natarajan CK, Das RR, Agarwal R, Chandrasekaran A, Paul VK. When do newborns die? A systematic review of timing of overall and cause-specific neonatal deaths in developing countries. J Perinatol 2016; 36 Suppl 1(Suppl 1): S1-S11.
6. Juran S, Broer PN, Klug SJ, et al. Geospatial mapping of access to timely essential surgery in sub-Saharan Africa. BMJ Global Health 2018; 3(4): e000875.
7. Gage AD, Carnes F, Blossom J, et al. In Low- And Middle-Income Countries, Is Delivery In High-Quality Obstetric Facilities Geographically Feasible? Health Affairs 2019; 38(9): 1576-84.
We read with interest the article by Blanchet et al on Protecting essential health services in low-income and middle-income countries and humanitarian settings while responding to the COVID-19 pandemic. We concur with this paper’s message that essential health services in maternal and newborn health must be prioritised and protected during the pandemic, and welcome the priority list of 120 essential services which has been co-produced with context-specific expertise from Afghanistan, Ethiopia, Pakistan and Zanzibar. This list was based on the Disease Control Priorities, 3rd edition, Highest Priority Package (DCP3 HPP) which listed 108 key interventions thought most important to achieve essential universal health coverage(1).
However, we were dismayed not to find a separate category of interventions to provide essential elements of postnatal care to women. Several components of this care are listed under other categories (e.g. safe blood transfusion to treat postpartum haemorrhage, management of maternal sepsis, manual removal of the placenta). However, the list does not distinguish which of these components relate directly to postnatal care and therefore conflates these components with other aspects of care within the broader obstetric continuum. There is additionally a lack of representation of key conditions that occur frequently and primarily in the postnatal period (e.g. lactational mastitis and postnatal depression), which exists within the WHO essential interv...
We read with interest the article by Blanchet et al on Protecting essential health services in low-income and middle-income countries and humanitarian settings while responding to the COVID-19 pandemic. We concur with this paper’s message that essential health services in maternal and newborn health must be prioritised and protected during the pandemic, and welcome the priority list of 120 essential services which has been co-produced with context-specific expertise from Afghanistan, Ethiopia, Pakistan and Zanzibar. This list was based on the Disease Control Priorities, 3rd edition, Highest Priority Package (DCP3 HPP) which listed 108 key interventions thought most important to achieve essential universal health coverage(1).
However, we were dismayed not to find a separate category of interventions to provide essential elements of postnatal care to women. Several components of this care are listed under other categories (e.g. safe blood transfusion to treat postpartum haemorrhage, management of maternal sepsis, manual removal of the placenta). However, the list does not distinguish which of these components relate directly to postnatal care and therefore conflates these components with other aspects of care within the broader obstetric continuum. There is additionally a lack of representation of key conditions that occur frequently and primarily in the postnatal period (e.g. lactational mastitis and postnatal depression), which exists within the WHO essential interventions list but was not included in the DCP3 HPP(2). Furthermore, several essential services that are listed by Blanchet et al, e.g. contraception, maternal wellbeing, and vaccinations, do not appear to be contextualised to postnatal care where they would be most critical to be provided. The spectrum of newborn conditions and interventions was captured on this list much more holistically, with its own category.
We highlight this important omission as the postnatal period presents a high risk of complications leading to maternal morbidity and mortality - particularly in LMICs and humanitarian settings. The largest burden of maternal deaths occurs during labour, delivery and the immediate postnatal period (first 24-hour period after the expulsion of the placenta), followed by the extended postnatal period (up to 42 days after the end of the pregnancy)(3). Between 20% and 44% of maternal deaths in sub-Saharan Africa, for example, are estimated to occur in the postnatal period(4)(5). Yet, the Countdown to 2030 report showed that postnatal services to have the lowest median national coverage of interventions on the continuum of maternal healthcare (6). The most important causes of postnatal deaths among women are haemorrhage, sepsis, hypertensive diseases of pregnancy, and indirect causes such as postnatal depression, HIV and malaria. The vast majority of these deaths are preventable with timely access to good quality care.
The WHO currently recommends a package of routine postnatal care interventions(7)(8).This package of critical elements enables health providers to detect and manage conditions with a very high risk of maternal mortality and morbidity (such as late-onset eclampsia, and postpartum haemorrhage and sepsis), monitor physical and mental wellbeing of postpartum women, and provide supportive care in order to initiate and sustain breastfeeding, education on newborn care and warning signs, and ensure continuity of care such as access to postpartum contraception. We stress here that these interventions comprise a package, and are not a list of one-off, unrelated, solely clinical care components. It is a holistic package of observations, diagnoses, treatments, and nutritional, physical and mental support components which are essential to be provided to every woman postnatally to support her and her newborn. The timescale of provision of this package begins at birth and last for a minimum of six weeks. Its elements can be provided by a range of health professionals and allied health personnel in joint cooperation within a functioning system on various levels, including in health facilities, on an outpatient level, and in the community.
Given that the largest burden of maternal ill-health occurs in the postnatal period, we call for inclusion of postnatal care services for women as a separate category within the essential list of services during the COVID-19 pandemic. We understand that the list presented by Blanchet et al was based on the DCP3 HPP. However, to make progress in reducing maternal mortality and morbidity in limited-resource settings during this unprecedented crisis, we must use such pre-existing “laundry lists” of individual interventions critically. Entanglement with other aspects of the obstetric continuum can result in postnatal care being pushed or missed off the global maternal and newborn health agenda. To harness the maximal value of the comprehensive package of essential services in maternal care we must ensure it is coordinated and inclusive across the entire obstetric continuum and not a scattering of elements here or there. Postnatal care for women is already a neglected service, we cannot afford for it to fall further off the agenda especially during the COVID-19 pandemic.
References
1. Jamison DT, Alwan A, Mock CN, Nugent R, Watkins D, Adeyi O et al. Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition. The Lancet. 2018 Mar 17;391(10125):1108-1120. https://doi.org/10.1016/S0140-6736(17)32906-9
2. The Partnership for Maternal, Newborn & Child Health. 2011. A Global Review of the Key Interventions Related to Reproductive, Maternal, Newborn and Child Health (RMNCH). Geneva, Switzerland: PMNCH
3. World Health Organization. Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. 2015
4. Merdad L, Ali MM. Timing of maternal death: Levels, trends, and ecological correlates using sibling data from 34 sub-Saharan African countries. PLoS One. 2018 17;13(1): e0189416.
5. Alliance for Maternal and Newborn Health Improvement (AMANHI) mortality study group. Population-based rates, timing, and causes of maternal deaths, stillbirths, and neonatal deaths in south Asia and sub-Saharan Africa: a multi-country prospective cohort study. Lancet Glob Health. 2018 Dec;6(12):e1297-e1308.
6. Boerma T, Requejo J, Victora CG, Amouzou A, George A, Agyepong I, et al. Countdown to 2030: tracking progress towards universal coverage for reproductive, maternal, newborn, and child health. Vol. 391, The Lancet. Lancet Publishing Group; 2018. p. 1538–48.
7. WHO. 2015. Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. Third Edition. 2015. Geneva, Switzerland.
8. WHO. WHO recommendations on postnatal care of the mother and newborn. 2013. Geneva, Switzerland.
It was interesting to read Roder-DeWan S et al.,(1) paper entitle Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap.
This paper focuses on problems with the current approach, discuss the feasibility of redesign, propose reforms to transform current health systems. We support the authors that health system redesign is needed to enhance people’s access to standard care and reduce newborn mortality rate especially in low- income country which is higher than in high-income countries about nine times(1). This is also in line with Sustainable Development Goal No.3 (SDGs) target 3.1 that by 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births(2). Gabrysch S et al,(2019) found in their study that giving birth in a health care facility does not necessarily gives assurance of a survival benefit for women or babies however it should be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safeguarding uncomplicated births(3).
It is therefore important to reconsider the healthcare systems so that every pregnant woman receives the best of healthcare. Niyitegeka J et al,(2017) in a study conducted in Rwanda found out that women who had to travel more than 90 minutes to the nearest district hospital had significantly worse neonatal outcomes compared to those had Odds Ratio 5.12 times referred from health centers located on the same...
It was interesting to read Roder-DeWan S et al.,(1) paper entitle Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap.
This paper focuses on problems with the current approach, discuss the feasibility of redesign, propose reforms to transform current health systems. We support the authors that health system redesign is needed to enhance people’s access to standard care and reduce newborn mortality rate especially in low- income country which is higher than in high-income countries about nine times(1). This is also in line with Sustainable Development Goal No.3 (SDGs) target 3.1 that by 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births(2). Gabrysch S et al,(2019) found in their study that giving birth in a health care facility does not necessarily gives assurance of a survival benefit for women or babies however it should be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safeguarding uncomplicated births(3).
It is therefore important to reconsider the healthcare systems so that every pregnant woman receives the best of healthcare. Niyitegeka J et al,(2017) in a study conducted in Rwanda found out that women who had to travel more than 90 minutes to the nearest district hospital had significantly worse neonatal outcomes compared to those had Odds Ratio 5.12 times referred from health centers located on the same compound as the hospital(4). The gap to high-quality care should be closed by health system redesign.
References:
1. Roder-DeWan S, Nimako K, Twum-Danso NAY, Amatya A, Langer A, Kruk M. Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap. BMJ Glob Health. 2020 Oct 1;5(10):e002539.
2. WHO | SDG 3: Ensure healthy lives and promote wellbeing for all at all ages [Internet]. WHO. World Health Organization; [cited 2020 Nov 1]. Available from: http://www.who.int/sdg/targets/en/
3. Gabrysch S, Nesbitt RC, Schoeps A, Hurt L, Soremekun S, Edmond K, et al. Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials. Lancet Glob Health. 2019 Aug 1;7(8):e1074–87.
4. Niyitegeka J, Nshimirimana G, Silverstein A, Odhiambo J, Lin Y, Nkurunziza T, et al. Longer travel time to district hospital worsens neonatal outcomes: a retrospective cross-sectional study of the effect of delays in receiving emergency cesarean section in Rwanda. BMC Pregnancy Childbirth [Internet]. 2017 Jul 25 [cited 2020 Nov 2];17. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5526290/
I congratulate the authors who successfully conducted a survey on the current provision of global health education (GHE) in United Kingdom (UK) medical schools.1 Their findings are in keeping with a recent cross-sectional study into the timetables of UK medical schools.2 In the methods section of the paper, the global health learning outcomes and competencies surveyed were listed. However, global surgery was neither surveyed nor discussed in this paper.
This occurred despite global surgery being added as a mandatory learning objective to the national undergraduate curriculum in surgery by the Royal College of England in 2015.3 Post 2015, GHE studies2 and study protocols4 have typically strived to ensure that global surgery is assessed within their study designs. This is particularly important as global surgery often becomes the ‘neglected stepchild of global health’.5 It is easy to see why given that approximately two-thirds of UK medical courses are reported not to cover this topic within their core curriculum.2 It is not in the best interests of the population for a subject of such importance to be ignored by global health researchers and educational institutions.
Therefore, whilst it is encouraging that a study has been done with the aim of identifying gaps in GHE teaching in UK medical schools, the study design in and of itself has resulted in the researchers missing gaps.2 This exemplifies the importance of having a diverse range of stakeholders involve...
Show MoreIntroduction and Brief Overview
Show MoreThe Global Health Security (GHS) Index is the first comprehensive assessment and benchmarking of health security and related capabilities across the 195 countries that make up the States Parties to the International Health Regulations (IHR [2005])1. The GHS Index takes into account countries’ capability to prevent, detect, and respond to public health emergencies while also assessing the robustness of the healthcare system in each country. This index is comprehensive since it has the ability to consider political and socioeconomic risks, as well as adherence to international norms, which can influence countries’ abilities to stop outbreaks1,2. The GHS Index has been the creation of Open Philanthropy Project, the Bill & Melinda Gates Foundation and the Robertson Foundation1.
The GHS Index treats biosafety and biosecurity as critical components of global health security. As such, the tool includes numerous indicators measuring country capacities and accounts for differences in priorities between high income and low/middle income countries. The GHS index is based on 6 categories, 34 indicators, and 85 sub-indicators. The six categories comprise prevention, detection and reporting, rapid response, health system, compliance with international norms, and risk environment5.
This article describes the practical value of the GHS Index and also explains how the methodology of assigning country ranks and scores is helpful in aidin...
We have read this excellent article with interest. As physicians based in Pakistan: a low-middle income country and not having English as our first language, we could relate to the challenges mentioned in this manuscript. Authors have very rightly pointed out that the issue with most of the researchers based in the low-income (LIC) and middle-income countries (LMIC) is not of poor or low-quality science. We need data and experience sharing from all parts of the world in order to complete the bigger picture and understand the issues that we face today in health, environment, and social sciences. One of the main challenges authors based in the LIC and LMIC face is the issue of presentation of that data i a presentable form. Due to the lack of training opportunities, many authors are unable to write manuscripts that meet the high standards of global scientific journals. This deprives these authors of an opportunity to publish in journals with a global audience and the world misses out on reading a different perspective from the LIC or LMIC. In this context, the introduction of PREPSS is an excellent and welcome initiative that must be supported and promoted.
Show MoreIn this context, we would like to highlight the role of AuthorAID: a global platform of more than 17,000 researchers from all around the globe. We have been extensively using this platform for more than a decade to learn and now collaborate and teach other researchers based in the LIC and LMIC. AuthorAID also pr...
A few thoughts on the paper.
In relation to SAM terminology. No one could argue with the logic of acute v chronic. However, SAM is well understood at a policy level. It is however understood at above six months. The work that ENN and MAMI have done on identifying wasting at birth is a narrative change which can lay the foundation for the bridging language that the paper talks about.
Narrative is a story that people can understand.
As pointed out, consistency is important, but consistency must hover across the 1000 day window. Currently, our terminology for narrating fetal undernutrition is very weak. While simplistic, if children are being born wasted, then they are also wasted in utero. To fully open the curtains, we would suggest that the SAM terminology be adapted to include fetal malnutrition. The narrative neither stops nor begins at birth regardless of the terminology we use.
In relation to the false positives and visa versa. Given current programming capacity and coverage rates well below 20% for CMAM false negatives represent only a tiny fraction of those who need treatment and do not receive it. Focus on false positives takes away from the substantive issue of low coverage rates for Essential Nutrition Actions across the 1000 day window.
On a broader theme, it would be helpful to explore how the food system and the food system summit support people in immediate need.
A conversation starter
Show MoreThe food system belongs to...
Editor, the commentary highlights the sad situation the Levant region in the middle east has reached. The Syrian healthcare workers are most needed in Syria and not in Germany. It is their very country which is in most need for their services. Syria now has shortage of trained doctors and nurses to help fellow country men and women recover from war injuries and myriad of infectious and non-communicable diseases. Integrating in Europe is never easy for a people from Muslim countries, even if the were professionals (https://www.dailymail.co.uk/news/article-8854519/Muslim-doctor-refused-s...). I have lived in London for over 30 years and still feel an outsider in the UK. How will these refugees cope with the threat of their children losing their Arabic language or Muslim identity. Careers are not everything. It just baffles me why the Syrians who came to Europe could not seek refuge in rich Arab nations. Something terribly wrong is going on in the middle east and coming to Germany is not the answer. Syrian refugees are looking for a quick fix, but they should go back to their own country and tough it out to rebuild what was demolished before someone else comes and takes their places! Britons and Germans did not run away from their countries during the two world wars! Did millions of Britons leave to America to escape WWII? Why have did almost...
Show MoreCandal-Pedreira and colleagues showed that for 304 retracted papers, overall citations increased not decreased following retraction, but citations did seem to decrease for retracted papers in higher impact journals and those with higher citation rates, although that decrease might have been temporary.1 It is disturbing that retracted papers continue to be cited.
We approached the issue of changes in citations rates after retraction in a different way. We assessed citation rates of retracted and unretracted publications from individuals with more than one retracted publication in the Retraction Watch database.2 Using this approach, we found that, overall, citations for 989 retracted publications declined after the retraction and citations for 9671 unretracted papers also declined after the author’s first retraction, but the decline was greater for retracted papers. For example, for retracted publications, 671 papers had 3566 citations in the 3rd year before their retraction and 831 papers had 1575 citations in the 3rd year after their retraction. In contrast, 5311 unretracted papers had 17935 citations in the 3rd year before the author’s first retraction, and 7388 papers had 17252 citations in the 3rd year after the author’s first retraction.
Part of the difficulty in conducting and interpreting such analyses is the different lengths of time pre-and post-retraction for different papers. To try to address that issue, we calculated the slope of the citations/yea...
Show MoreTitle: An integrated primary health care response to COVID-19 in Siaya, Kenya
Authors: Neema Kaseje, Andy Haines, Kennedy Oruenjo, Dan Kaseje, and Marcel Tanner.
We note that the article makes a strong case for the critical role of community health workers (CHWs) in pandemics, and we would like to outline the experience of rapid scale up of a programme to support CHWs in Siaya, Western Kenya.
On November 6th 2020, the Kenya Ministry of Health (MOH) reported a total of 59’595 COVID-19 cases and 1072 deaths due to COVID-19 (1).
In the last 4 months, to respond to the COVID-19 pandemic, we deployed CHWs, equipped with mobile technology, and accompanied by young university graduates under 30 years old. They visited households door to door and screened community members for symptoms of COVID-19. They isolated, tested, and managed suspected cases of COVID-19. Symptomatic testing was performed at home (by the Siaya rapid response team) and in health facilities (by clinicians). Youth were included to build their capacity in health interventions and provide them with practical experience during the lockdown period in Kenya. They were selected based on their academic credentials, their interest in working with CHWs, and their ability to use digital tools. CHWs and youth educated households about preventive measures including frequent handwashing, universal mask wearing (indoors when visitors are present and outdoors), and home management of mild case...
Show MoreWe thank Hanson and colleagues for their editorial response1 to our paper, Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap2. Reassessment of care models for childbirth in low-income countries is urgently needed to change stubbornly flat trajectories of maternal and newborn mortality. The central point of our paper is that the current childbirth care model that sends one-third or more of pregnant women to deliver in under-equipped, understaffed, low-volume health clinics in the highest mortality countries is not evidence-based, ethical or equitable and that convergence with global best practice—delivery in highly skilled facilities—is long overdue.
Hanson and colleagues note that primary care facilities might perform better if they were “staffed and equipped to standard”, but evidence does not support this strategy3. For example, the most rigorous randomized study in this field, the Better Birth Study, showed that despite extensive coaching and support, primary care facilities in India failed to reduce mortality over control facilities4. High and middle-income countries have long determined that low birth volumes and lack of surgical and advanced care make primary care delivery unadvisable. This clinical reality is no different in low-income settings.
Other points that Hanson and colleagues make align with the core arguments we offer for health system redesign. We agree that redesign should focus...
Show MoreWe read with interest the article by Blanchet et al on Protecting essential health services in low-income and middle-income countries and humanitarian settings while responding to the COVID-19 pandemic. We concur with this paper’s message that essential health services in maternal and newborn health must be prioritised and protected during the pandemic, and welcome the priority list of 120 essential services which has been co-produced with context-specific expertise from Afghanistan, Ethiopia, Pakistan and Zanzibar. This list was based on the Disease Control Priorities, 3rd edition, Highest Priority Package (DCP3 HPP) which listed 108 key interventions thought most important to achieve essential universal health coverage(1).
However, we were dismayed not to find a separate category of interventions to provide essential elements of postnatal care to women. Several components of this care are listed under other categories (e.g. safe blood transfusion to treat postpartum haemorrhage, management of maternal sepsis, manual removal of the placenta). However, the list does not distinguish which of these components relate directly to postnatal care and therefore conflates these components with other aspects of care within the broader obstetric continuum. There is additionally a lack of representation of key conditions that occur frequently and primarily in the postnatal period (e.g. lactational mastitis and postnatal depression), which exists within the WHO essential interv...
Show MoreIt was interesting to read Roder-DeWan S et al.,(1) paper entitle Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap.
Show MoreThis paper focuses on problems with the current approach, discuss the feasibility of redesign, propose reforms to transform current health systems. We support the authors that health system redesign is needed to enhance people’s access to standard care and reduce newborn mortality rate especially in low- income country which is higher than in high-income countries about nine times(1). This is also in line with Sustainable Development Goal No.3 (SDGs) target 3.1 that by 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births(2). Gabrysch S et al,(2019) found in their study that giving birth in a health care facility does not necessarily gives assurance of a survival benefit for women or babies however it should be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safeguarding uncomplicated births(3).
It is therefore important to reconsider the healthcare systems so that every pregnant woman receives the best of healthcare. Niyitegeka J et al,(2017) in a study conducted in Rwanda found out that women who had to travel more than 90 minutes to the nearest district hospital had significantly worse neonatal outcomes compared to those had Odds Ratio 5.12 times referred from health centers located on the same...
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