107 e-Letters

  • Understanding the Kenyan governance in context to deprived population to reduce under five child mortality: time to take off the blindfold

    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...

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  • Geographic Coverage of Surveillance systems: is the Sub Saharan Africa region being misrepresented?

    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...

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  • Ethics of Implementation Research

    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.

  • Brazilian health system: the turnaround goes beyond resilience

    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...

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  • Poor physical, social and psychological health is costing pregnant women their life in India

    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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  • Costing per sustained recovery is more meaningful for policy

    Garg et al. provide a useful, but somewhat incomplete, economic perspective on Community Management of Acute Malnutrition (CMAM) in India. Potential returns, like cost per recovered child, adjusted for spontaneous improvement under the existing system, are crucial for policy makers. Sixteen weeks after completion of the treatment phase (sustenance phase), only 123/838 children (14.7%) met the definition of recovery.1 For simplicity’s sake, we ignore: (i) anticipated lower recovery rates in public programme settings; and (ii) costs for linkages with the government-run Anganwadi centres for supplementary food during the sustenance phase.1 With these assumptions, our calculation of costs per recovered child are 6.8 (100/14.7) times higher than those of Garg et al.: US$ 1575/- (Rs. 97,650/-) and US$ 381 (Rs. 23,622/-) in research and Government settings, respectively. Further, annual budgetary requirements may be considerably higher due to non-response, relapse, and fresh cases of Severe Acute Malnutrition (SAM). Data from rural Meerut, near Delhi, provides a ballpark estimate of spontaneous recovery rates (27%) within a similar follow-up period.2 Actual costs per child recovered, even unadjusted for potentially equivalent spontaneous healing, are thus much higher than those quoted by Garg et al. However, they offer no cost-effectiveness analysis reporting cost per life saved or Disability-Adjusted Life Year averted to enable robust comparisons with the existing system or oth...

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  • How to ensure safety of medications without spreading hysteria

    The information conveyed by Valerie Evans, Peter Roderick, and Allyson Pollock is compelling and of serious concern. While I agree that the explosion of brand-name fixed dose combination (FDC) medications in the Indian market is not safe or rational, I worry that the presentation of the information in this analysis may create some hysteria based on some of the lay media coverage of this study. It is unfortunate that there is such little clinical evidence on the safety and efficacy of the most commonly used Metformin FDCs that are sold to treat type 2 diabetes in India, but is irresponsible to publish such an article without some discussion of the potential harms that could come from abruptly stopping the Metformin FDCs .

    I agree that “the convenience of FDCs should not trump efficacy” - but there is already significant distrust in Western medicine by many patients in India without further added hysteria. The authors of this study bring to light the importance of tighter regulation and improved standards for the pharmaceutical industry in India, but the paper would have been better with a more evenhanded presentation of the information. Efficacy data on the Metformin FDCs may be limited, but there is no telling the degree of hyperglycemic crises that may emerge if many patients stop all their medications on the basis of lay media coverage of this analysis without first consulting with their prescribing physicians.

  • The Social Determinants of Health: What's missing?

    Donkin et al have highlighted the constructive steps being taken to implement policy change facilitating the Social Determinants of Health (SDH) across the globe 1. Although progress is not universal, what has been achieved deserves praise.

    We write, however, to highlight one key omission from the standard SDH model: religious faith. This deserves greater recognition as a social determinant of health for two reasons. First, is scale: a recent study demonstrated that 84% of the world’s 7.4 billion people affiliated themselves to a religious group 2. Second is the impact of religious faith on health, shaping both health beliefs and use of healthcare services 3.

    Theories of supernatural causation of illness are ancient and diverse. They are also universal: a 1980 study of health belief systems worldwide found evidence that supernatural causes of illness “far outweigh” natural ones 4. Of course many such models may be counter to the Western biomedical model. They should, however, still be acknowledged, not least because when believers encounter Western biomedicine the two models typically become mixed without any sense of conflict.

    The close link between healthcare services and religion is evident in both the historical (for example, medieval Christian hospitals in Europe) and contemporary (e.g. faith-based non-governmental organisations worldwide) contexts. The relationship between religion and healthcare is not confined to simple delivery. Religious fait...

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  • Efficacy and cost analysis of three types of therapeutic feeds in children with severe acute malnutrition in trbal villages of Nandurbar,Maharashtra,India. cra, India

    We, read with interest the article by Garg et al on costing of therapeutic feeds.
    We report our results on a similar trial conducted on 1092 tribal children of SAM,randomly given 3 therapeutic feeds i.e .C-RUTF(commercially produced ready to use therapeutic food),L-RUTF (locally produced RUTF) and ARF(Amylase rich energy dense food) giving 550,513 and 420 kcals respectively.Pea nut paste,sugar ,milk powder,oil were common ingredients,in identical proportions in C-RUTF and L-RUTF while ARF contained amylase rich flour instead of peanut paste.Micro nutrients were present in all three alike.At the end of 8 weeks of treatment,52.8% recovered in C-RUTF group,43.5% in L-RUTF group and 44.8% recovered in ARF group; the difference being statistically significant.The cost of treatment was 63, 59 and 43 USD approx. in the 3 groups respectively.Thus, though cost of ARF was the least compared to C-RUTF and L-RUTF ,recovery rates in ARF group were also compromised.The logistics of preparing the feeds in tribal village Anganwadis,issues of cleanliness in food preparation,time and labour required were also matters of concern.All these factors will require consideration while scaling up of community management of SAM.
    The clinical trial was registered under clinical trial registry of India,no.CTRI/2014/09/004958 and the data is the property of the Govt. of Maharashtra,India.

  • RE: Implementing One Health as an integrated approach to health in Rwanda

    I read the article “Implementing One Health as an integrated approach to health in Rwanda” by Nyatanyi et al1 with great interest and wish to share our efforts on Implementation of One Health in a Rural Medical School following concept of Public Money Stewardship. We have been working on human health coupled with ecological studies for a long time; however, we started working on One Health after sanction of a project on zoonosis by a joint task force of Indian Council for Medical Research and Indian Council for Agricultural Research (ICMR-ICAR) in 2015. The work is being carried out in project mode but we are working on various factors, as given below, so that we may give guidelines to the government for its implementation in programme mode, now preferably in a manner similar to that given in the study by Nyatanyi et al1.

    One health laboratory: We have created a facility harbouring a containment laboratory, a BSL-2 laboratory as well as separate laboratories for serology and molecular testing. Planning for this facility included assessment of workload and availability of space and funds. Since we had limited funds made available to us from public money, we designed the facility for optimum use and thus followed the concept of public money stewardship given by Mahatma Gandhi whose principles we follow in our Institute. We also wanted to make this laboratory to be environmentally conscious and thus used solar panels to power it in a hybrid manner.2 Total...

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