BMJ Global Health最新文献

Introduction: Ensuring free access to essential medicines is a cornerstone of universal health coverage, yet many countries face persistent local disparities in medicine availability. This study investigates the factors driving variation in essential medicine availability in primary health facilities across Indonesia, focusing on the functionality of Local Pharmaceutical Systems (LOPHAS) and the influence of socioeconomic and geographical environments.

Methods: Enumerators visited each of the 514 district health offices and 9831 primary health centres (PHCs) to conduct a nationwide health facility assessment. These data were combined with publicly available information on spatial, geographical, socioeconomic and health system factors. Using regression analysis, multilevel modelling and spatial autocorrelation techniques, we identified facility-level, district-level and provincial-level factors associated with the availability of 50 essential medicines in public health facilities.

Results: On average, 66% out of 50 surveyed medicines were available in PHCs, with district-level availability ranging from 83% in top-performing areas to just 43% in the lowest. PHCs with a pharmacist, clear guidelines and proper storage infrastructure had significantly higher availability, compared with those without. Other key drivers included the application of inventory management principles (eg, First-Expired, First-Out), autonomy in procurement and district level stock levels. Spatial analysis revealed strong clustering of medicine availability within a 2 km radius (Moran's I: 0.67), with high-availability clusters present even in low-performing districts, highlighting the role of localised factors.

Conclusion: Essential medicine availability in Indonesian PHCs varies substantially and is closely linked to the functionality of local pharmaceutical systems. Strengthening human resources-particularly by ensuring the presence of a pharmacist in every PHC-and improving physical infrastructure are critical priorities. Beyond PHC-level interventions, targeted efforts to enhance the capacity of district health offices in managing pharmaceutical supply chains are essential, especially in rural and remote districts of eastern Indonesia.

Introduction: While pathogen genomics using next-generation sequencing (NGS) has been recommended by the WHO as an essential tool for national communicable disease surveillance programmes, procurement and supply chain management (PSM) systems for this new technology are still evolving. To assess the status of PSM systems for pathogen genomics, we examined perspectives from end-users and manufacturers across South and Southeast Asia.

Methods: Between 2022 and 2023, a cross-sectional survey was conducted among institutional partners supporting pathogen genomics among primarily low- and middle-income countries in South and Southeast Asia. This was complemented by qualitative interviews with the major regional NGS manufacturers. A PSM framework was employed to assess sales, procurement, production, distribution and post-sales support. Analyses are expressed as proportions and means or medians for continuous variables.

Results: A total of 42 partners across 13 countries, 3 genomics manufacturers and 22 laboratory personnel contributed data to this assessment. PSM challenges were reported by all countries and for all sequencing platforms. High costs of equipment and consumables were identified by 85% of respondents. Long equipment purchasing lead times and reagent re-supply times were reported by 69% and 77% of countries, respectively, with reagent resupply times averaging 8 weeks (IQR 6.2-9.0). Additional barriers included customs clearance, variability of import procedures, taxes and duties. Manufacturers reported a range of strategies to respond to PSM bottlenecks, including establishing regional hubs, distributor networks and financing schemes.

Conclusion: Coordinated national and regional efforts are required to improve PSM systems for pathogen genomic sequencing to enhance timely early disease detection and response capacity in South and Southeast Asia.

Introduction: A prior systematic review assessed progress in health and health-related sustainable development goals (HHSDGs) from 2015 to 2019, identifying an important need for countries to strengthen implementation of multisectoral work, capacity building, financial stability and data availability. We undertook an updated systematic review to assess additional progress, challenges and opportunities for HHSDG implementation from 2019 to 2025, including the pandemic periods. This update aims to assess where countries are presently in HHSDG implementation and if further recommendations can be made in the final stretch to the 2030 targets.

Methods: We followed a comparable comprehensive search strategy as the first review, focusing on implementation and acceleration strategies for HHSDGs. We undertook a qualitative synthesis from peer-reviewed and grey literature for specific databases, including studies and reports published from June 2019 to January 2025.

Results: A total of 192 publications were included in the review of which 150 provided national-level information and 42 provided multicountry or regional information. Findings suggest a high level of political commitment in most countries and many HHSDG efforts being aligned with existing national development strategies. There was a noteworthy shift towards decentralised, subnational approaches to provide contextually relevant interventions. Multisectoral, multistakeholder, integrated approaches for implementation are increasing and proving to be effective. Diverse monitoring and evaluation strategies were employed, and (cross-country) knowledge sharing was instrumental to SDG policy and programme planning. Service disruptions incurred by the COVID-19 pandemic, lack of quality data and obtaining sustainable funding were frequently cited challenges to implementation.

Conclusions: Ensuring continuous financial investments and strengthening data availability are essential to accelerate HHSDG implementation. Recommendations for progress include strengthening primary healthcare, fostering multisectoral collaboration and addressing deep-rooted societal perceptions around gender inequity. Future research should examine the interplay of multiple SDGs, and the impact of factors such as cost-effective cross-regional approaches for project implementation.

Since 2022, the seventh cholera pandemic has escalated globally, with reported cases rising from 223 370 in 2021 to 560 823 in 2024 across affected countries. Cholera-related deaths also increased significantly, reaching 6028 in 2024. These figures likely underestimate cholera's true burden due to surveillance and reporting challenges. In response, the WHO classified the resurgence as a Grade 3 emergency in January 2023, activating its Incident Management System for a global response. To provide updates on cholera trends, public health responses and challenges, the WHO published 33 Rapid Risk Assessments and 17 Disease Outbreak News reports (2021-2023), followed by 30 editions of a monthly multi-country cholera outbreak external situation report starting in March 2023. The reports were published on various web pages, including the WHO Health Emergencies Programme page, which had 3 million visits in 2 years, showing the global demand for timely epidemiological insights. In June 2024, a survey was conducted to assess the impact and usefulness of the report, and it demonstrated that WHO's cholera situation report was mainly used for public health planning and decision-making in public health (44%), general information (24%), research (15%), advocacy or campaign activities (13%) and media reporting (5%). The situation report was overall rated as very useful by 70% of survey participants. Complementary tools, like WHO's Global Cholera and Acute Watery Diarrhoea Dashboard, have further improved situational awareness. This article assesses the development, execution and impact of WHO's cholera situation report. Finally, we present recommendations for strengthening surveillance systems, improving data sharing and fostering collaboration to enhance the global response to the ongoing cholera emergency.

Introduction: Maximising the impact of new and forthcoming long-acting injectable HIV pre-exposure prophylaxis (PrEP) products will require novel delivery approaches that widen accessibility and prioritise clients' needs and preferences. To understand the potential barriers and facilitators to delivering injectable PrEP via private pharmacies in Kenya, we conducted qualitative formative research.

Methods: From July to September 2023, we interviewed pharmacy providers, pharmacy clients and other key stakeholders of HIV service delivery in Central and Western Kenya. Our purposive sample included some providers and clients with prior experience delivering or obtaining oral PrEP at a pharmacy as part of a pilot study and some without such experience. We analysed verbatim transcripts thematically using a combination of inductive and deductive approaches, the latter informed by the Consolidated Framework for Implementation Research.

Results: We interviewed 25 pharmacy clients, 16 pharmacy providers and nine key stakeholders. Each group was ~50% female, and median age among clients was 25 (IQR 23-29). Overall, participants supported the idea of pharmacy-based injectable PrEP delivery. Anticipated facilitators included perceived benefits of injectable over oral PrEP; characteristics of pharmacies (eg, long operating hours) that could fulfil clients' need for accessible, fast and private injectable PrEP services; and existing skillsets of pharmacy providers, especially those already trained on injectable contraception. Anticipated barriers included gaps in enabling policy; pharmacies' lack of integration with the public health sector, such as its health information system; low client knowledge of and/or ability to pay for injectable PrEP and pharmacy staffing and compensation structures that could disincentivise providers.

Conclusions: Participants in this study expressed cautious optimism that private pharmacies could be an effective delivery channel for injectable PrEP in Kenya. If private pharmacies facilitate access to and use of injectable PrEP, they could play a pivotal role in ending HIV as a public health threat.

Background: Congenital heart disease (CHD) is the leading congenital cause of death in newborns worldwide. Approximately one-quarter of CHDs are considered critical, requiring intervention during the first year of life to enable survival. While pulse oximetry screening (POS) for critical CHD (CCHD) is now standard in high-income countries, its use in low-resource settings remains limited.

Methods: This prospective cohort study aimed to: (1) assess the feasibility of implementing routine POS and (2) estimate the incidence of CCHDs in two large tertiary hospitals in Accra, Ghana with high delivery volumes. Eligible participants included all live-born infants less than 48 hours old who were not receiving supplemental oxygen at the time of enrolment. Newborns underwent POS, and those with positive POS screening were referred for echocardiography.

Results: Over the 1-year study period (February 2024 to January 2025), a total of 7889 deliveries were recorded at Korle-Bu Teaching Hospital and 37 Military Hospital. Among eligible infants, 96% (5725/5981) underwent POS screening. 29 newborns failed screening. CHD was confirmed in 19 cases (0.33% of all screened). Nine infants had CCHD (0.16%). Ten were diagnosed with non-CCHD (0.17%).

Conclusions: POS was successfully implemented in two large tertiary hospitals in Accra, Ghana and identified newborns with CHD. Early detection of cases that would have otherwise gone undiagnosed underscores the importance of systematic screening for timely recognition. These findings support the integration of pulse oximetry into routine newborn care in resource-limited settings.

Introduction: Millions of people lack access to safe and effective pharmaceuticals because they are unaffordable or unavailable, particularly in 'developing' and 'least-developed' countries (DCs, LDCs), and increasingly in high-income countries (HICs). Management of intellectual property (IP) related to new medicines has a significant impact on access to safe, affordable and effective medicines. The Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) provides the international legal framework for IP protection and mandates 20-year patents in all technological fields, including pharmaceuticals. TRIPS contains flexibilities, such as compulsory licensing (CL) and transition provisions for LDCs, which governments can use to facilitate access to health technologies. The use of these flexibilities is underreported in the literature, and a thorough analysis has not been undertaken since the COVID-19 pandemic.

Methods: A scoping review of three medical and legal databases and temporal analysis of all known instances of use or potential use of CLs and the LDC pharmaceutical transition measure between 2001-2024.

Results: 61% of the 149 CL instances were executed. The relative rates of CL use between countries have shifted: HICs represent over half of CL instances in the last decade. CLs are increasingly considered for chronic, non-communicable and rare diseases. The threat of CL use continues to provide impetus for price negotiations, voluntary licences or other measures to improve access. Almost all eligible countries have invoked the right to use the LDC transition measure.

Conclusions: TRIPS flexibilities have been used to facilitate access to medicines (including vaccines) over the quarter-century since the adoption of the World Trade Organization's Doha Declaration on TRIPS and Public Health. The flexibilities play a vital role in ensuring that new medicines are affordable and are likely to continue to be in a future where geopolitical forces have drastically altered the financing structures of medicines provision in DCs and LDCs.

Objective: The objective of this gap map is to provide an overview of existing evidence on the health of South Asian migrants and refugees in Australia and highlight research gaps.

Method: We searched four databases until June 2025 to include quantitative, qualitative and mixed methods studies conducted in Australia and published from the year 2000 onwards on health of migrants and refugees from South Asian countries. Two reviewers screened titles/abstracts and full texts using Covidence to establish eligibility. The included studies were then coded in Evidence for Policy & Practice Information Centre - Reviewer (EPPI-Reviewer) to generate a gap map.

Results: The evidence gap map summarises findings from 129 studies (66 qualitative, 52 quantitative and 11 mixed methods studies) reporting on the health and well-being of migrants from South Asian countries residing in Australia. The gap map depicts that mental health conditions, non-communicable diseases and maternal health are relatively well-evidenced domains compared with other health conditions. Knowledge, attitudes, perceptions and behaviours are the most frequently evaluated outcomes, followed by experiences with healthcare system, prevalence of health conditions and factors associated with healthcare access and utilisation. There are evident data gaps assessing survival/mortality, access and utilisation of health services and cost-effectiveness. There is sparse evidence on the effectiveness of interventions/strategies to improve health status, access and utilisation of health services and their impact on survival and mortality. Health literacy, language proficiency, competing priorities, negative beliefs, past experiences, confusion in navigating the healthcare system and cost of services were reported as barriers in accessing healthcare services.

Conclusions: These findings highlight the scarcity of evidence beyond the descriptive measures on health of South Asian migrants in Australia.

Implications: Priority areas for future research include generating data to establish causal relationships between population-specific risk factors and adverse health outcomes by establishing long-term cohorts. These data would assist in designing and evaluating context-specific interventions that are feasible and acceptable to improve health outcomes in this population.

Introduction: Towards the 'End TB Strategy' targets, the WHO recommends the provision of tuberculosis (TB) preventive therapy (TPT) for high-risk groups including people living with HIV (PLWH). 3 years after the release of the updated 2020 WHO guidelines, we investigated the implementation of TPT services at HIV clinics in low-income and middle-income countries (LMICs), focusing on TB screening, populations eligible for TPT and available TPT regimens.

Methods: In 2023, we surveyed HIV care clinics in the International Epidemiology Databases to Evaluate AIDS consortium in Africa, the Asia-Pacific and Latin America and the Caribbean. We used descriptive statistics to summarise TPT implementation according to WHO guidelines and multivariable logistic regression models to estimate associations with clinic characteristics.

Results: Of 172 HIV clinics included, 142 (83%) were in Africa, 22 (13%) in the Asia-Pacific and 8 (5%) in Latin America; 108 (63%) were located in urban areas. After ruling out active TB, TPT was reportedly offered to PLWH (122 clinics, 71%), household contacts of individuals with active TB (120 clinics, 70%) and other high-risk populations. TPT for PLWH was more frequently available in clinics in lower-income and low-middle-income countries, in high TB burden countries, and in district hospitals compared with other facility types. Clinics reported use of isoniazid-based (160 clinics, 93%) and shorter rifamycin-based (129 clinics, 75%) TPT regimens. Reported barriers to TPT initiation included patient refusal at 71 (41%) and drug shortages at 67 (39%) clinics.

Conclusions: TPT was available at most HIV care clinics in LMICs but further efforts are needed to reinforce WHO recommendations and ensure that TPT is consistently accessible to people at higher risk of developing active TB, especially PLWH.