BMJ Global Health最新文献

Introduction: Disparities of power between high-income (HICs) and low- and middle-income countries (LMICs) have long characterised the structures of global health, including knowledge production and training. Historical case study analysis is an often-overlooked tool to improve our understanding of how to mitigate inequalities.

Methods: Drawing from the contemporary experience of collaborators from Canada and Ethiopia, we chose to examine the historical relationship between Ethiopian Emperor Haile Selassie and Canadian Jesuit Lucien Matte as a case study for international collaborations based on the model of an 'invited guest'. We used critical historical context and qualitative content analysis methodologies to assess written correspondence between them from the 1940s to the 1970s and drew from postcolonial theory to situate this case study in a broader context.

Results: The respectful and responsive relationship that developed between Emperor Haile Selassie and Lucien Matte reveals important characteristics needed for meaningful collaborations in global health education. Matte came to Ethiopia fully cognizant of the imperial context of his work and prepared to take on the position of invited guest. As a result, many of both Matte and Haile Selassie's goals were achieved. At the same time, however, this case study also revealed how problematic constructions of authoritative power can arise even when productive partnerships among individuals occur. Matte and Haile Selassie's collaboration reinscribed belief in the superiority of western theories of intellectual and social development. In addition, their prescriptive vision for education in Ethiopia repeatedly dismissed competing local positions.

Conclusion: As international partnerships in global health education continue to exist and form, historical case studies offer valuable insights to guide such work. Among the most crucial arenas of knowledge is the need to understand powerful dynamics that have and continue to shape HIC-LMIC interaction. The historical case study of Matte and Haile Selassie reveals how problematic power differentials can be reinforced or mitigated.

Introduction: Thailand was one of the first low- and middle-income countries to publicly fund seasonal influenza vaccines, but the lack of predictability in the timing of epidemics and difficulty in predicting the dominant influenza subtypes present a challenge for existing vaccines. Next-generation influenza vaccines (NGIVs) are being developed with the dual aims of broadening the strain coverage and conferring longer-lasting immunity. However, there are no economic evaluations of NGIVs in Thailand.

Methods: We estimated the health impact and cost-effectiveness of NGIVs in Thailand between 2005 and 2009 using a combined epidemiological and economic model. We fitted the model to data on laboratory-confirmed influenza cases and then simulated the number of influenza infections, symptomatic cases, hospitalisations and deaths under different vaccination scenarios based on WHO-preferred product characteristics for NGIVs. We used previous estimates of costs and disability adjusted life years (DALYs) for influenza health outcomes to estimate incremental net monetary benefit, vaccine threshold prices and budget impact.

Results: With the current vaccine programme, there were an estimated 61 million influenza infections. Increasing coverage to 50% using improved vaccines reduced infections to between 23 and 57 million, and with universal vaccines to between 21 and 49 million, depending on the age groups targeted. Depending on the comparator, threshold prices for NGIVs ranged from US$2.80 to US$12.90 per dose for minimally improved vaccines and US$24.60 to US$69.90 for universal vaccines.

Conclusion: Influenza immunisation programmes using NGIVs are anticipated to provide considerable health benefits and be cost-effective in Thailand. However, although NGIVs might even be cost-saving in the long run, there could be significant budget implications for the Thai government even if the vaccines can be procured at a substantial discount to the maximum threshold price.

Equitable health research requires actively engaging communities in producing new knowledge to advocate for their health needs. Community-based participatory research (CBPR) relies on the coproduction of contextual and grounded knowledge between researchers, programme implementers and community partners with the aim of catalysing action for change. Improving coproduction competencies can support research quality and validity. Yet, frameworks and guidance highlighting the ideal competencies and conditions needed for all research partners to contribute meaningfully and equitably are lacking. This paper aims to advance CBPR by laying out seven core competencies and conditions that can promote power sharing in knowledge production, application and dissemination at the individual, community, organisational and systems levels.Competencies were developed through an iterative process, that synthesised pre-existing literature and frameworks with a wide range of tacit knowledge from researchers, activists, implementation partners and community researchers from Bangladesh, India, Kenya, Sierra Leone and the UK.The seven core competencies and conditions are: (1) capacity to interpret and respond to individual and relational identity, connection, uniqueness and inequities; (2) ability of communities and partners to work in the most suitable, inclusive and synergistic way; (3) aptitude for generating safe and inclusive spaces for multidirectional knowledge and skills exchange that goes beyond the research focus; (4) expertise in democratic leadership and/or facilitation to balance competing priorities and ensure shared decision-making; (5) capacity to analyse readiness for action, successes and areas for improvements throughout the research process; (6) ability to instigate sustainable change processes within the political dimensions of systems, policies and practices using advocacy, lobbying or activism approaches and (7) skills to interpret and disseminate findings and outputs that are understandable, respectful and promote community ownership. We present core competency and condition areas, individual and collective expertise associated with competencies, likely outcomes, examples of activities and sources of evidence.

Only a third of tuberculosis (TB) cases in Nigeria in 2020 were diagnosed and notified, in part due to low detection and under-reporting from the private health sector. Using a standardised patient (SP) survey approach, we assessed how management of presumptive TB in the private sector aligns with national guidelines and whether this differed from a study conducted before the start of the COVID-19 pandemic. 13 SPs presented a presumptive TB case to 511 private providers in urban areas of Lagos and Kano states in May and June 2021. Private provider case management was compared with national guidelines divided into three main steps: SP questioned about cough duration; sputum collection attempted for TB testing; and non-prescription of anti-TB medications, antibiotics and steroids. SP visits conducted in May-June 2021 were directly compared to SP visits conducted in the same areas in June-July 2019. Overall, 28% of interactions (145 of 511, 95% CI 24.5% to 32.5%) were correctly managed according to Nigerian guidelines, as few providers completed all three necessary steps. Providers in 71% of visits asked about cough duration (362 of 511, 95% CI 66.7% to 74.7%), 35% tested or recommended a sputum test (181 of 511, 95% CI 31.3% to 39.8%) and 79% avoided prescribing or dispensing unnecessary medications (406 of 511, 95% CI 75.6% to 82.8%). COVID-19 related questions were asked in only 2.4% (12 of 511, 95% CI 1.3% to 4.2%) of visits. During the COVID-19 pandemic, few providers completed all steps of the national guidelines. Providers performed better on individual steps, particularly asking about symptoms and avoiding prescription of harmful medications. Comparing visits conducted before and during the COVID-19 pandemic showed that COVID-19 did not significantly change the quality of TB care.

Introduction: The private sector plays a substantial role in delivering and financing healthcare in low- and middle-income countries (LMICs). Supporting governments to govern the private sector effectively, and so improve outcomes across the health system, requires an understanding of the evidence base on private health sector governance. This paper reports on a scoping review, which synthesised evidence on the approaches used to govern private sector delivery and financing of healthcare in LMICs, the effectiveness of these approaches and the key enablers and barriers to strengthening governance.

Methods: We undertook a systematic search of databases of published articles and grey literature to identify eligible papers published since 2010, drawing on WHO's governance definition. Data were extracted into a pretested matrix and analysed using narrative synthesis, structured by WHO's six governance behaviours and an additional cross-cutting theme on capacities.

Results: 107 studies were selected as relevant, covering 101 LMICs. Qualitative methods and document/literature review were predominant. The findings demonstrate the relevance of the WHO governance behaviours, but the lack of robust evidence for approaches to implementing them. Valuable insights from the literature include the need for a clear vision around governance aims; the importance of ensuring that policy dialogue processes are inclusive and transparent, avoiding interest group capture; the benefits of exploiting synergies between governance mechanisms; and the need to develop capacity to enact governance among both public and private actors.

Conclusion: Governance choices shape not just the current health system, but also its future development. Common barriers to effective governance must be addressed in policy design, stakeholder engagement, public and private sector accountability, monitoring and capacity. Achieving this will require in-depth explorations of governance mechanisms and more rigorous documentation of implementation and outcomes in diverse contexts.

Introduction: Achieving universal health coverage (UHC) through an effective health financing system is a challenge for many low-income countries. Learning is key to success due to many uncertainties and unknowns. Using the case of translating strategic health purchasing into policy and practice in Burkina Faso, our study seeks to understand how policy learning can shape policy processes and outcomes.

Methods: We used a qualitative case study design and Dunlop and Radaelli's conceptualisation of policy learning to identify which modes of learning did or did not occur, what helped or hindered them and the resulting policy outcomes. Dunlop and Radaelli frame policy learning as epistemic, reflexive, negotiative or hierarchical. We collected data through documentary review and in-depth individual interviews with 21 key informants. We analysed the data manually using pattern-matching techniques.

Results: The introduction of strategic health purchasing in Burkina Faso was initially seen as an opportunity to reduce the fragmentation of the health financing system by coupling a performance-based financing scheme and a user fee exemption policy. However, this has faltered, and our findings suggest that an inability to harness all modes of learning has led to blockages. Indeed, while reflective learning was present, epistemic, hierarchical and learning through bargaining were absent, preventing national policy actors from defending their own policy or scheme from reaching compromises. But thanks to facilitating processes led by a well-resourced organisation and contextual elements that encouraged the emergence of more pluralistic modes of learning, some progress was achieved in operationalising strategic health purchasing.

Conclusions: Some modes of learning seem to be overlooked in countries' efforts to achieve UHC. Facilitation techniques and initiatives that encourage the use of all modes of learning, while supporting countries to take full ownership and responsibility for consolidating their own learning health systems, should be promoted.

Introduction: Many National Immunisation Programmes attempt to leverage the private sector ; however, there is limited consolidated and synthesised documentation on good practices, gaps and lessons learnt. A 2017 WHO guidance document recommended best practices for private sector engagement (PSE) in immunisation. We conducted a pragmatic scoping review to identify gaps, update and consolidate evidence on promising practices in PSE for vaccination.

Methods: Building on two previous reviews published in 2011 and 2017, we conducted a pragmatic scoping review of peer-reviewed publications from low-income and middle-income countries since September 2016 in PubMed that pertained to PSE and immunisation service delivery. We extracted and analysed findings using a new analytical framework covering motivations, enablers and barriers, risks and challenges, and engagement mechanisms.

Results: We collated over 80 well-documented analyses of PSE for vaccination, derived from 54 peer-reviewed publications from 1998 to 2016 included in prior reviews, 21 new publications from 24 countries published since 2016 and 1 new systematic review. The level of PSE was mixed, ranging from 3%-4% to >60% of all childhood vaccinations. Promising practices for PSE included using governance and policy to leverage private providers' motivations and including them in programme efforts. Planning and monitoring efforts were effective when linked with regulatory requirements based on national standards for services, reporting and performance monitoring. Information systems were effective when they included private sector services in vaccine monitoring and surveillance. Challenges identified included ensuring compliance with national schedules and standards and minimising financial exclusion. Few studies documented successful public-private partnership models or other innovative financing models.

Conclusion: The published evidence captures numerous strategies to facilitate stronger immunisation programme engagement with the private sector. Stronger PSE can potentially reach zero-dose and underimmunised populations in low-resource settings and build resilient systems. Untapped opportunities exist for more structured testing of approaches to inform global guidance.

Background: In many resource-limited settings, understaffed hospitals rely on patients' families to provide care during admission. These care tasks are often performed informally, untrained and unsupported. The WHO has called for innovative approaches to tackle health worker shortages globally. Family participation interventions could be such an innovation, but current family participation should be understood before implementation. This review explored the barriers and facilitators family caregivers experience participating in resource-limited adult hospital care.

Methods: For this qualitative systematic review, MEDLINE, Embase, CINAHL and the Global Health Library were searched from inception to 17 February 2023. Studies were included if they described experiences of family caregivers participating in hospital-like environments, were performed in a low- or middle-income country and included qualitative data. Open coding was performed, followed by thematic analysis. The risk of bias was assessed using the Joanna Briggs Institute Qualitative Assessment and Review Instrument.

Results: 3099 studies were screened, and 16 were included, involving 466 participants. All studies were published between 2009 and 2023. Three studies were performed in Africa, three in South America and 10 in Asia. 13 main themes were identified, seven for barriers and six for facilitators, including 50 subthemes. The main barriers identified were caregiver burden, a discouraging hospital environment, economic burden, ineffective collaboration with health workers, lack of support, sacrificing personal life to care and unpreparedness for caregiving. The main facilitators identified were a caregiving mindset, competence for caregiving, effective collaboration with health workers, encouraging hospital environment, sufficient financial means and supportive caregiving systems.

Discussion: This review presents the first overview of barriers and facilitators experienced by family caregivers participating in resource-limited hospital care. Research in more contexts and among other stakeholders is necessary to comprehend family participation holistically. To improve family participation, this review suggests prioritising educational interventions.

Prospero registration number: CRD42023384414.

Introduction: With shifts in international aid, international donors have increasingly regarded non-governmental organisations (NGOs) as capable of providing alternative public service arrangements. As funding flows to NGOs, particularly in contexts where both actors work towards strengthening health system resilience, NGO-donor relationships evolve. However, despite calls to investigate the contribution of relationships between actors within health systems, including NGOs and their donors, to health system resilience, empirical research is limited. Understanding these relationships is crucial for comprehending their role in fostering resilient health systems. This research fills this gap, by examining how NGO-donor coordination contributes to health system resilience in Lebanon.

Methods: This research focuses on Lebanon's primary health system, primarily managed by NGOs through contracts and heavily funded by donors. It examines NGOs operating under the national primary healthcare network (PHCN). The participants, including staff from these NGOs and donor agencies funding them, were purposively selected. 31 semi-structured interviews were conducted. The analysis framework relied on a thematic analysis.

Results: The findings revealed that the flexibility in NGO-donor coordination in Lebanon depends on donors' trust, regular coordination and donors' willingness to listen to NGOs' needs. In this light, they uncovered that flexible NGO-donor coordination enhances NGOs' resilience capacities in shocks, allowing them to operate flexibly. By strengthening NGOs' resilience, which contributes to the resilience of the broader health system, this relationship contributes to health system resilience.

Conclusion: The findings contradict the mainstream development literature on NGO-donor relationships. The latter focuses on donor funding requirements that often result in rigid NGO-donor coordination, making it difficult for NGOs to be resilient. Rather, they emphasise the donors' role in implementing flexible development approaches, through flexible NGO-donor coordination, strengthening health system resilience. Overall, this paper contributes to the health system resilience literature by exploring how specific configurations of NGO-donor coordination strengthen health system resilience.