BMJ Global Health最新文献

We apply a primary healthcare (PHC) perspective to gauge Pakistan's health systems response to COVID-19, to identify stewardship lessons for integrating the PHC pandemic response. Analysis of Pakistan's response against the Astana PHC framework shows that the imperative for national survival helped mobilise an agile response across a fragmented health security context. The findings show effective multisector governance in responding to the health and social aspects of the pandemic, as well as the rapid roll-out of several public health functions and emergency care. However, we found weak maintenance of essential health services and ad hoc, short-lived efforts for community engagement.Critical enablers that helped steward the response across complex power-sharing arrangements included solidarity across society, collaborative data-driven decision-making, leveraging of siloed domestic resources and private sector coordination. At the same time, a more PHC-centric response was constrained by weak political prioritisation of essential health services, uneven services, weak direction to civil society volunteerism for community engagement and weak regulation of private sector contribution.We conclude that a mindset shift is required from short-term tactical measures to long-term investment in PHC-oriented transformative stewardship. Future preparedness must build attention to essential service package for emergencies, mobilisation of both private and public primary care providers, effective community engagement vision across societal actors and market regulation, within a collaborative governance framework.

Background: Despite strong evidence-based strategies for prevention and management, global efforts to reduce deaths from postpartum haemorrhage (PPH) have failed, and it remains the leading cause of maternal mortality. We conducted a detailed review of all maternal deaths from 33 facilities in Malawi to identify health system weaknesses leading to deaths from PPH.

Methods: Data were collected regarding every maternal death occurring across all district and central hospitals in Malawi. Deaths occurring from August 2020 to December 2022 were reviewed by multidisciplinary facility-based teams who compiled case narratives from clinical notes and then subsequently reviewed by obstetricians to confirm the cause of death according to international criteria. Data were summarised using proportions/frequencies, comparisons made using χ² or Wilcoxon rank sum tests, and logistic regression conducted to calculate ORs with CIs.

Results: PPH was the cause of 20.4% of maternal deaths. Most deaths from PPH occurred within 24 hours of birth (80.0%), among women who had been referred to a higher-level facility (57.0%) and were admitted in stable condition (60.0%). Vacuum births carried an increased risk of death from PPH (OR 4.25 (95% CI 1.15 to 20.13, p=0.039)). Detailed reviews identified that deaths from PPH were more likely to be associated with factors such as 'lack of obstetric lifesaving skills' (26.7% vs 10.1%, p<0.001), 'inadequate monitoring' (51.5% vs 40.7%, p=0.012) and 'communication problems between facilities' (11.5% vs 6.2%, p=0.019) than deaths from other causes.

Conclusions: Our analysis represents the largest published review of maternal deaths from PPH. We demonstrate that key health system weaknesses are contributing to these preventable maternal deaths. Case reviews conducted by multidisciplinary facility-based teams identified common and recurrent avoidable factors associated with deaths from PPH. Global efforts must now be focused on strategies that address these weaknesses, strengthening health systems and empowering healthcare workers to reduce maternal deaths from PPH.

Background: Limited information is available on the value of integrating family planning and nutrition services to improve related outcomes among women of reproductive age and effective approaches to achieve this. This study aimed to ascertain the perspectives and experiences of global and regional stakeholders about integrating family planning and nutrition services, examine facilitators and barriers and identify opportunities and considerations for integration.

Methods: We conducted semistructured interviews with 34 global and regional stakeholders in family planning, nutrition and related domains. Participants were identified through purposive sampling. Interviews were conducted virtually, recorded and transcribed. Data were analysed using thematic analysis.

Results: Stakeholders considered the integration of family planning and nutrition services potentially valuable given the biological links between family planning and nutritional status, and potential practical benefits including increased service coverage, reduced burden on beneficiaries to access services and increased cost-effectiveness of service delivery. Integration was commonly described within the context of comprehensive health service packages, with integration models encompassing health systems strengthening, life course and multisectoral approaches. Facilitators and barriers included systemic and structural, resource-related and contextual factors. The need for more robust evidence to support integration and identify effective and cost-effective integration models was emphasised.

Conclusions: Integrating family planning with nutrition services and both with other health services directed towards women of reproductive age and their children may offer greater value in improving health and related outcomes, as opposed to siloed approaches. Further evidence quantifying benefits and highlighting the effectiveness of such integration strategies is key to informing future programmatic efforts.

Background: The way that healthcare services are organised and delivered (termed 'healthcare delivery arrangements') is a key aspect of a health system. Changing the way health care is delivered, for example, task shifting that delivers the same care at lower cost, may be one way of improving healthcare system sustainability. We synthesised the existing randomised trial evidence to compare the effects of alternative healthcare delivery arrangements versus usual care in Nepal.

Methods: For eligible studies published since 2005, we searched MEDLINE, Embase, CENTRAL, CINAHL, Scopus, the WHO clinical trials registry and NepJOL on 31 October 2024. Two authors independently assessed studies for eligibility, extracted data and evaluated the risk of bias using the Cochrane risk of bias tool and certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluations. We calculated risk ratios (RRs), mean differences (MDs) and percentage points (PPs) with 95% CIs for the outcomes and performed meta-analysis where appropriate.

Results: Four studies met the inclusion criteria. One evaluated task shifting, two information and communication technology, and one care coordination. No meta-analyses were performed. Low certainty evidence indicates task shifting of medical abortion by doctors to midlevel providers may result in equivalent complete abortion (RR: 2.55, 95% CI: 0.82 to 4.27). Similarly, the use of a mobile phone call reminder may improve on-time medicine collection among patients with HIV compared with usual care (RR: 1.29, 95% CI: 1.12 to 1.48), while the integration of postpartum family planning and postpartum intrauterine contraceptive device (PPIUCD) insertion with maternity services may improve PPIUCD uptake compared with usual care (PP: 0.173, 95% CI: 0.098 to 0.246).

Conclusion: More evaluation is needed for alternative delivery arrangements due to limited low-certainty evidence from current trials. There was insufficient evidence on outcomes such as cost, safety, and patient and provider perspectives.

Prospero registration number: CRD42022327298.

Introduction: Home-based records (HBRs) are widely used for recording health information including child immunisations. We studied levels and inequalities in HBR ownership in low-income and middle-income countries (LMICs) using data from national surveys conducted since 2010.

Methods: We used data from national household surveys (Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS)) from 82 LMICs. 465 060 children aged 6-35 months were classified into four categories: HBR seen by the interviewer; mother/caregiver never had an HBR; mother/caregiver had an HBR that was lost; and reportedly have an HBR that was not seen by the interviewer. Inequalities according to age, sex, household wealth, maternal education, antenatal care and giving birth in an institutional setting were studied, as were associations between HBR ownership and vaccine coverage. Pooled analyses were carried out using country weights based on child populations.

Results: An HBR was seen for 67.8% (95% CI 67.4% to 68.2%) of the children, 9.2% (95% CI 9.0% to 9.4%) no longer had an HBR, 12.8% (95% CI 12.5% to 13.0%) reportedly had an HBR that was not seen and 10.2% (95% CI 9.9% to 10.5%) had never received one. The lowest percentages of HBRs seen were in Kiribati (22.1%), the Democratic Republic of Congo (24.5%), Central African Republic (24.7%), Chad (27.9%) and Mauritania (35.5%). The proportions of HBRs seen declined with age and were inversely associated with household wealth and maternal schooling. Antenatal care and giving birth in an institutional setting were positively associated with ownership. There were no differences between boys and girls. When an HBR was seen, higher immunisation coverage and lower vaccine dropout rates were observed, but the direction of this association remains unclear.

Interpretation: HBR coverage levels were remarkably low in many LMICs, particularly among children from the poorest families and those whose mothers had low schooling. Contact with antenatal and delivery care was associated with higher HBR coverage. Interventions are urgently needed to ensure that all children are issued HBRs, and to promote proper storage of such cards by families.

Introduction: Despite recommendations from the WHO, antenatal care (ANC) coverage remains low in many low-income and middle-income countries (LMICs). Community health workers (CHWs) can play an important role in expanding ANC coverage through pregnancy identification, provision of health education, screening for complications, delivery of therapeutic care and referral to higher levels of care. However, despite the success of CHW programmes in various countries, WHO has called for additional research to develop evidence-based models that optimise CHW service delivery and that can be replicated across geographies.

Methods: The ProCCM Trial was a cluster-randomised controlled trial to compare proactive home visits by CHWs (intervention, 69 village clusters) to the provision of CHW care at community fixed sites only (control, 68 village clusters) in the Bankass health district in Central Mali. In this study, we conducted a cost-effectiveness analysis of proactive CHW home visits in improving ANC utilisation, a secondary outcome of the ProCCM trial. We analysed five ANC outcomes: (1) number of ANC contacts, (2) at least one ANC contact, (3) at least four ANC contacts, (4) at least eight ANC contacts and (5) ANC initiated in the first trimester. We assumed two perspectives, a CHW programme's and the Full ANC programme's perspective, which included facility-based as well as community-based ANC. We estimated programme costs, incremental cost-effectiveness ratios (ICERs) and probabilities of the intervention being more cost-effective than the control at different willingness-to-pay (WTP) thresholds.

Results: Proactive home visits were cost-saving from the CHW programme's perspective (ICERs: -$21.39 to -$79.20 per ANC utilisation outcome) and from the Full ANC programme perspective (ICERs: -$1.70 to -$6.30 per ANC utilisation outcome) compared with the fixed-site CHW care. The likelihood of the intervention being more cost-effective than the control was 100% at WTP thresholds $0 per ANC utilisation outcome and between $12.5 and $50.00 per ANC utilisation outcome in the CHW- and Full ANC programme perspectives, respectively.

Conclusion: Our results provide evidence that proactive home visits produce more value per dollar spent as a means of improving the uptake of ANC services compared with fixed-site CHW services.

Trial registration number: NCT02694055.

Conscientious objection is a critical topic that has been sparsely discussed from a global health perspective, despite its special relevance to our inherently diverse field. In this Analysis paper, we argue that blanket prohibitions of a specific type of non-discriminatory conscientious objection are unjustified in the global health context. We begin both by introducing a nuanced account of conscience that is grounded in moral psychology and by providing an overview of discriminatory and non-discriminatory forms of objection. Next, we point to the frequently neglected but ubiquitous presence of moral uncertainty, which entails a need for epistemic humility-that is, an attitude that acknowledges the possibility one might be wrong. We build two arguments on moral uncertainty. First, if epistemic humility is necessary when dealing with values in theory (as appears to be the consensus in bioethics), then it will be even more necessary when these values are applied in the real world. Second, the emergence of global health from its colonial past requires special awareness of, and resistance to, moral imperialism. Absolutist attitudes towards disagreement are thus incompatible with global health's dual aims of reducing inequity and emerging from colonialism. Indeed, the possibility of global bioethics (which balances respect for plurality with the goal of collective moral progress) hinges on appropriately acknowledging moral uncertainty when faced with inevitable disagreement. This is incompatible with blanket prohibitions of conscientious objection. As a brief final note, we distinguish conscientious objection from the problem of equitable access to care. We note that conflating the two may actually lead to a less equitable picture on the whole. We conclude by recommending that international consensus documents, such as the Universal Declaration on Bioethics and Human Rights, be amended to include nuanced guidelines regarding conscientious objection that can then be used as a template by regional and national policymaking bodies.

Background: In developing countries, due to improper management of domestic animals' exposures, under-five (U5) children have been affected by diarrhoea. However, there is no evidence that shows the presence of diarrhoea-causing pathogens in the faeces of U5 children and animals residing in the same houses in the Sidama region, Ethiopia.

Methods: A laboratory-based matched case-control study was conducted on children aged 6-48 months in the Sidama region of Ethiopia from February to June 2023. The study enrolled 113 cases, and 113 controls visited the selected health facilities during the study period. Faecal specimens from the case and control children and domestic animals were collected using transport media. Data were collected at children-residing homes by interviewing caretakers using the KoboCollect application. The presence of diarrhoea-causing pathogens (Campylobacteria, Escherichia coli, non-typhoidal salmonella, Shigella and Cryptosporidium) was detected using culture media, biochemical tests, gram stain, catalase and oxidase tests. The diarrhoea risk factors were identified using conditional logistic regressions and the random forest method using R.4.3.2.

Results: Of the faecal specimens diagnosed, 250 (64.1%) tested positive for one or more pathogens. Faecal specimens from chickens tested more positive for E. coli and Campylobacteria. Of the pairs of faecal specimens taken from case children and animals living in the same house, 104 (92%) tested positive for one or more similar pathogens. Among the factors, disposing of animal waste in an open field, storing drinking water in uncovered containers, caretakers poor knowledge about the animals' faeces as a risk factor for diarrhoea and ≤2 rooms in the living house were significantly associated with diarrhoea.

Conclusion: The finding shows that diarrhoea-causing pathogens are transmitted from domestic animals' faeces to children aged 6-48 months in the Sidama region. The improper management of animals' faeces and related factors were the predominant risk factors for diarrhoea.