BMJ Global Health最新文献

Objective: To determine whether liquefied petroleum gas (LPG) can reduce perinatal mortality in a setting with high reliance on biomass fuels for cooking.

Design: Community-based two-arm parallel cluster randomised controlled trial, in Sherpur, Bangladesh.

Participants: 4944 pregnant women were recruited, with 2472 in each group. Eligible women were pregnant between 40 and 120 days, aged 15-49 years, permanent residents and planning to give birth in their cluster of residence.

Intervention: LPG stove and fuel to birth. Controls continued with usual cooking practices.

Main outcome: Primary outcome at the individual level: perinatal mortality.

Secondary outcomes: early neonatal mortality, neonatal mortality, preterm birth and personal exposure to particulate matter 2.5 (PM2.5).

Results: The final birth outcomes included 4592 participants. The perinatal mortality rate (PMR) was 50 per 1000 births in the intervention group compared with 61 per 1000 births in the control group (relative risk (RR) 0.83; 95% CI 0.65 to 1.06). PM2.5 concentrations were 47.2 µg/m³ in the intervention versus 60.3 µg/m³ in the control; mean difference -0.133 (95% CI -0.194 to -0.072). In late pregnancy, it was 62·7 µg/m³ in the intervention versus 88·7 µg/m³ in the control, mean difference -0.149 (-0.198 to -0.101). Early neonatal mortality was 22% in the intervention compared with 30% in the control (RR 0.73; 95% CI 0.50 to 1.05). Preterm birth rates were similar. In post hoc subgroup of small versus large households (HH), the PMR was lower in the smaller HH in the intervention group (67, rate 54 per 1000 births) than in the control group (102, 71 per 1000 births, adjusted RR 0.75; 95% CI 0.56 to 1.00; p=0.047).

Conclusions: Reductions in perinatal mortality favoured the intervention but were statistically non-significant. These findings demonstrate a reduction in mortality in smaller HH when cooking needs are adequately covered by clean fuel.

Trial registration number: ACTRN12618001214224; Australian and New Zealand Clinical Trials Registry.

Background: Paediatric sepsis remains a significant cause of mortality in low- and middle-income countries (LMICs), where health systems are often resource-constrained. Global sepsis protocols, although effective in high-income settings, may not be well-suited to LMIC contexts.

Methods: We conducted a mixed-methods study in two hospitals in the Ashanti Region of Ghana: Komfo Anokye Teaching Hospital (KATH) and Presbyterian Hospital, Agogo (PreHA). Specifically, we conducted a retrospective chart review, followed by key informant interviews with clinical staff, and integrated our findings with a previously published situational analysis. Qualitative data analysis employed the Three Delays Framework and the Donabedian Model to identify locations and causes of delays in care.

Results: Seventy-one charts met the inclusion criteria for review, having a history of fever or hypothermia and complete vital signs documented (16 from PreHA, 55 from KATH). Despite KATH managing more severely ill patients with higher sepsis scores and longer stays, mortality rates were similar at both sites. The chart review highlighted gaps in documentation and inconsistent care processes. Key informant interviews revealed themes such as provider altruism, community financial support and the positive role of research collaborations, while also illustrating systemic delays linked to financial and resource constraints.

Conclusion: Paediatric sepsis care in Ghana is influenced by complex and interconnected structural, cultural and procedural factors. Our findings indicate that contextually adapted care pathways are crucial for improving sepsis outcomes in resource-constrained settings. Co-designed interventions, rather than wholly imported protocols, may offer a more sustainable approach to strengthening health systems in LMICs.

Japan's Prime Minister recently announced a strategic partnership with the World Bank to support human resource development for Universal Health Coverage (UHC) in the Global South. While this pivot from infrastructure to human capital is timely, it risks falling into the 'training trap'-producing skilled workers whom national governments cannot afford to employ. This commentary argues that in many low- and middle-income countries, the primary bottleneck to workforce expansion is not a lack of trained staff, but the 'paradoxical surplus': a coexistence of acute health needs, unemployed health workers and rigid fiscal constraints on public sector wage bills. Drawing on recent evidence from sub-Saharan Africa and beyond, we demonstrate that supply-side interventions (education) without demand-side reforms (employment) will merely fuel brain drain. We propose that the true value of the Japan-World Bank partnership lies in bridging the gap between Ministries of Health and Finance. Japan must leverage the World Bank's macroeconomic influence to expand 'fiscal space' for health, ensuring that Official Development Assistance (ODA) for education is matched by domestic capacity to absorb and retain graduates. Only by coupling training with fiscal reform can Japan's UHC pledge become a sustainable reality.

Introduction: Digital payments are increasingly favoured over cash for remunerating healthcare workers in large-scale health campaigns due to perceived advantages in efficiency and security. However, evidence to guide their scaling and optimisation is limited. This study aimed to identify and prioritise a global research agenda for digital payments in health campaigns in sub-Saharan Africa (SSA).

Methods: We employed the Child Health and Nutrition Research Initiative methodology. In stage 1, we defined the context and criteria (answerability, feasibility, sustainability/equity, impact). In stage 2, 420 stakeholders were engaged via an online survey, generating 450 research questions, which were refined to a final pool of 35. In stage 3, these 35 questions were scored by 63 experts against the predefined criteria. Research Priority Scores (RPS) and Average Expert Agreement (AEA) were computed for ranking in stage 4.

Results: The overall RPS for the 35 questions ranged from 38.6% to 6.0% (mean 28.2%, SD 6.4%). The AEA ranged from 67.2% to 82.7% (mean 77%, SD 3.4%), indicating strong consensus. RPS and AEA showed a strong positive correlation (r=0.989, p<0.01). The top-ranked research questions were: (1) Minimum requirements for health systems to digitise payments responsibly (RPS 38.6%); (2) Optimisation of digital payments to enhance campaign effectiveness in SSA (RPS 36.8%); (3) Incentives for digital payment adoption in the healthcare sector (RPS 36.1%); (4) Cost-benefit analysis of digital payments vs cash (RPS 36.3%) and (5) Coverage of mobile money agents and its impact on uptake and satisfaction (RPS 34.0%).

Conclusions: This study provides an expert-consensus roadmap for research on digital payments in health campaigns. Addressing these priorities will generate critical evidence to develop robust, equitable and effective digital payment systems, ultimately strengthening health systems and improving health outcomes in SSA.

Background: Primary healthcare (PHC) is critical towards achieving Universal Health Coverage (UHC). In Ghana, PHC is organised at the district level and plays a key role in the country's pursuit of UHC. However, many districts face challenges not only with limited resources but also with how effectively they are used. We examined how efficiently districts in Ghana use their health resources and what factors are associated with this efficiency.

Methods: We used a two-step stochastic frontier analysis model using data from 181 districts. The output variable was a composite coverage index derived from eight PHC service indicators for 2021, primarily reflecting maternal and child health and infectious disease services. Input variables included district health expenditure for 2020/2021 and the number of health facilities and clinical staff in 2021. We then assessed the associations between efficiency scores generated by the model and health systems, socioeconomic and demographic factors, such as health facility type, insurance coverage, literacy level, Gini coefficient, poverty incidence, urbanisation and population density.

Results: On average, districts operated at 87% efficiency, with scores ranging from 65% to 99%. Two factors were associated with the efficiency. First, districts with a higher proportion of PHC facilities tended to use resources more efficiently (coeff=0.151; 95% CI=0.041 to 0.261). Second, districts with greater income inequality were less efficient, measured by the Gini coefficient (coeff=-0.858; 95% CI=-1.146 to -0.252).

Conclusion: Districts in Ghana have the potential to improve PHC outputs by about 13% on average by better use of existing resources and addressing determinants of efficiency. Findings suggest that districts with a higher proportion of PHC facilities and lower income inequality tend to be more efficient. These patterns highlight the value of strengthening PHC infrastructure and pursuing equity-focused policies as part of strategies to enhance efficiency in district health systems.

Introduction: Shorter time to diagnosis may lead to better cancer outcomes in Southern Africa. This study measured the time from symptoms to first healthcare visit (patient interval; PI) and diagnosis (diagnostic interval; DI) and associated factors for breast, cervical and colorectal cancer in Zimbabwe and South Africa (SA).

Methods: A cross-sectional survey collected data on socio-demographics, cancer awareness, barriers to seeking care, symptoms, healthcare visits and diagnosis after recent cancer diagnosis. Cox regression was used to determine factors associated with PI and DI.

Results: This study included 1021 participants (Zimbabwe 396, SA 625). Symptom and risk factor recall was low. Median PIs were shorter than DIs across cancers and regions. For breast cancer, those reporting more health-seeking barriers had longer PIs (Zimbabwe HR 0.801, 95% CI 0.703 to 0.913; SA HR 0.885, 95% CI 0.817 to 0.958), while greater emotional response to symptoms was associated with a shorter PI (Zimbabwe HR 1.194, 95% CI 1.101 to 1.295; SA HR 1.145, 95% CI 1.079 to 1.216). Interpreting a cervical symptom as serious (Zimbabwe) was associated with a shorter PI. DIs were longer in less-resourced regions and increased with number of healthcare visits before diagnosis. Significantly shorter DIs occurred when the first provider was a clinic doctor or specialist compared with a clinic nurse.

Conclusions: Efforts to improve timely cancer diagnosis in Zimbabwe and SA should focus on supporting primary healthcare providers in managing and referring symptomatic patients, enhancing cancer symptom awareness and interpretation, and addressing barriers to care.

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.