BMJ Global Health最新文献

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.

Despite strong commitments to improving children's well-being, nearly a third of Ghanaian children aged 36-59 months are not developmentally on track, with additional challenges due to the COVID-19 pandemic. Improvements in children's health and well-being rely on effective intersectoral policies, however, not enough is known about how to achieve this in practice, particularly in low- and middle-income countries. We report on a case study of participatory intersectoral policymaking for child health in Ghana in 2021, feeding into the national Early Childhood Care and Development Policy. We used systematic methods to analyse policy documents from 22 Ministries, Departments and Agencies; procedural outputs from national policy convenings; and children's inputs via a national competition, worksheets at a policy convening and video interviews. Data sources were analysed separately using content analysis for real-time application of findings into the policy process. Subsequently, data were re-analysed together, using an 'insider-outsider' approach, to provide a holistic view of the policy process. Beyond traditional child-centred policy areas (ie, health, education, youth and sports, social protection), most ministries lacked budgeted child-specific policies, partly because policymakers felt this was outside their mandate. Analysing children's inputs to the policy process showed they had substantive policy ideas on their health and well-being that were intersectoral in nature. While underlying social and cultural assumptions about children's place in society impeded their participation in policymaking, stakeholders nonetheless expressed their commitment to amplifying and institutionalising children's contributions. Our study adds evidence on how to operationalise intersectoral partnerships, including by mapping mandates, budgets and roles across different functions and levels of government, with the mobilising participation of civil society. We also report on new mechanisms for including children's perspectives in policymaking. Our findings have implications for child health policy and for other health initiatives that require effective intersectoral, participatory approaches.

Introduction: There is a growing literature on the significance of private sector engagement and collaboration for optimal response to health emergencies. The current study examines how the private sector was engaged by the Ghanaian government to implement effectively the national COVID-19 emergency response.

Methods: The study drew on a qualitative research design, interviewing 20 respondents in 15 unique organisations. Interviews were recorded, transcribed and analysed using a thematic analytical approach.

Findings: The findings of the study suggest that the government demonstrated leadership in mobilising, resourcing, and collaborating with the private health sector to deliver its pandemic response via a defined emergency response plan, a coordinated pandemic response structure and a robust platform for information gathering and sharing. However, the government fell short of providing the enabling environment for the private health sector to expand their capacity to meet increased demand for health services during the pandemic. There were also challenges related to the over concentration of resources in the public health response and national level structures to the detriment of clinical care and sub-national level structures. Generally, the findings also indicate a fragmented private health sector that is not only unattractive for the government to engage and collaborate with, but also weak in terms of capacity (financial and human resources) to partner government and respond to any major health emergency.

Conclusion: There is a need for policymakers to put in place an appropriate policy framework that will help in organising, engaging and collaborating with private health entities. The gaps identified and lessons learnt from implementing the pandemic response should be addressed as a matter of urgency to improve the readiness of Ghana's health system for future health emergencies.

Despite their central role in achieving health equity and Universal Health Coverage, only a minority of community health workers (CHWs) is formally recognised as health workforce and receives a salary. Community health policies are formed within the power dynamics of global health practice. We argue that critical investigations of the power dynamics that influence the design of CHW programmes can contribute system-level insights to strengthen their roles.We present a national-level case study of the Liberian Community Health Assistant programme as an exemplar case of successfully introducing a nationwide CHW policy that professionalises CHWs. Using a theory of how power is exercised (Steven Lukes) for our analysis, we argue that Liberia's success in overcoming external funder push-back on the payment of CHWs was enabled by strong political commitment and (re-)claiming government authority in and outside of decision-making processes. Consensus-building across government departments strengthened the government's decision-making power. The availability and strategic use of suitable and contextualised evidence focused on the rights of CHWs allowed for proactive engagement with external funders' concerns. To draw on learnings from the experience of Liberia, we recommend looking beyond the common effectiveness-oriented narratives in academic literature that focus on CHW's functional role. By focussing on how power is exerted through policy negotiations around professionalisation, it could be possible to reframe conventional approaches to the role of CHW in other contexts as well.

Background: In 2021, over one million children developed tuberculosis, resulting in 214 000 deaths, largely due to inadequate diagnosis and treatment. The diagnosis and treatment of tuberculosis is limited in most high-burden countries because services are highly centralised at secondary/tertiary levels and are managed in a vertical, non-integrated way. To improve case detection and treatment among children, the World Health Organisation (WHO) recommends decentralised and integrated tuberculosis care models. The Integrating Paediatric TB Services Into Child Healthcare Services in Africa (INPUT) stepped-wedge cluster-randomised trial evaluated the impact of integrating tuberculosis services into healthcare for children under five in Cameroon and Kenya, compared with usual care, finding a 10-fold increase in tuberculosis case detection in Cameroon but no effect in Kenya.

Methods: We estimated intervention impact on healthcare outcomes, resource use, health system costs and cost-effectiveness relative to the standard of care (SoC) using a decision tree analytical approach and data from the INPUT trial. INPUT trial data on cascades, resource use and intervention diagnostic rate ratios were used to parametrise the decision tree model. Health outcomes following tuberculosis treatment were modelled in terms of mortality and disability-adjusted life-years (DALYs).

Findings: For every 100 children starting antituberculosis treatment under SoC, an additional 876 (95% uncertainty interval (UI) -76 to 5518) in Cameroon and -6 (95% UI -61 to 96) in Kenya would start treatment under the intervention. Treatment success would increase by 5% in Cameroon and 9% in Kenya under the intervention compared with SoC. An estimated 350 (95% UI -31 to 2204) and 3 (95% UI -22 to 48) deaths would be prevented in Cameroon and Kenya, respectively. The incremental cost-effectiveness ratio for the intervention compared with SoC was US$506 and US$1299 per DALY averted in Cameroon and Kenya, respectively.

Interpretation: Although likely to be effective, the cost-effectiveness of integrating tuberculosis services into child healthcare services depends on baseline service coverage, tuberculosis detection and treatment outcomes.

Introduction: Paediatric tuberculosis (TB) underdiagnosis is a critical concern. The INPUT stepped-wedge cluster-randomised trial assessed the impact of integrating child TB services into child healthcare on TB case detection among children under age 5 years.

Methods: We compared the standard of care, providing TB care in specific TB clinics (control phase), with the Catalysing Paediatric TB Innovations (CaP-TB) intervention, integrating TB services across all child health services (intervention phase). 12 clusters in Cameroon and Kenya transitioned from the standard of care to the intervention at randomly assigned times. Children with presumptive TB were enrolled after obtaining their parents' consent and were followed throughout TB diagnostic procedures and treatment. Study outcomes included the rate of children with presumptive TB receiving TB investigations and that of children diagnosed with TB (the primary outcome was case detection), per thousand children under 5 years attending facilities. Generalised linear mixed Poisson models estimated the intervention's effect as adjusted rate ratios (aRR) and associated 95% CIs. Ad hoc country-stratified analyses were conducted.

Results: During control and intervention phases, respectively, 121 909 and 109 614 children under 5 years attended paediatric entry points, 133 (1.1 per thousand) and 610 (5.6 per thousand) children with presumptive TB received TB investigations, and 79 and 74 were diagnosed with TB, corresponding to a case detection rate of 0.64 and 0.68 per thousand, respectively. CaP-TB significantly increased TB investigations in both countries overall (aRR=3.9, 95% CI 2.4 to 5.4), and in each. Overall, TB case detection was not statistically different between intervention and control (aRR 1.32, 95% CI 0.66 to 2.61, p=0.43). Country-stratified analysis revealed a 10-fold increase (aRR 9.75, 95% CI 1.04 to 91.84, p=0.046) in case detection with CaP-TB in Cameroon and no significant effect in Kenya (aRR 0.94, 95% CI 0.44 to 2.01, p=0.88).

Conclusion: CaP-TB increased TB investigations in both study countries and markedly enhanced TB case detection in one, underlining integrated TB services' potential to address paediatric TB underdiagnosis.

Net Zero is the dominant framework for organising health system decarbonisation. Yet throughout Net Zero's rise to prominence, greenhouse gas emissions have remained on a dangerous trajectory. In this analysis, we synthesise strands of Net Zero critique from the climate policy literature, examine their implications for health systems and briefly present an alternative framework for decarbonisation. We begin by reviewing three families of Net Zero critique which have, to date, received little attention in the sustainable healthcare space: unambitious and inequitable pledges, accounting failures, and structural problems with the framework itself. Together, these critiques challenge the idea that the Net Zero agenda is best positioned to deliver upon the Paris Agreement commitment to limit temperature rise to below 1.5°C-2°C. We then consider how each challenge manifests in the health sector with examples from state and non-state actors. Finally, we briefly introduce an alternative 'reduce and support' approach which aims to address some of Net Zero's weaknesses. Reduce-and-support represents a conceptual pivot that would extend current best practices in science-based mitigation targets while exchanging the atomised trading of problematic carbon offsets for resource pooling towards collective efforts at deep decarbonisation. We discuss the moral, political and practical advantages of this framework and identify areas for future work. By considering the adoption of reduce-and-support, health systems can provide leadership for ratcheting climate ambition at this pivotal moment of accelerating climate breakdown.

Background: Surgical diseases contribute substantially to death and disability in Cameroon. Strategic planning for surgical, obstetric and anaesthesia (SOA) care in low-income and middle-income countries (LMICs) requires consideration of the policy environment in addition to the issue severity. We aimed at the current landscape of SOA care in Cameroon, incorporating a framework for political prioritisation.

Methods: A scoping review of published and grey literature was performed. Literature specific to Cameroon, published between 2010 and 2020 and written in either English or French, was included. Abstracts and full texts were screened for discussion of SOA policy context, care and delivery conditions, and issue characteristics. Data extraction and analysis were performed using the Shiffman and Smith framework for political prioritisation accounting for actors, ideas, political context and issue characteristics.

Results: 121 articles were included. By specialty, 83 articles were specific to surgery, 45 to obstetrics and 6 to anaesthesia. Policy environment was discussed by 20% (n=25) articles; 30% (n=37) discussed actor power; 22% (n=27) discussed ideas in SOA care and 93% discussed issue characteristics. Core challenges to political prioritisation of SOA care in Cameroon are limited actor support, a lack of consensus definitions, gaps in capacity and a need for systematic data collection on surgical diseases. Policy opportunities include leveraging existing multilateral partnerships to unify SOA actors, conducting national assessments of SOA care capacity, formalisation of task shifting to build capacity, defining essential SOA procedures, including surgical care in future health coverage, and defining and including SOA benchmarks in strategic planning.

Conclusions: Integrating a framework for political prioritisation into a situational analysis of SOA care is critical to understanding an LMIC's policy context and actors, in addition to issue severity. Such an approach can serve as a baseline for analysis in evidence-informed policy-making for SOA care, even in the absence of centralised, country-wide data.