BMJ Global Health最新文献

The emergence and spread of antimicrobial-resistant organisms is a major global health challenge. We report on the approach and outcomes of a programme which aimed to take a One Health approach, incorporating an understanding that the health of humans, animals and the environment are linked. Combating the Threat of Antimicrobial Resistance in Pacific Island Countries (COMBAT-AMR) was funded by the Australian Department of Foreign Trade and designed to build capacity across human and animal health to address the threat of antimicrobial resistance (AMR) in Fiji, Samoa, Papua New Guinea and the Solomon Islands between 2020 and 2023.Semi-structured interviews were undertaken with implementers, key stakeholders and participants across the programme themes (n=53). Evaluation of specific activities included participant surveys, competency assessments and document reviews.Both the human health and animal health sectors made significant progress in capacity-building and mentoring of local staff and collection and analysis of surveillance data. However, the sectors largely operated in parallel, with limited planning or resources allocated for explicit intersectoral activities. Resources allocated to animal health were also insufficient to compensate for under-resourced animal health sectors in comparison to human health sectors in the target countries.The increasing use of One Health approaches to address AMR necessitates careful consideration of strategies to support intersectoral collaboration at the design and implementation stages. The comprehensive evaluation of the COMBAT-AMR programme contributes to the current evidence base regarding operationalising One Health principles in building capacity in AMR in low- and middle-income countries.

Improving healthcare access in underserved areas remains a major challenge worldwide, particularly in low-income and middle-income countries. In Brazil, the Telehealth Network of Minas Gerais (TNMG) was created to address this gap by integrating digital health strategies into the public health system. This study describes TNMG's implementation framework, key projects, effectiveness, cost-benefit and actual coverage, while also identifying success factors and challenges over its 20-year trajectory. A retrospective analysis of operational data was conducted, including historical landmarks and project outcomes. TNMG's strategy is based on a structured and adaptive framework encompassing needs assessment, research and development, pilot testing and integration into routine care. The model aligns with national health policies and involves in-house software development, workforce training, performance monitoring and regular audits. Over two decades, TNMG has demonstrated the capacity for scale and sustainability. Its tele-ECG service spans 1374 municipalities in 14 states, with over 11.9 million ECGs interpreted remotely from June 2006 to October 2025, reducing diagnostic delays. Teleconsultations, which were initially associated with the prevention of 80% of unnecessary referrals, were expanded during COVID-19 to include risk stratification, direct consultations and telemonitoring. The tele-acute myocardial infarction project was associated with lower in-hospital mortality, from 17.2% to 11.6%, and scaled nationally in 2024 to 450 prehospital ambulances. A national telespirometry service has completed over 43 000 tests from December 2021 to October 2025, contributing to improved access to respiratory care. TNMG's success is linked to its cyclical process of implementation and innovation, alignment with public policies, cost-benefit and strong partnerships across sectors. However, challenges such as infrastructure limitations, digital literacy gaps and regulatory barriers persist. In conclusion, TNMG offers a scalable and sustainable model to reduce health inequities through digital health. Its experience provides actionable insights for other regions and countries aiming to strengthen health systems and expand access through telehealth.

In May 2025, the World Health Assembly adopted the historic WHO Pandemic Agreement, aimed at strengthening global pandemic preparedness and equity. This legally binding treaty emerged from years of negotiation shaped by the COVID-19 pandemic's stark inequities-particularly those experienced by African nations. While the treaty introduces important innovations, notably the Pathogen Access and Benefit-Sharing system, significant challenges remain. Ambiguities in equity commitments, geopolitical fragmentation and rising nationalism threaten effective implementation. For Africa, realising the treaty's promise requires robust legal frameworks, enhanced manufacturing and regulatory capacities and sustainable financing mechanisms that reduce donor dependency. This analysis critically examines the treaty's provisions and political economy, emphasising the need for enforceable obligations, continental leadership and multi-sectoral accountability. We propose the establishment of a Pandemic Peer Review Mechanism to embed political accountability at national and regional levels. Only through coordinated African leadership, institutional investment and global solidarity can the Pandemic Agreement deliver equitable health outcomes in a fracturing global order.

Background: Congenital anomalies are among the common health problems faced by children in low- and middle-income countries, contributing substantially to infant mortality rates. Due to limited access to newborn screening programmes in most of the resource-limited settings, many congenital anomalies go undiagnosed and untreated, leading to adverse outcomes. This study aimed to develop and validate a newborn screening tool for congenital anomalies for use in resource-limited settings.

Methods: A Delphi approach was used to assemble a group of experts and develop the screening tool. Tool validation was done by applying it to a reasonable number of neonates who were delivered and/or admitted to the neonatal intensive care unit of St. Paul's Hospital Millennium Medical College. Data were collected using Kobo Collect and then exported to Microsoft Excel and SPSS V.26 for analysis. Frequencies, percentages, mean and SD were used to describe categorical results. The sensitivity and specificity of the screening tool were calculated to assess its validity.

Results: A total of 1160 neonates were screened for congenital anomalies, of which 673 (58%) were male. The mean age of the newborns was 26.9±33 hours. Term newborns accounted for 898 (77.4%) of the study population. The prevalence of congenital anomalies in our series was 5.7%, with the most involved body systems being the central nervous system (33.7%), genitourinary (18.5%), gastrointestinal (11%) and musculoskeletal (11%). More than one anomaly was diagnosed in 11 (13.6%) neonates. The sensitivity and specificity of this tool were 86.4% and 97.8%, respectively. Furthermore, the positive and negative predictive values of the screening tool were 70.4% and 99.2%, respectively.

Conclusion: Congenital anomalies are not rare findings in our hospital. The neonatal screening tool, which was developed through this study, has commendable validity results in addition to being low-cost and easily implementable.

Introduction: The underlying causes of supply-side and demand-side challenges in immunisation are poorly understood, leading to symptomatic solutions. This study engaged stakeholders to develop model-based tools for understanding underlying mechanisms, addressing barriers and supporting the design of interventions and policies for immunisation services in Tanzania.

Methods: Between March 2023 and April 2024, we conducted a qualitative study involving eight in-depth interviews, 12 focus group discussions with 75 participants, and two participatory group model building workshops with 14-16 participants each. Immunisation stakeholders including vaccinators, vaccine coordinators, programme managers, community members and non-governmental organisations provided insights on barriers and facilitators to immunisation access, supply and demand. Their perspectives, combined with evidence from scientific and grey literature, informed the development of a causal loop diagram of immunisation in Tanzania, exploring potential leverage points for improvement.

Results: Several feedback mechanisms influencing vaccine uptake were identified, including vaccine confidence, risk-benefit perception, vaccine operations (planning, distribution and administration), health workforce, awareness campaigns, safety communication, service accessibility and service quality. Concerns about vaccine safety reduce willingness to vaccinate while limited accessibility and poor service quality diminish motivation to attend sessions. Despite early recovery efforts, the COVID-19 pandemic impacted these mechanisms, exacerbating misinformation, workforce and financial shortages, decreasing vaccine uptake and exposing weak system resilience. Barriers related to infrastructure, accessibility, workforce and service quality varied by region, with rural areas facing greater obstacles. Overall, immunisation resilience and sustainability remain vulnerable due to insufficient investment.

Conclusion: Linking demand and supply dynamics highlights potential leverage points for sustainable and resilient immunisation services, including vaccine acceptability and operational challenges. Addressing these requires adequate investments and accountability in vaccine safety surveillance and communication, awareness campaigns, vaccination sites, workforce capacity and effective vaccine operations. Quantitative modelling and scenario analysis are needed to confirm leverage points and design effective interventions and policies.

Subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is an injectable contraceptive method with a small needle and prefilled syringe system that has been approved for self-injection (SI) by clients. As DMPA-SC for SI programmes are being scaled, employing an implementation science lens is critical to understanding what works. This study explored providers' and clients' experiences with providing and receiving services, respectively, for DMPA-SC for SI in Nigeria, using an implementation science framework.Between 2021 and 2023, we conducted N=141 interviews with providers offering DMPA-SC for SI, and N=129 interviews with their clients using DMPA-SC for SI in Lagos, Enugu and Plateau States. Using Proctor et al's implementation science framework, we noted observations for each interview question, extracted related quotes, and coded observations and quotes by implementation outcome (acceptability, appropriateness, feasibility, fidelity, cost, efficiency, safety, client-centredness and adoption).Among clients, learning about DMPA-SC and SI from social network members facilitated acceptability and adoption of the method. Clients reported that provider outreach was appropriate for contraceptive information. However, providers desired support to mitigate their own out-of-pocket costs and enhance the feasibility of outreach. Occasionally, providers used clients' age or education to decide whether they could self-inject independently, rather than clients' ability to perform SI procedures, limiting client-centredness Many providers felt their fidelity to SI provision protocols could improve with refresher trainings on the latest guidelines around offering SI. Clients indicated that proactive follow-up support from providers for continued SI and side effect management was appropriate and desired; providers concurred with offering such support.Findings suggest that programme scale-up efforts should prioritise: (1) leveraging peer support or social networks to facilitate acceptability of DMPA-SC for SI among clients, (2) improving access to training aids to ensure fidelity to protocols and facilitate adoption among clients and providers, (3) emphasising shared decision-making in judgement-free client trainings to encourage client-centredness, and (4) investing in models for proactive follow-up support to improve feasibility of continuation for clients' desired length of time.

Effective coverage measurement has emerged as a tool to help understand health system performance for the provision of high-quality health care. Using a cascade approach that combines data on demand- and supply-side steps, effective coverage measures highlight where gaps in the health system exist and how improvements might be made so that more people benefit from the potential of the health services available to them. In practice, however, there are challenges in making this work. This analysis paper aimed to highlight those challenges in calculating effective coverage in Ethiopia, using antenatal care as a test case, and propose a solution.In Ethiopia, government leaders are committed to taking a data-informed approach to improving health care quality. To support this, an effective coverage technical working group was formed of individuals with experience of effective coverage analysis in Ethiopia to share knowledge and create learning for a way forward.Through methods analysis of one common indicator, the effective coverage of antenatal care, four key challenges were identified by the group: (1) features of the data sources used, (2) the number of cascade steps included in the effective coverage calculations, (3) the data elements included within cascade steps and (4) the methods applied to generate composite indicators.Multiple small differences were observed to have an influence on the usability of effective coverage measures for decision-making. The group concluded that greater transparency in reporting effective coverage measures was urgently needed and proposed and discussed the use of a reporting checklist for this purpose.

Africa renewed its efforts to document maternal and perinatal deaths in 2014 following the release of the WHO's maternal and perinatal death surveillance and response (MPDSR) guidelines. Successful implementation of MPDSR requires timely notification and a thorough documentation of maternal and perinatal deaths, the development of causal pathways, and the enactment of targeted improvement (change) actions to prevent future avoidable deaths. Similar to the Plan-Do-Study-Act (PDSA) iterative process used in the Model for Improvement (MFI), MPDSR rests on robust data reporting systems without which quality improvement initiatives are ineffective. Unfortunately, many African health systems have significant challenges with data collection and reporting, often compounded by a disconnect between public and private sectors, which erode efforts to improve MPDSR. Over the past decades, countries across Africa have produced MPDSR reports that, despite often appearing comprehensive, mask underlying operational deficiencies. These reports consistently highlight substantial barriers to implementing effective death reviews. Findings show that of 47 countries, 25 (53%) provided MPDSR reports, with East and Southern Africa contributing more than half. Notably, under 30% and 12% of maternal and neonatal deaths in the District Health Information Software (DHIS) were notified to MPDSR, and about 63% of maternal deaths were reviewed. Our analysis of MPDSR reports from 25 African countries, covering 2015 to 2022, supplemented by data from DHIS, reveals critical issues: a widespread shortage of skilled maternity healthcare workers trained in MPDSR, inadequate data harmonisation and lack of standardised maternal and newborn health metrics, insufficient funding, the absence of functioning MPDSR committees at facility level and weak leadership committed to maternal and newborn health goals. Addressing these bottlenecks is essential for strengthening MPDSR efforts and should guide WHO and other development partners to scale up maternal and perinatal death surveillance across Africa.

Introduction: The WHO has set a 2030 target to raise effective cataract surgical coverage (eCSC) by 30 percentage points in every country, requiring gains in surgical access and quality. Despite this mandate, evidence on how low- and middle-income health systems are implementing eCSC remains limited.

Methods: We conducted a qualitative comparative case study in Kenya and Nepal. 20 interviews were held with senior stakeholders from government, non-governmental organisations, academic institutions and clinical networks. Transcripts were thematically analysed using the consolidated framework for implementation research, adapted into a growing systems framework to capture national-level dynamics.

Results: Implementation unfolds within the inherent structures of each cataract system rather than through centrally imposed directives. In Kenya, cataract services operate within devolved county structures supported by non-governmental organization (NGO) partnerships and national technical coordination. In Nepal, vertically organised NGO networks deliver care through a hub-and-spoke outreach model with limited government oversight. Both systems incorporate context-specific adaptations to overcome barriers in access and postoperative quality. Public-private partnerships expand reach but are weakened by fragmented financing, reliance on donors and high out-of-pocket costs. Outcome monitoring is sporadic and seldom informs planning, limiting system-wide learning.

Conclusion: The eCSC target prompts change less by prescribing reform than by revealing the features that enable or constrain implementation. Sustained progress will require embedding outcome monitoring within routine information systems, strengthening public stewardship of mixed provider networks, mobilising domestic financing and designing services attuned to geographic and sociocultural realities.

Introduction: Motivated health workers are pivotal in providing adequate health services. This study aims to understand what motivates and demotivates maternal health workers. We do so in Somalia, an understudied country in Africa with pervasive security challenges and one of the highest avoidable maternal mortality rates.

Methods: This qualitative study explores health workers' motivation in three tertiary hospitals in the capital, Mogadishu. Twenty skilled healthcare professionals were interviewed, including nurses, midwives, physicians, specialists and supervisors. The interviews were transcribed verbatim and analysed using thematic analysis.

Results: Key factors influencing healthcare workers' motivation include job satisfaction, monetary and work-related support, effective managerial practices, career development and intrinsic motivation. Most health workers expressed a powerful combination of altruism, volunteerism and religious conviction, driving their professional commitment to the community. Challenges that led to demotivation included high patient volume, staff shortages, limited supplies, infrastructural constraints, unregulated managerial practices and health system limitations. While most health workers primarily wanted to meet patients' needs and did not consider salary a decisive motivating factor, others were demotivated by low pay and heavy workload.

Conclusion: Maternal health workers in Somalia face challenges that impact their motivation. Mitigating burnout through workload management and continued education can contribute to a more motivated and resilient healthcare workforce. Policy recommendations include offering long-term contracts, providing access to training and implementing fair and transparent employment policies. Further research is needed to evaluate the effectiveness of both financial and non-financial incentives in motivating health workers in Somalia.