BMJ Global Health最新文献

Introduction: An adequate health workforce is one of the cornerstones of a healthy nation. Over the last two decades, Africa has gained momentum in mitigating critical health workforce gaps, but urgent actions are still needed to accelerate progress towards universal health coverage and ensuring health security. This analysis provides an overview of the health workforce in the WHO African Region for the last decade.

Methods: Data were extracted and triangulated from the National Health Workforce Accounts (NHWA), health labour market analyses, countries' human resources for health (HRH) profiles, HRH strategic plans and annual reports. A descriptive analysis of health worker stock, training capacity and unemployment levels was undertaken. The density of health workers was calculated per 10 000 population for each country and examined by occupational groups and income levels of the countries to provide a more comprehensive understanding of the health workforce dynamics.

Results: The stock of the health workforce progressively increased from 1.6 million in 2013 to 4.3 million in 2018 and 5.1 million in 2022. The stock of doctors, nurses, midwives, dentists and pharmacists was 2.6 million in 2022, representing a threefold increase over 10 years, with an annual growth rate of 13%. The density of these five health workforce occupations grew by 1.9% per annum between 2018 and 2022, from 11.14 per 10 000 in 2013 to 26.82 per 10 000 in 2022. The health professions education capacity in the region increased by 70%, with the annual education output growing from 148 357 graduates in 2018 to over 255 000 in 2022. The comprehensiveness of the findings can be attributed to improvement in health workforce data availability and quality as more countries implement the NHWA. The improvements in the health workforce in the region are also partly attributable to increasing investments in the capacity of health professions education institutions to produce more health workers, and use of evidence in planning, decision-making and high-level advocacy at various levels to invest in health workers.

Conclusion: This study provides crucial insights for policy reforms and investments to enhance the health workforce, which is essential to achieving universal health coverage and ensuring health security. While progress is notable, countries with unique challenges need targeted analyses and continuous support to develop the necessary number and skills of health workers in the African region.

Background: Parenting programmes, including those delivered in the Global South, are effective strategies to reduce violence against children (VAC). However, there is limited evidence of their impact when implemented at scale within routine delivery systems. This study aimed to address this gap by evaluating the real-world delivery of Parenting for Lifelong Health for Teens in Tanzania.

Methods: Participating parents/caregivers and their adolescent girls were recruited by local implementing partners in 2020-2021 as part of a community-based HIV prevention initiative focused on addressing drivers of female adolescent HIV-vulnerability such as VAC, caregiver-adolescent relationships and sexual reproductive health communication. The 14-session, group-based parenting programme was delivered by trained teachers and community facilitators. Quantitative surveys administered by providers measured a variety of outcomes including child maltreatment (primary outcome) and multiple secondary outcomes linked to increased risk of VAC. Multilevel models examined pre-post effects as well as variation by attendance and baseline demographic variables.

Results: Pre-post data from 27 319 parent/caregiver-child dyads were analysed, of which 34.4% of parents/caregivers were male. Analyses showed large reductions in child maltreatment (parents/caregivers: IRR=0.55, (95% CI 0.54, 0.56); adolescents: IRR=0.57, (95% CI 0.56, 0.58)), reduced intimate partner violence experience, reduced school-based violence, increased communication about sexual health, reduced poor supervision, reduced financial insecurity, reduced parenting stress, reduced parent and adolescent depression, and reduced adolescent conduct problems. In contrast to these positive outcomes, parents/caregivers and adolescents also reported reduced parental positive involvement and support of education, with those experiencing greater adversity reporting less change than those with less adversity.

Conclusions: This study is the first to examine the large-scale implementation of an evidence-based parenting programme in the Global South. Although additional research is necessary to examine potential negative effects on positive parenting and parent support of education, findings suggest that Furaha Teens can sustain its impact on key outcomes associated with VAC when delivered at scale.

Background: Caesarean section (CS) is the most common major surgery conducted globally, with rates rising. CS also contributes to maternal morbidity and mortality, with increased risks in low-resource settings. We conducted a detailed review of maternal deaths from 2020 to 2022 in Malawi to determine the burden of deaths related to CS, avoidable health system factors, and causes of death associated with this procedure.

Methods: Data were collected regarding every maternal death occurring across all district and central hospitals in Malawi, alongside facility-level aggregated birth data. Maternal deaths were reviewed by facility-based multidisciplinary teams with subsequent confirmation of cause of death by obstetricians according to international criteria. Logistic regression was applied to estimate the odds of associations of leading causes of death with CS while adjusting for potential confounders.

Results: Despite a low national CS rate, most deaths occurred following CS (51.8%, 276/533). Women who delivered by CS were five times (OR 5.60, 95% CI 4.74 to 6.67) more likely to die than women who delivered vaginally. The leading causes of death following CS were postpartum haemorrhage (26.0%, 68/277), eclampsia (15.6%, 41/277) and infection (14.1%, 37/277). Deaths from pregnancy-related infection were more often associated with CS (OR 2.03, 95% CI 1.12 to 3.72). Health system factors more frequently associated with deaths following CS than vaginal birth included 'prolonged abnormal observations without action' (p=0.006), 'delay in starting treatment' (p=0.006) and 'lack of blood transfusion' (p=0.03).

Conclusions: We found a high burden of maternal death following CS in this low-resource setting. Until now, international attention and many clinical trials have been focused on improving the safety of vaginal birth. Our findings highlight the need to ensure the safe and appropriate use of this potentially life-saving intervention to reduce maternal deaths. To avoid the high burden of death following CS we highlight, there is urgent need to develop and trial CS-specific interventions.

Background: The alcohol industry uses many of the tobacco industry's strategies to influence policy-making, yet unlike the Framework Convention on Tobacco Control, there is no intergovernmental guidance on protecting policies from alcohol industry influence. Systematic assessment of alcohol industry penetration and government safeguards is also lacking. Here, we aimed to identify the nature and extent of industry penetration in a cross-section of jurisdictions. Using these data, we suggested ways to protect alcohol policies and policy-makers from undue industry influence.

Methods: As part of the International Alcohol Control Study, researchers from 24 jurisdictions documented whether 22 indicators of alcohol industry penetration and government safeguards were present or absent in their location. Several sources of publicly available information were used, such as government or alcohol industry reports, websites, media releases, news articles and research articles. We summarised the responses quantitatively by indicator and jurisdiction. We also extracted examples provided of industry penetration and government safeguards.

Results: There were high levels of alcohol industry penetration overall. Notably, all jurisdictions reported the presence of transnational alcohol corporations, and most (63%) reported government officials or politicians having held industry roles. There were multiple examples of government partnerships or agreements with the alcohol industry as corporate social responsibility activities, and government incentives for the industry in the early COVID-19 pandemic. In contrast, government safeguards against alcohol industry influence were limited, with only the Philippines reporting a policy to restrict government interactions with the alcohol industry. It was challenging to obtain publicly available information on multiple indicators of alcohol industry penetration.

Conclusion: Governments need to put in place stronger measures to protect policies from alcohol industry influence, including restricting interactions and partnerships with the alcohol industry, limiting political contributions and enhancing transparency. Data collection can be improved by measuring these government safeguards in future studies.

Objectives: The COVID-19 pandemic may have influenced alcohol and tobacco consumption in low-income and middle-income countries, yet the effects are relatively unknown. In this study, we estimated the medium-term effects of the pandemic on tobacco and alcohol consumption in India.

Methods: We used data from the fifth round of the National Family Health Survey 2019-2021, a nationally representative survey conducted between June 2019 and April 2021. We employed propensity score matching to evaluate the change in tobacco and alcohol consumption patterns by exploiting the gap in survey activities due to the pandemic lockdown-no data collection took place from April to October 2020. Individuals surveyed after the lockdown were considered COVID-19-affected, while those surveyed before were considered as unaffected.

Results: The tobacco use rate was 1.4% lower and alcohol consumption was 0.3% lower for COVID-19-affected individuals relative to non-affected individuals. By tobacco product, there was a 0.9%, 0.6% and 0.4% decrease in the use of smokeless tobacco, cigarettes and bidi, respectively. Recent initiation decreased by 2.3%, 1.6% and 1.4%, for cigarettes, smokeless tobacco and alcohol, respectively. Tobacco use declined to a greater extent in low-wealth and rural populations, and in male and older subsamples. Alcohol use decreased in urban households, and among male and young subsamples, relative to their counterparts. Secondhand smoke exposure decreased by 4.6%.

Conclusion: Tobacco and alcohol consumption, including recent initiation, decreased during the pandemic in India. Varying effects by subgroups suggest the need for targeted future control policies that support cessation and limit consumption.

Introduction: Digital data systems have the potential to improve data quality and provide individual-level information to understand gaps in the quality of care. This study explored experiences and perceptions of a perinatal eRegistry in two hospitals in Mtwara region, Tanzania. Drawing from realist evaluation and systems thinking, we go beyond a descriptive account of stakeholders' experiences and provide insight into key structural drivers and underlying social paradigms.

Methods: We carried out 6 weeks of focused ethnographic observations at the labour wards of the two hospitals and 29 semi-structured qualitative interviews with labour ward staff, as well as with administrative and managerial stakeholders at hospital, district and regional levels. Multi-stage reflexive thematic data analysis was carried out.

Results: We provide an in-depth account of the day-to-day functioning of the eRegistry in the two hospitals, including both aspects of positive change and key challenges with its integration into routine documentation duties. Experiences with and perceptions of the eRegistry were inextricably linked to broader systemic constraints relating to staffing, workload and infrastructure. A key underlying theme shaping the way people engaged with the eRegistry was the notion of data ownership: the presence or absence of a feeling of being responsible, involved and in control of data.

Conclusion: Some of the key systemic challenges in recording accurate, timely information about women and their babies are not solved by digital tools. Our findings also underline that when healthcare workers feel that data are not primarily for them, they document only for reporting purposes. The eRegistry increased a sense of data ownership among the nurse-midwives directly involved with data entry, but the potential for promoting and supporting data use feedback loops for improvement in care provision remained largely untapped. Our findings highlight the importance of local relevance and ownership in digitisation of routine health information systems.

Introduction: Low- and middle-income countries (LMICs) often dedicate limited domestic funds to expand quality early childhood care and education (ECCE), making complementary international donor support potentially important. However, research on the allocation of international development assistance for ECCE has been limited.

Methods: We analysed data from the Creditor Reporting System on aid projects to assess global development assistance for ECCE in 134 LMICs from 2007 to 2021. By employing keyword-searching and funding-allocation methods, we derived two estimates of ECCE aid: a lower-bound estimate comprising projects primarily focusing on ECCE and an upper-bound estimate comprising projects with both primary and partial ECCE focus, as well as those that could benefit ECCE but did not include ECCE keywords. We also assessed aid directed to conflict-affected countries and to ECCE projects integrating COVID-19-related activities.

Results: Between 2007 and 2021, the lower-bound ECCE aid totaled US$3646 million, comprising 1.7% of the total US$213 279 million allocated to education. The World Bank led in ECCE aid, contributing US$1944 million (53.3% out of total ECCE aid). Low-income countries received less ECCE aid per child before 2016, then started to catch up but experienced a decrease from US$0.8 (2020) per child to US$0.6 (2021) per child. Funding for ECCE projects with COVID-19 activities decreased from a total of US$50 million in 2020 to US$37 million in 2021, representing 11.4% and 6.6% of annual total ECCE aid, respectively. Over 15 years, conflict-affected countries received an average of US$0.3 per child, a quarter of the aid received by non-conflict-affected countries (US$1.2 per child).

Conclusion: Although ECCE aid increased significantly between 2007 and 2021, its proportion of total educational aid fell short of UNICEF's suggested 10% minimum. Recommendations include increasing the share of ECCE aid in total educational aid, increasing aid to low-income and conflict-affected countries, and investing more in preparing ECCE programmes for future global crises.

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.