BMJ Global Health最新文献

Introduction: The private sector occupies a dominant position in Georgia's health system, with most hospitals, primary care clinics, diagnostic facilities, pharmacies and insurance companies under for-profit ownership. Robust governance arrangements are required to align the profit-orientation of providers with health policy objectives.

Methods: This paper examines governance arrangements in Georgia's 'mixed' health system. It draws on document analysis, key informant interviews and a validation workshop. Analysis is guided by the WHO's 'governance behaviours' framework, focusing on strategy, regulation, purchasing and information generation as well as mechanisms for policy dialogue, actor alignment and trust building.

Results: Georgia has established a complex array of governance mechanisms for its dominant private health sector, but these remain weakly enforced. Strategic plans lack detailed implementation and budgetary integration; regulation and purchasing structures are fragmented; data systems and oversight capacity are limited; and consultation mechanisms underdeveloped-together constraining accountability, efficiency and progress towards universal health coverage.

Concluding discussion: Georgia's experience highlights a persistent gap between governance intent and implementation capacity. In highly marketised systems, sustained political commitment and investment in state capacity for enforcement, data use and stakeholder dialogue are essential to align private incentives with policy goals-and advance universal health coverage.

Background: Significant physiological changes occur in adolescence, including the onset of menarche in girls. However, the extent to which menstrual bleeding contributes to anaemia and micronutrient deficiencies remains unclear. This study assesses the prevalence of anaemia and micronutrient deficiencies and examines their association with menarcheal status, menstrual bleeding severity and other factors among adolescent girls in Lebanon.

Methods: Data were collected as part of a nationally representative cross-sectional study involving 2254 adolescent girls, 10-19 years of age. Household interviews were used to gather information on household demographics and wealth, and individual interviews assessed dietary diversity, menarcheal status and menstrual bleeding severity (assessed for post-menarche girls only). Blood samples were analysed to determine haemoglobin, ferritin, retinol-binding protein, folate and vitamin B12 levels. We used multivariable models to identify factors associated with anaemia and deficiencies in iron, folate, vitamin B12 and vitamin A.

Results: Overall, 20.3% of girls had anaemia, 29.5% iron deficiency, 13.9% iron deficiency anaemia, 14.4% folate deficiency, 17.7% vitamin B12 deficiency and 3.9% vitamin A deficiency. Among post-menarche adolescent girls, 22.4% reported severe menstrual bleeding. Bleeding severity was significantly associated with iron deficiency and iron deficiency anaemia in multivariable models. Iron deficiency was the primary predictor of anaemia, and a significant dose-response relationship was found between menstrual bleeding and anaemia in iron-deficient girls. Post-menarche status, but not bleeding severity, was associated with 46% and 54% higher prevalence of B12 and folate deficiencies, respectively. Neither menarcheal status nor bleeding severity was associated with vitamin A deficiency.

Conclusion: Among adolescent girls in Lebanon, anaemia and micronutrient deficiencies were common, and menstrual bleeding severity was strongly associated with iron deficiency and anaemia in iron deficient girls. Menstrual health is a key predictor of nutritional status in adolescent girls and should be integrated into health programmes and nutrition assessments.

Introduction: Undernutrition is a cause of nearly half of all deaths among children under 5 years old. Small-quantity lipid-based nutrient supplements (SQ-LNS) have been shown to prevent child wasting, stunting, anaemia and mortality among children 6-23 months of age in low- and middle-income countries (LMICs). Scaling up effective preventive interventions is urgent given the current global food insecurity and nutrition crisis.

Method: To prioritise SQ-LNS scale-up activities, we identified countries with the highest burdens of wasting, stunting and all-cause mortality among children 6-23 months of age at the national level using the most recent national survey data including the Demographic and Health Survey and Multiple Indicator Cluster Surveys, as well as the Lives Saved Tool in LMICs. National-level estimates informed a care cascade model to assess the potential impact of SQ-LNS on all-cause mortality, stunting and wasting. We also conducted a subnational level analysis among the 20 highest burden countries with the most recent available survey data to identify the highest burden regions.

Results: Our analysis identified the top 20 countries with the highest burden of the three outcomes as: Niger, South Sudan, Yemen, Sudan, Somalia, Democratic Republic of Congo, Eritrea, Nigeria, Central African Republic, Guinea, Equatorial Guinea, Chad, Papua New Guinea, Benin, Mali, Angola, Pakistan, Timor-Leste, Sierra Leone and Côte d'Ivoire, although for some countries the survey data were collected >10 years ago. Some of these countries also ranked high in population estimates of acute food insecurity. The care cascade model demonstrates that a large number of cases of stunting and wasting and deaths could be potentially averted if SQ-LNS is provided.

Conclusion: Most of the top 20 countries are in Sub-Saharan Africa, with a few in South and Southeast Asia. This geographical concentration underscores the urgent need for targeted interventions in these regions to prevent child malnutrition.

Background: Primary healthcare is crucial for universal health coverage in low- and middle-income countries. While research on improving workforce performance has focused on training and incentives, the impact of basic payment system functions remains underexplored. This study investigates salary delays among public-sector primary care workers across 16 low- and middle-income countries and the association of delays with worker outcomes.

Methods: We analysed data from World Bank Service Delivery Indicators and Health Results-Based Financing surveys (2010-2018), covering 22 003 primary care workers from 8301 public-sector facilities. Salary delay was defined as any self-reported delay in receiving the previous month's base salary. We examined patterns of delays and their associations with worker motivation, satisfaction and performance using fixed-effects linear probability models.

Findings: On average, 37% of health workers experienced salary delays, ranging from 2% to 83% across countries, primarily due to funding shortages and administrative issues. Delays were more common among workers without formal contracts and in rural or lower-level facilities. Experiencing a salary delay was associated with a 3.1 percentage point (pp) lower probability of being satisfied with one's salary (95% CI -5.7 to -0.5), a 4.6 pp lower probability of feeling motivated (95% CI -7.0 to -2.3), a 1.9 pp higher probability of unauthorised absence (95% CI +0.3 to +3.5) and a 5.6 pp higher probability of outside employment (95% CI +2.5 to +8.6).

Interpretation: Salary delays are prevalent among public primary healthcare workers in resource-poor settings, affecting vulnerable groups and associated with negative worker outcomes. Addressing delays requires diagnosing bottlenecks across administrative tiers, improving cash-to-payroll execution and allocating resources equitably to settings and worker groups where delays are most concentrated. Future work should examine payment processes across administrative levels and incorporate routine measurement of salary timeliness to support accountability and inform targeted strategies to reduce delays.

Objective: To examine household-level patterns of self-reliance among forcibly displaced and host populations using the Self-Reliance Index (SRI) and identify opportunities for strengthening humanitarian programming, policy frameworks and service delivery systems that support sustainable well-being.

Methods: This secondary analysis draws on data from 7850 households collected by 10 organisations across 16 countries between 2020 and 2024. The SRI assesses self-reliance across 12 domains. We analysed baseline and longitudinal data disaggregated by camp and non-camp settings using descriptive and inferential statistics.

Findings: Baseline SRI scores were low overall (mean=2.21, SD=0.81, scale 1-5), indicating unmet essential needs and high reliance on external assistance. Among 1962 households assessed longitudinally, non-camp households demonstrated significant improvements (p<0.001) in employment (+0.66), financial resources (+0.0.60), debt reduction (+1.05) and savings (+1.21). Camp-based households, in contrast, showed minimal improvements, with some domains declining.

Conclusion: These findings highlight the potential for targeted programming in non-camp environments to foster household resilience. Policy reforms, multisectoral investments and inclusive development strategies are essential to support sustainable self-reliance among displaced populations and host communities.

Introduction: Same-day initiation (SDI) of antiretroviral therapy is recommended for people presenting with HIV who have no contraindications. We reviewed the evidence on SDI interventions in low- and middle-income countries (LMICs).

Methods: We conducted a systematic review and meta-analysis of randomised controlled trials of SDI in adults diagnosed with HIV in LMICs. We searched MEDLINE, Embase and the Cochrane Library up to December 2024. Primary outcomes were viral suppression and retention in care 6-12 months after enrolment. Based on a qualitative assessment of the complex trial interventions, we considered two subgroups: (1) interventions newly introducing SDI and (2) interventions improving SDI implementation in settings where it was already routinely available. We conducted random-effects meta-analysis, assessed risk of bias using the ROBUST instrument and used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of evidence.

Results: We identified 12 eligible trials, 7 introducing and 5 improving SDI. The trial interventions introducing SDI were sufficiently similar for meta-analysis. Introducing SDI likely has an important benefit for viral suppression (relative risk (RR) 1.18, 95% CI 1.06 to 1.30, moderate certainty) and retention in care (RR 1.12, 95% CI 1.00 to 1.25, low certainty) at 6-12 months The five trials improving SDI were too heterogeneous for meaningful meta-analysis. Individually, they showed either low to very low certainty for an important effect or, when implementing SDI in patients with tuberculosis (TB) symptoms, moderate to high certainty for little to no effect on viral suppression and retention in care.

Conclusion: Newly introducing SDI likely improves viral suppression and retention in care. However, the impact of interventions to improve SDI where already available is less clear. Two studies provided evidence against the concern that SDI may have adverse effects in participants with TB symptoms.

Prospero registration number: CRD42023482522.

Background: The link between drinking water salinity and increased blood pressure and hypertension risk among coastal and other populations remains unclear. To investigate this, we performed a systematic review and meta-analysis of observational studies on drinking water salinity and cardiovascular outcomes.

Methods: We systematically searched MEDLINE, Embase and Web of Science for relevant studies published until 10 May 2025. Observational studies reporting on the association between sodium in drinking water and systolic/diastolic blood pressure (SBP/DBP), hypertension, coronary heart disease (CHD), stroke and composite cardiovascular outcomes were prespecified to be included. We assessed study quality using the Newcastle-Ottawa Scale and performed random effects meta-analysis.

Results: We identified 27 observational studies (involving 74 063 unique participants from 7 countries), 15 of which included coastal populations. Comparing higher versus lower drinking water salinity, the mean differences were 3.22 mm Hg (95% CI 1.11 to 5.33) for SBP and 2.82 mm Hg (95% CI 1.44 to 4.20) for DBP. The pooled OR for hypertension, comparing higher versus lower water salinity, was 1.26 (95% CI 1.07 to 1.48). These associations were generally consistent across subgroups but were statistically significant for studies conducted in coastal populations and for those published after 2000. However, we found an insufficient number of studies with reliable data on CHD or stroke outcomes.

Conclusions: Higher drinking water salinity is associated with an elevated risk of blood pressure and hypertension, especially among coastal populations. More research is needed to examine connections with CHD and stroke, and to create strategies to counter salinity's effects, particularly in climate-vulnerable coastal areas.

The COVID-19 Treatment QuickStart Consortium worked with governments in seven low- and middle-income countries (LMICs), Ghana, Laos, Malawi, Nigeria, Rwanda, Uganda and Zambia, to implement COVID-19 test-and-treat programmes at 776 health facilities, including training over 5000 staff and facilitating a donation of 11 300 courses of the oral antiviral nirmatrelvir/ritonavir for treatment. This paper describes the process of implementing COVID-19 test-and-treat programmes in each country, provides aggregate programme monitoring data on numbers tested and treated and analyzes programme enablers and challenges. Between country-level programme initiation (Ghana, May 2023; Laos and Malawi, July 2023; Nigeria, June 2023; Rwanda, March 2023; Uganda, September 2023; Zambia, December 2022) and June 2024, a total of 731 970 SARS-CoV-2 tests were conducted. Of 6724 positive tests, a subset were documented to meet eligibility criteria for nirmatrelvir/ritonavir initiation, and 3041 patients were prescribed nirmatrelvir/ritonavir. The largest number of prescriptions was in Zambia. Programme enablers included decentralisation of services; task-shifting from higher to lower health worker cadres; increased access to point of care antigen tests, including self-tests; and the integration of COVID-19 with other health services. Challenges included COVID-19 de-prioritisation at the time of programme rollout, test commodity stockouts and expiries, and dwindling national surveillance efforts. Learnings from rapid initiation and scale-up of COVID-19 test-and-treat programmes in these seven countries can be used to inform future pandemic preparedness strategies in LMICs.