Bulletin of the World Health Organization最新文献

Objective: To develop a framework and index for measuring universal health coverage (UHC) at the district level in India and to assess progress towards UHC in the districts.

Methods: We adapted the framework of the World Health Organization and World Bank to develop a district-level UHC index (UHC _d ). We used routinely collected health survey and programme data in India to calculate UHC _d for 687 districts from geometric means of 24 tracer indicators in five tracer domains: reproductive, maternal, newborn and child health; infectious diseases; noncommunicable diseases; service capacity and access; and financial risk protection. UHC _d is on a scale of 0% to 100%, with higher scores indicating better performance. We also assessed the degree of inequality within districts using a subset of 14 tracer indicators. The disadvantaged subgroups were based on four inequality dimensions: wealth quintile, urban-rural location, religion and social group.

Findings: The median UHC _d was 43.9% (range: 26.4 to 69.4). Substantial geographical differences existed, with districts in southern states having higher UHC _d than elsewhere in India. Service coverage indicator levels were greater than 60%, except for noncommunicable diseases and for service capacity and access. Health insurance coverage was limited, with about 10% of the population facing catastrophic and impoverishing health expenditure. Substantial wealth-based disparities in UHC were seen within districts.

Conclusion: Our study shows that UHC can be measured at the local level and can help national and subnational government develop prioritization frameworks by identifying health-care delivery and geographic hotspots where limited progress towards UHC is being made.

Objective: To assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on protests by health workers.

Methods: We conducted an interrupted time series analysis of data from 159 countries for 2 years before and after the World Health Organization classified COVID-19 as a pandemic in March 2020, thus between 2018 and 2022. We produced models examining two main outcomes: (i) the total weekly number of health worker protests globally; and (ii) the number of countries with one or more health worker protests in a given week.

Findings: In total, there were 18 322 health worker protests in 133 countries between 2018 and 2022. The number of weekly health worker protests globally increased by 47% (30.1/63.5), an increase of 30.1 protests per week (95% confidence interval, CI: 11.7-48.6) at the onset of the COVID-19 pandemic. Furthermore, the number of countries experiencing such protests in a given week increased by 24% (5.7/24.1) following the declaration of the pandemic (an increase of 5.7 countries; 95% CI: 3.5-7.8).

Conclusion: The pandemic increased the overall level of health worker protests globally as well as the number of countries experiencing such protests. These protests highlight discontent in the health workforce. Given the ongoing global health workforce crisis, understanding and addressing the drivers of health worker discontent is important for global health policy and security.

Health-care technology is central to boosting the productivity and quality of health-care systems. In many sub-Saharan African countries, however, medical device management systems are weak or absent. The aim of this article is to illustrate, using a case study, how policy reforms can help ensure policy on health-care technology is translated into everyday practice and how an integrated systems approach can enhance the operation of medical device management. Between 2011 and 2023, a plan to improve medical device management systems in the United Republic of Tanzania was developed and implemented through Swiss-Tanzanian cooperation within the Health Promotion and System Strengthening Project. The availability of biomedical engineers was increased through new training courses and the creation of permanent positions in government. Moreover, additional district and regional maintenance and repair workshops were built, and a National Centre for Calibration and Training was established to ensure the correct functioning of medical devices. The introduction of an electronic medical device management system provided health facilities and the health ministry with data on the operational status of medical devices and the need for repairs and spare parts. Every level of government was encouraged to allocate more human and financial resources to medical device management. Following this decade-long effort, the percentage of functioning equipment increased substantially, and costs were reduced by repairing rather than replacing equipment. The project also demonstrated the value of an integrated, system-strengthening approach that considered personnel, maintenance and repair facilities, documentation and management, and government policy and budgeting.

As an increasing number of jurisdictions legalize assisted dying, attention is focusing on palliative care clinicians' role in service delivery. Gary Humphreys reports.

Most phase III trials in drug-resistant tuberculosis have either been underpowered to quantify differences in microbiological endpoints or have taken up to a decade to complete. Composite primary endpoints, dominated by differences in treatment discontinuation and regimen changes, may mask important differences in treatment failure and relapse. Although new regimens for drug-resistant tuberculosis appear very effective, resistance to new drugs is emerging rapidly. There is a need for shorter, safer and more tolerable regimens, including those active against bedaquiline-resistant tuberculosis. Transitioning from multiple regimen A versus regimen B trials to a single large phase III platform trial would accelerate the acquisition of robust estimates of relative efficacy and safety. Further efficiencies could be achieved by adopting modern adaptive platform designs. Collaboration among trialists, affected community representatives, funders and regulators is essential for developing such a phase III platform trial for drug-resistant tuberculosis treatment regimens.

Problem: By 31 December 2021, only 5.5% (861 879/15 670 530) of the Somali population had been fully vaccinated against coronavirus disease 2019 (COVID-19).

Approach: To rapidly increase COVID-19 vaccine coverage in 2022, the health ministry and its partners (World Health Organization and United Nations Children's Fund) adopted a more responsive strategy. This strategy included careful microplanning, better targeting of populations and providing people-centred vaccination services close to their homes. These services were combined with childhood vaccination and basic health-care provision using the existing polio network and community health workers. Additionally, a digital tool for recording COVID-19 vaccination data and a mobile phone-based electronic registration system were introduced.

Local setting: Somalia, a fragile and conflict-affected state, faced challenges when implementing COVID-19 vaccination, including inexperience in managing mass adult vaccination, inadequate infrastructure and health workforce. Furthermore, insecurity in some areas and severe drought resulted in large-scale displacement of people.

Relevant changes: The implementation of a more context-specific strategy helped Somalia reach substantially more people with COVID-19 vaccination and 42.1% coverage by 31 December 2022. Additionally, 84 600 zero-dose children received their first childhood vaccine during the integrated campaigns. The increased coverage has led to public health benefits that outweigh the investment in the COVID-19 vaccination campaigns.

Lessons learnt: Successful roll-out of adult vaccination is achievable even in a fragile and conflict-affected setting through implementation of a tailored contextualized approach. Key factors include good microplanning, use of digital tools, better population-targeting, bundling vaccines together and delivering vaccination services close to people's homes.

Objective: To test the effect of proactive home visits by trained community health workers (CHWs) on child survival.

Methods: We conducted a two arm, parallel, unmasked cluster-randomized trial in 137 village-clusters in rural Mali. From February 2017 to January 2020, 31 761 children enrolled at the trial start or at birth. Village-clusters received either primary care services by CHWs providing regular home visits (intervention) or by CHWs providing care at a fixed site (control). In both arms, user fees were removed and primary health centres received staffing and infrastructure improvements before trial start. Using lifetime birth histories from women aged 15-49 years surveyed annually, we estimated incidence rate ratios (IRR) for intention-to-treat and per-protocol effects on under-five mortality using Poisson regression models.

Findings: Over three years, we observed 52 970 person-years (27 332 in intervention arm; 25 638 in control arm). During the trial, 909 children in the intervention arm and 827 children in the control arm died. The under-five mortality rate declined from 142.8 (95% CI: 133.3-152.9) to 56.7 (95% CI: 48.5-66.4) deaths per 1000 live births in the intervention arm; and from 154.3 (95% CI: 144.3-164.9) to 54.9 (95% CI: 45.2-64.5) deaths per 1000 live births in the control arm. Intention-to-treat (IRR: 1.02; 95% CI: 0.88-1.19) and per-protocol estimates (IRR: 1.01; 95% CI: 0.87-1.18) showed no difference between study arms.

Conclusion: Though proactive home visits did not reduce under-five mortality, system-strengthening measures may have contributed to the decline in under-five mortality in both arms.