Global health in low-income and middle-income countries: a framework for action

Results from medical research from high-income countries may not apply to low- and middle-income countries. Some expatriate physicians combine clinical duties with research. We present global health research conducted by Dutch medical doctors in Global Health and Tropical Medicine in low- and middle-income countries and explore the value of their research. We included all research conducted in the last 30 years by medical doctors in Global Health and Tropical Medicine in a low- and middle-income country, resulting in a PhD thesis. Articles and co-authors were found through Medline. More than half of the 18 identified PhD theses concerned maternal health and obstetrics, and the majority of the research was conducted in low-income countries, mostly in rural hospitals. Over 70 local co-authors were involved. Different aspects of these studies are discussed.

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Addressing power imbalances in global health: Pre-Publication Support Services (PREPSS) for authors in low-income and middle-income countries

BMJ Global Health ◽

10.1136/bmjgh-2020-002323 ◽

2020 ◽

Vol 5 (2) ◽

pp. e002323

Author(s):

Clara Busse ◽

Ella August

Keyword(s):

Global Health ◽

Low Income ◽

Health Research ◽

Research Process ◽

Support Service ◽

Global Health Research ◽

Contextual Knowledge ◽

Middle Income ◽

Middle Income Countries ◽

Structural Inequities

The contextual knowledge and local expertise that researchers from low-income and middle-income countries (LMICs) contribute to studies in these settings enrich the research process and subsequent publications. However, health researchers from LMICs are under-represented in the scientific literature. Distally, power imbalances between LMICs and high-income countries, which provide funding and set priorities for research in LMICs, create structural inequities that inhibit these authors from publishing. More proximally, researchers from LMICs often lack formal training in research project management and in publishing peer-reviewed research. Though academic journals may value research from LMICs conducted by local researchers, they have limited time and financial resources to support writing, causing them to reject manuscripts with promising results if they lack development. Pre-Publication Support Service (PREPSS) is a non-profit, non-governmental organisation that works to meet this need. PREPSS provides onsite training, peer-review and copy editing services to researchers in LMICs who wish to publish their health research in peer-reviewed journals. Authors are not charged for these services. After receiving PREPSS services, authors submit their manuscript to a peer-reviewed journal. The PREPSS model is one of many interventions necessary to restructure global health research to better support health researchers in LMICs and reduce current power imbalances.

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How global is global health research? A large-scale analysis of trends in authorship

BMJ Global Health ◽

10.1136/bmjgh-2020-003758 ◽

2021 ◽

Vol 6 (1) ◽

pp. e003758

Author(s):

Michelle C Dimitris ◽

Matthew Gittings ◽

Nicholas B King

Keyword(s):

Global Health ◽

Low Income ◽

Health Research ◽

Large Scale ◽

Health Science ◽

Global Health Research ◽

Middle Income ◽

Middle Income Countries ◽

Income Status ◽

Over Time

Many have called for greater inclusion of researchers from low- and middle-income countries (LMICs) in the conduct of global health research, yet the extent to which this occurs is unclear. Prior studies are journal-, subject-, or region-specific, largely rely on manual review, and yield varying estimates not amenable to broad evaluation of the literature. We conducted a large-scale investigation of the contribution of LMIC-affiliated researchers to published global health research and examined whether this contribution differed over time. We searched titles, abstracts, and keywords for the names of countries ever classified as low-, lower middle-, or upper middle-income by the World Bank, and limited our search to items published from 2000 to 2017 in health science-related journals. Publication metadata were obtained from Elsevier/Scopus and analysed in statistical software. We calculated proportions of publications with any, first, and last authors affiliated with any LMIC as well as the same LMIC(s) identified in the title/abstract/keywords, and stratified analyses by year, country, and countries’ most common income status. We analysed 786 779 publications and found that 86.0% included at least one LMIC-affiliated author, while 77.2% and 71.2% had an LMIC-affiliated first or last author, respectively; however, analagous proportions were only 58.7%, 36.8%, and 29.1% among 100 687 publications about low-income countries. Proportions of publications with LMIC-affiliated authors increased over time, yet this observation was driven by high research activity and representation among upper middle-income countries. Between-country variation in representation was observed, even within income status categories. We invite comment regarding these findings, particularly from voices underrepresented in this field.

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Enhancing quality of medical care in low income and middle income countries through simulation-based initiatives: recommendations of the Simnovate Global Health Domain Group

BMJ Simulation and Technology Enhanced Learning ◽

10.1136/bmjstel-2016-000180 ◽

2017 ◽

Vol 3 (Suppl 1) ◽

pp. S15-S22 ◽

Cited By ~ 6

Author(s):

Lekha Puri ◽

Jishnu Das ◽

Madhukar Pai ◽

Priya Agrawal ◽

J Edward Fitzgerald ◽

...

Keyword(s):

Quality Of Care ◽

Global Health ◽

Medical Care ◽

Low Income ◽

Middle Income ◽

Health Domain ◽

Middle Income Countries ◽

Simulation Based ◽

Quality Of Medical Care

BackgroundQuality of medical care in low income and middle income countries (LMICs) is variable, resulting in significant medical errors and adverse patient outcomes. Integration of simulation-based training and assessment may be considered to enhance quality of patient care in LMICs. The aim of this study was to consider the role of simulation in LMICs, to directly impact health professions education, measurement and assessment.MethodsThe Simnovate Global Health Domain Group undertook three teleconferences and a direct face-to-face meeting. A scoping review of published studies using simulation in LMICs was performed and, in addition, a detailed survey was sent to the World Directory of Medical Schools and selected known simulation centres in LMICs.ResultsStudies in LMICs employed low-tech manikins, standardised patients and procedural simulation methods. Low-technology manikins were the majority simulation method used in medical education (42%), and focused on knowledge and skills outcomes. Compared to HICs, the majority of studies evaluated baseline adherence to guidelines rather than focusing on improving medical knowledge through educational intervention. There were 46 respondents from the survey, representing 21 countries and 28 simulation centres. Within the 28 simulation centres, teachers and trainees were from across all healthcare professions.DiscussionBroad use of simulation is low in LMICs, and the full potential of simulation-based interventions for improved quality of care has yet to be realised. The use of simulation in LMICs could be a potentially untapped area that, if increased and/or improved, could positively impact patient safety and the quality of care.

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Towards ‘a balanced delegation’ or enhancing global health governance? Analysis of parties’ participation in the Conference of the Parties to WHO Framework Convention on Tobacco Control

Tobacco Control ◽

10.1136/tobaccocontrol-2018-054710 ◽

2018 ◽

Vol 28 (6) ◽

pp. 636-642 ◽

Cited By ~ 1

Author(s):

Evgeniya Plotnikova ◽

Sarah E Hill ◽

Alex Wright ◽

Jeff Collin

Keyword(s):

Global Health ◽

Tobacco Control ◽

Low Income ◽

Low Income Countries ◽

Global Health Governance ◽

Health Governance ◽

Middle Income ◽

Middle Income Countries ◽

Biennial Conference ◽

Declining Attendance

IntroductionThe success of the WHO Framework Convention on Tobacco Control (FCTC) depends on parties’ active participation in its governance and implementation, particularly via biennial Conference of the Parties (COP) meetings. The COP’s efficacy is threatened by declining attendance and reductions in travel support for low-income and middle-income countries, and there are growing concerns about transparency and representation in country delegations amid industry efforts to shape their composition.MethodsWe examined parties’ participation in the COP based on official meeting records, and the relationship between attendance and strength of tobacco control based on national global tobacco control reports.ResultsAttendance at the COP has decreased over time, and at several meetings would have fallen below 66% (the threshold for decision-making) if it was not for high levels of participation among low-income and lower-middle-income countries. Despite their higher attendance at COP meetings, these countries represent a smaller share of meeting attendees due to the smaller size of their delegations. Additionally, there has been a decline in the proportion of delegates from ministries of health and tobacco control focal points. Nationally, COP participation is correlated with stronger tobacco control policies; attendance by low-income countries has a strong correlation with implementation of advertising bans, while attendance among high-income and lower-middle-income countries shows a moderate correlation with implementation of tobacco taxes.ConclusionsSupporting states to actively engage in the COP is crucial for ongoing FCTC implementation, strengthening national capacity for tobacco control, and protecting the legitimacy and efficacy of global health governance.

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Sustainable development for global mental health: a typology and systematic evidence mapping of external actors in low-income and middle-income countries

BMJ Global Health ◽

10.1136/bmjgh-2019-001826 ◽

2019 ◽

Vol 4 (6) ◽

pp. e001826 ◽

Cited By ~ 2

Author(s):

Valentina Iemmi

Keyword(s):

Mental Health ◽

Sustainable Development ◽

Mental Disorders ◽

Global Health ◽

Low Income ◽

Global Mental Health ◽

Middle Income ◽

Evidence Mapping ◽

Middle Income Countries ◽

External Actors

IntroductionMental disorders account for a substantial burden of disease and costs in low-income and middle-income countries (LMICs), but attract few resources. With LMIC governments often under economic pressure, an understanding of the external funding landscape is urgently needed. This study develops a new typology of external actors in global health adapted for the sustainable development goals (SDGs) era and uses it to systematically map available evidence on external actors in global mental health.MethodsThe new typology was developed in line with conceptualisation in the literature and the SDGs to include 11 types of external actors for health in LMICs. Five databases (EconLit, Embase, Global Health, MEDLINE, PsycINFO) were searched for manuscripts published in peer-reviewed journals in English, French, Italian, Portuguese or Spanish between 1 January 2000 and 31 July 2018 and reporting information on external actors for mental disorders in LMICs. Records were screened by abstract, then full-text against inclusion criteria. Data were extracted and synthesised using narrative analysis.Results79 studies were included in the final review. Five were quantitative studies analysing the resource flow of development assistance for mental health globally over the last two decades. The remainder were qualitative studies providing a description of external actors: the majority of them were published in the last decade, focused on Africa, and on public sector (bilateral and multilateral governmental organisations) and third sector organisations (non-governmental organisations). Evidence was particularly scarce for for-profit organisations and individual households.ConclusionThis study reveals opportunities for unlocking additional funding for global mental health in the SDG-era from an ecosystem of external actors, and highlights the need to coordinate efforts and to use sustainable, ethical approaches to disbursements. Further research is needed to understand all external actors and the allocation of their contributions in different settings.

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Improving resource mobilisation for global health R&D: a role for coordination platforms?

BMJ Global Health ◽

10.1136/bmjgh-2018-001209 ◽

2019 ◽

Vol 4 (1) ◽

pp. e001209 ◽

Cited By ~ 2

Author(s):

Naomi Beyeler ◽

Sara Fewer ◽

Marcel Yotebieng ◽

Gavin Yamey

Keyword(s):

Global Health ◽

Low Income ◽

Priority Setting ◽

Low Income Countries ◽

Global Health Research ◽

Investment Strategies ◽

Middle Income ◽

The Sustainable Development ◽

Middle Income Countries ◽

Development Goals

Achieving many of the health targets in the Sustainable Development Goals will not be possible without increased financing for global health research and development (R&D). Yet financing for neglected disease product development fell from 2009-2015, with the exception of a one-time injection of Ebola funding. An important cause of the global health R&D funding gap is lack of coordination across R&D initiatives. In particular, existing initiatives lack robust priority-setting processes and transparency about investment decisions. Low-income countries (LICs) and middle-income countries (MICs) are also often excluded from global investment initiatives and priority-setting discussions, leading to limited investment by these countries. An overarching global health R&D coordination platform is one promising response to these challenges. This analysis examines the essential functions such a platform must play, how it should be structured to maximise effectiveness and investment strategies for diversifying potential investors, with an emphasis on building LIC and MIC engagement. Our analysis suggests that a coordination platform should have four key functions: building consensus on R&D priorities; facilitating information sharing about past and future investments; building in accountability mechanisms to track R&D spending against investment targets and curating a portfolio of prioritised projects alongside mechanisms to link funders to these projects. Several design features are likely to increase the platform’s success: public ownership and management; separation of coordination and financing functions; inclusion of multiple diseases; coordination across global and national efforts; development of an international R&D ‘roadmap’ and a strategy for the financial sustainability of the platform’s secretariat.

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Which public health interventions are effective in reducing morbidity, mortality and health inequalities from infectious diseases amongst children in low-income and middle-income countries (LMICs): protocol for an umbrella review

BMJ Open ◽

10.1136/bmjopen-2019-032981 ◽

2019 ◽

Vol 9 (12) ◽

pp. e032981

Author(s):

Elodie Besnier ◽

Katie Thomson ◽

Donata Stonkute ◽

Talal Mohammad ◽

Nasima Akhter ◽

...

Keyword(s):

Public Health ◽

Global Health ◽

Infectious Diseases ◽

Health Inequalities ◽

Low Income ◽

Health Interventions ◽

Umbrella Review ◽

Public Health Interventions ◽

Middle Income ◽

Middle Income Countries

IntroductionDespite significant progress in the last few decades, infectious diseases remain a significant threat to children’s health in low-income and middle-income countries. Effective means of prevention and control for these diseases exist, making any differences in the burden of these diseases between population groups or countries inequitable. Yet, gaps remain in our knowledge of the effect these public health interventions have on health inequalities in children, especially in low-income and middle-income countries. This umbrella review aims to address some of these gaps by exploring which public health interventions are effective in reducing morbidity, mortality and health inequalities from infectious diseases among children in low-income and middle-income countries.Methods and analysisAn umbrella review will be conducted to identify systematic reviews or evidence synthesis of public health interventions that reduce morbidity, mortality and/or health inequalities due to infectious diseases among children (aged under 5 years) in low-income and middle-income countries. The interventions of interest are public health interventions targeting infectious diseases or associated risk factors in children. We will search for reviews reporting health and health inequalities outcomes in and between populations. The literature search will be undertaken using the Cochrane Library, Medline, EMBASE, the CAB Global Health database, Health Evidence, the Campbell Collaboration Library of Systematic Reviews, International Initiative for Impact Evaluation Systematic review repository, Scopus, the Social Sciences Citation Index and PROSPERO. Additionally, a manual search will be performed in Google Scholar and three international organisations websites (UNICEF Office of Research—Innocenti, UNICEF, WHO) to capture grey literature. Data from the records meeting our inclusion/exclusion criteria will be collated using a narrative synthesis approach.Ethics and disseminationThis review will exclusively work with anonymous group-level information available from published reviews. No ethical approval was required.The results of the review will be submitted for publication in academic journals and presented at international public health conferences. Additionally, key findings will be summarised for dissemination to a wider policy and general public audience as part of the Centre for Global Health Inequalities Research’s policy work.PROSPERO registration numberCRD42019141673

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Teaching patient safety in global health: lessons from the Duke Global Health Patient Safety Fellowship

BMJ Global Health ◽

10.1136/bmjgh-2018-001220 ◽

2019 ◽

Vol 4 (1) ◽

pp. e001220 ◽

Cited By ~ 8

Author(s):

Bria E Johnston ◽

Randall Lou-Meda ◽

Sindy Mendez ◽

Karen Frush ◽

Judy Milne ◽

...

Keyword(s):

Patient Safety ◽

Quality Improvement ◽

Global Health ◽

Low Income ◽

Experiential Training ◽

Middle Income ◽

Implementation Challenges ◽

Intensive Training ◽

Middle Income Countries ◽

Local Safety

Health systems in low-income and middle-income countries (LMICs) have a high burden of medical errors and complications, and the training of local experts in patient safety is critical to improve the quality of global healthcare. This analysis explores our experience with the Duke Global Health Patient Safety Fellowship, which is designed to train clinicians from LMICs in patient safety, quality improvement and infection control. This intensive fellowship of 3–4 weeks includes (1) didactic training in patient safety and quality improvement, (2) experiential training in patient safety operations, and (3) mentorship of fellows in their home institution as they lead local safety programmes. We have learnt several lessons from this programme, including the need to contextualise training to local needs and resources, and to focus training on building interdisciplinary patient safety teams. Implementation challenges include a lack of resources and data collection systems, and limited recognition of the role of safety in global health contexts. This report can serve as an operational guide for intensive training in patient safety that is contextualised to global health challenges.

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How do primary healthcare workers in low-income and middle-income countries obtain information during consultations to aid safe prescribing? A systematic review protocol

BMJ Open ◽

10.1136/bmjopen-2018-023015 ◽

2019 ◽

Vol 9 (1) ◽

pp. e023015 ◽

Cited By ~ 1

Author(s):

Chris Smith ◽

Michelle Helena van Velthoven ◽

Neil Pakenham-Walsh

Keyword(s):

Global Health ◽

Low Income ◽

Primary Healthcare ◽

Healthcare Workers ◽

Inappropriate Prescribing ◽

Adverse Outcomes ◽

Cochrane Central Register ◽

Middle Income ◽

Middle Income Countries ◽

Use Of Resources

IntroductionThere is a wide variety in prescribing by primary healthcare workers in low-income and middle-income countries. While there is much information available, both online and offline, there is variation in quality and relevance to different settings. Acting on incorrect or out-of-date information can lead to inappropriate prescribing and impact on patient safety. The aim of this review is to systematically review the evidence on how primary healthcare workers obtain information during consultations to prescribe safely and appropriately.Methods and analysisWe will identify relevant articles by searching electronic databases: Medline (Ovid), EMBASE (Ovid), Cochrane Central Register of Controlled Trials, CABI Global Health (Ovid), WHO global health library, POPLINE, Africa-Wide Information (Ebsco), Library, Information Science & Technology Abstracts (Ebsco), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform. Also, the Health Information For All network will be consulted and evidence databases (TRIP database, Epistemonikos, PDQ Evidence) will be searched. We will hand-search reference lists, run citation searches of included studies and email authors of identified papers. Observational and intervention studies involving primary healthcare workers in low-income and middle-income countries who prescribe and/or dispense medication will be included. The primary outcome is the proportion of healthcare workers obtaining information relevant to consultations from different sources. Secondary outcomes are the change in healthcare provider and patient knowledge or behaviour, adverse outcomes and use of resources. We will exclude studies focusing on secondary care. We anticipate a limited scope for meta-analysis and will provide a narrative overview of findings and tabular summaries of extracted data.Ethics and disseminationNo ethics approval is required. Findings will be disseminated through the Healthcare Information For All network.PROSPERO registration numberCRD42018091088.

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