Evaluating health systems strengthening interventions in low-income and middle-income countries: are we asking the right questions?

The availability of medical specialists has accelerated in low-income and middle-income countries (LMICs), driven by factors including epidemiological and demographic shifts, doctors’ preferences for postgraduate training, income growth and medical tourism. Yet, despite some policy efforts to increase access to specialists in rural health facilities and improve referral systems, many policy questions are still underaddressed or unaddressed in LMIC health sectors, including in the context of universal health coverage. Engaging with issues of specialisation may appear to be of secondary importance, compared with arguably more pressing concerns regarding primary care and the social determinants of health. However, we believe this to be a false choice. Policy at the intersection of essential health services and medical specialties is central to issues of access and equity, and failure to formulate policy in this regard may have adverse ramifications for the entire system. In this article, we describe three critical policy questions on medical specialties and health systems with the aim of provoking further analysis, discussion and policy formulation: (1) What types, and how many specialists to train? (2) How to link specialists’ production and deployment to health systems strengthening and population health? (3) How to develop and strengthen institutions to steer specialisation policy? We posit that further analysis, discussion and policy formulation addressing these questions presents an important opportunity to explicitly determine and strengthen the linkages between specialists, health systems and health equity.

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Advancing research on emergency care systems in low-income and middle-income countries: ensuring high-quality care delivery systems

BMJ Global Health ◽

10.1136/bmjgh-2018-001265 ◽

2019 ◽

Vol 4 (Suppl 6) ◽

pp. e001265 ◽

Cited By ~ 8

Author(s):

Rachel T Moresky ◽

Junaid Razzak ◽

Teri Reynolds ◽

Lee A Wallis ◽

Benjamin W Wachira ◽

...

Keyword(s):

Health Systems ◽

Emergency Care ◽

Low Income ◽

Communicable Diseases ◽

Middle Income ◽

Care Research ◽

Middle Income Countries ◽

Emergency Care Systems ◽

Care Systems ◽

Research Questions

Emergency care systems (ECS) address a wide range of acute conditions, including emergent conditions from communicable diseases, non-communicable diseases, pregnancy and injury. Together, ECS represent an area of great potential for reducing morbidity and mortality in low-income and middle-income countries (LMICs). It is estimated that up to 54% of annual deaths in LMICs could be addressed by improved prehospital and facility-based emergency care. Research is needed to identify strategies for enhancing ECS to optimise prevention and treatment of conditions presenting in this context, yet significant gaps persist in defining critical research questions for ECS studies in LMICs. The Collaborative on Enhancing Emergency Care Research in LMICs seeks to promote research that improves immediate and long-term outcomes for clients and populations with emergent conditions. The objective of this paper is to describe systems approaches and research strategies for ECS in LMICs, elucidate priority research questions and methodology, and present a selection of studies addressing the operational, implementation, policy and health systems domains of health systems research as an approach to studying ECS. Finally, we briefly discuss limitations and the next steps in developing ECS-oriented interventions and research.

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Understanding antimicrobial use in subsistence farmers in Chikwawa District Malawi, implications for public awareness campaigns

10.31235/osf.io/e7b6n ◽

2021 ◽

Author(s):

Eleanor MacPherson ◽

Joanna Reynolds ◽

Esnart Sanudi ◽

Alexander Nkaombe ◽

John Mankhomwa ◽

...

Keyword(s):

Low Income ◽

Public Awareness ◽

Antibiotic Use ◽

Subsistence Farming ◽

Formal Sector ◽

Middle Income ◽

The Public ◽

Middle Income Countries ◽

Awareness Campaigns ◽

The Right

Drug resistant infections are increasing across the world and urgent action is required to preserve current classes of antibiotics. Antibiotic use practices in low-and-middle-income countries have gained international attention, especially as antibiotics are often accessed beyond the formal health system. Public awareness campaigns have gained popularity, often conceptualising antimicrobial resistance (AMR) as a problem of excess, precipitated by irrational behaviour. Insufficient attention has been paid to people’s lived experiences of accessing medicines in low-income contexts. In Chikwawa District, Malawi, a place of extreme scarcity, our study aimed to understand the care and medicine use practices of households dependent on subsistence farming. Adopting an anthropological approach, we undertook medicine interviews (100), ethnographic fieldwork (six-month period) and key informant interviews (33) with a range of participants in two villages in rural Chikwawa. The most frequently used drugs were cotrimoxazole and amoxicillin, not considered to be of critical importance to human health. Participants recognised that keeping, sharing, and buying medicines informally was not the “right thing.” However, they described using antibiotics and other medicines in these ways due to conditions of extreme precarity, the costs and limitations of seeking formal care in the public sector, and the inevitability of future illness. Our findings emphasise the need in contexts of extreme scarcity to equip policy actors with interventions to address AMR through strengthening health systems, rather than public awareness campaigns that foreground overuse and the dangers of using antibiotics beyond the formal sector.

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Voices from low-income and middle-income countries: a systematic review protocol of primary healthcare interventions within public health systems addressing intimate partner violence against women

BMJ Open ◽

10.1136/bmjopen-2017-019266 ◽

2018 ◽

Vol 8 (3) ◽

pp. e019266 ◽

Cited By ~ 5

Author(s):

Marcos Claudio Signorelli ◽

Stav Hillel ◽

Daniel Canavese de Oliveira ◽

Beatriz Paulina Ayala Quintanilla ◽

Kelsey Hegarty ◽

...

Keyword(s):

Public Health ◽

Systematic Review ◽

Health Systems ◽

Low Income ◽

Partner Violence ◽

Intimate Partner ◽

Risk Of Bias ◽

Middle Income ◽

Public Health Systems ◽

Middle Income Countries

IntroductionIntimate partner violence (IPV) considerably harms the health, safety and well-being of women. In response, public health systems around the globe have been gradually implementing strategies. In particular, low-income and middle-income countries (LMIC) have been developing innovative interventions in primary healthcare (PHC) addressing the problem. This paper describes a protocol for a systematic review of studies addressing the impacts and outcomes of PHC centre interventions addressing IPV against women from LMIC.Methods and analysisA systematic search for studies will be conducted in African Index Medicus, Africa Portal Digital Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Index Medicus for the Southeast Asia Region, IndMed, Latin American and Caribbean Health Science Literature Database (LILACS), Medecins Sans Frontieres, MEDLINE, Minority Health and Health Equity Archive, ProQuest, PsycINFO, Scientific Electronic Library Online, (SciELO) and Social Policy and Practice. Studies will be in English, Spanish and Portuguese, published between 2007 and 2017, addressing IPV against women from LMIC, whose data quantitatively report on the impacts and outcomes for survivors and/or workers and/or public health systems preintervention and postintervention. Two trilingual reviewers will independently screen for study eligibility and data extraction, and a librarian will cross-check for compliance. Risk of bias and quality assessment of studies will be measured according to: (1) the Cochrane Collaboration’s tool for assessing risk of bias for randomised controlled trials and (2) the Methodological Index for Non-Randomised Studies (MINORS). Data will be analysed and summarised using meta-analysis and narrative description of the evidence across studies. This systematic review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols(PRISMA P) guidelines.Ethics and disseminationThis systematic review will be based on published studies, thus not requiring ethical approval. Findings will be presented in conferences and published in a peer-reviewed journal.PROSPERO registration numberCRD42017069261.

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Innovative financing to fund surgical systems and expand surgical care in low-income and middle-income countries

BMJ Global Health ◽

10.1136/bmjgh-2020-002375 ◽

2020 ◽

Vol 5 (6) ◽

pp. e002375 ◽

Cited By ~ 1

Author(s):

Ché L Reddy ◽

Alexander W Peters ◽

Desmond Tanko Jumbam ◽

Luke Caddell ◽

Blake C Alkire ◽

...

Keyword(s):

Health Systems ◽

Low Income ◽

Critical Role ◽

Scale Up ◽

Surgical Care ◽

Healthcare Intervention ◽

Strengthen Health System ◽

Middle Income ◽

Middle Income Countries ◽

Fiscal Space

Strong surgical systems are necessary to prevent premature death and avoidable disability from surgical conditions. The epidemiological transition, which has led to a rising burden of non-communicable diseases and injuries worldwide, will increase the demand for surgical assessment and care as a definitive healthcare intervention. Yet, 5 billion people lack access to timely, affordable and safe surgical and anaesthesia care, with the unmet demand affecting predominantly low-income and middle-income countries (LMICs). Rapid surgical care scale-up is required in LMICs to strengthen health system capabilities, but adequate financing for this expansion is lacking. This article explores the critical role of innovative financing in scaling up surgical care in LMICs. We locate surgical system financing by using a modified fiscal space analysis. Through an analysis of published studies and case studies on recent trends in the financing of global health systems, we provide a conceptual framework that could assist policy-makers in health systems to develop innovative financing strategies to mobilise additional investments for scale-up of surgical care in LMICs. This is the first time such an analysis has been applied to the funding of surgical care. Innovative financing in global surgery is an untapped potential funding source for expanding fiscal space for health systems and financing scale-up of surgical care in LMICs.

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