Crise global da atenção primária à saúde / Global crisis in primary health care / Crisis global de la atención primaria

Enquanto no Norte Global se discute uma crise na Atenção Primária à Saúde, a maioria dos países nunca chegou a constituir sistemas de saúde baseados propriamente numa atenção primária robusta. Nesse cenário, o Brasil apresenta uma tendência mais favorável, com conquistas importantes para a atenção primária e a medicina de família e comunidade nos últimos dez anos. Restam desafios a serem superados para que o Sistema Único de Saúde alcance níveis satisfatórios de acesso a seus serviços, com profissionais adequadamente formados e valorizados pela população.

While the Global North is discussing a crisis in primary health care, the majority of countries have never managed to establish health systems based on robust primary care. Brazil presents a more favorable trend, with important achievements for primary care and family practice over the last ten years. There are still challenges to be overcome so that the Unified Health System achieves satisfactory levels of access to its services, with professionals who are properly trained and valued by the public.

Mientras que en el Norte Global se habla de una crisis de la atención primaria, la mayoría de los países nunca han creado realmente sistemas sanitarios basados en una atención primaria robusta. Brasil, muestra una tendencia más favorable, con importantes logros para la atención primaria y la medicina familiar y comunitaria en los últimos diez años. Aún quedan retos por superar para que el Sistema Único de Salud alcance niveles satisfactorios de acceso a sus servicios, con profesionales debidamente formados y valorados por la población.

The Grenada Learning and Memory Scale: Psychometric features and normative data in Caribbean preschool children.

OBJECTIVE: Neuropsychological assessment of preschool children is essential for early detection of delays and referral for intervention prior to school entry. This is especially pertinent in low- and middle-income countries (LMICs), which are disproportionately impacted by micronutrient deficiencies and teratogenic exposures. The Grenada Learning and Memory Scale (GLAMS) was created for use in limited resource settings and includes a shopping list and face-name association test. Here, we present psychometric and normative data for the GLAMS in a Grenadian preschool sample. METHODS: Typically developing children between 36 and 72 months of age, primarily English speaking, were recruited from public preschools in Grenada. Trained Early Childhood Assessors administered the GLAMS and NEPSY-II in schools, homes, and clinics. GLAMS score distributions, reliability, and convergent/divergent validity against NEPSY-II were evaluated. RESULTS: The sample consisted of 400 children (190 males, 210 females). GLAMS internal consistency, inter-rater agreement, and test-retest reliability were acceptable. Principal components analysis revealed two latent factors, aligned with expected verbal/visual memory constructs. A female advantage was observed in verbal memory. Moderate age effects were observed on list learning/recall and small age effects on face-name learning/recall. All GLAMS subtests were correlated with NEPSY-II Sentence Repetition, supporting convergent validity with a measure of verbal working memory. CONCLUSIONS: The GLAMS is a psychometrically sound measure of learning and memory in Grenadian preschool children. Further adaptation and scale-up to global LMICs are recommended.

A qualitative study of nurse participation in global health in the English NHS: participation, interest, and barriers to participation.

BACKGROUND: Nurses contribute to the largest demographic of the healthcare workforce. However, given current global shortages of workforce capacity, this often leads to limited capacity to engage in extracurricular educational developments beyond their immediate role. Consequently, this significantly limits the range of workforce training and development opportunities that are available to them, which could enhance the variety of skills that are brought to the National Health Service (NHS). OBJECTIVE: We aimed to understand prior, current, and future participation in global health activities such as global health conferences, networks, and placements, among National Health Service (NHS) staff. Furthermore, we investigated the barriers and facilitators to participation in global health activities for nurses in our sample. METHOD: Qualitative and quantitative data was gathered from an online survey conducted in England from July to November 2021. Thematic analysis was used to examine the qualitative data collected from one open-ended question, whereas statistical analysis was used to examine the remaining quantitative data. RESULTS: Most (84%) nurses in our sample had not participated in a global health activity. Our results highlighted three barriers to participation, including insufficient communication, a lack of awareness, and capacity issues. CONCLUSION: This study showed that, despite low levels of prior participation, there is a strong desire among surveyed nurses to be involved in global health activities and education. Our findings also suggest that enhanced communication of opportunities available is needed, in addition to organisational support which incorporates strategies to overcome capacity constraints.

The path to sustainable cardiac surgery in Rwanda: analysis of costs for consumables used during cardiac surgery for a non-governmental organization.

BACKGROUND: Until local healthcare infrastructure is strengthened, cardiac surgical care in low- and middle-income countries is often provided by non-governmental organizations by way of visiting healthcare teams. This is generally considered to be a cost-effective alternative to transporting patients to high income countries for surgical care, but the costs of cardiac surgery consumables under this model are poorly understood. Our objective was to identify the per-patient cost of cardiac surgery consumables used in single and double valve replacements performed by a non-governmental organization in Rwanda. METHODS: Financial data from 2020 were collected from Team Heart, a non-governmental organization that supports cardiac surgical care in Rwanda. A comprehensive list of consumables was generated, including surgical, perfusion, anesthesia, and inpatient supplies and medications. Acknowledging the variability in perioperative needs, the quantities of consumables were calculated from an average of six patients who underwent single or double-valve replacement in 2020. Total costs were calculated by multiplying purchasing price by average quantity per patient. Costs absorbed by the local hospital were excluded from the calculations. RESULTS: The total cost per patient was estimated at $9,450. Surgical supplies comprised the majority of costs ($6,140 per patient), with the most substantial cost being that of replacement valves ($3,500 per valve), followed by surgical supplies ($1,590 per patient). CONCLUSIONS: This preliminary analysis identifies a cost of just over $9,000 per patient for consumables used in cardiac valve surgery in Rwanda, which is lower than the estimated costs of transporting patients to centers in high income countries. This work highlights the relative cost effectiveness of cardiac surgical care in low- and middle- income countries under this model and will be instrumental in guiding the allocation of local and international resources in the future.

Vulnerability, social value and the equitable sharing of benefits from research: beyond the placebo and access debates.

The vulnerability of research participants is a critical topic for the 2024 revision of the Declaration of Helsinki, with the proposal to include "social value. " However, this proposal has been withdrawn and the relationship between the two concepts has not been clarified. This paper attempts to clarify: (1) the recent reform for the ethical inclusion of vulnerable study participants to promote diversity; (2) the social value, prerequisite for everyone, especially for those who are vulnerable and the most in need; (3) the requirements for promoting the inclusion of vulnerable participants, in particular the review of the norms for placebo-controlled trials and post-trial access; (4) finally, the direction of research ethics reform to achieve social value and equitable global health.

The challenging concept of eradication: A core concept guiding and frustrating public health.

The celebrated 1980 announcement that smallpox had been eradicated was made using the following definition of eradication: "Permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate efforts: intervention measures are no longer needed." Public health around the world works with this definition of "eradication," setting it as a goal for other infectious disease control programs. The definition is simple. Its application, however, has produced long-running and complex public health campaigns that threaten the commitment of funders, health care providers, and governments. In this paper, the authors demonstrate the disease-specific challenges of eradication through the example of the Global Polio Eradication Initiative (GPEI). While many deem eradication worth its high costs because it is the end of morbidity and mortality from a disease, it does not mean the end of disease control efforts. Public health must be prepared for the possibility of disease reoccurrence in the form of undetected natural reservoirs of disease, lab leaks from stored samples, bioterror attacks using stolen samples, and the synthetic recreation of microbes. This paper clarifies the role of reoccurrence prevention in eradication, calling for its addition in the definition of eradication.

RéSUMé: L'annonce célèbre de 1980 que la variole a été éradiquée utilisait la définition d'éradication suivante : « Réduction permanente à zero de l'incidence mondiale d'infection causée par un agent spécifique en conséquence d'efforts délibérés : mesures d'intervention ne sont plus nécessaires. ¼ La santé publique globale emploie cette définition de « éradication ¼, la fixant comme objectif pour d'autres programmes de contrôle des maladies transmissibles. La définition est simple. Pourtant, son application a produit des campagnes de santé publique complèxes et de longues durées, qui menacent l'engagement des bailleurs de fonds, les prestataires des soins de santé, et les gouvernements. Dans cet article savant, les auteurs démontrent les obstacles d'éradication spécifiques à une maladie transmissible à travers l'exemple de la Global Polio Eradication Initiative (GPEI). Tandis que l'éradication pourrait peut-être mériter les côuts élevés associés puisqu'elle signifie la fin de la morbidité et la mortalité d'une infection, ceci ne représente pas la fin des efforts de contrôle des maladies. La santé publique doit se préparer pour la possibilité de la réapparition d'une maladie infectieuse en forme de reservoir de maladie naturel non-détecté, fuites de laboratoires des échantillons conservés, attaques bioterroristes utilisant des échantillons volés, et la récréation synthétique des microbes. Cet article savant clarifie le rôle de la prévention de réocurrence dans l'éradication, et demande que ce role soit ajouté à la definition d'éradication.

Efficacy and Safety of a Novel Low-Dose Triple Single-Pill Combination Compared With Placebo for Initial Treatment of Hypertension.

BACKGROUND: Single-pill combinations of 3 or more low-dose blood pressure (BP)-lowering drugs hold promise for initial or early treatment of hypertension. OBJECTIVES: We conducted a placebo-controlled trial of a new single-pill combination containing low doses of telmisartan, amlodipine, and indapamide in 2 dose options to assess efficacy and safety. METHODS: This international, randomized, double-blind, placebo-controlled, parallel-group trial enrolled adults with hypertension receiving 0 to 1 BP-lowering drugs. After a 2-week placebo run-in during which any BP-lowering medication was stopped, participants were eligible if home systolic BP (SBP) was 130 to 154 mm Hg. Participants were randomized in a 2:2:1 ratio to GMRx2 » dose (telmisartan 10 mg/amlodipine 1.25 mg/indapamide 0.625 mg), GMRx2 ½ dose (telmisartan 20 mg/amlodipine 2.5 mg/indapamide 1.25 mg), or placebo. The primary efficacy outcome was difference in change in home SBP from randomization to week 4, and primary safety outcome was treatment discontinuation due to an adverse event. RESULTS: From June 14, 2021 to October 18, 2023, a total of 295 participants (mean age: 51 years; 56% female) were randomized and 96% completed the trial. Baseline mean home BP was 139/86 mm Hg and clinic BP was 138/86 mm Hg after placebo run-in. The placebo-corrected least square mean differences in home SBP at Week 4 were -7.3 mm Hg (95% CI: -4.5 to -10.2) for GMRx2 » dose and -8.2 mm Hg (95% CI: -5.2 to -11.3) for GMRx2 ½ dose; reductions for clinic BP were 8.0/4.0 and 9.5/4.9 mm Hg. At Week 4, clinic BP control (<140/90 mm Hg) was 37%, 65%, and 70% for placebo, GMRx2 » dose, and GMRx2 ½ dose, respectively (both doses P < 0.001 vs placebo). Placebo, GMRx2-triple », and GMRx2 ½ treatment discontinuation due to an adverse event occurred in 1 (1.6%), 0, and 6 (5.1%), respectively; out of normal range serum sodium or potassium was observed in 4 (6.3%), 12 (10.6%), and 12 (10.1%), respectively, but no participant had a serum sodium <130/>150 mmol/L or potassium <3.0/>6.0 mmol/L. Serious adverse events were reported by 2 participants in the placebo and GMRx2 ½ groups and none in the GMRx2 » group. CONCLUSIONS: In a population with mild-to-moderate BP elevation, both dose versions of the novel low-dose triple single-pill combination showed good tolerability and clinically relevant BP reductions compared with placebo. (Efficacy and Safety of GRMx2 Compared to Placebo for the Treatment of Hypertension: NCT04518306).

Artificial intelligence and the politics of avoidance in global health.

For decades, global health actors have centered technology in their interventions. Today, artificial intelligence (AI) is emerging as the latest technology-based solution in global health. Yet, AI, like other technological interventions, is not a comprehensive solution to the fundamental determinants of global health inequities. This article gathers and critically appraises grey and peer-reviewed literature on AI in global health to explore the question: What is avoided when global health prioritizes technological solutions to problems with deep-seated political, economic, and commercial determinants? Our literature search and selection yielded 34 documents, which we analyzed to develop seven areas where AI both continues and disrupts past legacies of technological interventions in global health, with significant implications for health equity and human rights. By focusing on the power dynamics that underpin AI's expansion in global health, we situate it as the latest in a long line of technological interventions that avoids addressing the fundamental determinants of health inequities, albeit at times differently than its technology-based predecessors. We call this phenomenon the 'politics of avoidance.' We conclude with reflections on how the literature we reviewed engages with and recognizes the politics of avoidance and with suggestions for future research, practice, and advocacy.

An evidence map on traditional medicine across health outcomes.

Background: Traditional medicine (TM) plays a significant role in healthcare either as part of the primary healthcare system or as an adjunct to conventional medicine. This study aimed to map systematic reviews (SRs) of TM modalities across health conditions and identify gaps in the research literature to facilitate priority setting in future TM research. Methods: We searched 17 databases from January 2018 to December 2022. Reviewers in pairs independently performed the database search, screened each record for inclusion, extracted data, and performed quality assessments using the AMSTAR 2 - A Measurement Tool to Assess systematic Reviews. To be included in this evidence map, the studies had to be SRs of clinical studies that evaluated the effectiveness of a TM modalities. The included SRs were analyzed according to TM modality, ICD-11 disease classification, and health outcomes, and visualized using graphical plots. Results: We retrieved 241,509 records. After excluding duplicate records, 181,616 titles and abstracts were screened and 20,856 records were selected for full-text assessment, of which 18,137 records were further excluded. The final 2719 included SRs were primarily in adults (2591) with only 128 SRs in the pediatric population. The most commonly evaluated health conditions were diseases of the digestive system, circulatory system, and genitourinary system, with herbal medicine (n = 1867) and acupuncture (n = 471) being the most investigated TM modalities in treating these illnesses. Based on AMSTAR 2 criteria, the methodology quality of the included SRs is considerably low. Conclusion: This evidence map provides a comprehensive overview of the extent and nature of the available research onTM modalities across health conditions. It provides an initial step towards characterizing the global evidence base and outlining gaps in the existing evidence. We regard this study as laying the basis for future research of TM modalities. Registration: The protocol of this map is registered in PROSPERO (CRD42023416355).

Adapting the Goeckerman Regimen for Psoriasis Treatment in Kenya: A Case Study of Successful Management in a Resource-Limited Setting.

Introduction:  Goeckerman therapy, which combines ultraviolet B (UVB) light with crude coal tar (CCT), remains highly effective for moderate-to-severe psoriasis. While it is rarely still used in the USA as effective biotherapeutics have become more readily available, it offers an alternative therapy in developing countries with limited access to newer medications. Moi Teaching & Referral Hospital (MTRH) in Eldoret, Kenya, in collaboration with UCSF, developed a modified Goeckerman regimen suitable for local healthcare needs, condensing the treatment into an intensive two-week program. Case Report:  A 55-year-old female with erythrodermic psoriasis traveled 350 kilometers to MTRH. After the diagnosis was confirmed, she underwent a nine-day inpatient treatment with narrow-band UVB phototherapy and topical medications under occlusion as a modified Goeckerman regimen. Response to Treatment:  Significant improvement was observed within three days, with full recovery in ten days. Follow-up one month later showed no active lesions, and her psoriasis remained controlled for four months with topical treatments. Conclusion:  The modified Goeckerman regimen at MTRH, in collaboration with UCSF, effectively treated severe psoriasis in a challenging healthcare context. This case highlights the potential for adapting established treatments to improve patient outcomes in developing countries with limited access to systemic therapies.

One Health policy for combatting African trypanocide resistance.

The rise of African trypanocide resistance (ATr) is influenced by various factors such as evolutionary changes in the pathogen, the presence of resistance genes in the population, poor policy decisions, limited private-public partnerships to engage local communities, and insufficient funding for the development of new drugs over the past sixty years. These challenges have been exacerbated by the inadequate implementation of drug liberalization policies in the mid 20th century, leading to poor pharmacovigilance practices for veterinary drugs in low and middle income countries (LMICs). One health (OH), a disease management framework, provides practical solutions for addressing ATr, drawing on its success in managing previous epidemics like avian influenza in 2004 and the recent COVID-19 pandemic, where institutional collaborations were rapidly established. To combat ATr, OH initiatives involving both international and local partners at the policy and grassroots levels are crucial to generate community interest. The importance of political commitment, media involvement, and nongovernmental organizations cannot be overstated, as they are essential for resource mobilization and long-term sustainability in LMICs.

Advancing Antenatal Care in Ethiopia: The Impact of Tele-Ultrasound on Antenatal Ultrasound Access in Rural Ethiopia.

Introduction: Access to antenatal ultrasound is limited in low-income countries such as Ethiopia. Virtual care platforms that facilitate supervision and mentoring for ultrasound scanning may improve patient access by facilitating task-sharing of antenatal ultrasound with midlevel providers. The purpose of this study was to assess the feasibility of a large volume tele-ultrasound program in Ethiopia, its impact on antenatal care (ANC) and patient access, and its sustainability as it transitioned from a pilot project to a continuing clinical program. Methods: Health care providers at two health centers in the North Shoa Zone, Ethiopia, performed antenatal tele-ultrasound exams with remote guidance from obstetricians located in urban areas. Data regarding ANC and ultrasound utilization, participant travel, ultrasound findings, specialist referrals, and participant experience were collected through a mobile app. Results: Between November 2020 and December 2023, 7,297 tele-ultrasound exams were performed. Of these, 489 tele-ultrasound exams were performed during the period of data collection from October to December 2022. The availability of tele-ultrasound at the two health centers significantly reduced participant travel distance (4.2 km vs. 10.2 km; p < 0.01; one-way distance). Most participants (99.2%) indicated the tele-ultrasound service was very important or important, with high levels of satisfaction. Clinically significant findings were identified in 26 cases (5.3%), leading to necessary referrals. Conclusion: This study demonstrated the feasibility of a large volume tele-ultrasound program in Ethiopia, its impact on improving the quality of ANC, and its sustainability. These findings lay a foundation upon which low-income countries can develop tele-ultrasound programs to improve antenatal ultrasound access.

Epidemiological profile trends and cost of pediatric sickle cell disease in Brazil from 2008 to 2022.

OBJECTIVE: This study aimed to investigate the epidemiological trends of Pediatric Sickle Cell Disease (SCD) in Brazil over the period 2008-2022, with a focus on understanding the incidence, mortality rates, and associated healthcare costs. The study explored potential associations between patient characteristics and the occurrence of crises in pediatric SCD cases. METHODS: A cross-sectional study was conducted, analyzing national annual rates of pediatric SCD hospitalizations using data from the FioCruz platform. Descriptive and inferential analyses, including time series and ARIMA regression, were employed. Economic dimensions were assessed using cost categorization. The study followed STROBE reporting guidelines. RESULTS: Data on 81,942 pediatric SCD hospitalizations were collected, with a predominance of crisis-related cases (74.08 %). Males and children under five years old were most affected. Regional disparities were observed, with the Southwest region recording the highest hospitalization rates. ICU costs were higher for crisis-related hospitalizations. Mortality rates were significantly higher for crisis-related cases (p < 0.001), with ARIMA regression indicating a significant association between hospitalizations for crisis-related cases and mortality. CONCLUSION: This study highlights the significant burden of pediatric SCD in Brazil, particularly crisis-related cases, suggesting a need for focused interventions. By prioritizing early detection, equitable access to healthcare, and evidence-based interventions, Brazil can mitigate the burden of SCD and improve patient outcomes. These findings contribute to informing public health policies and interventions aimed at addressing the challenges of pediatric SCD management in Brazil.

Stakeholder perspectives on factors that influence global prioritization for MNH in humanitarian settings.

Background: Maternal and newborn mortality rates are disproportionately high in crisis and conflict-affected countries. This study aims to understand factors influencing how MNH in humanitarian and fragile settings (HFS) is prioritized on the global health agenda during the Sustainable Development Goal (SDG) era. This includes examining the policies and processes driving agenda setting and decision-making, as well as the perceptions of global actors. It further reflects on the role of global milestones, reports, convenings, and high-level champions, based on the premise that global prioritization leads to increased attention and resource allocation, ultimately contributing to improved outcomes for mothers and newborns in crisis-affected areas. Methods: A qualitative study conducted from April 2022 to June 2023, employing a desk review and 23 semi-structured key informant interviews with global actors from donor agencies, implementing organizations, research institutes, United Nations agencies, professional associations, and coalitions, predominantly based in the Global North. Data were analyzed using inductive thematic analysis and the research was guided by the Walt and Gibson Health Policy Triangle framework. Results: Participants believe that global agenda-setting and investment decisions for MNH are primarily driven by UN agencies, donors, and implementing organizations at the global level. Although the Millennium Development Goal era successfully prioritized MNH, this focus has diminished during the SDGs, especially for HFS. Identified barriers include the complexity of reducing mortality rates in these contexts, limited political will, MNH investment fatigue, and a preference for quick wins. Fragmentation between humanitarian and development sectors and unclear mandates in protracted crises also hinder progress. Without enhanced global advocacy, accountability, and targeted investments in HFS, respondents deem global MNH targets unattainable. Conclusions: While waning donor interest and the siloing of HFS in global MNH decision-making pose challenges, targeted actions to address these barriers may include designating quotas for humanitarian actors in global MNH convenings, developing shared messages that convey common interests, and adopting an equity lens. Prioritizing MNH in HFS on the global agenda demands sustained commitment to ensure these settings are not an afterthought through dedicated advocacy and accountability, high-level political engagements, global milestones, and by leveraging opportunities to capture mainstream interest. Failing to shift global priorities will result in continued stagnation and worsening MNH outcomes across HFS.

Colombian surgical outcomes study insights on perioperative mortality rate, a main indicator of the lancet commission on global surgery - a prospective cohort study.

Background: Surgical care holds significant importance in healthcare, especially in low and middle-income countries, as at least 50% of the 4.2 million deaths within the initial 30 days following surgery take place in these countries. The Lancet Commission on Global Surgery proposed six indicators to enhance surgical care. In Colombia, studies have been made using secondary data. However, strategies to reduce perioperative mortality have not been implemented. This study aims to describe the fourth indicator, perioperative mortality rate (POMR), with primary data in Colombia. Methods: A multicentre prospective cohort study was conducted across 54 centres (hospitals) in Colombia. Each centre selected a 7-day recruitment period between 05/2022 and 01/2023. Inclusion criteria involved patients over 18 years of age undergoing surgical procedures in operating rooms. Data quality was ensured through a verification guideline and statistical analysis using mixed-effects multilevel modelling with a case mix analysis of mortality by procedure-related, patient-related, and hospital-related conditions. Findings: 3807 patients were included with a median age of 48 (IQR 32-64), 80.3% were classified as ASA I or II, and 27% of the procedures had a low-surgical complexity. Leading procedures were Orthopedics (19.2%) and Gynaecology/Obstetrics (17.7%). According to the Clavien-Dindo scale, postoperative complications were distributed in major complications (11.7%, 10.68-12.76) and any complication (31.6%, 30.09-33.07). POMR stood at 1.9% (1.48-2.37), with elective and emergency surgery mortalities at 0.7% (0.40-1.23) and 3% (2.3-3.89) respectively. Interpretation: The POMR was higher than the ratio reported in previous national studies, even when patients had a low-risk profile and low-complexity procedures. The present research represents significant public health progress with valuable insights for national decision-makers to improve the quality of surgical care. Funding: This work was supported by Universidad del Rosario and Fundación Cardioinfantil-Instituto de Cardiología grant number CTO-057-2021, project-ID IV-FGV017.

The effectiveness of competency-based global health education programs for medical students.

PURPOSE: This study aimed to develop a competency-based global health education (GHE) program for medical students and analyze its effectiveness. METHODS: The study had a pretest-posttest control group design. The program was developed based on the eight global health competency domains for medical students and implemented for 18 hours over 6 weeks beginning in September 2023. The intervention and control groups comprised 34 students and 41 students, respectively. The analytical methods used were t-test, chi-square test, and analysis of covariance. RESULTS: Experience with global health activities and pretest scores were controlled as covariates to exclude the effects of participants' general characteristics and pretest scores. The intervention group had outscored the control group on interest in a global health career and the necessity of GHE and also showed significantly higher posttest scores on global competence, global citizenship, and global health competence. Students were generally satisfied with the GHE program. CONCLUSION: A global health competency-based GHE program effectively increases medical students' interest in global health careers, their understanding of the need for GHE, and their global competence, global citizenship, and global health competence. This study is expected to promote GHE program development and research.

The experiences of medical and pharmacy students participating in a collaborative online international learning on social accountability and global health: a qualitative study.

BACKGROUND: Social accountability aims to promote a collective ethic that upholds the fundamental values of equity, efficiency, solidarity, and social justice in healthcare and is now considered as a critical mission of academic health centers. Collaborative Online International Learning (COIL) is a pedagogical approach that uses digital technology to provide experiential international learning, specifically for increasingly diverse and multicultural healthcare work environments. The SOLID'AIRS program is an innovative French-language COIL that aims to set up international exchanges and workshops on social accountability between health sciences students. The aim of our study was to assess the impact of participation in the SOLID'AIRS program on medical and pharmacy students. METHOD: Five universities in four different countries were involved in SOLID'AIRS. We conducted a qualitative study by performing individual, semi-directed interviews with students who participated in the program from 2021 to 2022. A thematic analysis was conducted in five chronological phases: (1) reading, (2) descriptive coding, (3) conceptual coding, (4) identification of themes and (5) production of a coherent thematic structure. RESULTS: After including sixteen student participants, 13 medical and 3 pharmacy students, we identified four main themes related to the impact of participation: (1) previous experiences in social accountability and international learning, (2) perception of the program, (3) perceived impacts of the program, and (4) difficulties encountered and avenues to improve the program. Overall, the program was well received by all participants who reported the advantages and limitations of the online learning format. The primary advantage of this format was its feasibility. The participants noted both professional and personal benefits of the program for their current and future practice, including greater reflexivity towards health sciences practice. Based on the challenges faced during the program, particularly in coordinating group work and communication, participants suggested increased supervision of group projects by collaborators, and organizing at least one in-person meeting for future editions. The participants reported encountering difficulties during the COIL and suggested ways of improvement. CONCLUSION: Participating in a COIL on social accountability appears to be an effective way to adopt a reflective approach to medical practice and should be implemented and evaluated in other educational contexts.

Neurosurgical Advocacy in the Prevention of Neural Tube Defects: Impacting Global Fortification Policies Through Leadership, Collaboration, and Stakeholder Engagement.

The G4 Alliance and its member organizations formed a delegation that participated in the 76th World Health Assembly (WHA) in 2023, which unanimously adopted the resolution to address micronutrient deficiencies through safe, effective food fortification to prevent congenital disorders such as spina bifida and anencephaly, the first neurosurgery-led resolution since the founding of the World Health Organization. The WHA included other resolutions and side events by the G4 Alliance and other organizations relevant to neurosurgery. An opportunity exists for neurosurgeons to harness the momentum from this resolution to promote initiatives to prevent neurosurgical disease or expand access to neurosurgical care.