The Lancet and colonialism: past, present, and future.

The historical and contemporary alignment of medical and health journals with colonial practices needs elucidation. Colonialism, which sought to exploit colonised people and places, was justified by the prejudice that colonised people's ways of knowing and being are inferior to those of the colonisers. Institutions for knowledge production and dissemination, including academic journals, were therefore central to sustaining colonialism and its legacies today. This invited Viewpoint focuses on The Lancet, following its 200th anniversary, and is especially important given the extent of The Lancet's global influence. We illuminate links between The Lancet and colonialism, with examples from the past and present, showing how the journal legitimised and continues to promote specific types of knowers, knowledge, perspectives, and interpretations in health and medicine. The Lancet's role in colonialism is not unique; other institutions and publications across the British empire cooperated with empire-building through colonisation. We therefore propose investigations and raise questions to encourage broader contestation on the practices, audience, positionality, and ownership of journals claiming leadership in global knowledge production.

Applicability of European Society of Cardiology guidelines according to gross national income.

AIMS: To assess the feasibility to comply with the recommended actions of ESC guidelines on general cardiology areas in 102 countries and assess how compliance relates to the country's income level. METHODS AND RESULTS: All recommendations from seven ESC guidelines on general cardiology areas were extracted and labelled on recommended actions. A survey was sent to all 102 ESC national and affiliated cardiac societies (NCSs). Respondents were asked to score recommended actions on their availability in clinical practice on a four-point Likert scale (fully available, mostly/often available, mostly/often unavailable, fully unavailable), and select the top three barriers perceived as being responsible for limiting their national availability. Applicability was assessed overall, per World Bank gross national income (GNI) level, and per guideline.A total of 875 guideline recommendations on general cardiology was extracted. Responses were received from 64 of 102 (62.7%) NCSs. On average, 71·6% [95% confidence interval (CI): 68.6-74.6] of the actions were fully available, 9.9% (95% CI: 8.7-11.1) mostly/often available, 6.7% (95% CI: 5.4-8.0) mostly/often unavailable, and 11·8% (95% CI: 9.5-14.1) fully unavailable. In low-income countries (LICs), substantially more actions were fully unavailable [29·4% (95% CI: 22.6-36.3)] compared with high-income countries [HICs, countries 2.4% (95% CI: 1.2-3.7); P < 0.05]. Nevertheless, a proportion of actions with the lowest availability scores were often fully or mostly unavailable independent of GNIs. Actions were most often not available due to lack of reimbursement and other financial barriers. CONCLUSION: Local implementation of ESC guidelines on general cardiology is high in HICs and low in LICs , being inversely correlated with country gross national incomes.

Population health outcomes in Nigeria compared with other west African countries, 1998-2019: a systematic analysis for the Global Burden of Disease Study.

BACKGROUND: Population-level health and mortality data are crucial for evidence-informed policy but scarce in Nigeria. To fill this gap, we undertook a comprehensive assessment of the burden of disease in Nigeria and compared outcomes to other west African countries. METHODS: In this systematic analysis, using data and results of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019, we analysed patterns of mortality, years of life lost (YLLs), years lived with disability (YLDs), life expectancy, healthy life expectancy (HALE), and health system coverage for Nigeria and 15 other west African countries by gender in 1998 and 2019. Estimates of all-age and age-standardised disability-adjusted life-years for 369 diseases and injuries and 87 risk factors are presented for Nigeria. Health expenditure per person and gross domestic product were extracted from the World Bank repository. FINDINGS: Between 1998 and 2019, life expectancy and HALE increased in Nigeria by 18% to 64·3 years (95% uncertainty interval [UI] 62·2-66·6), mortality reduced for all age groups for both male and female individuals, and health expenditure per person increased from the 11th to third highest in west Africa by 2018 (US$18·6 in 2001 to $83·75 in 2018). Nonetheless, relative outcomes remained poor; Nigeria ranked sixth in west Africa for age-standardised mortality, seventh for HALE, tenth for YLLs, 12th for health system coverage, and 14th for YLDs in 2019. Malaria (5176·3 YLLs per 100 000 people, 95% UI 2464·0-9591·1) and neonatal disorders (4818·8 YLLs per 100 000, 3865·9-6064·2) were the leading causes of YLLs in Nigeria in 2019. Nigeria had the fourth-highest under-five mortality rate for male individuals (2491·8 deaths per 100 000, 95% UI 1986·1-3140·1) and female individuals (2117·7 deaths per 100 000, 1756·7-2569·1), but among the lowest mortality for men older than 55 years. There was evidence of a growing non-communicable disease burden facing older Nigerians. INTERPRETATION: Health outcomes remain poor in Nigeria despite higher expenditure since 2001. Better outcomes in countries with equivalent or lower health expenditure suggest health system strengthening and targeted intervention to address unsafe water sources, poor sanitation, malnutrition, and exposure to air pollution could substantially improve population health. FUNDING: The Bill & Melinda Gates Foundation.

Health systems research in burn care: an evidence gap map.

BACKGROUND: Burn injury is associated with significant mortality and disability. Resilient and responsive health systems are needed for optimal response and care for people who sustain burn injuries. However, the extent of health systems research (HSR) in burn care is unknown. This review aimed to systematically map the global HSR related to burn care. METHODS: An evidence gap map (EGM) was developed based on the World Health Organization health systems framework. All major medical, health and injury databases were searched. A standard method was used to develop the EGM. RESULTS: A total of 6586 articles were screened, and the full text of 206 articles was reviewed, of which 106 met the inclusion criteria. Most included studies were cross-sectional (61%) and were conducted in hospitals (71%) with patients (48%) or healthcare providers (29%) as participants. Most studies were conducted in high-income countries, while only 13% were conducted in low-and middle-income countries, accounting for 60% of burns mortality burden globally. The most common health systems areas of focus were service delivery (53%), health workforce (33%) and technology (19%). Studies on health policy, governance and leadership were absent, and there were only 14 qualitative studies. CONCLUSIONS: Major evidence gaps exist for an integrated health systems response to burns care. There is an inequity between the burden of burn injuries and HSR. Strengthening research capacity will facilitate evidence-informed health systems and policy reforms to sustainably improve access to affordable, equitable and optimal burn care and outcomes.

Promoting equitable health workforce distribution through improved migration governance: A mixed methods study of African health professionals' perceptions in Australia.

BACKGROUND: This study examined skilled health worker (SHW) migration governance in African countries and Australia, with an emphasis on areas of influence for achieving an equitable global health workforce distribution. METHODS: We used a mixed-methods research design with African SHW migrants in Australia. An institutional and rights-based framing of governance guided thematic analysis of the interviews, which was mapped to survey findings from a Bayesian Exploratory Factor Analysis. RESULTS: The findings imply that Australian state actors enforce laws that attract SHW migrants and promote safe clinical practice, but do not adequately address their integration concerns or role in health system strengthening. Non-state actors in Australia make donations to African health institutions but rarely promote health workforce equity. African state actors respond to increased SHW migration trends by increasing health worker training and limiting migration, but they lack a comprehensive governance framework for involving citizens and engaging foreign governments. There is limited evidence of a shared community definition of SHW migration governance in many African countries. CONCLUSION: When stakeholders in both sending and receiving countries recognise the indivisibility of the rights at stake (for example, SHW rights as migrants and the right to health), support for an equity-focused SHW migration governance system may increase. Promoting these rights can result in policies that enhance health system strengthening in destination and source countries. Similarly, growing adoption of these rights in sending countries should help inspire a coordinated plan for strengthening health system and SHW migration governance.

Self-reliance or social accountability? The raison d'être of community health committees in Nigeria.

Social justice requires that communities demand social accountability. We conducted this study to inform ongoing efforts to facilitate social accountability through community health committees in Nigeria. We theorised that committees may see themselves in two ways - as outwardly-facing ('social accountability') and/or as inwardly-facing ('self-reliance'). We analysed the minutes of their meetings, alongside interviews and group discussions with committee members, community members, health workers, and health managers in four states across Nigeria. The committees' raison d'être reflects a bias for self-reliance in three ways. First, seen as a platform for the community to co-finance health services, members tend to be the local elite who can make financial contributions. Second, in a one-sided relationship, they function more to achieve the goals of governments (e.g. to improve the uptake of services), than of the community (e.g. rights-based demands for government support). Third, their activities in the community reflect greater concern to ensure that their community makes the most of what the government has already provided (e.g. helping to drive the uptake of existing services) than asking for more. Optimising the committees for social accountability may require support by actors who do not have conflicts of interests in ensuring that they have the necessary information and strategies to demand social accountability.

How (not) to promote sub-national ownership of national initiatives in decentralised health systems: The free maternal and child health programme in Nigeria, 2008-2015.

BACKGROUND: Promoting the sub-national ownership of national health initiatives is essential for efforts to achieve national health goals in federal systems where sub-national governments are semi-autonomous. Between 2008 and 2015, Nigerian government implemented a pilot free maternal and child health (MCH) programme in selected states to improve MCH by reducing physical and financial barriers of access to services. This study was conducted to better understand why the programme was neither adopted nor scaled-up by sub-national governments after pilot phase. METHODS: We conducted a qualitative evaluation of the programme in Imo and Niger States, with data from programme documents, in-depth interviews (45) and focus group discussions (16) at State and community levels. Data was analysed using manual thematic coding approach. RESULT: Our analysis indicates that the programme design had two mutually dependent goals, which were also in tension with one another: 1. To ensure programme performance, the designers sought to shield its implementation from sub-national government politics and bureaucracy; and 2. To gain the buy-in of the same sub-national government politicians and bureaucrats, the designers sought to demonstrate programme performance. The potential for community advocacy for sub-national adoption and scale-up was not considered in the design. Therefore, limited involvement of sub-national governments in the programme design limited sub-national ownership during implementation. And limited oversight of implementation by sub-national government policymakers limited programme performance. CONCLUSION: Efforts to promote sub-national ownership of national initiatives in decentralised health systems should prioritise inclusiveness in design, implementation, and oversight, and well-resourced community advocacy to sub-national governments for adoption and scale-up.

Addressing power asymmetries in global health: Imperatives in the wake of the COVID-19 pandemic.

Seye Abimbola and co-authors argue for a transformation in global health research and practice in the post-COVID-19 world.

Improving the quality of care for people who had a stroke in a low-/middle-income country: A qualitative analysis of health-care professionals' perspectives.

BACKGROUND AND OBJECTIVE: Efforts to improve the adoption of evidence-based interventions for optimal patient outcomes in low-/middle-income countries (LMICs) are persistently hampered by a plethora of barriers. Yet, little is known about strategies to address such barriers to improve quality stroke care. This study seeks to explore health professionals' views on strategies to improve quality stroke care for people who had a stroke in a LMIC. METHODS: A qualitative interview study design was adopted. A semi-structured interview guide was used to conduct in-depth interviews among forty stroke care providers in major referral centres in Ghana. Participants were from nursing, medical, specialist and allied health professional groups. A purposive sample was recruited to share their views on practical strategies to improve quality stroke care in clinical settings. A thematic analysis approach was utilized to inductively analyse the data. RESULTS: A number of overarching themes of strategies to improve quality stroke care were identified: computerization and digitization of medical practice, allocation of adequate resources, increase the human resource capacity to deliver stroke care, development of clinical guideline/treatment protocols, institutionalization of multidisciplinary care and professional development opportunities. These strategies were however differentially prioritized among different categories of stroke care providers. CONCLUSION: Closing the gap between existing knowledge on how to improve quality of stroke care in LMICs has the potential to be successful if unique and context-specific measures from the views of stroke care providers are considered in developing quality improvement strategies and health systems and policy reforms. However, for optimal outcomes, further research into the effectiveness and feasibility of the proposed strategies by stroke care providers is needed.

Access to care for childhood cancers in India: perspectives of health care providers and the implications for universal health coverage.

BACKGROUND: There are multiple barriers impeding access to childhood cancer care in the Indian health system. Understanding what the barriers are, how various stakeholders perceive these barriers and what influences their perceptions are essential in improving access to care, thereby contributing towards achieving Universal Health Coverage (UHC). This study aims to explore the challenges for accessing childhood cancer care through health care provider perspectives in India. METHODS: This study was conducted in 7 tertiary cancer hospitals (3 public, 3 private and 1 charitable trust hospital) across Delhi and Hyderabad. We recruited 27 healthcare providers involved in childhood cancer care. Semi-structured interviews were audio recorded after obtaining informed consent. A thematic and inductive approach to content analysis was conducted and organised using NVivo 11 software. RESULTS: Participants described a constellation of interconnected barriers to accessing care such as insufficient infrastructure and supportive care, patient knowledge and awareness, sociocultural beliefs, and weak referral pathways. However, these barriers were reflected upon differently based on participant perception through three key influences: 1) the type of hospital setting: public hospitals constituted more barriers such as patient navigation issues and inadequate health workforce, whereas charitable trust and private hospitals were better equipped to provide services. 2) the participant's cadre: the nature of the participant's role meant a different degree of exposure to the challenges families faced, where for example, social workers provided more in-depth accounts of barriers from their day-to-day interactions with families, compared to oncologists. 3) individual perceptions within cadres: regardless of the hospital setting or cadre, participants expressed individual varied opinions of barriers such as acceptance of delay and recognition of stakeholder accountabilities, where governance was a major issue. These influences alluded to not only tangible and structural barriers but also intangible barriers which are part of service provision and stakeholder relationships. CONCLUSION: Although participants acknowledged that accessing childhood cancer care in India is limited by several barriers, perceptions of these barriers varied. Our findings illustrate that health care provider perceptions are shaped by their experiences, interests and standpoints, which are useful towards informing policy for childhood cancers within UHC.

Using developmental evaluation to enhance continuous reflection, learning and adaptation of an innovation platform in Australian Indigenous primary healthcare.

Effective efforts to strengthen health systems need diverse, multi-stakeholder networks working together on complex or 'wicked' problems such as prevention and control of chronic diseases, solutions to which go beyond the role and capability of one organisation. The contextual complexities inherent in 'wicked' problems mean that solutions warrant a systems approach that encompasses innovation and new ways of thinking about, facilitating and implementing collective decision-making processes and change practices.Innovation platforms are a mechanism for facilitating communication and collaboration among diverse stakeholders, promoting joint action and stimulating innovation. Developmental evaluation is an approach that is increasingly being used to evaluate innovative and emergent programmes and projects, as it enables evaluators to provide real-time feedback so that evaluation findings can be used to guide development and adaptations. Developmental evaluation emphasises learning and adaptation, and aligns well with the implementation of innovation platforms that have continuous reflection, learning and adaptation as a specific design principle.Here, we outline our rationale for applying a developmental evaluation to enhance the formation, functioning and outcomes of an innovation platform aimed at accelerating and strengthening large-scale quality improvement efforts in Australian Aboriginal and Torres Strait Islander primary healthcare. We provide examples to explain how the developmental evaluation findings were used for adaptation of the innovation platform and assess to what extent our application of developmental evaluation was consistent with, and reflective of, its essential principles.Our evaluation aligned strongly with the principles of developmental evaluation, and the approach we took was well suited to situations with a developmental purpose, innovation niche and complexity such as innovation platforms. As a result, along with the increasing interest in multi-stakeholder platforms (e.g. innovation platforms) and the inherent challenges with evaluating these complex networks, we anticipate our use of this approach being of interest globally.

Beyond positive a priori bias: reframing community engagement in LMICs.

Showing the causal link between community engagement and improved health outcomes is a 'holy grail' of health policy. This article argues that this 'holy grail' has remained elusive because community engagement in primary health care is under-theorized, having been based on positive a priori assumptions, e.g. that people necessarily want to be engaged in governing their health system. By adopting a theory-driven approach and an agnostic premise, we show that understanding why, how and when community engagement may emerge or function spontaneously is important for informing efforts to support community engagement in primary health care primary health care governance. We draw on empirical research on community engagement in Nigeria and on the literature to identify the 'why' (coalition of service users can emerge in response to under-governance); the 'how' (five modes: through meetings; reaching out within their community; lobbying governments; augmenting government support; and taking control of service delivery) and the 'when' (as geographical, socio-economic and institutional context align, such that the benefits of action outweigh costs). Understanding the broad patterns of mechanisms and of contextual factors that apply across communities is, after all, our 'holy grail'-and this understanding should inform efforts to tailor support for community engagement in governance in different settings.

The NASSS framework for ex post theorisation of technology-supported change in healthcare: worked example of the TORPEDO programme.

BACKGROUND: Evaluation of health technology programmes should be theoretically informed, interdisciplinary, and generate in-depth explanations. The NASSS (non-adoption, abandonment, scale-up, spread, sustainability) framework was developed to study unfolding technology programmes in real time-and in particular to identify and manage their emergent uncertainties and interdependencies. In this paper, we offer a worked example of how NASSS can also inform ex post (i.e. retrospective) evaluation. METHODS: We studied the TORPEDO (Treatment of Cardiovascular Risk in Primary Care using Electronic Decision Support) research programme, a multi-faceted computerised quality improvement intervention for cardiovascular disease prevention in Australian general practice. The technology (HealthTracker) had shown promise in a cluster randomised controlled trial (RCT), but its uptake and sustainability in a real-world implementation phase was patchy. To explain this variation, we used NASSS to undertake secondary analysis of the multi-modal TORPEDO dataset (results and process evaluation of the RCT, survey responses, in-depth professional interviews, videotaped consultations) as well as a sample of new, in-depth narrative interviews with TORPEDO researchers. RESULTS: Ex post analysis revealed multiple areas of complexity whose influence and interdependencies helped explain the wide variation in uptake and sustained use of the HealthTracker technology: the nature of cardiovascular risk in different populations, the material properties and functionality of the technology, how value (financial and non-financial) was distributed across stakeholders in the system, clinicians' experiences and concerns, organisational preconditions and challenges, extra-organisational influences (e.g. policy incentives), and how interactions between all these influences unfolded over time. CONCLUSION: The NASSS framework can be applied retrospectively to generate a rich, contextualised narrative of technology-supported change efforts and the numerous interacting influences that help explain its successes, failures, and unexpected events. A NASSS-informed ex post analysis can supplement earlier, contemporaneous evaluations to uncover factors that were not apparent or predictable at the time but dynamic and emergent.

What do Accredited Social Health Activists need to provide comprehensive care that incorporates non-communicable diseases? Findings from a qualitative study in Andhra Pradesh, India.

BACKGROUND: The Indian National Program for Cardiovascular Disease, Diabetes, Cancer and Stroke (NPCDCS) was introduced to provide non-communicable disease (NCD) care through primary healthcare teams including Accredited Social Health Activists (ASHAs). Since ASHAs are being deployed to provide NCD care on top of their regular work for the first time, there is a need to understand the current capacity and challenges faced by them. METHODS: A desktop review of NPCDCS and ASHA policy documents was conducted. This was followed by group discussions with ASHAs, in-depth interviews with their supervisors and medical officers and group discussions with community members in Guntur, Andhra Pradesh, India. The multi-stakeholder data were analysed for themes related to needs, capacity, and challenges of ASHAs in providing NCD services. RESULTS: This study identified three key themes-first, ASHAs are unrecognised as part of the formal NPCDCS service delivery team. Second, they are overburdened, since they deliver several NPCDCS activities without receiving training or remuneration. Third, they aspire to be formally recognised as employees of the health system. However, ASHAs are enthusiastic about the services they provide and remain an essential link between the health system and the community. CONCLUSION: ASHAs play a key role in providing comprehensive and culturally appropriate care to communities; however, they are unrecognised and overburdened and aspire to be part of the health system. ASHAs have the potential to deliver a broad range of services, if supported by the health system appropriately. TRIAL REGISTRATION: The study was registered with "Clinical Trials Registry - India" (identifier CTRI/2018/03/012425 ).

How food insecurity could lead to obesity in LMICs: When not enough is too much: a realist review of how food insecurity could lead to obesity in low- and middle-income countries.

While food insecurity is a well-known cause of under-nutrition and stunting, in recent decades it has also been linked with obesity. Understanding and thus minimising the risk factors for obesity in low- and middle-income country contexts, which often lack the health system capacity to treat the consequent obesity-related illnesses, is crucial. This study adopted realist review methodology because it enabled us to analyse and organise the evidence from low- and middle-income countries into a coherent scheme. By comparing this evidence to existing theory on food security and nutrition, we aimed to provide a richer understanding of the nuances and the socio-demographic nature of the food insecurity-obesity relationship. The review generated 13 peer-reviewed articles which studied the relationship between food insecurity and overweight/obesity in low- and middle-income countries. Affordability of high-energy, processed foods was identified as a main mechanism, which determined whether or not food insecurity leads to obesity in low- and middle-income countries. Other mechanisms identified were: quantity and diversity of food consumed; spatial-temporal access to nutritious food; inter-personal food choice and distribution; and non-dietary behaviours. Despite the limited empirical evidence available, our review presents meaningful and policy-relevant insights into the food insecurity-obesity relationship in from low- and middle-income countries. Interventions to address the food insecurity-obesity link need to address diet quality, and demand a broad understanding across a variety of experiences.