Interpersonal Violence and Gender Inequality in Adolescents: A Systematic Analysis of Global Burden of Disease Data From 1990 to 2019.

PURPOSE: Interpersonal violence is a leading cause of adolescent deaths and disability. This study investigates sex differences in burden of interpersonal violence for adolescents and explores associations with gender inequality. METHOD: Using data from the 2019 Global Burden of Disease study, we report numbers, proportions, rates of interpersonal violence deaths and disability adjusted life years (DALYs) for all ages, and rate of change (from 1990 to 2019) in adolescents aged 10-24 years disaggregated by sex and geography. We explored associations with gender inequality using gender inequality index. RESULTS: One in four (24.8%) all-age interpersonal violence deaths are in adolescents. In 2019, the rate of deaths in adolescent males was almost six times higher than females (9.3 vs. 1.6 per 100,000); and since 1990, the rate of decline in DALYs for females was double than that for males (-28.9% vs. -12.7%). By contrast, the burden of sexual violence is disproportionately borne by adolescent females, with over double the rate than males (DALYs: 42.8 vs. 17.5 per 100,000). In countries with greater gender inequality, the male-to-female ratio (deaths and DALYs) was increased among older adolescents, pointing to benefits for males in more gender equal settings. DISCUSSION: Social identities, relationships, and attitudes to violence are established in adolescence, which is an inflection point marking the emergence of disproportionate burdens of interpersonal violence. Our findings affirm that global agendas must be expanded to address interrelated factors driving multiple forms of interpersonal violence experienced by adolescents and reverberating to the next generation.

Development, Objectives and Operation of Return-of-Service Bursary Schemes as an Investment to Build Health Workforce Capacity in South Africa: A Multi-Methods Study.

BACKGROUND: South Africa uses government-funded return-of-service (RoS) schemes to train, recruit and retain skilled health professionals in underserved areas. These educate health professionals locally or internationally in return for a commitment to serve in a specified area for an agreed period. While such schemes are used widely and are funded by substantial public funds, their exact makeup differs across jurisdictions, and little is known about why these differences have emerged or how they influence their effectiveness or impact on the health system. We aimed to fill these gaps through an analysis of the origins, architecture, and evolution of RoS schemes in South Africa. METHODS: A multimethod research study including a policy review, a literature review, and semi-structured interviews of policymakers was undertaken between October 2020 and August 2022. The included policy documents and literature were analysed using the Walt and Gilson framework and narrative synthesis. Qualitative data were analysed using inductive, thematic analysis in NVIVO 12. RESULTS: RoS schemes are used as a recruitment and retention strategy and a mechanism to address equity in access to medical education. Whilst there is evidence of RoS schemes existing in 1950, no evidence of beneficiaries was found in databases until 1989. The impact of these schemes is likely being limited by sub-optimal institutional arrangements and poor transparency in their design and implementation. CONCLUSION: Despite rigorous research methods, the origins of RoS policies in South Africa could not be established due to poor preservation of institutional memory. Opportunities to monitor the value of public investment into RoS programs are being missed and often the underlying objective of the programs has not been well-specified. Policies were found to have been developed and operate in isolation from other health workforce planning activities and thus may not be maximising their impact as a retention and training tool.

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.

Social networks and skilled health worker migration in Nigeria: An ego network analysis.

BACKGROUND: Nigeria provides a good case study for researchers, activists, and governments seeking to understand how social networks can help mitigate the negative impact of skilled health worker (SHW) migration in low and middle-income countries. This study aimed to map the social networks of SHWs and explore how they influence migration intentions. METHODS: We combined semi-structured qualitative interviews with an ego-network analysis of 22 SHWs living in Nigeria, used R-Studio to display and visualise their networks, and NVivo for thematic analysis of transcribed interviews. RESULTS: The network size and frequency of interaction were smaller among SHWs seeking to remain in Nigeria, however when compared to SHWs seeking to migrate, they had ties with a diverse group of stakeholders interested in improving health services. The influence of social networks on SHW migration intentions was observed within the following themes: access to information on migration opportunities, modelling of migration behaviour, support for decision making, and opportunities for policy engagement. CONCLUSION: The social networks of SHWs can aid the diffusion of norms that are relevant for improving SHW migration governance. Through their social networks, SHWs can improve awareness of the challenges associated with SHW migration among state actors and the public.

It is not all about salary: a discrete-choice experiment to determine community health workers' motivation for work in Nigeria.

INTRODUCTION: Community health workers (CHWs) constitute the majority of primary healthcare (PHC) workers in Nigeria, yet little is understood about their motivations or the most effective interventions to meet their needs to ensure quality health coverage across the country. We aimed to identify factors that would motivate CHWs for quality service delivery. METHODS: A discrete-choice experiment was conducted among 300 CHWs across 44 PHC facilities in the Federal Capital Territory, Abuja Nigeria. Based on the literature review and qualitative research, five attributes, namely: salary, educational opportunities, career progression and in-service training, housing and transportation, were included in the experiment. CHWs were presented with 12 unlabelled choice sets, using tablet devices, and asked to choose which of two hypothetical jobs they would accept if offered to them, or whether they would take neither job. Mixed multinomial logistic models were used to estimate stated preferences for the attributes and the likely uptake of jobs under different policy packages was simulated. RESULTS: About 70% of the respondents were women and 39% worked as volunteers. Jobs that offered career progression were the strongest motivators among the formally employed CHWs (ß=0.33) while the 'opportunity to convert from CHW to another cadre of health workers, such as nursing' was the most important motivator among the volunteers' CHWs (ß=0.53). CHWs also strongly preferred jobs that would offer educational opportunities, including scholarship (ß=0.31) and provision of transport allowances (ß=0.26). Policy scenario modelling predicted combined educational opportunities, career progression opportunities and an additional 10% of salary as incentives was the employment package that would be most appealing to CHWs. CONCLUSION: CHWs are motivated by a mix of non-financial and financial incentives. Policy interventions that would improve motivation should be adequate to address various contexts facing different CHWs and be flexible enough to meet their differing needs.

Utility of the Right to Health for Addressing Skilled Health Worker Shortages in Low- and Middle-Income Countries.

BACKGROUND: As a fundamental human right, the right to health (RTH) can influence state actors' behaviour towards health inequities. Human rights advocates have invoked the RTH in a collective demand for improved access to essential medicines in low- and middle-income countries (LMICs). Similarly, scholars have used the RTH as a framework for analysing health problems. However, its utility for addressing skilled health worker (SHW) shortages in LMICs has been understudied. Realising that SHW shortages occur due to existing push-and-pull factors within and between LMICs and high-income countries (HICs), we sought to answer the question: "how, why, and under what circumstance does the RTH offer utility for addressing SHW shortages in LMICs?" METHODS: We conducted a realist synthesis of evidence identified through a systematic search of peer-reviewed articles in Embase, Global Health, Medline (Ovid), ProQuest - Health & Medical databases, Scopus (Elsevier), Web of Science (Clarivate), CINAHL (EBSCO), APAIS-Health, Health Systems Evidence and PDQ-EVIDENCE; as well as grey literature from Google Scholar. RESULTS: We found that the RTH offers utility for addressing SHW shortages in LMICs through HIC state actors' concerns for their countries' reputational risk, recognition of their obligation to support health workforce strengthening in LMICs, and concerns for the cost implication. State actors in LMICs will respond to adopt programs inspired by the RTH when they are convinced that it offers tangible national benefits and are not overly burdened with ensuring its success. The socio-economic and institutional factors that constrain state actors' response include financial cost and sustainability of rights'-based options. CONCLUSION: State and non-state actors can use the RTH as a resource for promoting collective action towards addressing SHW shortages in LMICs. It can also inform negotiations between state actors in LMICs and their HIC counterparts.

Governance systems for skilled health worker migration, their public value and competing priorities: an interpretive scoping review.

BACKGROUND: Governments worldwide participate in skilled health worker (SHW) migration agreements to protect access to health services in their countries. Previous studies have described the value offered by these agreements in separate source and destination country perspectives. OBJECTIVE: We sought to identify and summarise existing literature on shared value creation for both source and destination countries. METHOD: We conducted a systematic scoping review of health databases and grey literature. Using Mark Moore and Colin Talbot frameworks, we summarised the public value propositions in migration agreements and how state actors addressed competing priorities. RESULTS: Most articles (34/63, 53.9%) reported transnational SHW mobility as the public value proposition for source and destination countries. Fewer articles, 14 (22.2%) and 9 (14.3%) articles, respectively, referred to achieving health workforce sustainability and building capacity for SHW migration governance as shared public values. The most identified competing public value (CPV) was an overriding focus on addressing SHW shortages in destination countries (20/63, 37.7%). Efforts to address this CPV include mitigation of the adverse effects of migration (43/63, 68.3%) and promoting health workforce development in source countries (15, 23.8%). At the same time, state actors retained regulatory discretion for protecting their country's public health interest (34, 54%). Most articles reported the lack of funds (15/63, 23.8%) and implementation mechanisms (19/63, 30.2%) as constraints on the authorising environment and the operational capacity of SHW migration governance systems. CONCLUSION: Regarding SHW migration governance, the literature reports shared public value propositions for source and destination countries. It also shows how the value-creating process in the management of SHW migration favours destination countries. Future studies will need to explore shared value creation models that ensure equity in the governance of SHW migration.

"We're on the ground, we know what needs to be done": Exploring the role of Aboriginal Health Workers in primary health care.

Background: Aboriginal Health Workers (AHWs) are core providers of primary health care (PHC) for First Nations peoples in Australia. However, the national AHW workforce is aging and in short supply. There is a poor understanding of the factors contributing to this attrition from the perspectives of AHWs themselves. This study aimed to systematically explore the current functioning and sustainability of AHWs in NSW PHC by amplifying AHW voices. Materials and methods: This study was co-designed with three Aboriginal health services in NSW. It included a literature review exploring the role of AHWs in NSW, and yarns with AHWs and their supervisors at participating services. Yarning is an Indigenous approach to knowledge generation centered upon storytelling. The yarns were guided by the USAID-developed Community Health Worker Assessment and Improvement Matrix. Yarn transcripts were analyzed using cyclical thematic analysis to identify key facilitators and challenges for AHW practice. Results: The yarns highlighted five categories of change that are required to ensure AHW sustainability: community connection, recognition, value, support, and an inclusive health system. The yarns revealed that there are both service- and system-level factors influencing each of these categories of change. Conclusions: The lived experiences of AHWs in NSW emphasize five key categories of change that are required to ensure workforce sustainability. It is evident that a system-wide paradigm shift to better include holistic approaches to health is necessary to truly ensure sustainability. Co-designing similar studies with ACCHOs across NSW can help inform this change.

Charting the Rights of Community Health Workers in India: The Next Frontier of Universal Health Coverage.

Community health workers (CHWs) have the capacity to bring essential health services to under-resourced communities. Globally, CHWs have made significant contributions to poverty alleviation, increased food security, and reductions in health inequalities. India's one million accredited social health activists (ASHAs), the largest cohort of CHWs in the world, have been credited with increasing the rate of institutional deliveries and the uptake of vaccinations. ASHAs operate at the margins of health systems and the formal health workforce, often due to misperceptions of their skills and discrimination based on gender, socioeconomic status, education, and rurality. The "voluntary" nature of their work can entrench their precarious status, which is characterized by a lack of access to employment rights, adequate remuneration, and institutional support. This article argues that the prioritization of the labor rights of CHWs in the design and implementation of the World Health Organization's 2018 Guideline on Health Policy and System Support to Optimize Community Health Worker Programmes can serve to ensure safe working conditions and freedom from discrimination, coercion, and violence. It further argues that the resultant enhancement and protection of CHWs' rights and long-term security provides an essential pathway for harnessing their potential to transform universal health coverage.

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.

How well are non-communicable disease services being integrated into primary health care in Africa: A review of progress against World Health Organization's African regional targets.

OBJECTIVE: In Africa, mortality due to non-communicable diseases (NCDs) is projected to overtake the combined mortality from communicable, maternal, neonatal, and nutritional diseases by 2030. To address this growing NCD burden, primary health care (PHC) systems will require substantial re-orientation. In this study, we reviewed the progress of African countries towards integrating essential NCD services into PHC. METHODS: A review of World Health Organization (WHO) reports was conducted for all 47 countries in the WHO African Region. To report each country's progress, we used an a priori framework developed by the WHO regional office for Africa (AFRO). Twelve indicators were used to measure countries' progress. The proportion of countries meeting each indicator was tabulated using a heat map. Correlation between country income status and attainment of each indicator was also assessed. FINDINGS: No country met all the recommended indicators to integrate NCD services into PHC and seven countries met none of the indicators. Few countries (30%) had nationally approved guidelines for NCD management and very few reported availabilities of all essential NCD medicines (13%) and technologies (11%) in PHC facilities. There was no overall correlation between a country's GDP per capita and the aggregate of targets being met (rho = 0.23; P = .12). There was, however, a modestly negative correlation between out-of-pocket expenditure and overall country progress (rho = -0.58; P < .001). CONCLUSION: Progress by AFRO Member States in integrating NCD care into PHC is variable across the region. Enhanced government commitment and judicious resource allocation to prioritize NCDs are needed. Particular areas of focus include increasing the uptake of simplified guidelines for NCDs; increasing workforce capacity to manage NCDs; and removing access barriers to essential medicines and basic diagnostic technologies.

Reformulation and strengthening of return-of-service (ROS) schemes could change the narrative on global health workforce distribution and shortages in sub-Saharan Africa.

Despite policies for addressing shortages and maldistribution of health professionals, sub-Saharan Africa continues to experience shortages and maldistribution of skilled health professionals. Policies such as return-of-service schemes or state-funded educational initiatives do not seem to be achieving their intended objectives, potentially due to poor design, implementation; and lack of monitoring and evaluation of the strategies. A focus by global health experts on strengthening and reformulating educational initiatives offers potential for producing, retaining and recruiting health professionals.

Hypertension in Rural India: The Contribution of Socioeconomic Position.

Background Various indicators of socioeconomic position (SEP) may have opposing effects on the risk of hypertension in disadvantaged settings. For example, high income may reflect sedentary employment, whereas greater education may promote healthy lifestyle choices. We assessed whether education modifies the association between income and hypertension in 3 regions of South India at different stages of epidemiological transition. Methods and Results Using a cross-sectional design, we randomly selected villages within each of rural Trivandrum, West Godavari, and Rishi Valley. Sampling was stratified by age group and sex. We measured blood pressure and anthropometry and administered a questionnaire to identify lifestyle factors and SEP, including education, literacy, and income. Logistic regression was used to assess associations between various components of SEP and hypertension, and interaction analyses were used to determine whether educational attainment modified the association between income and hypertension. Trivandrum, the region of highest SEP, had the greatest prevalence of hypertension, whereas Rishi Valley, the lowest SEP region, had the least. Overall, greater income was associated with greater risk of hypertension. In interaction analyses, there was no evidence that educational attainment modified the association between income and hypertension. Conclusions Education is widely considered to ameliorate the risk of hypertension in high-income countries. Why this effect is absent in rural India merits investigation.

Effectiveness of a scalable group-based education and monitoring program, delivered by health workers, to improve control of hypertension in rural India: A cluster randomised controlled trial.

BACKGROUND: New methods are required to manage hypertension in resource-poor settings. We hypothesised that a community health worker (CHW)-led group-based education and monitoring intervention would improve control of blood pressure (BP). METHODS AND FINDINGS: We conducted a baseline community-based survey followed by a cluster randomised controlled trial of people with hypertension in 3 rural regions of South India, each at differing stages of epidemiological transition. Participants with hypertension, defined as BP ≥ 140/90 mm Hg or taking antihypertensive medication, were advised to visit a doctor. In each region, villages were randomly assigned to intervention or usual care (UC) in a 1:2 ratio. In intervention clusters, trained CHWs delivered a group-based intervention to people with hypertension. The program, conducted fortnightly for 3 months, included monitoring of BP, education about hypertension, and support for healthy lifestyle change. Outcomes were assessed approximately 2 months after completion of the intervention. The primary outcome was control of BP (BP < 140/90 mm Hg), analysed using mixed effects regression, clustered by village within region and adjusted for baseline control of hypertension (using intention-to-treat principles). Of 2,382 potentially eligible people, 637 from 5 intervention clusters and 1,097 from 10 UC clusters were recruited between November 2015 and April 2016, with follow-up occurring in 459 in the intervention group and 1,012 in UC. Mean age was 56.9 years (SD 13.7). Baseline BP was similar between groups. Control of BP improved from baseline to follow-up more in the intervention group (from 227 [49.5%] to 320 [69.7%] individuals) than in the UC group (from 528 [52.2%] to 624 [61.7%] individuals) (odds ratio [OR] 1.6, 95% CI 1.2-2.1; P = 0.001). In secondary outcome analyses, there was a greater decline in systolic BP in the intervention than UC group (-5.0 mm Hg, 95% CI -7.1 to -3.0; P < 0.001) and a greater decline in diastolic BP (-2.1 mm Hg, 95% CI -3.6 to -0.6; P < 0.006), but no detectable difference in the use of BP-lowering medications between groups (OR 1.2, 95% CI 0.8-1.9; P = 0.34). Similar results were found when using imputation analyses that included those lost to follow-up. Limitations include a relatively short follow-up period and use of outcome assessors who were not blinded to the group allocation. CONCLUSIONS: While the durability of the effect is uncertain, this trial provides evidence that a low-cost program using CHWs to deliver an education and monitoring intervention is effective in controlling BP and is potentially scalable in resource-poor settings globally. TRIAL REGISTRATION: The trial was registered with the Clinical Trials Registry-India (CTRI/2016/02/006678).

Assessment of Barriers and Facilitators to the Delivery of Care for Noncommunicable Diseases by Nonphysician Health Workers in Low- and Middle-Income Countries: A Systematic Review and Qualitative Analysis.

Importance: Cardiovascular disease, cancer, and other noncommunicable diseases (NCDs) are the leading causes of mortality in low- and middle-income countries. Previous studies show that nonphysician health workers (NPHWs), including nurses and volunteers, can provide effective diagnosis and treatment of NCDs. However, the factors that facilitate and impair these programs are incompletely understood. Objective: To identify health system barriers to and facilitators of NPHW-led care for NCDs in low- and middle-income countries. Data Sources: All systematic reviews in PubMed published by May 1, 2018. Study Selection: The search terms used for this analysis included "task shifting" and "non-physician clinician." Only reviews of NPHW care that occurred entirely or mostly in low- and middle-income countries and focused entirely or mostly on NCDs were included. All studies cited within each systematic review that cited health system barriers to and facilitators of NPHW care were reviewed. Data Extraction and Synthesis: Assessment of study eligibility was performed by 1 reviewer and rechecked by another. The 2 reviewers extracted all data. Reviews were performed from November 2017 to July 2018. All analyses were descriptive. Main Outcomes and Measures: All barriers and facilitators mentioned in all studies were tallied and sorted according to the World Health Organization's 6 building blocks for health systems. Results: This systematic review and qualitative analysis identified 15 review articles, which cited 156 studies, of which 71 referenced barriers to and facilitators of care. The results suggest 6 key lessons: (1) select qualified NPHWs embedded within the community they serve; (2) provide detailed, ongoing training and supervision; (3) authorize NPHWs to prescribe medication and render autonomous care; (4) equip NPHWs with reliable systems to track patient data; (5) furnish NPHWs consistently with medications and supplies; and (6) compensate NPHWs adequately commensurate with their roles. Conclusions and Relevance: Although the health system barriers to NPHW screening, treatment, and control of NCDs and their risk factors are numerous and complex, a diverse set of care models has demonstrated strategies to address nearly all of these challenges. These facilitating approaches-which relate chiefly to strong, consistent NPHW training, guidance, and logistical support-generate a blueprint for the creation and scale-up of such programs adaptable across multiple chronic diseases, including in high-income countries.

Organisation of primary health care systems in low- and middle-income countries: review of evidence on what works and why in the Asia-Pacific region.

INTRODUCTION: This paper synthesises evidence on the organisation of primary health care (PHC) service delivery in low-income and middle-income countries (LMICs) in the Asia Pacific and identifies evidence of effective approaches and pathways of impact in this region. METHODS: We developed a conceptual framework describing key inputs and outcomes of PHC as the basis of a systematic review. We searched exclusively for intervention studies from LMICs of the Asia-Pacific region in an effort to identify 'what works' to improve the coverage, quality, efficiency, equity and responsiveness of PHC. We conducted a narrative synthesis to identify key characteristics of successful interventions. RESULTS: From an initial list of 3001 articles, we selected 153 for full-text review and included 111. We found evidence on the impact of non-physician health workers (NPHWs) on coverage and quality of care, though better integration with other PHC services is needed. Community-based services are most effective when well integrated through functional referral systems and supportive supervision arrangements, and have a reliable supply of medicines. Many studies point to the importance of community engagement in improving service demand. Few studies adopted a 'systems' lens or adequately considered long-term costs or implementation challenges. CONCLUSION: Based on our findings, we suggest five areas where more practical knowledge and guidance is needed to support PHC systems strengthening: (1) NPHW workforce development; (2) integrating non-communicable disease prevention and control into the basic package of care; (3) building managerial capacity; (4) institutionalising community engagement; (5) modernising PHC information systems.

Monitoring progress in reducing maternal mortality using verbal autopsy methods in vital registration systems: what can we conclude about specific causes of maternal death?

Reducing maternal mortality is a key focus of development strategies and one of the indicators used to measure progress towards achieving the Sustainable Development Goals. In the absence of medical certification of the cause of deaths that occur in the community, verbal autopsy (VA) methods are the only available means to assess levels and trends of maternal deaths that occur outside health facilities. The 2016 World Health Organization VA Instrument facilitates the identification of eight specific causes of maternal death, yet maternal deaths are often unsupervised, leading to sparse and generally poor symptom reporting to inform a reliable diagnosis using VAs. There is little research evidence to support the reliable identification of specific causes of maternal death in the context of routine VAs. We recommend that routine VAs are only used to capture the event of a maternal death and that more detailed follow-up interviews are used to identify the specific causes.

Strengthening and measuring research impact in global health: lessons from applying the FAIT framework.

BACKGROUND: To date, efforts to measure impact have largely focused on health research in high-income countries, reflecting where the majority of health research funding is spent. Nevertheless, there is a growing body of health and medical research being undertaken in low- and middle-income countries (LMICs), supported by both development aid and established research funders. The Framework to Assess the Impact of Translational health research (FAIT) combines three approaches to measuring research impact (Payback, economic assessment and case study narrative). Its aim is to strengthen the focus on translation and impact measurement in health research. FAIT has been used by several Australian research initiatives; however, it has not been used in LMICs. Our aim was to apply FAIT in an LMIC context and evaluate its utility. METHODS: We retrospectively applied all three FAIT methods to two LMIC studies using available data, supplemented with group discussion and further economic analyses. Results were presented in a scorecard format. RESULTS: FAIT helped clarify pathways of impact for the projects and provided new knowledge on areas of impact in several domains, including capacity-building for research, policy development and economic impact. However, there were constraints, particularly associated with calculating the return on investment in the LMIC context. The case study narrative provided a layperson's summary of the research that helped to explain outcomes and succinctly communicate lessons learnt. CONCLUSION: Use of FAIT to assess the impact of LMIC research was both feasible and useful. We make recommendations related to prospective use, identification of metrics to support use of the Payback framework, and simplification of the economic assessment, which may facilitate further application in LMIC environments.

Evaluating access to essential medicines for treating childhood cancers: a medicines availability, price and affordability study in New Delhi, India.

INTRODUCTION: Limited access to essential medicines (EMs) for treating chronic diseases is a major challenge in low-income and middle-income countries. Although India is the largest manufacturer of generic medicines, there is a paucity of information on availability, price and affordability of anti-neoplastic EMs, which this study evaluates. METHODS: Using a modified WHO/Health Action International methodology, data were collected on availability and price of 33 strength-specific anti-neoplastic EMs and 4 non-cancer EMs. Seven 'survey anchor' hospitals (4 public and 3 private) and 32 private-sector retail pharmacies were surveyed. Median price ratios (MPRs) were calculated by comparing consumer prices with international reference prices (IRPs). RESULTS: On average, across survey anchor areas (hospital and private-sector retail pharmacies combined), the mean availability of anti-neoplastic EMs and non-cancer medicines was 70% and 100%, respectively. Mean availability of anti-neoplastic EMs was 38% in private-sector retail pharmacies, 43% in public hospital pharmacies and 71% in private hospital pharmacies. Median MPR of lowest-priced generic versions was 0.71 in retail pharmacies. The estimated cost of chemotherapy medicines needed for treating a 30 kg child with standard-risk leukaemia was INR 27 850 (US$442) and INR 17 500 (US$278) for Hodgkin's lymphoma, requiring 88 and 55 days' wages, respectively, for the lowest paid government worker. CONCLUSION: Most anti-neoplastic EMs are found in survey anchor areas, however, mean availability was less than non-cancer medicines; not meeting the WHO target of 80%. Medicine prices were relatively low in New Delhi compared with IRPs. However, the cost of chemotherapy medicines seems unaffordable in the local context.

Methodological challenges to collecting clinical and economic outcome data: Lessons from the pilot dialysis outcomes India study.

AIM: Contemporary data on clinical and economic outcomes and quality of care amongst dialysis patients in India are not available. This pilot prospective study aimed to evaluate the feasibility of data collection and follow up within routine dialysis practice to inform setting up a dialysis registry. METHODS: An electronic instrument was developed to collect information on clinical and socio-demographic characteristics, outcome and out-of-pocket expenditure on incident patients commencing haemodialysis (HD) at two centres. Dialysis unit staff were trained in collecting and entering information on an electronic case record form. Patients were followed up at 1, 3, 6, 9 and 12 months to ascertain outcomes and treatment related costs. RESULTS: A total of 119 patients (37 females, age 47.5 ± 17.2 years) were enrolled. After 1 year, 38 (32%) patients were continuing on HD; 35 (29%) had died, 30 (25%) underwent a kidney transplant, and 16 (13%) had stopped dialysis. We noted a high prevalence of catastrophic health expenditure. Data collection was facilitated by appointing a designated staff member who received an incentive. Collection of financial information, clinical course for patients transferring out of the primary unit and the cause of death, when it occurred out of hospital was challenging. CONCLUSION: Prospective data collection of incident dialysis patients was feasible but is resource-intensive. High out-of-pocket costs force some patients to stop dialysis and can generate a sense of despair. Poor patient experiences and suspicion over the use of such data adversely affects collection of important clinical and health economic data.