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.

Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries?

BACKGROUND: Healthcare providers' (HCPs) professionalism refers to their commitment and ability to respond to the health needs of the communities they serve and to act in the best interest of patients. Despite attention to increasing the number of HCPs in low- and middle-income countries (LMIC), the quality of professional education delivered to HCPs and their resulting professionalism has been neglected. The Global Action Plan on Antimicrobial Resistance (AMR) seeks to reduce inappropriate use of antibiotics by urging patients to access antibiotics only through qualified HCPs, on the premise that qualified HCPs will act as more responsible and competent gatekeepers of access to antibiotics than unqualified HCPs. METHODS: We investigate whether weaknesses in HCP professionalism result in boundaries between qualified HCPs and unqualified providers being blurred, and how these weaknesses impact inappropriate provision of antibiotics by HCPs in two LMIC with increasing AMR-Pakistan and Cambodia. We conducted 85 in-depth interviews with HCPs, policymakers, and pharmaceutical industry representatives. Our thematic analysis was based on a conceptual framework of four components of professionalism and focused on identifying recurring findings in both countries. RESULTS: Despite many cultural and sociodemographic differences between Cambodia and Pakistan, there was a consistent finding that the behaviour of many qualified HCPs did not reflect their professional education. Our analysis identified five areas in which strengthening HCP education could enhance professionalism and reduce the inappropriate use of antibiotics: updating curricula to better cover the need for appropriate use of antibiotics; imparting stronger communication skills to manage patient demand for medications; inculcating essential professional ethics; building skills required for effective collaboration between doctors, pharmacists, and lay HCPs; and ensuring access to (unbiased) continuing medical education. CONCLUSIONS: In light of the weaknesses in HCP professionalism identified, we conclude that global guidelines urging patients to only seek care at qualified HCPs should consider whether HCP professional education is equipping them to act in the best interest of the patient and society. Our findings suggest that improvements to HCP professional education are needed urgently and that these should focus not only on the curriculum content and learning methods, but also on the social purpose of graduates.

What can motivate Lady Health Workers in Pakistan to engage more actively in tuberculosis case-finding?

BACKGROUND: Many interventions to motivate community health workers to perform better rely on financial incentives, even though it is not clear that monetary gain is the main motivational driver. In Pakistan, Lady Health Workers (LHW) are responsible for delivering community level primary healthcare, focusing on rural and urban slum populations. There is interest in introducing large-scale interventions to motivate LHW to be more actively involved in improving tuberculosis case-finding, which is low in Pakistan. METHODS: Our study investigated how to most effectively motivate LHW to engage more actively in tuberculosis case-finding. The study was embedded within a pilot intervention that provided financial and other incentives to LHW who refer the highest number of tuberculosis cases in three districts in Sindh province. We conducted semi-structured interviews with 20 LHW and 12 health programme managers and analysed these using a framework categorising internal and external sources of motivation. RESULTS: Internal drivers of motivation, such as religious rewards and social recognition, were salient in our study setting. While monetary gain was identified as a motivator by all interviewees, programme managers expressed concerns about financial sustainability, and LHW indicated that financial incentives were less important than other sources of motivation. LHW emphasised that they typically used financial incentives provided to cover patient transport costs to health facilities, and therefore financial incentives were usually not perceived as rewards for their performance. CONCLUSIONS: This study indicated that interventions in addition to, or instead of, financial incentives could be used to increase LHW engagement in tuberculosis case-finding. Our finding about the strong role of internal motivation (intrinsic, religious) in Pakistan suggests that developing context-specific strategies that tap into internal motivation could allow infectious disease control programmes to improve engagement of community health workers without being dependent on funding for financial incentives.

How can we improve priority-setting for investments in health research? A case study of tuberculosis.

BACKGROUND: Although enhanced priority-setting for investments in health research for development is essential to tackling inequalities in global health, there is a lack of consensus on an optimal priority-setting process. In light of the current surge in tuberculosis (TB) research investment, we use TB as a case study. METHODS: We investigated two critical aspects of a research prioritisation process, namely the criteria that should be used to rank alternative research options and which stakeholders should be involved in priority-setting. We conducted semi-structured interviews with 24 key informants purposively selected from four distinct groups - academia, funding bodies, international policy or technical agencies, and national disease control programmes. Interview transcripts were analysed verbatim using a framework approach. We also performed a systematic analysis of seven diverse TB research prioritisation processes. RESULTS: There was consensus that well-defined and transparent criteria for assessing research options need to be agreed at the outset of any prioritisation process. It was recommended that criteria should select for research that is likely to have the greatest public health impact in affected countries rather than research that mainly fills scientific knowledge gaps. Some interviewees expressed strong views about the need - and reluctance - to make politically challenging decisions that place some research areas at a lower priority for funding. The importance of taking input from stakeholders from countries with high disease burden was emphasised; such stakeholders were notably absent from the majority of prioritisation processes we analysed. CONCLUSIONS: This study indicated two critical areas for improvement of research prioritisation processes such that inequalities in health are better addressed - the need to deprioritise some research areas to generate a specific and meaningful list for investment, and greater involvement of experts working in high disease-burden countries.

Investments in tuberculosis research - what are the gaps?

Through decades of research, numerous studies have generated robust evidence about effective interventions for tuberculosis control. Yet, the global annual decline in incidence of approximately 1 % is evidence that current approaches and investment strategies are not sufficient. In this article, we assess recent tuberculosis research funding and discuss two critical gaps in funding and in scientific evidence from topics that have been left off the research priority agenda.We first examine research and development funding goals in the 2011-2015 Global Plan to Stop Tuberculosis and analyze disbursements to different research areas by funders worldwide in 2014. We then summarize, through a compilation of published literature and consultation with 35 researchers across multiple disciplines in the London School of Hygiene and Tropical Medicine TB Centre, priorities identified by the tuberculosis research community. Finally, we compare researchers' priority areas to the global funding agendas and activities.Our analysis shows that, among the five key research areas defined in the 2011-2015 Global Plan - namely drugs, basic science, vaccines, diagnostics and operational research - drug discovery and basic science on Mycobacterium tuberculosis accounted for 60 % of the $2 billion annual funding target. None of the research areas received the recommended level of funding. Operational research, which had the lowest target, received 66 % of its target funding, whereas new diagnostics received only 19 %. Although many of the priority research questions identified by researchers fell within the Global Plan categories, our analysis highlights important areas that are not explicitly mentioned in the current plan. These priority research areas included improved understanding of tuberculosis transmission dynamics, the role of social protection and social determinants, and health systems and policy research.While research priorities are increasingly important in light of the limited funding for tuberculosis, there is a risk that we neglect important research areas and encourage the formation of research silos. To ensure that funding priorities, researchers' agendas and national tuberculosis control policies are better coordinated, there should be more, and wider, dialogue between stakeholders in high tuberculosis burden countries, researchers, international policymakers and funders.

The effect of surgery on the outcome of treatment for multidrug-resistant tuberculosis: a systematic review and meta-analysis.

BACKGROUND: In 2014 only 50 % of multidrug-resistant tuberculosis (MDR-TB) patients achieved a successful treatment outcome. With limited options for medical treatment, surgery has re-emerged as an adjuvant therapeutic strategy. We conducted a systematic review and meta-analysis to assess the evidence for the effect of surgery as an adjunct to chemotherapy on outcomes of adults treated for MDR-TB. METHODS: Databases and grey literature sources were searched using terms incorporating surgery and MDR-TB. No language or publication type limits were applied. Articles published pre-1990, without a comparator group, or reporting <10 surgical participants were excluded. Two-stage sifting in duplicate was employed. Data on WHO-defined treatment outcomes were abstracted into a standardised database. Study-level risk of bias was evaluated using standardised tools. Outcome-level evidence quality was assessed using GRADE. Forest plots were generated, random effects meta-analysis conducted, and heterogeneity assessed using the I(2) statistic. RESULTS: Of 1024 unique citations identified, 62 were selected for full-text review and 15 retained for inclusion. A further four articles were included after bibliography/citation searching, and one additional unpublished manuscript was identified, giving 20 articles for final inclusion. Six were meta-analyses/systematic reviews and 14 were primary research articles (observational studies). From the 14 primary research articles, a successful outcome (cured/treatment completed) was reported for 81.9 % (371/453) and 59.7 % (1197/2006) in the surgical and non-surgical group respectively, giving a summary odds ratio of 2.62 (95 % confidence interval 1.94-3.54). Loss to follow-up and treatment failure were lower in the surgery group (both p = 0.01). Overall GRADE quality of evidence for all outcomes considered was "very low". CONCLUSIONS: This meta-analysis suggests that surgery as an adjunct to chemotherapy is associated with improved treatment outcomes in MDR-TB patients. However, inherent limitations in observational study design, insufficient reporting, and lack of adjustment for confounders, led to grading of the evidence as very low quality. Data on rationale for surgical referral, subsequent outcomes and resource-limited settings are scarce, precluding evidence-based recommendations on the suitability of surgery by patient characteristics or setting. It is hoped that highlighted methodological and reporting gaps will encourage improved design and reporting of future surgical studies for MDR-TB.

The effect of early versus late treatment initiation after diagnosis on the outcomes of patients treated for multidrug-resistant tuberculosis: a systematic review.

BACKGROUND: Globally it is estimated that 480 000 people developed multidrug-resistant tuberculosis (MDR-TB) in 2014 and 190 000 people died from the disease. Successful treatment outcomes are achieved in only 50 % of patients with MDR-TB, compared to 86 % for drug susceptible disease. It is widely held that delay in time to initiation of treatment for MDR-TB is an important predictor of treatment outcome. The objective of this review was to assess the existing evidence on the outcomes of multidrug- and extensively drug-resistant tuberculosis patients treated early (≤4 weeks) versus late (>4 weeks) after diagnosis of drug resistance. METHODS: Eight sources providing access to 17 globally representative electronic health care databases, indexes, sources of evidence-based reviews and grey literature were searched using terms incorporating time to treatment and MDR-TB. Two-stage sifting in duplicate was employed to assess studies against pre-specified inclusion and exclusion criteria. Only those articles reporting WHO-defined treatment outcomes were considered for inclusion. Articles reporting on fewer than 10 patients, published before 1990, or without a comparison of outcomes in patient groups experiencing different delays to treatment initiation were excluded. RESULTS: The initial search yielded 1978 references, of which 1475 unique references remained after removal of duplicates and 28 articles published pre-1990. After title and abstract sifting, 64 papers underwent full text review. None of these articles fulfilled the criteria for inclusion in the review. CONCLUSIONS: Whilst there is an inherent logic in the theory that treatment delay will lead to poorer treatment outcomes, no published evidence was identified in this systematic review to support this hypothesis. Reports of programmatic changes leading to reductions in treatment delay exist in the literature, but attribution of differences in outcomes specifically to treatment delay is confounded by other contemporaneous changes. Further primary research on this question is not considered a high priority use of limited resources, though where data are available, improved reporting of outcomes by time to treatment should be encouraged.

Economic interventions to improve population health: a scoping study of systematic reviews.

BACKGROUND: Recognizing the close relationship between poverty and health, national program managers, policy-makers and donors are increasingly including economic interventions as part of their core strategies to improve population health. However, there is often confusion among stakeholders about the definitions and operational differences between distinct types of economic interventions and financial instruments, which can lead to important differences in interpretation and expectations. METHODS: We conducted a scoping study to define and clarify concepts underlying key economic interventions - price interventions (taxes and subsidies), income transfer programs, incentive programs, livelihood support programs and health-related financial services - and map the evidence currently available from systematic reviews. RESULTS: We identified 195 systematic reviews on economic interventions published between 2005 and July 2015. Overall, there was an increase in the number of reviews published after 2010. The majority of reviews focused on price interventions, income transfer programs and incentive programs, with much less evidence available from systematic reviews on livelihood support programs and health-related financial services. We also identified a lack of evidence on: health outcomes in low income countries; unintended or perverse outcomes; implementation challenges; scalability and cost-effectiveness of economic interventions. CONCLUSIONS: We conclude that while more research is clearly needed to assess suitability and effectiveness of economic interventions in different contexts, before interventions are tested and further systematic reviews conducted, a consistent and accurate understanding of the fundamental differences in terminology and approaches is essential among researchers, public health policy makers and program planners.

Quantitatively evaluating the effect of social barriers: a case-control study of family members' opposition and women's intention to use contraception in Pakistan.

BACKGROUND: Uptake of family planning services in Pakistan has remained slow over the past decade despite a rapid increase in availability and awareness, indicating that social barriers may be preventing uptake. Social barriers such as opposition by family members have largely been studied qualitatively; there is a lack of quantitative evidence about the effect of different family members' opposition on women's intention to use contraceptives. The objective of this study was to quantitatively evaluate the effect of family members' opposition to family planning on intention to use contraception amongst poor women in Pakistan who have physical access to family planning services. METHODS: An unmatched case control study (nested within a larger cohort study) was conducted in two public hospitals in Karachi, Pakistan. Univariable and multivariable logistic regression analyses were conducted to compare risk factors between women that were not intending to use any contraceptive methods in the future (cases) and women that were planning to use contraceptive methods (controls). RESULTS: 248 cases and 496 controls were included in the study. Negative contraceptive intent was associated with no knowledge of contraception (AOR = 3.79 [2.43-5.90]; p < 0.001), husband's opposition (AOR = 21.87 [13.21-36.21]; p < 0.001) and mother-in-law's opposition (AOR = 4.06 [1.77-9.30]; p < 0.001). CONCLUSIONS: This study is the first to quantitatively assess the effect of opposition by different family members on women's contraceptive intent in Pakistan. Our results indicate that of all family members, husband's opposition has the strongest effect on women's intention to use contraception, even when the women have knowledge of and physical access to family planning services.

Novel methodology to assess sputum smear microscopy quality in private laboratories.

BACKGROUND: In South Asia, it is estimated that 80% of patients choose to attend a private facility for their healthcare needs. Although patients generally believe that the private-sector provides high quality services, private diagnostic laboratories are largely unregulated and little is known about the accuracy of results provided. This study assesses the accuracy of sputum smear microscopy for pulmonary tuberculosis diagnosis in private laboratories operating in Karachi, Pakistan. A novel evaluation methodology was designed in which patient-actors submitted sputum specimens spiked with cultured Mycobacterium tuberculosis (Mtb) for testing such that laboratories were not aware that they were being assessed. METHODS: Smear-negative sputum specimens from Indus Hospital TB Program patients were collected and combined with an attenuated, cultured Mtb strain to create Mtb-spiked samples; for negative standards, no Mtb was added to the smear-negative sputum specimens. Seven of the largest private laboratories across Karachi were chosen for evaluation and were sent six Mtb-spiked and one Mtb-negative sputum specimens. Patient-actors pretending to be laboratory customers submitted these specimens to each laboratory for testing over a three day period. RESULTS: Only three laboratories accurately classified all the Mtb-spiked specimens which were submitted. A further three misclassified all the Mtb-spiked specimens as smear-negative, thus providing the 'patients' with false negative results. CONCLUSIONS: TB sputum smear microscopy services are highly variable across private laboratories and are often of extremely poor quality. Engagement, capacity building and rigorous monitoring of standards at private laboratories are of vital importance for the control of TB. Our findings, while specific for TB diagnostic tests, could be symptomatic of other tests performed in private laboratories and warrant further investigation.

Millennium development goals and the water target: details, definitions and debate.

One of the primary targets of MDG 7, dealing with issues of environmental sustainability, is to halve by 2015 (from 1990 levels) the proportion of the population without sustainable access to safe drinking water and basic sanitation. It is undoubtedly difficult to summarise a complex target such as access to water or safety of water source in a single quantifiable indicator. However, in our opinion, the indicators used to estimate how much of the population has 'access' to 'safe' drinking water leave out some important elements that should be taken into account when determining whether the goals have been met. In addition, the authors propose a modification to Bradley's classification of water-related illness to include a category for waterborne diseases of a non-infectious aetiology.

Conducting rapid health needs assessments in the cluster era: experience from the Pakistan flood.

Due to its unprecedented scale, the Pakistan flood disaster tested the limits of disaster management and coordination. Under the leadership of the World Health Organization, the Global Health Cluster system for coordinating activities improved collaboration and efficiency in conducting rapid needs assessments. However, the involvement of non-Cluster members was lacking, and information on existing service provision was not collected adequately. The present rapid health needs assessment process under the Cluster system will be discussed, using the recent floods in Pakistan as an example.

Building better tuberculosis control systems in a post-COVID world: learning from Pakistan during the COVID-19 pandemic.

OBJECTIVES: All countries impacted by COVID-19 have had to change routine health service delivery. Although this has reversed some of the progress made in reducing the global burden of tuberculosis (TB) disease, there is an opportunity to incorporate lessons learned to improve TB programmes going forward. APPROACH: We use Pakistan as a case study to discuss three important adaptations in light of COVID-19: bringing care closer to patients; strengthening primary health care systems; and proactively addressing stigma and fear. FINDINGS: COVID-19 control in Pakistan has restricted people's ability to travel and this has forced the TB programme to reduce the need for in-person health facility visits and bring care closer to patients' homes. Strategies that may be useful for providing more convenient care to patients in the future include: : remote treatment support using telemedicine; collaborating with private healthcare providers; and establishing community medicine collection points. As part of the response to COVID-19 in Pakistan, the out-patient departments of major tertiary and secondary care hospitals were closed, and this highlighted the importance of strengthening primary healthcare for both better pandemic and TB control. Finally, stigma associated with COVID-19 and TB can be addressed using trusted community-based health workers, such as Lady Health Workers in Pakistan.

Mitigating the impact of COVID-19 on tuberculosis and HIV services: A cross-sectional survey of 669 health professionals in 64 low and middle-income countries.

OBJECTIVE: The experiences of frontline healthcare professionals are essential in identifying strategies to mitigate the disruption to healthcare services caused by the COVID-19 pandemic. METHODS: We conducted a cross-sectional study of TB and HIV professionals in low and middle-income countries (LMIC). Between May 12 and August 6, 2020, we collected qualitative and quantitative data using an online survey in 11 languages. We used descriptive statistics and thematic analysis to analyse responses. FINDINGS: 669 respondents from 64 countries completed the survey. Over 40% stated that it was either impossible or much harder for TB and HIV patients to reach healthcare facilities since COVID-19. The most common barriers reported to affect patients were: fear of getting infected with SARS-CoV-2, transport disruptions and movement restrictions. 37% and 28% of responses about TB and HIV stated that healthcare provider access to facilities was also severely impacted. Strategies to address reduced transport needs and costs-including proactive coordination between the health and transport sector and cards that facilitate lower cost or easier travel-were presented in qualitative responses. Access to non-medical support for patients, such as food supplementation or counselling, was severely disrupted according to 36% and 31% of HIV and TB respondents respectively; qualitative data suggested that the need for such services was exacerbated. CONCLUSION: Patients and healthcare providers across numerous LMIC faced substantial challenges in accessing healthcare facilities, and non-medical support for patients was particularly impacted. Synthesising recommendations of frontline professionals should be prioritised for informing policymakers and healthcare service delivery organisations.