Childbirth care in Egypt: a repeat cross-sectional analysis using Demographic and Health Surveys between 1995 and 2014 examining use of care, provider mix and immediate postpartum care content.

BACKGROUND: Egypt has achieved important reductions in maternal and neonatal mortality and experienced increases in the proportion of births attended by skilled professionals. However, substandard care has been highlighted as one of the avoidable causes behind persisting maternal deaths. This paper describes changes over time in the use of childbirth care in Egypt, focusing on location and sector of provision (public versus private) and the content of immediate postpartum care. METHODS: We used five Demographic and Health Surveys conducted in Egypt between 1995 and 2014 to explore national and regional trends in childbirth care. To assess content of care in 2014, we calculated the caesarean section rate and the percentage of women delivering in a facility who reported receiving four components of immediate postpartum care for themselves and their newborn. RESULTS: Between 1995 and 2014, the percentage of women delivering in health facilities increased from 35 to 87% and women delivering with a skilled birth attendant from 49 to 92%. The percentage of women delivering in a private facility nearly quadrupled from 16 to 63%. In 2010-2014, fewer than 2% of women delivering in public or private facilities received all four immediate postpartum care components measured. CONCLUSIONS: Egypt achieved large increases in the percentage of women delivering in facilities and with skilled birth attendants. However, most women and newborns did not receive essential elements of high quality immediate postpartum care. The large shift to private facilities may highlight failures of public providers to meet women's expectations. Additionally, the content (quality) of childbirth care needs to improve in both sectors. Immediate action is required to understand and address the drivers of poor quality, including insufficient resources, perverse incentives, poor compliance and enforcement of existing standards, and providers' behaviours moving between private and public sectors. Otherwise, Egypt risks undermining the benefits of high coverage because of substandard quality childbirth care.

Implementation research for public sector mental health care scale-up (SMART-DAPPER): a sequential multiple, assignment randomized trial (SMART) of non-specialist-delivered psychotherapy and/or medication for major depressive disorder and posttraumatic stress disorder (DAPPER) integrated with outpatient care clinics at a county hospital in Kenya.

BACKGROUND: Mental disorders are a leading cause of global disability, driven primarily by depression and anxiety. Most of the disease burden is in Low and Middle Income Countries (LMICs), where 75% of adults with mental disorders have no service access. Our research team has worked in western Kenya for nearly ten years. Primary care populations in Kenya have high prevalence of Major Depressive Disorder (MDD) and Posttraumatic Stress Disorder (PTSD). To address these treatment needs with a sustainable, scalable mental health care strategy, we are partnering with local and national mental health stakeholders in Kenya and Uganda to identify 1) evidence-based strategies for first-line and second-line treatment delivered by non-specialists integrated with primary care, 2) investigate presumed mediators of treatment outcome and 3) determine patient-level moderators of treatment effect to inform personalized, resource-efficient, non-specialist treatments and sequencing, with costing analyses. Our implementation approach is guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. METHODS/DESIGN: We will use a Sequential, Multiple Assignment Randomized Trial (SMART) to randomize 2710 patients from the outpatient clinics at Kisumu County Hospital (KCH) who have MDD, PTSD or both to either 12 weekly sessions of non-specialist-delivered Interpersonal Psychotherapy (IPT) or to 6 months of fluoxetine prescribed by a nurse or clinical officer. Participants who are not in remission at the conclusion of treatment will be re-randomized to receive the other treatment (IPT receives fluoxetine and vice versa) or to combination treatment (IPT and fluoxetine). The SMART-DAPPER Implementation Resource Team, (IRT) will drive the application of the EPIS model and adaptations during the course of the study to optimize the relevance of the data for generalizability and scale -up. DISCUSSION: The results of this research will be significant in three ways: 1) they will determine the effectiveness of non-specialist delivered first- and second-line treatment for MDD and/or PTSD, 2) they will investigate key mechanisms of action for each treatment and 3) they will produce tailored adaptive treatment strategies essential for optimal sequencing of treatment for MDD and/or PTSD in low resource settings with associated cost information - a critical gap for addressing a leading global cause of disability. TRIAL REGISTRATION: ClinicalTrials.gov NCT03466346, registered March 15, 2018.

A window-DEA based efficiency evaluation of the public hospital sector in Greece during the 5-year economic crisis.

The main objective of this study was to apply the non-parametric method of Data Envelopment Analysis (DEA) to measure the efficiency of Greek NHS hospitals between 2009-2013. Hospitals were divided into four separate groups with common characteristics which allowed comparisons to be carried out in the context of increased homogeneity. The window-DEA method was chosen since it leads to increased discrimination on the results especially when applied to small samples and it enables year-by-year comparisons of the results. Three inputs -hospital beds, physicians and other health professionals- and three outputs-hospitalized cases, surgeries and outpatient visits- were chosen as production variables in an input-oriented 2-year window DEA model for the assessment of technical and scale efficiency as well as for the identification of returns to scale. The Malmquist productivity index together with its components (i.e. pure technical efficiency change, scale efficiency change and technological scale) were also calculated in order to analyze the sources of productivity change between the first and last year of the study period. In the context of window analysis, the study identified the individual efficiency trends together with "all-windows" best and worst performers and revealed that a high level of technical and scale efficiency was maintained over the entire 5-year period. Similarly, the relevant findings of Malmquist productivity index analysis showed that both scale and pure technical efficiency were improved in 2013 whilst technological change was found to be in favor of the two groups with the largest hospitals.

Public funding and private investment for R&D: a survey in China's pharmaceutical industry.

BACKGROUND: In recent years, China has experienced tremendous growth in its pharmaceutical industry. Both the Chinese government and private investors are motivated to invest into pharmaceutical research and development (R&D). However, studies regarding the different behaviors of public and private investment in pharmaceutical R&D are scarce. Therefore, this paper aims to investigate the current situation of public funding and private investment into Chinese pharmaceutical R&D. METHODS: The primary data used in the research were obtained from the China High-tech Industry Statistics Yearbook (2002-2012) and China Statistical Yearbook of Science and Technology (2002-2012). We analyzed public funding and private investment in five aspects: total investment in the industry, funding sources of the whole industry, differences between provinces, difference in subsectors, and private equity/venture capital investment. RESULTS: The vast majority of R&D investment was from private sources. There is a significantly positive correlation between public funding and private investment in different provinces of China. However, public funding was likely to be invested into less developed provinces with abundant natural herbal resources. Compared with the chemical medicine subsector, traditional Chinese medicine and biopharmaceutical subsectors obtained more public funding. Further, the effect of the government was focused on private equity and venture capital investment although private fund is the mainstream of this type of investment. CONCLUSIONS: Public funding and private investment play different but complementary roles in pharmaceutical R&D in China. While being less than private investment, public funding shows its significance in R&D investment. With rapid growth of the industry, the pharmaceutical R&D investment in China is expected to increase steadily from both public and private sources.

Open access high throughput drug discovery in the public domain: a Mount Everest in the making.

High throughput screening (HTS) facilitates screening large numbers of compounds against a biochemical target of interest using validated biological or biophysical assays. In recent years, a significant number of drugs in clinical trails originated from HTS campaigns, validating HTS as a bona fide mechanism for hit finding. In the current drug discovery landscape, the pharmaceutical industry is embracing open innovation strategies with academia to maximize their research capabilities and to feed their drug discovery pipeline. The goals of academic research have therefore expanded from target identification and validation to probe discovery, chemical genomics, and compound library screening. This trend is reflected in the emergence of HTS centers in the public domain over the past decade, ranging in size from modestly equipped academic screening centers to well endowed Molecular Libraries Probe Centers Network (MLPCN) centers funded by the NIH Roadmap initiative. These centers facilitate a comprehensive approach to probe discovery in academia and utilize both classical and cutting-edge assay technologies for executing primary and secondary screening campaigns. The various facets of academic HTS centers as well as their implications on technology transfer and drug discovery are discussed, and a roadmap for successful drug discovery in the public domain is presented. New lead discovery against therapeutic targets, especially those involving the rare and neglected diseases, is indeed a Mount Everestonian size task, and requires diligent implementation of pharmaceutical industry's best practices for a successful outcome.

Developing wider workforce regulation in England: lessons from education, social work and social care.

This paper draws on the findings of a review of regulation of professionally qualified teachers, social workers and other staff in social care. It charts the process of developing and implementing both professional and wider workforce regulation in England, focusing on the implications for generic and integrated working and the development of cross-professional procedures for the protection of vulnerable adults and children from abuse. There are many uncertainties about how best to develop workforce regulation especially when integrated working is a policy goal. In light of the paucity of evidence of outcomes and benefits for improved practice and the protection of the public, there is a need for research to address this complex arena.

Salud pública y sostenibilidad de los sistemas públicos de salud / Public health and public health system sustainability

La salud pública y la asistencia sanitaria tienen orígenes históricosdiferenciados, y desde su despliegue moderno han seguido trayectoriasbastante separadas. El gran desarrollo de los sistemas desalud en la segunda mitad del Siglo XX potencia la perspectiva individualy supone una divergencia de las dos orientaciones, a pesar delos intentos de aproximación realizados a partir de la Conferencia deAlma Atá de la OMS. El declive del racionalismo y otros fenómenossociales colaboran a una mayor desatención al enfoque colectivo opoblacional de la Salud Pública; pero estas tendencias crean tambiénun problema creciente de racionalidad en la atención sanitaria individual,y de sostenibilidad a los sistemas públicos de salud. El debatesobre el escenario actual, lleva a enunciar los problemas de sostenibilidadmediados por agentes internos y externos, y a revisar laposible contribución de la Salud Pública a su mejora, propugnandoun nuevo intento de convergencia e integración de ambas perspectivas

Public health and healthcare originally started out separatelyfrom one another in the past, having later further developed takingdifferent paths in modern times. The major development the healthsystems underwent in the last half of the 20th century entailed aheightening of the individual standpoint and a division of these twoapproaches despite the attempts made to bring them together as ofthe WHO Alma-Ata Conference in 1978. The waning of rationalismand other social phenomena had a hand the collective or population-oriented focus being focused on to a lesser degree in PublicHealth, but these trends also gave rise to a growing problem ofrationality in individual healthcare and sustainability in the publichealth systems. The debate on the current scene stands to set out thesustainability-related problems mediated by internal and externalagents and to revise Public Health's possible contribution to theimprovement thereof by advocating yet a further attempt at bringingtogether and integrating these two diverging standpoints

Finding new tricks for old drugs: an efficient route for public-sector drug discovery.

With the annotation of the human genome approaching completion, public-sector researchers - spurred in part by various National Institutes of Health Roadmap Initiatives - have become increasingly engaged in drug discovery and development efforts. Although large and diverse chemical libraries of 'drug-like' compounds can be readily screened to yield chemically novel scaffolds, transforming these 'chemical probes' into drugs is a daunting endeavour. A more efficient approach involves screening libraries of approved and off-patent medications; both phenotypic- and molecular target-based screening of 'old drugs' can readily yield compounds that could be immediately used in clinical trials. Using case studies, we describe how this approach has rapidly identified candidate medications suitable for clinical trials in disorders such as progressive multifocal leukoencephalopathy and amyotrophic lateral sclerosis. This approach has also led to the discovery of the molecular targets responsible for serious drug side effects, thereby allowing efficient 'counter-screening' to avoid these side effects.

Hospital restructuring initiatives in Canada.

OBJECTIVES: Recent changes in the organization, staffing, and utilization of acute hospitals in Canada are reviewed with regard to the potential implications for quality of care, national nurse workforce requirements, and research. METHODS: Available national and selected provincial data and trends in hospital utilization, capacity, and staffing are synthesized. RESULTS: Health system reform in Canada has resulted in lower utilization of acute inpatient resources, excess hospital capacity, and increased budgetary constraints in the hospital sector. In response, there is widespread hospital restructuring, which includes modifications in nurse staffing ratios and skill mix. Little is known about the potential impact of these changes on patient outcomes. From a workforce perspective, changes in the hospital sector have reduced demand for registered nurses but nursing schools have not modified enrollments. As a result, new graduates are experiencing difficulty obtaining registered nurse positions. CONCLUSIONS: Research should be undertaken to evaluate the impact of changes in the organization and staffing of hospitals on patient outcomes, and on the future requirements for nurses.