The impact of scheduling ketamine as an internationally controlled substance on anaesthesia care in Sub-Saharan Africa: a case study and key informant interviews.

BACKGROUND: Access to anaesthesia and surgical care is a major problem for people living in Sub-Saharan Africa. In this region, ketamine is critical for the provision of anaesthesia care. However, efforts to control ketamine internationally as a controlled substance may significantly impact its accessibility. This research therefore aims to estimate the importance of ketamine for anaesthesia and surgical care in Sub-Saharan Africa and assess the potential impact on access to ketamine if it were to be scheduled. METHODS: This research is a mixed-methods study, comprising of a cross-sectional survey at the hospital level in Rwanda, and key informant interviews with experts on anaesthesia care in Sub-Saharan Africa. Data on availability of four anaesthetic agents were collected from hospitals (n = 54) in Rwanda. Semi-structured interviews with 10 key informants were conducted, collecting information on the importance of ketamine, the potential impact of scheduling ketamine internationally, and opinions on misuse of ketamine. Interviews were transcribed verbatim and analysed using a thematic analysis approach. RESULTS: The survey conducted in Rwanda found that availability of ketamine and propofol was comparable at around 80%, while thiopental and inhalational agents were available at only about half of the hospitals. Significant barriers impeding access to anaesthesia care were identified, including a general lack of attention given to the specialty by governments, a shortage of anaesthesiologists and migration of trained anaesthesiologists, and a scarcity of medicines and equipment. Ketamine was described as critical for the provision of anaesthesia care as a consequence of these barriers. Misuse of ketamine was not believed to be an issue by the informants. CONCLUSION: Ketamine is critical for the provision of anaesthesia care in Sub-Saharan Africa, and its scheduling would have a significantly negative impact on its availability for anaesthesia care.

Availability and stock-outs of paediatric antiretroviral treatment formulations at health facilities in Kenya and Uganda.

INTRODUCTION: The large number of deaths among children with HIV is driven by poor antiretroviral treatment (ART) coverage among this cohort. The aim of the study was to assess the availability and stock-outs of paediatric and adult ART formulations in Kenya and Uganda across various regions and types of health facilities. METHODS: A survey on availability and stock-outs of paediatric ART at health facilities was adapted from the standardized Health Action International-WHO Medicine Availability Monitoring Tool. All preferred and limited-use formulations, and three phased-out formulations according to the 2021 WHO optimal formulary list were included in the survey, as well as a selection of adult ART formulations suitable for older children, adolescents, and adults. Availability data were collected in June-July 2022 and stock-out data were obtained over the previous year from randomly selected public and private-not-for-profit (PNFP) facilities registered to dispense paediatric ART across six districts per country. All data were analysed descriptively. RESULTS: In total, 144 health facilities were included (72 per country); 110 were public and 34 PNFP facilities. Overall availabilities of preferred paediatric ART formulations were 52.2% and 63.5% in Kenya and Uganda, respectively, with dolutegravir (DTG) 10 mg dispersible tablets being available in 70.2% and 77.4% of facilities, respectively, and abacavir/lamivudine dispersible tablets in 89.8% and 98.2% of facilities. Of note, availability of both formulations was low (37.5% and 62.5%, respectively) in Kenyan PNFP facilities. Overall availabilities of paediatric limited-use products were 1.1% in Kenya and 1.9% in Uganda. At least one stock-out of a preferred paediatric ART formulation was reported in 40.0% of Kenyan and 74.7% of Ugandan facilities. Nevirapine solution stock-outs were reported in 43.1% of Ugandan facilities, while alternative formulations for postnatal HIV prophylaxis were not available. CONCLUSIONS: Recommended DTG-based first-line ART for children across all ages was reasonably available at health facilities in Kenya and Uganda, with the exception of Kenyan PNFP facilities. Availability of paediatric ART formulations on the limited-use list was extremely low across both countries. Stock-outs were reported regularly, with the high number of reported stock-outs of neonatal ART formulations in Uganda being most concerning.

Barriers to accessing internationally controlled essential medicines in sub-saharan Africa: A scoping review.

BACKGROUND: Access to internationally controlled essential medicines (ICEMs), medicines that are listed on both the World Health Organization's Essential Medicines List and one of three international drug control conventions, remains problematic in Sub-Saharan Africa (SSA). Previous reviews have focused only on specific ICEMs or ICEM-related healthcare fields, but none have focused on all ICEMs as a distinct class. This scoping review therefore aims to identify the barriers to accessing ICEMs across all relevant healthcare fields in SSA. METHODS: A scoping review was conducted across indexing platforms Embase, PubMed, Scopus and Web of Science of studies published between January 1 2012 and February 1 2022. Articles were eligible if they mentioned barriers to accessing ICEMs and/or ICEM-related healthcare fields, if studies were conducted in SSA, or included data on an SSA country within a multi-country study. The review was guided by the Access to Medicines from a Health System Perspective framework. RESULTS: The search identified 5519 articles, of which 97 met the inclusion criteria. Many barriers to access were reported and were common across the ICEMs drug class. Main barriers were: at the individual level, the lack of knowledge about ICEMs; at the health service delivery level, low availability, stockouts, affordability, long distances to health facilities, insufficient infrastructure to store and distribute ICEMs, and lack of ICEM knowledge and training among healthcare workers; at the health sector level, lack of prioritisation of ICEM-related healthcare fields by governments and subsequent insufficient budget allocation. Cross-cutting, governance-related barriers pertained to lack of proper quantification systems, cumbersome procurement processes, and strict national laws controlling ICEMs, leading to overly restrictive prescription practices. CONCLUSION: This review showed that there are a multitude of barriers to accessing ICEMs in SSA across all health system levels. Many of the barriers identified are applicable to all ICEMs, highlighting the importance of tackling barriers for this entire class of drugs together.

Barriers and enablers of community engagement practices for the prevention of snakebite envenoming in South Asia: A qualitative exploratory study.

Snakebite envenoming (SBE) is a grossly neglected tropical disease (NTD) that predominantly affects those living in rural settings in low-and-middle income countries. South Asia currently accounts for the highest global SBE-related mortality, and substantial morbidity rates. To alleviate the high burden in the region, community engagement (CE) is considered to be an integral component for optimizing SBE prevention and control. To better understand existing CE practices for SBE in the region, the experiences of SBE-CE actors concerning the barriers to, and enablers of CE practices were captured through semi-structured interviews. Fifteen key informants from India, Bangladesh and Nepal participated in the study. Important enablers included providing innovative, inclusive and continuous methods and materials, carefully planning of programs, performing monitoring and evaluation, SBE data availability, motivated and trained staff members, good organizational reputations, communication with other SBE-actors, collaborations, and the involvement of the government. Substantial barriers comprised a lack of SBE data, lack of innovative methods and materials for educational purposes, a shortage of human and physical resources, community resistance, untrained health care workers (HCWs), and ineffective traditional healing practices. In order to optimize and sustain SBE-CE practices, context-sensitive, multi-faceted approaches are needed that incorporate all these factors which influence its sustainable implementation.

Healthcare workers' perspectives on access to sexual and reproductive health services in the public, private and private not-for-profit sectors: insights from Kenya, Tanzania, Uganda and Zambia.

BACKGROUND: Access to sexual and reproductive health services remains a challenge for many in Kenya, Tanzania, Uganda and Zambia. Health service delivery in the four countries is decentralised and provided by the public, private and private not-for-profit sectors. When accessing sexual and reproductive health services, clients encounter numerous challenges, which might differ per sector. Healthcare workers have first-hand insight into what impediments to access exist at their health facility. The aim of this study was to identify differences and commonalities in barriers to access to sexual and reproductive health services across the public, private and private not-for-profit sectors. METHODS: A cross-sectional survey was conducted among healthcare workers working in health facilities offering sexual and reproductive health services in Kenya (n = 212), Tanzania (n = 371), Uganda (n = 145) and Zambia (n = 243). Data were collected in July 2019. Descriptive statistics were used to describe the data, while binary logistic regression analyses were used to test for significant differences in access barriers and recommendations between sectors. RESULTS: According to healthcare workers, the most common barrier to accessing sexual and reproductive health services was poor patient knowledge (37.1%). Following, issues with supply of commodities (42.5%) and frequent stockouts (36.0%) were most often raised in the public sector; in the other sectors these were also raised as an issue. Patient costs were a more significant barrier in the private (33.3%) and private not-for-profit sectors (21.1%) compared to the public sector (4.6%), and religious beliefs were a significant barrier in the private not-for-profit sector compared to the public sector (odds ratio = 2.46, 95% confidence interval = 1.69-3.56). In all sectors delays in the delivery of supplies (37.4-63.9%) was given as main stockout cause. Healthcare workers further believed that it was common that clients were reluctant to access sexual and reproductive health services, due to fear of stigmatisation, their lack of knowledge, myths/superstitions, religious beliefs, and fear of side effects. Healthcare workers recommended client education to tackle this. CONCLUSIONS: Demand and supply side barriers were manifold across the public, private and private not-for-profit sectors, with some sector-specific, but mostly cross-cutting barriers. To improve access to sexual and reproductive health services, a multi-pronged approach is needed, targeting client knowledge, the weak supply chain system, high costs in the private and private not-for-profit sectors, and religious beliefs.

Snakebite incidents, prevention and care during COVID-19: Global key-informant experiences.

Snakebite envenoming is a long-neglected disease causing significant morbidity and mortality in snakebite endemic low- and middle-income countries (LMICs). Global awareness on snakebite was increasing steadily up to 2020, and an increasing number of countries began to acknowledge the issue, when coronavirus disease 2019 (COVID-19) started to have an unprecedented impact on societies and health systems. To better understand how snakebite incidents, prevention and care are being affected during this global emergency, we collected perspectives of snakebite community- and health system stakeholders in a qualitative key-informant study. An open-ended survey and semi-structured interviews were conducted to gather information on changes in snakebite occurrence and circumstances, community responses, access to care and health outcomes in LMICs since the COVID-19 pandemic. Forty-three informants from 21 countries participated in the study. Based on informants' experiences, in spite of COVID-19 lockdowns, exposure to snakes did not change in many rural agrarian communities, where incidences are usually highest. However, we did find several access to care issues relating to avoidance of formal care, transport barriers, overburdened healthcare systems and -providers, and antivenom manufacturing and supply disruptions, which were unique per context. On a brighter note, ventilator availability had increased in several countries, although not automatically benefitting snakebite patients directly. In conclusion, we found apparent effects of the COVID-19 pandemic on snakebite prevention and care, although its severity was highly context- and time-dependent. Interactions between the pandemic effects and snakebite incidents most severely impact remote rural communities, showing the need to invest in community-based prevention and care.

The Burden of Snakebite in Rural Communities in Kenya: A Household Survey.

Annually, about 2.7 million snakebite envenomings occur worldwide, primarily affecting those living in rural regions. Effective treatment exists but is scarce, and traditional treatments are commonly used. To inform context-specific policies in Kenya, this study aimed to determine the health-seeking behavior and the health, social, and economic burden of snakebites in rural communities. Nonprobability sampling was used to survey 382 respondents from four snakebite-endemic counties, from February to August 2020, using a structured questionnaire. Descriptive statistics, Fisher's exact tests, binary logistic regressions, and Mantel-Haenszel tests were used for analysis. Life-time experience with snakebites included 13.1% of respondents who reported being personally bitten and 37.4% who reported knowing of a community member being bitten. Respondents reported death after a snakebite in 9.1% of bitten community members and in 14.6% of bitten family members. Risk of snakebite was not significantly associated with sex, educational level, or occupation. Snakebite victims were most often walking (38%) or farming (24%) when bitten. Of those bitten, 58% went to a health facility, 30% sought traditional treatment, and 12% first went to a traditional healer before visiting a facility. Significant differences existed in perceptions on the financial consequences of snakebites among those who had been personally bitten and those who had observed a snakebite. Most commonly mentioned preventive measures were wearing shoes and carrying a light in the dark. Community engagement, including engagement with traditional healers, is needed to reduce snakebites. This should be done through education and sensitization to improve used preventive measures and effective health-seeking behavior.

An exploratory focus group study on experiences with snakebites: health-seeking behaviour and challenges in rural communities of Kenya.

BACKGROUND: Snakebite envenoming is a long-hidden public health threat in the rural communities of Kenya. This study aimed to shed light on the health-seeking behaviour of people bitten by snakes, views on prevention measures and community needs and the consequences for snakebite patients in these areas. METHODS: Six focus group interviews were conducted in communities in the Kajiado (n=3) and Kilifi (n=3) counties. RESULTS: Traditional first-aid practices such as the use of a tourniquet and/or cutting the wound, use of a black stone and a variety of other traditional remedies were common. Challenges with transportation to health facilities and inadequately resourced facilities complicated accessing medical care. Community members voiced a need to improve access to trained healthcare workers and snakebite treatments at health facilities. CONCLUSION: While communities had high trust in evidence-based medical care, traditional treatment was often sought, causing delays in timely medical attention. Traditional practices were often used in the home environment and these were not usually administered by a traditional healer. The findings illustrate the need to combine improving the availability of effective snakebite treatment and healthcare worker training on snakebite with community education to reduce the impact of snakebite.

The Current State of Snakebite Care in Kenya, Uganda, and Zambia: Healthcare Workers' Perspectives and Knowledge, and Health Facilities' Treatment Capacity.

Snakebites continue to be a public health concern in sub-Saharan Africa, where availability of appropriate medical treatment is rare, even though death and disability can be prevented with timely intervention. A challenge is the lack of sociopolitical studies to inform health policies. This study aimed to identify snakebite patient profiles, healthcare workers' (HCWs) knowledge of snakebite, and facilities' snakebite treatment capacity in Kenya, Uganda, and Zambia to inform interventions to improve access to appropriate treatment. The research comprised a cross-sectional key informant survey among HCWs from health facilities in Kenya (n = 145), Uganda (n = 144), and Zambia (n = 108). Data were collected between March 2018 and November 2019. Most of the HCWs suggested that the number of snakebite incidents was similar between the genders, that most patients were aged 21-30 years, and most people were bitten when farming or walking. Overall, only 12% of HCWs had received formal training in snakebite management. Only about 20% of HCWs in each country said their health facility had the medicines needed to treat snakebites, with antivenom available in 0-34% of facilities across the sectors and countries, and snakebites were not systematically recorded. This research shows that an integrative approach through policies to increase resource allocation for health system strengthening, including community education, HCW training, and improved access to snakebite treatment, is needed. Part of this approach should include regulations that ensure antivenoms available in health facilities meet quality control standards and that snakebites are accommodated into routine reporting systems to assess progress.

Access to sexual and reproductive health commodities in East and Southern Africa: a cross-country comparison of availability, affordability and stock-outs in Kenya, Tanzania, Uganda and Zambia.

BACKGROUND: Access to sexual and reproductive health services continues to be a public health concern in Kenya, Tanzania, Uganda and Zambia: use of modern contraceptives is low, and unmet family planning needs and maternal mortality remain high. This study is an assessment of the availability, affordability and stock-outs of essential sexual and reproductive health commodities (SRHC) in these countries to inform interventions to improve access. METHODS: The study consisted of an adaptation of the World Health Organization/Health Action International methodology, Measuring Medicine Prices, Availability, Affordability and Price Components. Price, availability and stock-out data was collected in July 2019 for over fifty lowest-priced SRHC from public, private and private not-for-profit health facilities in Kenya (n = 221), Tanzania (n = 373), Uganda (n = 146) and Zambia (n = 245). Affordability was calculated using the wage of a lowest-paid government worker. Accessibility was illustrated by combining the availability (≥ 80%) and affordability (less than 1 day's wage) measures. RESULTS: Overall availability of SRHC was low at less than 50% in all sectors, areas and countries, with highest mean availability found in Kenyan public facilities (46.6%). Stock-outs were common; the average number of stock-out days per month ranged from 3 days in Kenya's private and private not-for-profit sectors, to 12 days in Zambia's public sector. In the public sectors of Kenya, Uganda and Zambia, as well as in Zambia's private not-for-profit sector, all SRHC were free for the patient. In the other sectors unaffordability ranged from 2 to 9 SRHC being unaffordable, with magnesium sulphate being especially unaffordable in the countries. Accessibility was low across the countries, with Kenya's and Zambia's public sectors having six SRHC that met the accessibility threshold, while the private sector of Uganda had only one SRHC meeting the threshold. CONCLUSIONS: Accessibility of SRHC remains a challenge. Low availability of SRHC in the public sector is compounded by regular stock-outs, forcing patients to seek care in other sectors where there are availability and affordability challenges. Health system strengthening is needed to ensure access, and these findings should be used by national governments to identify the gaps and shortcomings in their supply chains.