Listening to the Voices of Health Care Workers During the COVID-19 Pandemic: A Qualitative Study Providing In-Depth Insights Into Ethical and Individual Challenges.

In their daily practice, health care workers (HCWs) experience the effects of tensions between professional ethos and work realities, which can lead to ethical dilemmas. We aim to explore the ethical dilemmas that affected HCWs in Germany during the COVID-19 pandemic and to understand these in the context of the German health system. Between April and December 2022, we interviewed HCWs from various levels of care and key informants responsible for decisions related to HCWs in Germany. Three themes were identified in the data analyzed from 78 participants. The first highlighted the potency of pre-existing health system problems during the COVID-19 pandemic. The second captured the ethical dilemmas that were described as having arisen due to the tension between professional ethos and structural constraints. The third included factors related to increasing or diminishing the implications of ethical dilemmas. A lack of opportunities for HCWs to participate in political and managerial decisions was suggested to result in policies that do not meet the needs of HCWs and patients. Positive interpersonal interactions were described as helpful when coping with dilemmatic decision-making situations. In order to avoid negative consequences caused by unresolved ethical dilemmas, including moral distress, among HCWs, staff shortages and decision-making in the German health system urgently need to be addressed. HCWs' working conditions regularly evoke ethical dilemmas, particularly during public health emergencies. Together with HCWs, decision-makers must develop new models for working in health care settings that are in line with HCWs' professional ethos.

Where is the bottleneck? Drones and the paradoxes of digitising medical supplies in Ghana's landscapes of care.

Implemented in several African countries, medical drones have emerged as a major infrastructural innovation in national healthcare systems and are widely hailed for improving, if not revolutionising, access to medicine and care for rural populations. Being based on digitally driven, autonomous aviation systems, drones are part of wider efforts to use digital technologies in health systems. In this article, we explore the paradoxes that emerge from definitions of logistics as the bottleneck of quality healthcare. Based on ethnographic research in Ghana, we explore the ways in which drone systems have been built up and justified by private and political actors and used by pharmacists and other healthcare professionals along the supply chain as serving emergencies. However, they have transformed the existing landscape of medical supply chiefly because of the multiple ways in which emergencies are defined. We find that while the introduction of drones has dynamised supply chain processes but also reveals structural bottlenecks, e.g. the lack of medical products and malfunctioning institutions. Situated at the interface of critical studies on infrastructures and medical anthropology, our article contributes to the thriving scholarship on digital innovation in healthcare.

Stock-outs! Improvisations and processes of infrastructuring in Uganda's HIV/Aids and malaria programmes.

This paper examines the stock-outs of medicines and diagnostic devices in Uganda. Our aim is to trace and compare interruptions in the supply of antiretrovirals and Rapid Diagnostic Tests in order to provide an ethnographic account of the complex role that improvisations play within global health infrastructures. We will argue that the fragmented and mobile infrastructures of these key global health technologies require and necessitate improvisations by the different actors involved as well as on almost all levels of the Ugandan health-care system. The extent and abundance of improvisations in itself works to acquire infrastructural capacities, a process that we will call the infrastructuring of care and treatment. We will also show how this process of infrastructuring of care and treatment - here rendered visible through improvisations - produces new dilemmas and uncertainties. Our approach to infrastructure challenges technocratic overtones prevalent in current debates around the much-needed strengthening of health systems. Our study of stock-outs aims to show how the infrastructure of under-resourced health systems is maintained by a complex nexus of socio-material practices and improvisations.

Precarity and Preparedness: Non-Adherence as Institutional Work in Diagnosing and Treating Malaria in Uganda.

Access to anti-malarial drugs is increasingly governed by novel regulation technologies like rapid diagnostic tests (RDTs). However, high rates of non-adherence particularly to negative RDT results have been reported, threatening the cost-effectiveness of the two interrelated goals of improving diagnosis and reducing the over-prescription of expensive anti-malarial drugs. Below I set out to reconstruct prior treatment forms like presumptive treatment of malaria by paying particular attention to their institutional groundings. I show how novel regulation technologies affect existing institutions of care and argue that the institutional work of presumptive treatment goes beyond the diagnosis and treatment of a currently observed fever episode. Instead, in contexts of precarity, through what I will call "practices of preparedness," presumptive treatment includes a variety of practices, performances, temporalities, and opportunities that allow individuals to prepare for future episodes of fever.

Prototype Positive Control Wells for Malaria Rapid Diagnostic Tests: Prospective Evaluation of Implementation Among Health Workers in Lao People's Democratic Republic and Uganda.

Rapid diagnostic tests (RDTs) are widely used for malaria diagnosis, but lack of quality control at point of care restricts trust in test results. Prototype positive control wells (PCW) containing recombinant malaria antigens have been developed to identify poor-quality RDT lots. This study assessed community and facility health workers' (HW) ability to use PCWs to detect degraded RDTs, the impact of PCW availability on RDT use and prescribing, and preferred strategies for implementation in Lao People's Democratic Republic (Laos) and Uganda. A total of 557 HWs participated in Laos (267) and Uganda (290). After training, most (88% to ≥ 99%) participants correctly performed the six key individual PCW steps; performance was generally maintained during the 6-month study period. Nearly all (97%) reported a correct action based on PCW use at routine work sites. In Uganda, where data for 127,775 individual patients were available, PCW introduction in health facilities was followed by a decrease in antimalarial prescribing for RDT-negative patients ≥ 5 years of age (4.7-1.9%); among community-based HWs, the decrease was 12.2% (P < 0.05) for all patients. Qualitative data revealed PCWs as a way to confirm RDT quality and restore confidence in RDT results. HWs in malaria-endemic areas are able to use prototype PCWs for quality control of malaria RDTs. PCW availability can improve HWs' confidence in RDT results, and benefit malaria diagnostic programs. Lessons learned from this study may be valuable for introduction of other point-of-care diagnostic and quality-control tools. Future work should evaluate longer term impacts of PCWs on patient management.

The complexities of simple technologies: re-imagining the role of rapid diagnostic tests in malaria control efforts.

BACKGROUND: Malaria rapid diagnostic tests (RDTs) are assumed to be simple-to-use and mobile technologies that have the capacity to standardize parasitological diagnosis for malaria across a variety of clinical settings. In order to evaluate these tests, it is important to consider how such assumptions play out in practice, in everyday settings of clinics, health centres, drug stores and for community health volunteers. METHODS: This paper draws on qualitative research on RDTs conducted over the last nine years. In particular the study reports on four qualitative case studies on the use of RDTs from Uganda, Tanzania and Sierra Leone, including qualitative interviews, focus group discussions and participant observation. RESULTS: Results suggest that while RDTs may be simple to use as stand-alone technological tools, it is not trivial to make them work effectively in a variety of economically pressured health care settings. The studies show that to perform RDTs effectively might very well need exactly the infrastructure they were designed to substitute: the medical expertise, organizational capacity and diagnostic and treatment options of well-funded and functioning health systems. CONCLUSIONS: These results underline that successful malaria diagnosis and treatment requires as much investment in general health infrastructure as it does in new technologies.