Breast cancer early detection: A phased approach to implementation.

When breast cancer is detected and treated early, the chances of survival are very high. However, women in many settings face complex barriers to early detection, including social, economic, geographic, and other interrelated factors, which can limit their access to timely, affordable, and effective breast health care services. Previously, the Breast Health Global Initiative (BHGI) developed resource-stratified guidelines for the early detection and diagnosis of breast cancer. In this consensus article from the sixth BHGI Global Summit held in October 2018, the authors describe phases of early detection program development, beginning with management strategies required for the diagnosis of clinically detectable disease based on awareness education and technical training, history and physical examination, and accurate tissue diagnosis. The core issues address include finance and governance, which pertain to successful planning, implementation, and the iterative process of program improvement and are needed for a breast cancer early detection program to succeed in any resource setting. Examples are presented of implementation, process, and clinical outcome metrics that assist in program implementation monitoring. Country case examples are presented to highlight the challenges and opportunities of implementing successful breast cancer early detection programs, and the complex interplay of barriers and facilitators to achieving early detection for breast cancer in real-world settings are considered.

Laboratory medicine in Africa since 2008: then, now, and the future.

The Maputo Declaration of 2008 advocated for commitment from global stakeholders and national governments to prioritise support and harmonisation of laboratory systems through development of comprehensive national laboratory strategies and policies in sub-Saharan Africa. As a result, HIV laboratory medicine in Africa has undergone a transformation, and substantial improvements have been made in diagnostic services, networks, and institutions, including the development of a competent workforce, introduction of point-of-care diagnostics, and innovative quality improvement programmes that saw more than 1100 laboratories enrolled and 44 accredited to international standards. These improved HIV laboratories can now be used to combat emerging continental and global health threats in the decades to come. For instance, the unprecedented Ebola virus disease outbreak in west Africa exposed the severe weaknesses in the overall national health systems in affected countries. It is now possible to build robust health-care systems in Africa and to combat emerging continental and global health threats in the future. In this Personal View, we aim to describe the remarkable transformation that has occurred in laboratory medicine to combat HIV/AIDS and improve global health in sub-Saharan Africa since 2008.

Building Cross-Country Networks for Laboratory Capacity and Improvement.

Laboratory networks are vital to well-functioning public health systems and disease control efforts. Cross-country laboratory networks play a critical role in supporting epidemiologic surveillance, accelerating disease outbreak response, and tracking drug resistance. The East Africa Public Health Laboratory Network was established to bolster diagnostic and disease surveillance capacity. The network supports the introduction of regional quality standards; facilitates the rollout and evaluation of new diagnostic tools; and serves as a platform for training, research, and knowledge sharing. Participating facilities benefitted from state-of-the art investments, capacity building, and mentorship; conducted multicountry research studies; and contributed to disease outbreak response.

Regional initiatives in support of surveillance in East Africa: The East Africa Integrated Disease Surveillance Network (EAIDSNet) Experience.

The East African Integrated Disease Surveillance Network (EAIDSNet) was formed in response to a growing frequency of cross-border malaria outbreaks in the 1990s and a growing recognition that fragmented disease interventions, coupled with weak laboratory capacity, were making it difficult to respond in a timely manner to the outbreaks of malaria and other infectious diseases. The East Africa Community (EAC) partner states, with financial support from the Rockefeller Foundation, established EAIDSNet in 2000 to develop and strengthen the communication channels necessary for integrated cross-border disease surveillance and control efforts. The objective of this paper is to review the regional EAIDSNet initiative and highlight achievements and challenges in its implementation. Major accomplishments of EAIDSNet include influencing the establishment of a Department of Health within the EAC Secretariat to support a regional health agenda; successfully completing a regional field simulation exercise in pandemic influenza preparedness; and piloting a web-based portal for linking animal and human health disease surveillance. The strategic direction of EAIDSNet was shaped, in part, by lessons learned following a visit to the more established Mekong Basin Disease Surveillance (MBDS) regional network. Looking to the future, EAIDSNet is collaborating with the East, Central and Southern Africa Health Community (ECSA-HC), EAC partner states, and the World Health Organization to implement the World Bank-funded East Africa Public Health Laboratory Networking Project (EAPHLNP). The network has also begun lobbying East African countries for funding to support EAIDSNet activities.

Global health: Integrating national laboratory health systems and services in resource-limited settings.

Laboratory systems worldwide are challenged not only by the need to compete for scarce resources with other sections of national health care programmes, but also with the lack of understanding of the critical role that laboratories play in the accurate diagnosis and monitoring of patients suffering from high-burdens of disease. An effective approach to establishing cost-effective laboratory systems that provide rapid and accurate test results for optimal impact on patient care is to move away from disease-specific programmes and establish integrated laboratory services. An integrated laboratory network provides all primary diagnostic services needed for care and treatment without requiring patients to go to different laboratory facilities for specific tests. Such a network focuses on providing quality-assured basic laboratory testing through the use of common specimen collection, reporting and diagnostic platforms that can be used across diseases. An integrated laboratory system also provides specimen transport to specialised laboratories and an environment conducive to the introduction and use of new and more complex technologies that would benefit the patient population and public health systems as a whole. As such, this article described various strategies for, and practical examples of, the successful integration of laboratory services.

Toward a grounded theory of why some immunization programmes in sub-Saharan Africa are more successful than others: a descriptive and exploratory assessment in six countries.

The question of why some immunization programmes in sub-Saharan Africa are more successful than others is an intriguing one, but not one that is frequently raised or investigated. Borrowing techniques from both performance benchmarking and positive deviance inquiry, we explored this question in six countries. We first set out to define for a systematic sample of countries the key constructs commonly associated with improving immunization coverage, using an inductive, 'insider' point of view. We then explored their utility in generating hypotheses about coverage differences across countries through a preliminary application of the measures of these constructs to the countries in this sample. Our findings suggest that there are different paths to success, and that not only what countries do, but how they execute their programmes, seem to make a difference in coverage outcomes. In some cases, extramural, contextual factors may also help to explain these differences. We discuss several hypotheses generated by our study, identify methodological limitations, and recommend improvements to the methods we used. Similar formative studies are needed to validate our preliminary hypotheses, to generate new ones, and to raise our level of confidence in the early policy implications that we see emerging from our preliminary work in this area. Eventually, testing of the hypotheses generated by this and other formative studies could generate a robust theory of why some programmes are more successful than others, a phenomenon likely to be relevant to other child and maternal health programmes in sub-Saharan Africa.

The health of women in Latin America and the Caribbean

This report seeks to contribute to the debate about health policy and program design in Latin America and the Caribbean by focusing on the special topic of women's health. It aims to provide governments and program designers with information about priority needs in the region, and on how policies can yield optimal results. The report, which summarizes more than a dozen original background studies, represents the collaborative effort of three partners - the World Bank, the Inter-American Development Bank (IDB), and the Pan American Health Organization (PAHO). In addition, three regional consultations, sponsored by the IDB, were conducted in collaboration with the Population Council, Latin America and the Caribbean Office, to gain a deeper understanding of the issues related to reproductive health policy in the region. The study has two main objectives: (1) To analyze trends and differentials in women's health; examples of good practices in delivery and financing of women's health programs; and the key dimensions of women's health that are relevant for the health reforms currently underway in Latin America. (2) To provide guidance for governments and progam designers in addressing the most pressing causes of women's ill health, within the context of broader sectoral and national policies (AU)