[Telemedicine in maternal health in times of COVID-19: Five national and international projects]. / Télémédecine en santé maternelle en temps de Covid-19 : cinq projets internationaux et nationaux.

Telemedicine in maternal health consists on the use of remote communication to reach, diagnose, treat and follow up patients in the context of pre and post-natal care. Covid-19 has accelerated the use of telemedicine. In the Obstetrics Division of HUG we have developed five projects in Geneva and in low-resource zones of the world with the objective of improving access and quality of care. Based on our experience, the application of telemedicine to maternal health problems has shown three major advantages: improved access to care, standardized procedures and accelerated speed of intervention. However, to be effective, telemedicine requires a health staff with a good level of medical and computer skills as well as fluid communication among all participants and constant follow-up of the information flow.

La télémédecine en santé maternelle consiste à l'utilisation des moyens de communication à distance pour rejoindre, diagnostiquer, traiter et suivre les patientes dans le contexte des soins pré-, per- et postnatals. Le Covid-19 a accéléré l'utilisation de la télémédecine. Dans le Service d'obstétrique des HUG, nous avons développé cinq projets à Genève et dans des régions défavorisées du monde, avec l'objectif d'améliorer l'accès et la qualité des soins. Basée sur notre expérience, l'application de la télémédecine aux problèmes de santé maternelle présente trois avantages essentiels: la facilitation de l'accès aux soins, la standardisation des procédures et la vitesse d'intervention. Mais pour être efficace, elle présuppose un bon niveau de compétence médicale et informatique du staff sanitaire, une communication fluide entre les différents intervenants et un contrôle constant du flux d'informations.

Global action for training in malaria elimination.

The Rethinking Malaria Leadership Forum, held at Harvard Business School in February 2017 with collaboration of the Barcelona Institute for Global Health and the Swiss Tropical and Public Health Institute, identified this training gap as a high priority for both analysis and action. The gap in human resource training for malaria elimination needs to be addressed in order to assure continued progress. This paper identifies major gaps in skills and human resources, suggests institutions that can assist in filling the training gaps, and proposes global actions to implement expanded training for malaria elimination in endemic countries.

"In transition: ensuring the sexual and reproductive health and rights of transgender populations." A roundtable discussion.

This roundtable discussion is the result of a research symposium entitled In Transition: Gender [Identity], Law & Global Health where participants took up the challenge to engage with the question: What will it take to ensure the sexual and reproductive health and rights (SRHR) of transgender populations across the globe? The barriers to overcome are fierce, and include not only lack of access to health services and insurance but also stigma and discrimination, harassment, violence, and violations of rights at every turn. Transgender people must of course lead any sort of initiatives to improve their lives, even as partnerships are needed to build capacity, translate lived experience into usable data, and to make strategic decisions. The SRHR of transgender people can only be addressed with attention to the social, cultural, legal, historical, and political contexts in which people are situated, with social, psychological, medical, and legal gender affirmation as a key priority shaping any intervention. Bringing together nine diverse yet complementary perspectives, our intent is to jumpstart a global and multigenerational conversation among transgender activists, lawyers, policy-makers, programmers, epidemiologists, economists, social workers, clinicians and all other stakeholders to help think through priority areas of focus that will support the needs, rights, and health of transgender populations. Making the changes envisioned here is possible but it will require not only the advocacy, policy, programmatic and research directions presented here but also struggle and action locally, nationally, and globally.

Looking for Japan's missing third baby boom.

AIM: High-income countries are now experiencing a decline in fertility. After experiencing baby booms in 1947-1949 and 1971-1974, Japan's population has been decreasing since 2015. In an attempt to predict the next baby boom, we searched for any upward demographic trends occurring after 1974. METHODS: We analyzed time trends of the numbers and rates of live births, stillbirths and induced abortions using Japanese government data from 1975 to 2014. We then selected two birth cohorts: the first baby boomers who were 0-4 years old in 1950, and the second baby boomers who were 0-4 years old in 1975, and analyzed their rates of live births, stillbirths, and abortions by five-year age groups. RESULTS: There was no upswing in the numbers of births, stillbirths, or induced abortions; however, the abortion rate increased during 1996-2002. Compared with the first baby boomer cohort, the second baby boomer cohort had half the peak live birth rate for the same age group (25-29 years old), and half the peak rate of abortions, with a shift toward a younger age group (20-24). CONCLUSIONS: This analysis of Japanese fertility trends derived from all pregnancy outcomes showed no upward trend in fertility in Japan since 1974.

Moving towards universal health coverage: lessons from 11 country studies.

In recent years, many countries have adopted universal health coverage (UHC) as a national aspiration. In response to increasing demand for a systematic assessment of global experiences with UHC, the Government of Japan and the World Bank collaborated on a 2-year multicountry research programme to analyse the processes of moving towards UHC. The programme included 11 countries (Bangladesh, Brazil, Ethiopia, France, Ghana, Indonesia, Japan, Peru, Thailand, Turkey, and Vietnam), representing diverse geographical, economic, and historical contexts. The study identified common challenges and opportunities and useful insights for how to move towards UHC. The study showed that UHC is a complex process, fraught with challenges, many possible pathways, and various pitfalls--but is also feasible and achievable. Movement towards UHC is a long-term policy engagement that needs both technical knowledge and political know-how. Technical solutions need to be accompanied by pragmatic and innovative strategies that address the national political economy context.

Political economy challenges in nutrition.

BACKGROUND: Historically, implementing nutrition policy has confronted persistent obstacles, with many of these obstacles arising from political economy sources. While there has been increased global policy attention to improving nutrition in recent years, the difficulty of translating this policy momentum into results remains. DISCUSSION: We present key political economy themes emanating from the political economy of nutrition literature. Together, these interrelated themes create a complex web of obstacles to moving nutrition policy forward. From these themes, we frame six political economy challenges facing the implementation of nutrition policy today. Building awareness of the broader political and economic issues that shape nutrition actions and adopting a more systematic approach to political economy analysis may help to mitigate these challenges. CONCLUSION: Improving nutrition will require managing the political economy challenges that persist in the nutrition field at global, national and subnational levels. We argue that a "mindshift" is required to build greater awareness of the broader political economy factors shaping the global nutrition landscape; and to embed systematic political economy analysis into the work of stakeholders navigating this field. This mindshift may help to improve the political feasibility of efforts to reform nutrition policy and implementation-and ensure that historical legacies do not continue to shape the future.

Evaluating the quality and use of economic data in decisions about essential medicines.

OBJECTIVE: To evaluate the quality of economic data provided in applications to the World Health Organization (WHO) Model List of Essential Medicines and to evaluate the role of these data in decision-making by the expert committee that considers the applications. METHODS: We analysed applications submitted to the WHO Expert Committee on the Selection and Use of Essential Medicines between 2002 and 2013. The completeness of data on the price and cost-effectiveness of medicines was extracted from application documents and coded using a four-point scale. We recorded whether or not the expert committee discussed economic information and the outcomes of each application. Associations between the completeness of economic data and application outcomes were assessed using χ2 tests. FINDINGS: The expert committee received 134 applications. Only eight applications (6%) included complete price data and economic evaluation data. Many applicants omitted or misinterpreted the economic evaluation section of the application form. Despite the lack of economic data, all applications were reviewed by the committee. There was no significant association between the completeness of economic information and application outcomes. The expert committee tried to address information gaps in applications by further review and analysis of data related to the application. CONCLUSION: The World Health Organization should revise the instructions to applicants on economic data requirements; develop new mechanisms to assist applicants in completing the application process; and define methods for the use of economic data in decision-making.

Trends in Global Nutrition Policy and Implications for Japanese Development Policy.

BACKGROUND: Although the issue of nutrition was long underrepresented in the global health agenda, it regained international attention with the introduction of the Scaling Up Nutrition (SUN) framework. A historical review of global nutrition policies over 4 decades illustrates the evolution of nutrition policy themes and the challenges confronted by SUN. OBJECTIVE: This study reviews major events in global nutrition policy from the 1970s to the SUN movement around 2010 to illustrate the dynamics of global agenda setting for nutrition policy along with implications for the government of Japan. METHODS: The events are categorized according to each decade's nutrition paradigm: nutrition and its socioeconomic features in the 1970s, nutrition and community programs in the 1980s, nutrition as a political issue in the 1990s, and nutrition and evidence in the 2000s. RESULTS: This study identified 2 findings: First, the arguments that led to a global consensus on nutrition policy generated paradigm shifts in core ideas, and second, in response to these paradigm shifts, global nutrition policies have changed significantly over time. With regard to Japan, this analysis concludes that the government of Japan can take a greater initiative in the global health community as supporter of SUN by strategically developing a combination of financial, political, and practical approaches to improve global nutrition policy through the concepts of Universal Health Coverage and Human Security.

The Politics of Universal Health Coverage in Low- and Middle-Income Countries: A Framework for Evaluation and Action.

Universal health coverage has recently become a top item on the global health agenda pressed by multilateral and donor organizations, as disenchantment grows with vertical, disease-specific health programs. This increasing focus on universal health coverage has brought renewed attention to the role of domestic politics and the interaction between domestic and international relations in the health reform process. This article proposes a theory-based framework for analyzing the politics of health reform for universal health coverage, according to four stages in the policy cycle (agenda setting, design, adoption, and implementation) and four variables that affect reform (interests, institutions, ideas, and ideology). This framework can assist global health policy researchers, multilateral organization officials, and national policy makers in navigating the complex political waters of health reforms aimed at achieving universal health coverage. To derive the framework, we critically review the theoretical and applied literature on health policy reform in developing countries and illustrate the framework with examples of health reforms moving toward universal coverage in low- and middle-income countries. We offer a series of lessons stemming from these experiences to date.

Leveraging public health nurses for disaster risk communication in Fukushima City: a qualitative analysis of nurses' written records of parenting counseling and peer discussions.

BACKGROUND: Local public health nurses (PHNs) have been recognized as the main health service providers in communities in Japan. The Fukushima nuclear disaster in 2011 has, however, created a major challenge for them in responding to mothers' concerns. This was in part due to difficulties in assessing, understanding and communicating health risks on low-dose radiation exposure. In order to guide the development of risk communication plans, this study sought to investigate mothers' primary concerns and possible solutions perceived by a core healthcare profession like the PHNs. METHODS: A total of 150 records from parenting counseling sessions conducted between PHNs and mothers who have attended mandatory 18-month health checkups for their children at the Fukushima City Health and Welfare Center in 2010, 2011 (year of disaster) and 2012 were examined. Discussion notes of three peer discussions among PHNs organized in response to the nuclear disaster in 2012 and 2013 were also analyzed. All transcribed data were first subjected to text mining to list the words according to their frequencies and inter-relationships. The Steps Coding and Theorization method was then undertaken as a framework for qualitative analysis. RESULTS: PHNs noted mothers to have considerable needs for information on radiation risks as they impact on decisions related to relocations, concerns for child safety, and experiences with interpersonal conflicts within the family owing to differing risk perceptions. PHNs identified themselves as the information channels in the community, recommended the building of their risk communication capacities to support residents in making well-informed decisions, and advocated for self-measurement of radiation levels to increase residents' sense of control. PHNs also suggested a more standardized form of information dissemination and an expansion of community-based counseling services. CONCLUSIONS: Inadequate risk communication on radiation in the Fukushima nuclear incident has resulted in multiple repercussions for mothers in the community. Empowerment of local residents to assume more active roles in the understanding of their environment, increasing PHNs' capacity in communication, and an expansion of health services such as counseling will together better address risk communication challenges in post-disaster recovery efforts.

Recent pregnancy trends among early adolescent girls in Japan.

AIM: The paper examines recent time trends, explores potentially influential background factors and discusses prevention strategies of pregnancy among girls under 15 years of age in Japan. METHODS: Using Japanese government data, we first analyzed time trends of early adolescence (<15 years of age) abortion, live birth and child sexual abuse from 2003 to 2010. Second, we analyzed ecological correlations of early adolescent pregnancy (abortion, live birth and stillbirth) with pregnancy in other age groups, child sexual abuse, and indicators of juvenile victimization and juvenile delinquency, using prefectural data. RESULTS: We found that rates of both abortion and live birth in early adolescents have increased since 2005 (annual percent change 5.3% and 2.3%, respectively), despite declining rates in older age groups. The abortion ratio in early adolescence remained the highest among all age groups in Japan. The early adolescent pregnancy rate showed significant correlation with the rates of juvenile victimization of welfare crimes (obscenity, alcohol drinking, smoking and drug use) (Spearman's rank correlation coefficient [rs] = 0.42, P = 0.00) and juvenile delinquency among junior high school students (12-14 years of age) (rs = 0.69, P = 0.00). CONCLUSION: The observed rise in rates of abortion, live birth and child sexual abuse among early adolescents along with strong ecological correlations of their pregnancy rate with juvenile victimization and delinquency indicators suggests that epidemiological investigation and public health programs at the individual and community levels are needed to address the complex social roots of these trends and to produce effective improvements in early adolescent reproductive health.

Parenting in Fukushima City in the post-disaster period: short-term strategies and long-term perspectives.

Growing evidence indicates the adverse psychological and welfare consequences of nuclear power accidents particularly among parents of small children. However, little has been published about the public health experiences of and practical countermeasures to deal with such consequences for parents of small children in the aftermath of disasters. Based on our past research efforts to develop parenting support programmes in Fukushima City, we describe here the discussions and resulting strategies that developed from collaborative efforts between university researchers and public health nurses after the Fukushima nuclear plant accident caused by the Great East Japan Earthquake. The processes presented here may be useful to improve national and international preparedness to protect the health of parents and children in future nuclear disasters.

Simulation training on respectful emergency obstetric and neonatal care in north-western Madagascar: a mixed-methods evaluation of an innovative training program.

BACKGROUND: The rates of maternal and neonatal deaths in Madagascar are among the highest in the world. In response to a request for additional training from obstetrical care providers at the Ambanja district hospital in north-eastern Madagascar, a partnership of institutions in Switzerland and Madagascar conducted innovative training on respectful emergency obstetric and newborn care using e-learning and simulation methodologies. The training focused on six topics: pre-eclampsia, physiological childbirth, obstetric maneuvers, postpartum hemorrhage, maternal sepsis, and newborn resuscitation. Cross-cutting themes were interprofessional communication and respectful patient care. Ten experienced trainers participated in an e-training-of-trainers course conducted by the Swiss partners. The newly-trained trainers and Swiss partners then jointly conducted the hybrid remote/in-person training for 11 obstetrical care providers in Ambanja. METHODS: A mixed methods evaluation was conducted of the impact of the training on participants' knowledge and practices. Trainees' knowledge was tested before, immediately after, and 6 months after the training. Focus group discussions were conducted to elicit participants' opinions about the training, including the content and pedagogical methods. RESULTS: Trainees' knowledge of the six topics was higher at 6 months (with an average of 71% correct answers) compared to before the training (62%), although it was even higher (83%) immediately after the training. During the focus group discussions, participants highlighted their positive impressions of the training, including its impact on their sense of professional effectiveness. They reported that their interprofessional relationships and focus on respectful care had improved. Simulation, which was a new methodology for the participants native to Madagascar, was appreciated for its engaging and active format, and they enjoyed the hybrid delivery of the training. Participants (including the trainers) expressed a desire for follow-up engagement, including additional training, and improved access to more equipment. CONCLUSION: The evaluation showed improvements in trainees' knowledge and capacity to provide respectful emergency care to pregnant women and newborns across all training topics. The hybrid simulation-based training method elicited strong enthusiasm. Significant opportunity exists to expand the use of hybrid onsite/remote simulation-based training to improve obstetrical care and health outcomes for women and newborns in Madagascar and elsewhere.

Politics and Policies of Health Systems: Reflections on 50 Years of Observing Protests, Leaders, and Political Analysis.

This commentary presents reflections on my work over the past five decades related to the politics and policies of health systems from various perspectives. The essay is based on a plenary lecture at the Seventh Global Symposium on Health Systems Research in Bogotá, Colombia, in November 2022. The commentary examines a central concern in many of my writings-and a persistent challenge for people working to improve public health: How can the powerless influence policy? Using examples drawn from my past writings, I discuss three broad themes related to this question: the role of social protest movements, the impact of political leadership, and the relevance of political analysis. These reflections are offered in the hope of expanding the use of applied political analysis in public health, and thus contributing to improved health and health equity in the world.

Cost containment and quality of care in Japan: is there a trade-off?

Japan's health indices such as life expectancy at birth are among the best in the world. However, at 8·5% the proportion of gross domestic product spent on health is 20th among Organisation for Economic Co-operation and Development countries in 2008 and half as much as that in the USA. Costs have been contained by the nationally uniform fee schedule, in which the global revision rate is set first and item-by-item revisions are then made. Although the structural and process dimensions of quality seem to be poor, the characteristics of the health-care system are primarily attributable to how physicians and hospitals have developed in the country, and not to the cost-containment policy. However, outcomes such as postsurgical mortality rates are as good as those reported for other developed countries. Japan's basic policy has been a combination of tight control of the conditions of payment, but a laissez-faire approach to how services are delivered; this combination has led to a scarcity of professional governance and accountability. In view of the structural problems facing the health-care system, the balance should be shifted towards increased freedom of payment conditions by simplification of reimbursement rules, but tightened control of service delivery by strengthening of regional health planning, both of which should be supported through public monitoring of providers' performance. Japan's experience of good health and low cost suggests that the priority in health policy should initially be improvement of access and prevention of impoverishment from health care, after which efficiency and quality of services should then be pursued.