How to improve access to medical imaging in low- and middle-income countries ?

Imaging has become key in the care pathway of communicable and non-communicable diseases. Yet, there are major shortages of imaging equipment and workforce in low- and middle-income countries (LMICs). The International Society of Radiology outlines a plan to upscale the role of imaging in the global health agenda and proposes a holistic approach for LMICs. A generic model for organising imaging services in LMICs via regional Centres of Reference is presented. The need to better exploit IT and the potential of artificial intelligence for imaging, also in the LMIC setting, is highlighted.

To implement the proposed plan, involvement of professional and international organisations is considered crucial. The establishment of an International Commission on Medical Imaging under the umbrella of international organisations is suggested and collaboration with other diagnostic disciplines is encouraged to raise awareness of the importance to upscale diagnostics at large and to foster its integration into the care pathway globally.

Availability of facility resources and services and infection-related maternal outcomes in the WHO Global Maternal Sepsis Study: a cross-sectional study

Background
Infections are among the leading causes of maternal mortality and morbidity. The Global Maternal Sepsis and Neonatal Initiative, launched in 2016 by WHO and partners, sought to reduce the burden of maternal infections and sepsis and was the basis upon which the Global Maternal Sepsis Study (GLOSS) was implemented in 2017. In this Article, we aimed to describe the availability of facility resources and services and to analyse their association with maternal outcomes.
Methods
GLOSS was a facility-based, prospective, 1-week inception cohort study implemented in 713 health-care facilities in 52 countries and included 2850 hospitalised pregnant or recently pregnant women with suspected or confirmed infections. All women admitted for or in hospital with suspected or confirmed infections during pregnancy, childbirth, post partum, or post abortion at any of the participating facilities between Nov 28 and Dec 4 were eligible for inclusion. In this study, we included all GLOSS participating facilities that collected facility-level data (446 of 713 facilities). We used data obtained from individual forms completed for each enrolled woman and their newborn babies by trained researchers who checked the medical records and from facility forms completed by hospital administrators for each participating facility. We described facilities according to country income level, compliance with providing core clinical interventions and services according to women’s needs and reported availability, and severity of infection-related maternal outcomes. We used a logistic multilevel mixed model for assessing the association between facility characteristics and infection-related maternal outcomes.
Findings
We included 446 facilities from 46 countries that enrolled 2560 women. We found a high availability of most services and resources needed for obstetric care and infection prevention. We found increased odds for severe maternal outcomes among women enrolled during the post-partum or post-abortion period from facilities located in low-income countries (adjusted odds ratio 1·84 [95% CI 1·05–3·22]) and among women enrolled during pregnancy or childbirth from non-urban facilities (adjusted odds ratio 2·44 [1·02–5·85]). Despite compliance being high overall, it was low with regards to measuring respiratory rate (85 [24%] of 355 facilities) and measuring pulse oximetry (184 [57%] of 325 facilities).
Interpretation
While health-care facilities caring for pregnant and recently pregnant women with suspected or confirmed infections have access to a wide range of resources and interventions, worse maternal outcomes are seen among recently pregnant women located in low-income countries than among those in higher-income countries; this trend is similar for pregnant women. Compliance with cost-effective clinical practices and timely care of women with particular individual characteristics can potentially improve infection-related maternal outcomes.
Funding
UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Merck for Mothers, and US Agency for International Development.

Age at Primary Cleft Lip Repair

Background: The bellwether procedures described by the Lancet Commission on Global Surgery represent the ability to deliver adult surgical services after there is a clear and easily made diagnosis. There is a need for pediatric surgery bellwether indicators. A pediatric bellwether indicator would ideally be a routinely performed procedure, for a relatively common condition that, in itself, is rarely lethal at birth, but that should ideally be treated with surgery by a standard age. Additionally, the condition should be easy to diagnose, to minimize the confounding effects of delays or failures in diagnosis. In this study, we propose the age at primary cleft lip
(CL) repair as a bellwether indicator for pediatric surgery.
Method: We reviewed the surgical records of 71,346 primary cleft surgery patients and ultimately studied age at CL repair in 40,179 patients from 73 countries, treated by Smile Train partners for 2019. Data from Smile Train’s database were correlated with World Bank and WHO indicators.
Results: Countries with a higher average age at CL repair (delayed access to surgery) had higher maternal, infant, and child mortality rates as well as a greater risk of catastrophic health expenditure for surgery. There was also a negative correlation between delayed CL repair and specialist surgical workforce numbers, life expectancy, percentage of deliveries by C-section, total health expenditure per capita, and Lancet Commission on Global Surgery procedure rates.
Conclusion: These findings suggest that age at CL repair has potential to serve as a bellwether indicator for pediatric surgical capacity in Lower- and Middleincome Countr

Augmented, Mixed, and Virtual Reality-Based Head-Mounted Devices for Medical Education: Systematic Review

Background:
Augmented reality (AR), mixed reality (MR), and virtual reality (VR), realized as head-mounted devices (HMDs), may open up new ways of teaching medical content for low-resource settings. The advantages are that HMDs enable repeated practice without adverse effects on the patient in various medical disciplines; may introduce new ways to learn complex medical content; and may alleviate financial, ethical, and supervisory constraints on the use of traditional medical learning materials, like cadavers and other skills lab equipment.

Objective:
We examine the effectiveness of AR, MR, and VR HMDs for medical education, whereby we aim to incorporate a global health perspective comprising low- and middle-income countries (LMICs).

Methods:
We conducted a systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) and Cochrane guidelines. Seven medical databases (PubMed, Cochrane Library, Web of Science, Science Direct, PsycINFO, Education Resources Information Centre, and Google Scholar) were searched for peer-reviewed publications from January 1, 2014, to May 31, 2019. An extensive search was carried out to examine relevant literature guided by three concepts of extended reality (XR), which comprises the concepts of AR, MR, and VR, and the concepts of medicine and education. It included health professionals who took part in an HMD intervention that was compared to another teaching or learning method and evaluated with regard to its effectiveness. Quality and risk of bias were assessed with the Medical Education Research Study Quality Instrument, the Newcastle-Ottawa Scale-Education, and A Cochrane Risk of Bias Assessment Tool for Non-Randomized Studies of Interventions. We extracted relevant data and aggregated the data according to the main outcomes of this review (knowledge, skills, and XR HMD).

Results:
A total of 27 studies comprising 956 study participants were included. The participants included all types of health care professionals, especially medical students (n=573, 59.9%) and residents (n=289, 30.2%). AR and VR implemented with HMDs were most often used for training in the fields of surgery (n=13, 48%) and anatomy (n=4, 15%). A range of study designs were used, and quantitative methods were clearly dominant (n=21, 78%). Training with AR- and VR-based HMDs was perceived as salient, motivating, and engaging. In the majority of studies (n=17, 63%), HMD-based interventions were found to be effective. A small number of included studies (n=4, 15%) indicated that HMDs were effective for certain aspects of medical skills and knowledge learning and training, while other studies suggested that HMDs were only viable as an additional teaching tool (n=4, 15%). Only 2 (7%) studies found no effectiveness in the use of HMDs.

Conclusions:
The majority of included studies suggested that XR-based HMDs have beneficial effects for medical education, whereby only a minority of studies were from LMICs. Nevertheless, as most studies showed at least noninferior results when compared to conventional teaching and training, the results of this review suggest applicability and potential effectiveness in LMICs. Overall, users demonstrated greater enthusiasm and enjoyment in learning with XR-based HMDs. It has to be noted that many HMD-based interventions were small-scale and conducted as short-term pilots. To generate relevant evidence in the future, it is key to rigorously evaluate XR-based HMDs with AR and VR implementations, particularly in LMICs, to better understand the strengths and shortcomings of HMDs for medical education.

The need for adaptable global guidance in health systems strengthening for musculoskeletal health: a qualitative study of international key informants

Background
Musculoskeletal (MSK) conditions, MSK pain and MSK injury/trauma are the largest contributors to the global burden of disability, yet global guidance to arrest the rising disability burden is lacking. We aimed to explore contemporary context, challenges and opportunities at a global level and relevant to health systems strengthening for MSK health, as identified by international key informants (KIs) to inform a global MSK health strategic response.

Methods
An in-depth qualitative study was undertaken with international KIs, purposively sampled across high-income and low and middle-income countries (LMICs). KIs identified as representatives of peak global and international organisations (clinical/professional, advocacy, national government and the World Health Organization), thought leaders, and people with lived experience in advocacy roles. Verbatim transcripts of individual semi-structured interviews were analysed inductively using a grounded theory method. Data were organised into categories describing 1) contemporary context; 2) goals; 3) guiding principles; 4) accelerators for action; and 5) strategic priority areas (pillars), to build a data-driven logic model. Here, we report on categories 1–4 of the logic model.

Results
Thirty-one KIs from 20 countries (40% LMICs) affiliated with 25 organisations participated. Six themes described contemporary context (category 1): 1) MSK health is afforded relatively lower priority status compared with other health conditions and is poorly legitimised; 2) improving MSK health is more than just healthcare; 3) global guidance for country-level system strengthening is needed; 4) impact of COVID-19 on MSK health; 5) multiple inequities associated with MSK health; and 6) complexity in health service delivery for MSK health. Five guiding principles (category 3) focussed on adaptability; inclusiveness through co-design; prevention and reducing disability; a lifecourse approach; and equity and value-based care. Goals (category 2) and seven accelerators for action (category 4) were also derived.

Conclusion
KIs strongly supported the creation of an adaptable global strategy to catalyse and steward country-level health systems strengthening responses for MSK health. The data-driven logic model provides a blueprint for global agencies and countries to initiate appropriate whole-of-health system reforms to improve population-level prevention and management of MSK health. Contextual considerations about MSK health and accelerators for action should be considered in reform activities.

Global head and neck surgery research during the COVID pandemic: A bibliometric analysis

Background
Before the COVID-19 pandemic, access to otolaryngology and head-and-neck surgery was limited in low- and middle-income countries (LMICs). The pandemic has increased the burden on LMIC health systems by causing unanticipated expenses, delayed care, and changes in research activity. We aimed to assess the landscape of global ENT research during the pandemic.

Materials and methods
The authors developed a search strategy composed of the following keywords: “otolaryngology,” “head and neck surgery,” and “low- and middle-income countries.” Then, they searched eleven citation databases via the Web of Science from January 01, 2020, to May 03, 2021. They imported the result as metadata into VosViewer and ran bibliometric analyses to identify the most influential institutions, countries, and themes.

Results
During the study period, 3077 articles were published. Two hundred eighty-nine articles (9%) mentioned COVID-19 explicitly. The second most common theme was pediatric ENT (223 articles, 7%). The United States had the most publications [1616 articles, 12,033 citations, and 2986 total link strength (TLS)], followed by China (336 articles, 10,981 citations, and 571 TLS). South Africa, the first African country, was fourth (302 articles, 699 citations, and 908 TLS), while Brazil, the first South American country, was seventh (158 articles, 582 citations, and 376 TLS). The most prolific institution was the National Institute of Allergy and Infectious Diseases (186 articles, 1110 citations, and 674 TLS).

Conclusion
COVID-19 was the most common research theme during the pandemic, surpassing pediatric ENT.

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Background
Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality.

Methods
We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis.

Findings
We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality.

Interpretation
Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030.

The Future of Immersive Technology in Global Surgery Education

The second wave of immersive reality technology is required that enhances and exploits current applications, empirical evidence and worldwide interest. If this is successful, low- and middle-income countries will have improved access, less costs and reduced practical limitations. Affordability, availability, accessibility and appropriateness are determinates, and help from several innovative areas can achieve these targets. Artificial intelligence will allow autonomous support of trainees to accelerate their skills when interacting on mobile applications, as deep learning algorithms will generate models that identify data and patterns within them and provide feedback much like a human educator. Future immersive content needs to be high quality, tailored to the learners’ needs and created with minimal time and expenses. The co-creation process involves the integration of learners into the entire development process and a single learning goal can be identified that will have high reusability to surgical students. Sustainability of the material is ensured in the design stage leading to increased cost-effectiveness benefits. One framework has a proven high impact on the co-design of healthcare resources and is discussed. The connectivity of future immersive technology resources has been a major obstacle between regions in their uptake. A handful of collaboration platforms have been created that can deliver immersive content and experiences; the spearhead in this area will be from augmented reality and telesurgery. Opportunity for powerful, large-scale data culture via blockchain collaboration will be an emerging theme that will also drive towards affordability, availability, accessibility and appropriateness in the future global landscape of immersive technology in surgical education.

Future Health Spending Forecast in Leading Emerging BRICS Markets in 2030 – Health Policy Implications

Introduction: BRICS leading Emerging Markets are increasingly shaping the landscape of global health sector demand and supply for medical goods and services. BRICS’ share of global health spending and future projections will play a prominent role during upcoming 2020s. The purpose of current research was to examine decades long, underlying historical trends in BRICS’ nations health spending and explore these data as the grounds for reliable forecasting of their health expenditures up to 2030.

Methods: BRICS’ health spending data spanning 1995 – 2017 were extracted from IHME’s Financing Global Health 2019 database. Total health expenditure, government, prepaid private and out-of-pocket spending per capita and GDP share of total health spending, were forecasted 2018 – 2030. The ARIMA (Autoregressive Integrated Moving Average) models were used to obtain future projection based on time series analysis.

Results: Per capita health spending in 2030 is projected to be: Brazil: $1767 (95% PI: 1615, 1977) ; Russia: $1933 (95% PI: 1549, 2317); India: $468 (95% PI: 400.4, 535) ; China: $1707 (95% PI: 1079, 2334); South Africa $1379 (95% PI: 755, 2004). Health spending %GDP shares in 2030 are projected to be: Brazil: 8.4% (95% PI: 7.5, 9.4) ; Russia: 5.2% (95% PI: 4.5, 5.9) ; India: 3.5% (95% PI: 2.9%,4.1%) ; China: 5.9% (95% PI: 4.9, 7.0) ; South Africa: 10.4% (95% PI: 5.5, 15.3).

Conclusions: All BRICS expose long term trend to increase their per capita spending in PPP (purchase power parity) terms. India and Russia are highly likely to maintain stable total health spending GDP% share until 2030. China, as the major driver of global economic growth will be capable of significantly expanding its investment into the health sector across an array of indicators. Brazil is the only large nation whose GDP% share of health expenditure is about to contract substantially during the third decade of the 21st century. The steepest curve of increase in per capita spending until 2030 seems to be attributable to India while Russia should achieve the highest values in absolute terms. Health policy implications of long term trends in health spending indicate the need for Health Technology Assessment dissemination among BRICS ministries of health and national health insurance funds. Matters of cost-effective allocation of limited resources shall remain the core challenge in 2030 as well.

Essential Package of Palliative Care for Women With Cervical Cancer: Responding to the Suffering of a Highly Vulnerable Population

Women with cervical cancer, especially those with advanced disease, appear to experience suffering that is more prevalent, complex, and severe than that caused by other cancers and serious illnesses, and approximately 85% live in low- and middle-income countries where palliative care is rarely accessible. To respond to the highly prevalent and extreme suffering in this vulnerable population, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an essential package of palliative care for cervical cancer (EPPCCC). The EPPCCC consists of a set of interventions, medicines, simple equipment, social supports, and human resources, and is designed to be safe and effective for preventing and relieving all types of suffering associated with cervical cancer. It includes only inexpensive and readily available medicines and equipment, and its use requires only basic training. Thus, the EPPCCC can and should be made accessible everywhere, including for the rural poor. We provide guidance for integrating the EPPCCC into gynecologic and oncologic care at all levels of health care systems, and into primary care, in countries of all income levels.