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.

Research to improve surgical oncological care on the surgical department, Maputo Central Hospital

Purpose: Regarding adequate care for oncological patients, requiring surgical interventions at the Surgical Department of Maputo Central Hospital (MCH), the largest hospital in Mozambique, the aim of those studies, was first to assess the surgical resources, surgical oncology team skills, identify and characterize prevalent cancers treated and general knowledge in oncology and surgical oncology, expecting the development of a comprehensive curriculum in surgical oncology fellowship fit for the Hospital and all Mozambique country. Methods: The study 1, done in 2017, was based on surgeons questionnaire (The Cancer Units Assessment Checklist for low- or middle-income African countries (annex I), visiting the unities (oncology service, ICU, operations room, etc.) collecting information according to the Portuguese-speaking African Countries Assessment of Surgical Oncology Capacity Survey (PSAC-Surgery – annex II). The study 2, done in 2018, by retrospective analysis of individual cancer patient registries of MCH, the prevalent cancers has been identified and characterized (annex IV). And the general knowledge in oncology and surgical oncology, this issue was evaluated by simple test administered anonymously and without prior notice to all surgeons and residents at the Surgical Department (annex V). The domains was about basis of Oncology, Radiotherapy, Pathology, Chemotherapy, Pain management, Surgical oncology and Clinical pathway. The study 3, done in 2019, a three-round modified-Delphi approach was implemented to obtain consensus on surgical oncology training curriculum. The participants were purposefully selected 23 experts in surgical oncology working in Mozambique. In round one, participants answered a questionnaire regarding the content of the curriculum and the timing and venue of training. Draft of the curriculum was produced. In round 2, answers from the first round and the curriculum draft were presented to a purposeful selected sample of nationally recognized experts in oncology and surgical oncology, including members of the Mozambican College of Surgeons and leadership of the Ministry of Health. A final round was carried out to discuss the final version of the training program in surgical oncology with extensive participation of majority of african experts in surgical oncology (Aortic, Maputo). Results: Breast, esophagus and colorectal cancers were the most commonly treated neoplasms in MCH (at Surgical department). A range of technical and resource needs as well as the gaps in knowledge and skills were identified. All surgeons recognized the need to create a training program in oncology at the undergraduate level, specific training for residents and continuing oncological education for general surgeons, to improve the practice of surgical oncology. Basic principles of oncology and basic principles of surgical oncology should be included in the curriculum of surgical residency in Mozambique, a 24-months fellowship in surgical oncology should take place after residency in the surgical field and should occur at Maputo Central Hospital and at comprehensive cancer centers. The final proposal for the program was divided into the following structure: a – theoretical components; b – duration; c – location; d – methodology; e – technical skills in oncology; and f – competency and paid particular attention to the oncological diseases prevalent in Mozambique.

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.

Public Awareness Knowledge of Availability And Willingness to Use Neurosurgical Care Services in Africa: A CrossSectional ESurvey Protocol

Background: Barriers to care cause delays in seeking, reaching, and getting care. These delays affect low-and middle-income countries (LMICs), where 9 out of 10 LMIC inhabitants have no access to basic surgical care. Knowledge of healthcare utilization behavior within underserved communities is useful when developing and implementing health policies. Little is known about the neurosurgical health-seeking behavior of African adults. This study evaluates public awareness, knowledge of availability, and readiness for neurosurgical care services amongst African adults.

Methodology: The cross-sectional study will be run using a self-administered e-survey hosted on Google Forms (Google, CA, USA) disseminated from 10th May 2021 to 10th June 2021. The Questionnaire would be in two languages, English and French. The survey will contain closed-ended, open-ended, and Likert Scale questions. The structured questionnaire will have four sections with 42 questions; Sociodemographic characteristics, Definition of neurosurgery care, Knowledge of neurosurgical diseases, practice and availability, and Common beliefs about neurosurgical care. All consenting adult Africans will be eligible. A minimum sample size of 424 will be used. Data will be analyzed using SPSS version 26 (IBM, WA, USA). Odds ratios and their 95% confidence intervals, Chi-Square test, and ANOVA will be used to test for associations between independent and dependent variables. A P-value <0.05 will be considered statistically significant. Also, a multinomial regression model will be used.

Dissemination: The study findings will be published in an academic peer-reviewed journal, and the abstract will be presented at an international conference.

Highlights

The burden of neurosurgical diseases is enormous in low- and middle-income countries, especially in Africa.
Unfortunately, most neurosurgical needs in Africa are unmet because of delays in seeking, reaching, and getting care.
Most efforts aimed at reducing barriers to care have focused on improving the neurosurgical workforce density and infrastructure. Little or no efforts have been directed towards understanding or reducing the barriers to seeking care.
We aimed to understand public awareness, willingness to use, and knowledge of the availability of neurosurgical care in Africa.
The study findings can inform effective strategies that promote the utilization of neurosurgical services and patient education in Africa.

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.

Patterns of care of breast cancer patients in Morocco – A study of variations in patient profile, tumour characteristics and standard of care over a decade

Guided by a national cancer plan (2010–19), Morocco made significant investments in improving breast cancer detection and treatment. A breast cancer pattern-of-care study was conducted to document the socio-demographic profiles of patients and tumour characteristics, measure delays in care, and assess the status of dissemination and impact of state-of-the-art management. The retrospective study conducted among 2120 breast cancer patients registered during 2008–17 at the two premier-most oncology centres (Centre Mohammed VI or CM-VI and Institut National d’Oncologie or INO) also measured temporal trends of the different variables.

Median age (49 years) and other socio-demographic characteristics of the patients remained constant over time. A significant improvement in coverage of the state-financed health insurance scheme for indigent populations was observed over time. Median interval between onset of symptoms and first medical consultation was 6 months with a significant reduction over time. Information on staging and molecular profile were available for more than 90% and 80% of the patients respectively. Approximately 55% of the patients presented at stage I/II and proportion of triple-negative cancers was 16%; neither showing any appreciable temporal variation. Treatment information was available for more than 90% of the patients; 69% received surgery with chemotherapy and/or radiation. Treatment was tailored to stage and molecular profiles, though breast conservation therapy was offered to less than one-fifth. When compared using the EUSOMA quality indicators for breast cancer management, INO performed better than CM-VI. This was reflected in nearly 25% difference in 5-year disease-free survival for early-stage cancers between the centres.

Lessons for Latin America from Mexico’s Experience With Patient Safety and Covid Response

Globally, more than 1 in 10 patients continue to be harmed due to safety lapses during their care.[1] Unsafe care results in over three million deaths each year. The health burden of harm is estimated at 64 million Disability-Adjusted Life Years (DALYs) per year similar to that of HIV/AIDS. Most of this burden is in low- and middle-income countries (LMICs). Recent estimates suggest that as many as 4 in 100 people die from unsafe care in the developing world [1]. The COVID-19 pandemic has clearly shown the risk of patient harm. The estimated proportion of hospital-acquired COVID-19 cases ranges from 12.5% to 44% [1]. As many as one third of these cases are reported to be among healthcare staff.
In Mexico, the Patient Safety journey started in 2002, with the National Crusade for Quality in Health Care,[2] the first Quality Policy in Latin America. The efforts to improve patient safety in Mexico can be divided into three distinct waves. A fourth wave has commenced with the pandemic. These lessons on patient safety are even more important now in the COVID era and can be applied in the region and elsewher

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.