Think global, act local: Burn care in a resource-limited setting

The burden of burn injuries remains a major global health issue.1,2 Worldwide,millions of people suffer from burns and burn-related disabilities and deformities. Every year over 8 million people require medical attention due to burns. Burns cause an estimated loss of 8.5 million disability-adjusted life years (DALYs) each year due to premature death and disability.3 Five per cent of all injury-related deaths are caused by burns, which amounts to an estimated 120,000 deaths annually.4 Non-fatal burns are a leading cause of disability, which cause long-term physical and psychological problems.5,6 There are large differences in burn care worldwide.1 In high-income countries (HICs) major progress has been made in acute burn care over the past decades. With advancements made in the prevention of burns and treatments of wounds, the incidence of burns has decreased and the survival rate of patients has increased. The current mortality reported by HICs is 1.5%.7 This is in stark contrast to low- and middle-income countries (LMICs). In these countries the burden of burn incidence, mortality and morbidity remains high.1,8,9 The vast majority of all burns globally occur in LMICs. This is because people use open fires in daily life, for example for cooking, heating and agriculture. The incidence of burns in these countries is estimated to be 1.3 per 100,000 people, compared to 0.14 per 100,000 people in HICs.8,10 The few existing studies from LMICs show that poor populations are most at risk of sustaining burns, and that the majority of patients are children.1,2,9,11,12 The higher morbidity and mortality is a consequence of the fact that geographically isolated and economically disadvantaged populations have limited access to safe and timely burn care.2 Due to this lack of care, 95% of all fatal fire-related cases of mortality due to burns occurs in LMICs. Studies have estimated that the risk of child mortality due to burns is currently over seven times
higher in LMICs compared to HICs

The Chiranjeevi Yojana (CY) : a public-private-partnership to promote institutional births in Gujarat, India : studies of providers and users

Introduction: National, regional and local governments, particularly in lower middleincome countries, are encouraged to pursue partnerships with the pool of private providers available to them, in order to achieve the Sustainable Development Goal for maternal health. The state of Gujarat in India (population 60 million) has been a pioneer in designing a large-scale Public-Private-Partnership (PPP), the Chiranjeevi Yojana (CY), for emergency obstetric care (EmOC) for vulnerable women through qualified obstetricians. The program was instituted in 2006-07 and 865 obstetricians partnered with the state at the time.

Methodology: The papers in this thesis examine this CY program through three quantitative and one qualitative study. The studies were conducted in three districts of Gujarat state, Sabarkantha, Surendranagar and Dahod. The methods included two crosssectional surveys (i.e., a facility survey and a facility-based survey of women who gave birth) and in-depth interviews.

These four studies elucidate characteristics of CY providers and CY beneficiaries, as well as outcomes in the health system environment and the population. In order to synthesise these results coherently, I adapted the Anderson’s theoretical model to synthesise, explain and discuss the findings in my studies. In the adapted model, I present my findings in three clear and linked domains – (1) Environment – Health system and population environment in which the CY program was implemented (2) Enabler – Characteristics of the health system and population that were enabled, i.e., made eligible, as per program criteria to participate in the CY program and (3) Outcomes – in the health system and population environment, examined through (a) Health system and provider behaviours (b) Users’ behaviours (c) Health status of the mothers and (d) Financial status of households with respect to using obstetric services.

Results: The CY program influenced the health system’s environment towards increasing the availability of free CEmOC by 10 times, from 0.32 to 3.65 per 500,000 population, but actual performance of notionally free CEmOC functions was only 2 per 500,000 population (Study I). Providers’ behaviour was reflected in the en masse participation or non-participation of providers in ten out of seventeen urban centres. The facilities that participated in the CY program had a significantly higher likelihood, independently, of being general facilities (PR 1.9, 95% CI 1.3–2.9), or conducting lower proportion of caesarean births (PR 2.1, 95% CI 1.2–3.5) or having obstetricians new in private practice (PR 1.9, 95% CI 1.2–3.1) or being less expensive (PR 1.8, 95% CI 1.1–3.0) (Study II). The CY program criteria influenced the population environment by enabling mothers to become eligible for CY benefit. These mothers were significantly more likely to be vulnerable – rural, multiparous, scheduled tribe, and less educated. Users’ behaviours showed that eligible mothers had significantly less prevalence of ante-natal visits, as well as shorter hospital stay after birth. The evaluated health status showed low caesarean rates among eligible vulnerable mothers (6%) and high caesarean (40%) and episiotomy (63%) rates among ineligible mothers (Study III). The perceived health status of the population was reflected in the fact that most mothers and families were very happy with the care they had received and none reported any preferential treatment of paying mothers over CY beneficiary mothers. However, a few mothers who experienced instances of poor quality of care or rude behaviour, reflected back on their experience and still reported it as a “good (sari) delivery”. The financial status of the population showed only 15% of eligible mothers were CY beneficiaries, and only 4 % of them received a completely cashless birth. The median degree of subsidy for women in CY who birthed vaginally was 85% and by caesarean section was 71 % compared to out-of-pocket expenditure sustained by non-beneficiaries in the private health sector. Mothers without formal education were significantly less likely (OR 0.4, 95% CI 0.3–0.7) to receive CY benefit. Only having CY program knowledge (OR 4.7, 95% CI 2.6–8.4) and showing proof of poverty (OR 2.6, 95% CI 1.3–5.4) increased the likelihood of receiving the benefit. (Study III).

Discussion: Although the CY program increased the availability of free emergency obstetric care to 10 times more than the UN standards, their actual performance increased by only twice. This indicated poor management mechanisms within the state authorities. Although the CY program criteria recognised vulnerable mothers adequately accurately, their behaviours, health status and financial status showed mixed outcomes. Vulnerable populations behaviours to ensure improved maternal health and access to the CY program were varied, despite the program being in effect for seven years before our study. The health status of the vulnerable population, in terms of low caesarean rates, were below established norms in the literature, and among the non-vulnerable populations was much higher. The financial status of the eligible population was not much eased by the program since 85% of them did not receive the CY benefit. However, the highest median expenditure in our study (INR 7224) was well below the mean cost in private facilities across the nation (INR 15000) thus indicating a possible partial protection from out-of-pocket cost due to the CY program activity in the region.

Conclusion: The recently established Prime Minister’s People’s Health Program in India depends on PPPs for secondary and tertiary care all over the country. As revealed in this thesis, improved, adequate and effective health systems through PPPs requires better contract designing and managing capacities within in the state system. The health status and users’ behaviours could be assisted by the ongoing digitization of health systems such that (a) maternal health data is collected by both public and private sectors in enough detail to be able to categorise it by Robson’s criteria and thus monitor BEmOC and CEmOC performance, ante-natal visits, length of stay in hospital and other relevant variables (b) user feed-back is collected in a manner that captures actual experiences of women during birth, and that of their families during their interactions with the health system.

The role of community health workers in the surgical cascade: a scoping review

Background
Community health workers (CHWs) can increase access to various primary healthcare services; however, their potential for improving surgical care is under-explored. We sought to assess the role of CHWs in the surgical cascade, defined as disease screening, linkage to operative care, and post-operative care. Given the well-described literature on CHWs and screening, we focused on the latter two steps of the surgical cascade.

Methods
We conducted a scoping review of the peer-reviewed literature. We searched for studies published in any language from January 1, 2000 to May 1, 2020 using electronic literature databases including Pubmed/MEDLINE, Web of Science, SCOPUS, and Google Scholar. We included articles on CHW involvement in linkage to operative care and/or post-operative surgical care. Narrative and descriptive methods were used to analyze the data.

Results
The initial search identified 145 articles relevant to steps in the surgical cascade. Ten studies met our inclusion criteria and were included for review. In linkage to care, CHWs helped increase surgical enrollment, provide resources for vulnerable patients, and build trust in healthcare services. Post-operatively, CHWs acted as effective monitors for surgical-site infections and provided socially isolated patients with support and linkage to additional services. The complex and wide-ranging needs of surgical patients illustrated the need to view surgical care as a continuum rather than a singular operative event.

Conclusion
While the current literature is limited, CHWs were able to maneuver complex medical, cultural, and social barriers to surgical care by linking patients to counseling, education, and community resources, as well as post-operative infection prevention services. Future studies would benefit from more rigorous study designs and larger sample sizes to further elucidate the role CHWs can serve in the surgical cascade.

Challenges Affecting Health Referral Systems in Low-And Middle-Income Countries: A Systematic Literature Review

Aims: Low and middle-income countries are still facing challenges of dysfunctional referral systems which have impaired health service provision. This review aimed at investigating these challenges to understand their nature, cause, and the impacts they have on health service provision.

Methods: Database search was made in Google scholar, ACM Library, PubMed health, and BMC public health, and a total of 123 papers were generated. Only 14 fitted the inclusion criteria. Inclusion criteria included studies that were both quantitative and qualitative addressing challenges facing referral systems or health referral systems, studies describing the barriers to effective referral systems, and studies describing factors that affect referral systems. The review only included studies conducted in LMICs and included literature between January 2010 and February 2021.

Findings: Results revealed that human resource and financial constraints, non-compliance, and communication are the key challenges affecting referral systems in LMICs.

Recommendation: Countries that are facing these challenges need to overhaul the system and improve end-to-end communication between hospitals, improve capacity specifically in referral and emergency units, and sensitizing patients on the adherence to emergency protocols.

Resource constrained innovation in a technology intensive sector: Frugal medical devices from manufacturing firms in South Africa

Most medical devices are designed by western firms from efficient innovation systems with a focus on their home markets. A disproportionately high percentage of imported medical devices in low resource settings become non-functional. Despite interest from global health and innovation studies, little is known about firms in emerging markets appreciative of challenges in their home environments. Using empirical evidence from innovative manufacturing firms in South Africa, this study investigates frugal orientation and mechanisms to innovate under resource constraints, in a technology intensive sector typically under the purview of western firms. Systematic analysis of six devices by adapting a global health lens reveals that while some innovations specifically address health challenges of low resource, others are more affordable technological innovations with universal relevance and some frugal elements. Resource constrained innovation strategies involved building advanced internal manufacturing capabilities to overcome institutional voids while forging multiple knowledge collaborations to complement inhouse capabilities. This drives frugality around design, engineering and manufacturing processes. Innovation delivery strategies are complementary to these processes. The evidence suggests fundamentally new products were designed in collaborative bottom up processes. The role of the state and global non-profits in harnessing frugal innovations for public health was found to be critical.

Applying the Workload Indicators of Staffing Needs Method in Nursing Health Workforce Planning: Evidences from Four Hospitals in Vietnam

Background: Vietnam has encountered difficulties in ensuring an adequate and equitable distribution of health workforce. The traditional staffing norms stated in the Circular 08/TT-BYT issued in 2007 based solely on population or institutional size and do not adequately take into consideration the variations of need such as population density, mortality and morbidity patterns. To address this problem, more rigorous approaches are needed to determine the number of personnel in health facilities. One such approach is Workload Indicators of Staffing Need (WISN) developed by the World Health Organization (WHO), a facility-based workforce planning method that assists managers in defining the responsibilities of different workforce categories and improving the appropriateness and efficiency of a staff mix.

Methods: This study applied the WISN approach and was employed in 22 clinical departments at four hospitals in Vietnam between 2015 and 2018. 22 targeted group discussions involving nurses were conducted. Hospital personnel records have been retrieved. The data were analyzed according to WISN instructions.

Results: Of the 22 departments, there was a shortage of 1 to 2 nurses in 10 departments, with WISN ratios ranging between 0.88 and 0.95. Only 01 clinical colleges at Can Tho Hospital lacked 05 nurses, facing a high workload with a WISN ratio of 0.78. Administrative time represented 20-40% of the total work time of a nurse. In comparison, nurses at Can Tho Hospital spent time on administration from 24 onwards. 5% to 41.7% of their working time while nurses at Thanh Hoa Hospital spent 21% to 33%.

Conclusion: The application of the WISN enabled health managers to analyze the workload of nurses, calculate staffing needs, and thus effectively contribute to the workforce planning process. It is expected that the results of this research will encourage the use of the WISN tool in other hospitals and health facilities across the health system. At provincial and national levels, this study provides important evidence to help policy makers develop guidelines for personnel norms for health facilities in the context of limited resources, while the existing regulation is no longer appropriat

Mind the gap: Patterns of red blood cell product usage in South Africa, 2014 – 2019

Background. A key component of any successful healthcare system is the availability of sufficient, safe blood products delivered in an equitable manner. South Africa (SA) has a two-tiered healthcare system with public and privately funded sectors. Blood utilisation data for both sectors are lacking. Evaluation of blood utilisation patterns in each healthcare sector will enable implementation of systems to bring about more equality.

Objectives. To conduct a critical evaluation of red blood cell (RBC) product utilisation patterns at the South African National Blood Service (SANBS).

Methods. Operationally collected data from RBC requests submitted to SANBS blood banks for the period 1 January 2014 – 31 March 2019 were used to determine temporal RBC product utilisation patterns by healthcare sector. Demographic patterns were determined, and per capita RBC utilisation trends calculated.

Results. Of the 2 356 441 transfusion events, 65.9% occurred in the public and 34.1% in the private sector. Public sector patients were younger (median (interquartile range (IQR)) 33 (22 – 49) years) than in the private sector (median (IQR) 54 (37 – 68) years), and mainly female in both sectors (66.2% in the public sector and 53.4% in the private sector). Between 2014 and 2018, per capita RBC utilisation decreased from 11.9 to 11.0/1 000 population in the public sector, but increased from 34.8 to 38.2/1 000 population in the private sector.

Conclusions. We confirmed distinctly different RBC utilisation patterns between the healthcare sectors in SA. Possible drivers for these differences may be healthcare access, differing patient populations and prescriber habits. Better understanding of these drivers may help inform equitable public health policy.

Application of the research electronic data capture (REDCap) system in a low- and middle income country– experiences, lessons, and challenges

The challenges of reliably collecting, storing, organizing, and analyzing research data are critical in low- and middle-income countries (LMICs), particularly in Sub-Saharan Africa where several healthcare and biomedical research organizations have limited data infrastructure. The Research Electronic Data Capture (REDCap) System has been widely used by many institutions and hospitals in the USA for data collection, entry, and management and could help solve this problem. This study reports on the experiences, challenges, and lessons learned from establishing and applying REDCap for a large US-Nigeria research partnership that includes two sites in Nigeria, (the College of Medicine of the University of Lagos (CMUL) and Jos University Teaching Hospital (JUTH)) and Northwestern University (NU) in Chicago, Illinois in the United States. The largest challenges to this implementation were significant technical obstacles: the lack of REDCap-trained personnel, transient electrical power supply, and slow/ intermittent internet connectivity. However, asynchronous communication and on-site hands-on collaboration between the Nigerian sites and NU led to the successful installation and configuration of REDCap to meet the needs of the Nigerian sites. An example of one lesson learned is the use of Virtual Private Network (VPN) as a solution to poor internet connectivity at one of the sites, and its adoption is underway at the other. Virtual Private Servers (VPS) or shared online hosting were also evaluated and offer alternative solutions. Installing and using REDCap in LMIC institutions for research data management is feasible; however, planning for trained personnel and addressing electrical and internet infrastructural requirements are essential to optimize its use. Building this fundamental research capacity within LMICs across Africa could substantially enhance the potential for more cross-institutional and cross-country collaboration in future research endeavors.

Ghanaian views of short-term medical missions: The pros, the cons, and the possibilities for improvement

Background
Various governments in Ghana have tried to improve healthcare in the country. Despite these efforts, meeting health care needs is a growing concern to government and their citizens. Short term medical missions from other countries are one of the responses to meet the challenges of healthcare delivery in Ghana. This research aimed to understand Ghanaian perceptions of short-term missions from the narratives of host country staff involved. The study from which this paper is developed used a qualitative design, which combined a case study approach and political economy analysis involving in-depth interviews with 28 participants.

Result
Findings show short term medical mission programs in Ghana were largely undertaken in rural communities to address shortfalls in healthcare provision to these areas. The programs were often delivered free and were highly appreciated by communities and host institutions. While the contributions of STMM to health service provision have been noted, there were challenges associated with how they operated. The study found concerns over language and how volunteers effectively interacted with communities. Other identified challenges were the extent to which volunteers undermined local expertise, using fraudulent qualifications by some volunteers, and poor skills and lack of experience leading to wrong diagnoses sometimes. The study found a lack of awareness of rules requiring the registration of practitioners with national professional regulatory bodies, suggesting non enforcement of volunteers’ need for local certification.

Conclusion
Short Term Medical Missions appear to contribute to addressing some of the critical gaps in healthcare delivery. However, there is an urgent need to address the challenges of ineffective utilisation and lack of oversight of these programs to maximise their benefits

Understanding patient health-seeking behaviour to optimise the uptake of cataract surgery in rural Kenya, Zambia and Uganda: findings from a multisite qualitative study

Background
Cataract is a major cause of visual impairment globally, affecting 15.2 million people who are blind, and another 78.8 million who have moderate or severe visual impairment. This study was designed to explore factors that influence the uptake of surgery offered to patients with operable cataract in a free-of-charge, community-based eye health programme.

Methods
Focus group discussions and in-depth interviews were conducted with patients and healthcare providers in rural Zambia, Kenya and Uganda during 2018–2019. We identified participants using purposive sampling. Thematic analysis was conducted using a combination of an inductive and deductive team-based approach.

Results
Participants consisted of 131 healthcare providers and 294 patients. Two-thirds of patients had been operated on for cataract. Two major themes emerged: (1) surgery enablers, including a desire to regain control of their lives, the positive testimonies of others, family support, as well as free surgery, medication and food; and (2) barriers to surgery, including cultural and social factors, as well as the inadequacies of the healthcare delivery system.

Conclusions
Cultural, social and health system realities impact decisions made by patients about cataract surgery uptake. This study highlights the importance of demand segmentation and improving the quality of services, based on patients’ expectations and needs, as strategies for increasing cataract surgery uptake.