Contextualizing policy implementation, challenges, and plans for improving breast cancer early detection programs in Indonesia

Late-stage breast cancer (BC) is commonly diagnosed in limited-resource countries such as Indonesia. The lack of information for decision-making emphasizes the need for efforts to support evidence-informed practice for improving BC early detection in Indonesia. This study attempts to understand the local context evidence on policy implementation, challenges, and plans for enhancing BC early detection programs in Indonesia. The evidence gained from this study will help harness the power of scientific reasoning that shapes theories of how BC early detection intervention works and its operationalization in practice.

This study engaged three interrelated phases of qualitative methods. Phase I involved a document analysis in determining the predominant strategy and approach to the landscape of BC early detection programs. Phase II was an in-depth interview to clarify the operationalization of the technical aspect, eliciting stakeholder experiences and their perceptions about the factors supporting or hindering goal achievement. In phase III, two consecutive collaborative expert workshops and a collaborative learning process nested with the Indonesia Project ECHO team for Knowledge Summaries for Comprehensive Breast Cancer Control.

Current BC early detection strategies to downstage women’s symptomatic breast abnormalities are considered an essential preparatory step before starting a screening program at the enhanced or maximal level of resources. However, the absence of an integrated cancer registry system renders it impossible to measure the full effect of the program implementation as a public health policy. Emphasis on improving structural barriers during the follow-up of abnormalities, patient navigation for referrals, and a surveillance system to track the times from presentation to diagnosis and diagnosis to treatment is needed for Indonesia’s early detection services continuum.

The local context presented in this research increased the usability and usefulness of relevant evidence for decision-makers, thus bridging the gap in translating research findings into healthcare practice for BC early detection in Indonesia. Importantly, attention to providing a clear national guideline, developing a highly interoperable screening registry system, and ensuring the sustainability of pilot sites on mammography screening is critical to the success of expected outcomes.

An equity analysis on the household costs of accessing and utilising maternal and child health care services in Tanzania

Direct and time costs of accessing and using health care may limit health care access, affect welfare loss, and lead to catastrophic spending especially among poorest households. To date, limited attention has been given to time and transport costs and how these costs are distributed across patients, facility and service types especially in poor settings. We aimed to fill this knowledge gap.

We used data from 1407 patients in 150 facilities in Tanzania. Data were collected in January 2012 through patient exit-interviews. All costs were disaggregated across patients, facility and service types. Data were analysed descriptively by using means, medians and equity measures like equity gap, ratio and concentration index.

71% of patients, especially the poorest and rural patients, accessed care on foot. The average travel time and cost were 30 minutes and 0.41USD respectively. The average waiting time and consultation time were 47 min and 13 min respectively. The average medical cost was 0.23 USD but only18% of patients paid for health care. The poorest and rural patients faced substantial time burden to access health care (travel and waiting) but incurred less transport and medical costs compared to their counterparts. The consultation time was similar across patients. Patients spent more time travelling to public facilities and dispensaries while incurring less transport cost than accessing other facility types, but waiting and consultation time was similar across facility types. Patients paid less amount in public than in private facilities. Postnatal care and vaccination clients spent less waiting and consultation time and paid less medical cost than antenatal care clients.

Our findings reinforce the need for a greater investment in primary health care to reduce access barriers and cost burdens especially among the worse-offs. Facility’s construction and renovation and increased supply of healthcare workers and medical commodities are potential initiatives to consider. Other initiatives may need a multi-sectoral collaboration

Mortality Rate in Pakistan – among Low and Middle-Income Countries

Age-specific and sex-specific cause of death determination is becoming very important task particularly for low- and middle-income countries (LMICs). Therefore, consistent openly accessible information with reproducibility may have significant role in regulating the major causes of mortality both in premature child and adults. The United Nations (UN) reported that 86% deaths (48 million deaths) out of 56 million globally deaths occurred in the LMICs in 2010. The major dilemma is that most of the deaths do not have a diagnosis of COD in such countries. Despite of the allocation of a large portion of resources to decrease the devastating impacts of chronic illnesses, their prevalence as well as the health and economic consequences remains staggeringly high. There are multiple levels of interventions that can help in bringing about significant and promising improvements in the healthcare system. Currently, Pakistan is facing double burden of malnutrition with record high prevalence rates of chronic diseases. Pakistan spends only a marginal of its GDP (1.2%) versus the recommended 5% by World Health Organization. On average, there are eight hospitals per district, with people load per hospital being 165512.452 and poor data management in the country, and we lack a consistent local registry on all-cause of mortality. This article was planned to compile the data related to major causes and disease specific mortality rates for Pakistan and link these factors to the social-economic determinants of health.

Health Shocks and Coping Mechanisms in North Central Nigeria: The Gender Perspective

Introduction: Reliance on out-of-pockets (OOP) payments for health services has continued to hamper access to quality healthcare across Nigeria. Socio-demographic and socio-economic characteristics of the gender of the household head as it influences andimpacts health shocks and OOP payments havereceived very little attention globally. This studyinvestigatedthe gender perspective onhealth shocks, health expenditures and coping mechanisms in North Central, Nigeria. Methods: This is a cross-sectional analytical study involving both quantitative and qualitative data collection methods. A total of 1,192 households were studied using multi-stage sampling technique in both rural and urban communities in North Central, Nigeria. Data was analysed with SPSS version 20, and qualitative analysis was done by thematic analysis. Results: The finding showed that 458 (38.4%) of the respondents were female-headed households (FHHs). Female-headed households were less educated, earned lower income, resided more in rural communities and were less insured than male-headed households (MHHs). Health shocks were higher among the FHHs and they also pay higherpercentage of their household expenditure for healthcare through higher OOP payments. Also, more FHHs experienced Catastrophic Health Expenditure (CHE) and reported effects of health shocks on reduction in food consumption and loss of income than MHHs. Age, income, occupation and household size are all factors that influenced health shocks in this study. Conclusions: Innovative ways to financially protect women must be employed, to close up the equity gap and bring Nigeria closer to achieving UHC.

The microeconomic impact of out-of-pocket medical expenditure on the households of cardiovascular disease patients in general and specialized heart hospitals in Ibadan, Nigeria

Cardiovascular diseases (CVDs) present a huge threat to population health and in addition impose severe economic burden on individuals and their households. Despite this, there is no research evidence on the microeconomic impact of CVDs in Nigeria. Therefore, this study estimated the incidence and intensity of catastrophic health expenditures (CHE), poverty headcount due to out-of-pocket (OOP) medical spending and the associated factors among the households of a cohort of CVDs patients who accessed healthcare services in public and specialized heart hospitals in Ibadan, Nigeria.

This study adopts a descriptive cross-sectional study design. A standardized data collection questionnaire developed by the Initiative for Cardiovascular Health Research in Developing Countries was adapted to electronically collect data from all the 744 CVDs patients who accessed healthcare services in public and specialized heart hospitals in Ibadan between 4th November 2019 to the 31st January 2020. A sensitivity analysis, using rank-dependent thresholds of CHE which ranged from 5%-40% of household total expenditures was carried out. The international poverty line of $1.90/day recommended by the World Bank was utilized to ascertain poverty headcounts pre-and post OOP payments for healthcare services. Categorical variables like household socio-demographic and clinical characteristics, CHE and poverty headcounts, were presented using percentages and proportions. Unadjusted and adjusted logistic regression models were used to assess the factors associated with CHE and poverty. Data were analyzed using STATA version 15 and estimates were validated at 5% level of significance.

Catastrophic OOP payment ranged between 3.9%-54.6% and catastrophic overshoot ranged from 1.8% to 12.6%. Health expenditures doubled poverty headcount among households, from 8.13% to 16.4%. Having tertiary education (AOR: 0.49, CI: 0.26–0.93, p = 0.03) and household size (AOR: 0.40, CI: 0.24–0.67, p = 0.001) were significantly associated with CHE. Being female (AOR: 0.41, CI: 0.18–0.92, p = 0.03), household economic status (AOR: 0.003, CI: 0.0003–0.25, p = <0.001) and having 3–4 household members (AOR: 0.30, CI: 0.15–0.61, p = 0.001) were significantly associated with household poverty status post payment for medical services.

OOP medical spending due to CVDs imposed enormous strain on household resources and increased the poverty rates among households. Policies and interventions that supports universal health coverage are highly recommended.

A Systematic Review of the Cost-Effectiveness of Cleft Care in Low- and Middle-Income Countries: What is Needed?

The objective of this paper is to conduct a systematic review that summarizes the cost-effectiveness of cleft lip and/or palate (CL/P) care in low- and middle-income countries (LMICs) based on existing literature.

We searched eleven electronic databases for articles from January 1, 2000 to December 29, 2020. This study is registered in PROSPERO (CRD42020148402). Two reviewers independently conducted primary and secondary screening, and data extraction.

All CL/P cost-effectiveness analyses in LMIC settings.

Patients, Participants
In total, 2883 citations were screened. Eleven articles encompassing 1,001,675 patients from 86 LMICs were included.

Main Outcome Measures
We used cost-effectiveness thresholds of 1% to 51% of a country’s gross domestic product per capita (GDP/capita), a conservative threshold recommended for LMICs. Quality appraisal was conducted using the Joanna Briggs Institute (JBI) checklist.

Primary CL/P repair was cost-effective at the threshold of 51% of a country’s GDP/capita across all studies. However, only 1 study met at least 70% of the JBI criteria. There is a need for context-specific cost and health outcome data for primary CL/P repair, complications, and existing multidisciplinary management in LMICs.

Existing economic evaluations suggest primary CL/P repair is cost-effective, however context-specific local data will make future cost-effectiveness analyses more relevant to local decision-makers and lead to better-informed resource allocation decisions in LMICs.

Estimating the health burden of road traffic injuries in Malawi using an individual based model


Road traffic injuries are a significant cause of death and disability globally. However, in some countries the exact health burden caused by road traffic injuries is unknown. In Malawi, there is no central reporting mechanism for road traffic injuries and so the exact extent of the health burden caused by road traffic injuries is hard to determine. A limited number of models predict the incidence of death due to road traffic injury in Malawi. These estimates vary greatly, owing to differences in assumptions and so the health burden caused on the population by road traffic injuries remains unclear.


We use an individual based model and combine an epidemiological model of road traffic injuries with a health seeking behaviour and health system model. We provide a detailed representation of road traffic injuries in Malawi, from the onset of the injury through to the final health outcome. We also investigate the effects of an assumption made by other models, that multiple injuries do not contribute to health burden caused by road accidents.


Our model estimates an overall average incidence of death between 23.5 to 29.8 deaths per 100,000 person years due to road traffic injuries and an average of 180,000 to 225,000 disability-adjusted life years (DALYs) per year between 2010 and 2020 in an estimated average population size of 1,364,000 over the 10-year period. Our estimated incidence of death falls within the range of other estimates currently available for Malawi, whereas our estimated number of DALYs is greater than the only other estimate available for Malawi, the GBD estimate predicting and average of 126,200 DALYs per year over the same time period. Our estimates, which account for multiple injuries, predict a 22-58% increase in overall health burden compared to the model ran as a single injury model.


Road traffic injuries are difficult to model with conventional modelling methods, owing to the numerous types of injuries that occur. Using an individual based model framework, we can provide a detailed representation of road traffic injuries. Our results indicate a higher health burden caused by road traffic injuries than previously estimated.

Compliance with the World Health Organization’s surgical safety checklist and related postoperative outcomes: a nationwide survey among 172 health facilities in Ethiopia

Ministry of Health (MOH) of Ethiopia adopted World Health Organization’s evidence-proven surgical safety checklist (SSC) to reduce the occurrence of surgical complications, i.e., death, disability and prolong hospitalization. MOH commissioned this evaluation to learn about SSC completeness and compliance, and its effect on magnitude of surgical complications.

Health institution-based cross-sectional study with retrospective surgical chart audit was used to evaluate SSC utilization in 172 public and private health facilities in Ethiopia, December 2020–May 2021. A total of 1720 major emergency and elective surgeries in 172 (140 public and 32 private) facilities were recruited for chart review by an experienced team of surgical clinicians. A pre-tested tool was used to abstract data from patient charts and national database. Analyzed descriptive, univariable and bivariable data using Stata version-15 statistical software.

In 172 public and private health facilities across Ethiopia, 1603 of 1720 (93.2%) patient charts were audited; representations of public and private facilities were 81.4% (n = 140) and 18.6% (n = 32), respectively. Of surgeries that utilized SSC (67.6%, 1083 of 1603), the proportion of SSC that were filled completely and correctly were 60.8% (659 of 1083). Surgeries compliant to SSC guide achieved a statistically significant reduction in perioperative mortality (P = 0.002) and anesthesia adverse events (P = 0.005), but not in Surgical Site Infection (P = 0.086). Non-compliant surgeries neither utilized SSC nor completed the SSC correctly, 58.9% (944 of 1603).

Surgeries that adhered to the SSC achieved a statistically significant reduction in perioperative complications, including mortality. Disappointingly, a significant number of surgeries (58.9%) failed to adhere to SSC, a missed opportunity for reducing complications.

Knowledge and practice of Nepalese doctors on reutilization of medical/surgical tools from developed nations: a national level online cross-sectional survey

A manifold cause of global disparity in medical and surgical care exists, among which lack of access to proper biomedical equipment including surgical tools are a recurrent theme. Use and reuse of such donated tools are common in low resource settings including countries like Nepal; however, there is a lack of adequate data and less has been explored. Through this nationwide study, we aimed to discover the knowledge of donated medical and surgical devices and the practice of reusing single-use equipment by Nepalese medical practitioners and surgeons.

An online, questionnaire-based cross-sectional study was conducted using SurveyMonkey from October 2020 through January 2021. The link was sent to target respondents via email and social media and responses were recorded. Data processing and analysis were done using the same platform.

Among 466 respondents, 349 completed the survey. Around 81.5% recorded that their institute has never received medical devices or donations in the past, while 18.34% believed they had received such commodities. Most of the donations were received from countries like the United States, China, Japan, and India. Around 24% of the respondents reused the tools meant for single-use and only 5% communicated with the donors. Commodities like laparoscopic sets, sutures, dialysis machines, magnetic resonance imaging machines, surgical retractors, face masks, sanitizers, personal protective equipment, endoscopy apparatus, etc., were received. The majority of them were concerned about national guidelines regarding donating reusable tools which might not be acceptable through custom rules of the country, although the facilitation of functional yet unused tools is always welcome in the underserved regions of Nepal.

Nepalese medical professionals had adequate knowledge about the donated medical devices and only a few of them had practiced reusing single-use equipment. Mutual cooperation between donors and recipients is one of the most important aspects of safe medical/surgical tools delivery.

Barriers to accessing follow up care in post-hospitalized trauma patients in Moshi, Tanzania: A mixed methods study

Disproportionately high injury rates in Sub-Saharan Africa combined with limited access to care in both the acute injury phase and for injury patients requiring continued care after hospital discharge remains a challenge. We aimed to characterize barriers to transportation and access to care in a cohort of post-hospitalized injury patients in Moshi, Tanzania. This was a mixed-methods study of a prospective cohort of trauma registry patients presenting to Kilimanjaro Christian Medical Center between August 2018 and January 2020. We conducted standardized patient/family surveys and in-depth interviews at a 2-week follow up visit after hospital discharge, and focus groups with healthcare providers. Quantitative results were analyzed using descriptive statistics and multivariable logistic regression using R statistical software. Qualitative results were analyzed using thematic analysis through an iterative process using NVivo software. A total of 1,365 patients were enrolled in the trauma registry, with 169 patients followed up at 2 weeks. Over half of patients at follow-up, 101 (59.8%), reported challenges in traveling. The majority of patients were male (80.3%). Difficulty in traveling since injury was associated with female gender (aOR 5.85 [95% CI 1.20–33.59]) and a need for non-family members escorts for travel (aOR 7.10 [95% CI 1.43–41.66]). Those who reported assault or fall as the mechanism of injury as compared to road traffic injury and had health insurance were less likely to report challenges in traveling (aOR 0.19 [95% CI 0.03–0.90]), 0.11 [95% CI 0.01–0.61], 0.14 [95% 0.02–0.80]). Transportation barriers that emerged from qualitative data included inability to use regular means of transportation, financial challenges, physical barriers, rigid compliance to physician orders, access to healthcare, and social support barriers. Our findings demonstrate several areas to address transportation barriers for post-injury patients in Tanzania. Educational interventions such as clarification of doctors’ orders of strict bedrest, provision of vouchers to support financial challenges and alternate means of transportation given physical barriers and reliance on social support may address some of these barriers.