Building power-ful health systems: the impacts of electrification on health outcomes in LMICs

Critical disparities threaten health care in developing countries and hinder progress towards global development commitments. Almost a billion people and thousands of public services are not yet connected to electricity – a majority in sub-Saharan Africa. In economically fragile settings, clinics and health services struggle to gain and maintain their access to the most basic energy infrastructure. Less than 30% of health facilities in LMICs report access to reliable energy sources, truncating health outcomes and endangering patients in critical conditions. While ‘universal health coverage’ and ‘sustainable energy for all’ are two distinct SDGs with their respective targets, this review challenges their disconnect and inspects their interdependence in LMICs. To evaluate the impact of electrification on healthcare facilities in LMICs, this systematic review analysed relevant publications up to March 2021, using MEDLINE, Embase, Scopus, CENTRAL, clinicaltrials.gov and CINAHL. Outcomes captured were in accordance with the WHO HHFA modules. A total of 5083 studies were identified, 12 fulfilled the inclusion criteria of this review – most were from Africa, with the exception of two studies from India and one from Fiji. Electrification was associated with improvements in the quality of antenatal care services, vaccination rates, emergency capabilities and primary health services; with many facilities reporting high-quality, reliable and continuous oxygen supplies, refrigeration and enhanced medical supply chains. Renewable energy sources were considered in six of the included studies, most highlighting their suitability for rural health facilities. Notably, solar-powered oxygen delivery systems reduced childhood mortality and length of hospital stay. Unavailable and unreliable electricity is a bottleneck to health service delivery in LMICs. Electrification was associated with increased service availability, readiness and quality of care – especially for women, children and those under critical care. This study indicates that stable and clean electrification allows new heights in achieving SDG 3 and SDG7 in LMICs.

Blindness and visual impairment and their causes in India: Results of a nationally representative survey

Introduction
Avoidable blindness is a significant public health problem in India. Nationally representative RAAB surveys (Rapid Assessment of Avoidable Blindness) are being conducted periodically in the country to know the current status of blindness in the country. The current study describes the findings from the RAAB survey conducted during 2015–19 in India.

Methodology
A cross-sectional, population-based survey was conducted across the entire country among persons aged 50 years and above using RAAB version 6 methodology. Presenting and pinhole visual acuity was recorded followed by lens examination using a torchlight. In order to estimate the prevalence of blindness and visual impairment in overall population in India, district weights were assigned to each of the 31 surveyed districts and the prevalence was standardized using the RAAB software.

Results
The overall weighted, age-gender standardized, prevalence of blindness (presenting visual acuity <3/60 in better eye) in population aged ≥50 years was 1.99% (95% CI 1.94%, 2.13%) and of visual impairment (VI) (presenting visual acuity <6/12 in better eye) was 26.68% (95% CI 26.57–27.17%). On multivariate analysis, adjusted odds ratio showed that blindness was associated with age ≥ 80 years (OR = 20.3, 95% CI: 15.6–26.4) and being illiterate (OR = 5.6, 95% CI: 3.6–8.9). Blindness was not found to be significantly associated with either gender or locality.

Conclusion
The results of the survey demonstrate that currently more than one fourth of persons aged 50 years and above are visually impaired (PVA<6/12 in better eye) in India. The prevalence of blindness among them is 1.99%, and older age and illiteracy are significantly associated with blindness. Major causes of blindness included cataract (66.2%), corneal opacity (CO) (8.2%), cataract surgical complications (7.2%), posterior segment disorders (5.9%) and glaucoma (5.5%). The proportion of blindness and visual impairment that is due to avoidable causes include 92.9% and 97.4% respectively.

Global Neurosurgery in the Context of Global Public Health Practice–A Literature Review of Case Studies

Neurosurgical conditions are a substantial contributor to surgical burden worldwide, with low- and middle-income countries carrying a disproportionately large part. Policy initiatives such as the National Surgical, Obstetrics and Anesthesia Plans and Comprehensive Policy Recommendations for the Management of Spina Bifida and Hydrocephalus in Low-and-Middle-Income countries have highlighted the need for an intersectoral approach, not just at the hospital level but on a large scale encompassing national public health strategies. This article aims to show through case studies how addressing this surgical burden is not limited to the clinical context but extends to public health strategies as well.

For example, vitamin B12 and folic acid are micronutrients that, if not at adequate levels, can result in debilitating neurosurgical conditions. In Ethiopia, through coalesced efforts between neurosurgeons and policy makers, the government has made strides in implementing food fortification programs at a national level to address the neurosurgical burden. Traumatic brain injuries (TBIs) are another neurosurgical burden that unevenly affects LMICs. Countries such as Colombia and India have shown the importance of legislation and enforcement, coupled with robust data collection and auditing systems; strong academic advocacy of neurosurgeons can drastically reduce TBIs.

Despite the importance of public health efforts in addressing neurosurgical conditions, there is a lack of neurosurgeon involvement in public health and lack of integration of neurosurgical burden in national health planning systems. It is imperative that neurosurgeons advocate for and are included in aspects of public health policy. Neurosurgery does not stop within the bounds of the hospital, and neither should the role of a neurosurgeons

Predictors of facility-based delivery utilization in central Ethiopia: A case-control study

Background
Improving access to maternal health services has been a priority for the health sector in low-income countries; the utilization of facility delivery services has remained low. Although Ethiopia provides free maternal health services in all public health facilities utilization of services has not been as expected.

Objective
This study examined predictors of facility delivery service utilization in central Ethiopia.

Methods
We conducted a community-based case-control study within the catchment areas of selected public health facilities in central Ethiopia. Women who delivered their last child in a health facility were considered as cases and women who delivered their last child at home were considered as controls. Data were collected using a structured questionnaire. Multivariable logistic regression analysis was used to identify independent predictors of facility delivery utilization.

Result
Facility delivery was positive and strongly associated with practicing birth preparedness and complication readiness (BPCR) (AOR = 12.3, 95%CI: 3.9, 39.1); partners’ involvement about obstetric assistance (AOR = 3.1, 95%CI: 1.0, 9.0); spending 30 or less minutes to decide on the place of delivery and 45 or less minutes to walk to health facilities (AOR = 7.4, 95%CI: 2.4, 23.2 and AOR = 8.1, 95%CI: 2.5, 26.9, respectively). Additionally, having knowledge of obstetric complication, attending ≥ 4 antenatal care (ANC) visits, birth order and the use of free ambulance service also showed significant association with facility delivery.

Conclusion
Despite the availability of free maternal services there are still many barriers to utilization of delivery services. Strengthening efforts to bring delivery services closer to home and enhancing BPCR are necessary to increase institutional delivery service utilization.

Snakebite envenoming in humanitarian crises and migration: A scoping review and the Médecins Sans Frontières experience

Snakebite envenoming is a public health concern in many countries affected by humanitarian crises. Its magnitude was recognized internationally but associations between snakebite peaks and humanitarian crises were never clearly established or analysed. This scoping review searched any available evidence of this hypothesized association between snakebite types of crises, through PubMed/Medline by two researchers. The search also included hand searching, and reports from humanitarian organizations working in this area.

The scoping review yielded 41 results. None described a robust epidemiological link or evidence of causality. There is an evidence gap regarding our research question. Several publications however point or hint towards the occurrence of snakebite outbreaks during conflict, displacement, floods, and migration of impoverished agricultural workers. Non-systematic screening yielded another 11 publications (52 in total). We found Médecins Sans Frontières routine reports showing that 6469 patients were admitted in 2019 throughout its projects in 17 countries. The impact of snakebite was the highest in four countries particularly affected by humanitarian crises, South Sudan, Ethiopia, Central African Republic, and Yemen, with some hospitals receiving more than 1000 annual admissions. Time correlations with conflict and events are shown in Figures. We found no published epidemiological data formally showing any associations between humanitarian crises and snakebite incidence. However, the search publications showing peaks during crises, and monitoring curves in four countries point towards an increased risk during humanitarian crises.

We call for urgent population-based studies and surveillance. Stakeholders should consider upgrading snakebite care and antivenom supply during humanitarian crises in snakebite-endemic countries.

Association between triage level and outcomes at Médecins Sans Frontières trauma hospital in Kunduz, Afghanistan, 2015

Background Five million people die annually due to injuries; an increasing part is due to armed conflict in low-income and middle-income countries, demanding resolute emergency trauma care. In Afghanistan, a low-income country that has experienced conflict for over 35 years, conflict related trauma is a significant public health problem. To address this, the non-governmental organisation Médecins Sans Frontières (MSF) set up a trauma centre in Kunduz (Kunduz Trauma Centre (KTC)). MSF’s standardised emergency operating procedures include the South African Triage Scale (SATS). To date, there are few studies that assess how triage levels correspond with outcome in low-resource conflict settings

Aim This study aims to assess to what extent SATS triage levels correlated to outcomes in terms of hospital admission, intensive care unit (ICU) admission and mortality for patients treated at KTC.

Method and materials This retrospective study used routinely collected data from KTC registries. A total of 17 970 patients were included. The outcomes were hospital admission, ICU admission and mortality. The explanatory variable was triage level. Covariates including age, gender and delay to arrival were used. Logistic regression was used to study the correlation between triage level and outcomes.

Results Out of all patients seeking care, 28.7% were triaged as red or orange. The overall mortality was 0.6%. In total, 90% of those that died and 79% of ICU-admitted patients were triaged as red.

Conclusion The risk of positive and negative outcomes correlated with triage level. None of the patients triaged as green died or were admitted to the ICU whereas 90% of patients who died were triaged as red.

The Impact of COVID-19 on Hospital Admissions for Twelve High-Burden Diseases and Five Common Procedures in the Philippines: A National Health Insurance Database Study 2019-2020

Background
The Philippines has the highest cumulative COVID-19 cases and deaths in the Western-Pacific. To explore the broader health impacts of the pandemic, we assessed the magnitude and duration of changes in hospital admissions for 12 high-burden diseases and the utilization of five common procedures by lockdown stringency, hospital level, and equity in patient access.

Methods
Our analysis used Philippine social health insurance data filed by 1,295 hospitals in 2019 and 2020. We calculated three descriptive statistics of percent change comparing 2020 to the same periods in 2019: (1) year-on-year, (2) same-month-prior-year, and (3) lockdown periods.

Findings
Disease admissions declined (-54%) while procedures increased (13%) in 2020 versus 2019. The increase in procedures was caused by hemodialysis surpassing its 2019 utilization levels in 2020 by 25%, overshadowing declines for C-section (-5%) and vaginal delivery (-18%). Comparing months in 2020 to the same months in 2019, the declines in admissions and procedures occurred at pandemic onset (March-April 2020), with some recovery starting May, but were generally not reversed by the end of 2020. Non-urgent procedures and respiratory diseases faced the largest declines in April 2020 versus April 2019 (range: -60% to -70%), followed by diseases requiring regular follow-up (-50% to -56%), then urgent conditions (-4% to -40%). During the strictest (April-May 2020) and relaxed (May-December 2020) lockdown periods compared to the same periods in 2019, the declines among the poorest (-21%, -39%) were three-times greater than in direct contributors (-7%, -12%) and two-times more in the south (-16%, -32%) than the richer north (-8%, -10%). Year-on-year admission declines across the 12 diseases and procedures (except for hemodialysis) was highest for level three hospitals. Compared to public hospitals, private hospitals had smaller year-on-year declines for procedures, because of increases in utilization in lower level private hospitals.

Interpretation
COVID-19’s prolonged impact on the utilization of hospital services in the Philippines suggests a looming public health crisis in countries with frail health systems. Through the periodic waves of COVID-19 and lockdowns, policymakers must employ a whole-of-health strategy considering all conditions, service delivery networks, and access for the most vulnerable.

Maternal knowledge and attitudes to childhood hearing loss and hearing services in the Pacific Islands: A cross-sectional survey protocol for urban and rural/remote Samoa

Introduction
The successful implementation of ear and hearing health services for children depends on the support and engagement of primary caregivers. The World Health Organization recommends childhood hearing screening programs for all member states to enable early detection and intervention for children with hearing loss. Ear and hearing specialists are limited in the Pacific Islands, a region with one of the highest global rates of ear disease and hearing loss. Given that a significant proportion of childhood hearing loss is preventable through public health measures, collaboration with health promotion activities is recommended to improve primary caregiver knowledge of avoidable ear and hearing disorders among infants and young children. Previous work has examined the knowledge and attitudes of parents in an urban Pacific Island settings, and this study will investigate for differences between urban and rural/remote Pacific Island populations.

Study design
Cross-sectional survey.

Methods
Questionnaire administered to mothers attending immunization clinics with their infants in urban (Apia) and rural/remote (Savai’i) Samoa. A 25-item questionnaire was formally translated from the original English into Samoan by an accredited translator in collaboration with an Ear, Nose and Throat registered nurse. It will be administered in a semi-structured interview style by a Health Promotion Officer in Samoan. The participating mothers are required to respond with ‘yes,’ ‘no,’ or ‘unsure.’ The questions assess knowledge of biomedical etiology of hearing impairment (9 questions), beliefs regarding non-biomedical etiology of hearing impairment (2 questions), knowledge of otitis media and its risk factors (5 questions), knowledge of hearing loss identification and intervention (4 questions), and attitudes towards hearing services for children (6 questions).

Results
Not applicable. Data to be collected.

Conclusion
We publish these protocols to facilitate similar studies in other Low- and Middle-Income Countries, and especially among our Pacific Island neighbours.

Road Traffic Injuries in Malawi with special focus on the role of alcohol

Driving under the influence of alcohol is one of the principal causes of road traffic crashes (RTCs) [1]. The use of alcohol is also a risk factor for other road users, such as pedestrians and bicyclists. The association of alcohol in injurious and fatal RTCs has been well documented in most high-income countries, but data for low- and middle-income countries is scarce, particularly for African countries [2]. The study was a collaborative effort between Kamuzu Central Hospital (KCH), the Norwegian Institute of Public Health (NIPH) and Oslo University Hospital (OUH), with the financial support of UK Aid through the Global Road Safety Facility (GRSF) hosted by the World Bank, the International Council on Alcohol Drugs and Traffic Safety (ICADTS) and the Norwegian Council for Road Safety (Trygg Trafikk). The objective of the study was to generate new knowledge about road traffic injuries in Malawi and the extent of traffic accidents related to alcohol use, to increase capacity to conduct alcohol testing, and develop a database for the findings, which in turn will form the basis for future policymaking to reduce traffic accidents.
The objectives were achieved through collecting data on patients who sought treatment after road traffic crashes and admitted to the Emergency Department at KCH in Lilongwe, Malawi. A questionnaire was developed for data collection in cooperation between the project groups in Norway and Malawi. The data included basic information about the patients, alcohol use before the injury, and information about accident circumstances, including types of road users and vehicles involved. Participation was voluntary and anonymous. All weekdays, weekends and nights were covered. Alcohol was measured using a breathalyzer or saliva test for those who were not able to blow. Knowledge and training of local KCH employees to perform alcohol testing and record data were an important aspect of this study.
The project was approved by the National Health Science Research Committee (NHSRC) in Malawi. The Regional Committee for Medical and Health Research Ethics in Norway was consulted, and their conclusion was that no formal application was needed, with reference to the Norwegian Health Research Act Section, §2 and 4a. A Data Protection Impact Assessment was performed as required by NIPH. There were 1251 patients in the study, representing nearly 95 per cent of those who were asked to participate. The results show a rather high prevalence of alcohol use among several injured road user groups (totally about 25 percent), particularly among those injured during weekend nights and evenings, but also during weekday evenings and nights. It was estimated that about 15 per cent of injured motor vehicle drivers and riders had BACs above the legal limit of 0.8 grams/L at the time of the crash. The findings also show that it is important to focus on bus/minibus/lorry drivers who often carry passengers, where about one out of five tested positive for alcohol. It is worth noting that pedestrians had the highest prevalence of alcohol use before being injured. They constitute a vulnerable group; they often walk in the dark with no road lighting, no pavements, walkways or safe places to cross
the road. Combined with alcohol use their injury risk is even higher. The collected data can contribute to future road traffic safety procedures and measures. The long-term goal is to contribute to sustainable development goal 3, target 3.6, to reduce by half the number of global RTC deaths and injuries. Road Traffic Inuries in Malawi • Norwegian Institute of Public Health This study shows the importance of collecting adequate and relevant data for health authorities particularly in low- and middle-income countries in battling the challenge of alcohol-related road traffic crashes, deaths and injuries. Due to the COVID-19 pandemic, a
number of recommendations were presented to Malawian authorities at a virtual seminar held in autumn 2020.

Timeliness of diagnosis of breast and cervical cancers and associated factors in low-income and middle-income countries: a scoping review protocol

Introduction
Breast and cervical cancer are leading causes of morbidity and mortality in women globally, with disproportionately high burdens in low-income and middle-income countries (LMICs). While the incidence of both cancers increases across LMICs, many cases continue to go undiagnosed or diagnosed late. The aim of this review is to comprehensively map the current evidence on the time to breast or cervical cancer diagnosis and its associated factors in LMICs.

Methods and analysis
This scoping review (ScR) will be informed by Arksey and O’Malley’s enhanced ScR methodology framework. It will be reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. We will conduct a comprehensive search of the following electronic databases: MEDLINE (via PubMed), Cochrane Library, Scopus and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Two reviewers will independently screen all abstracts and full texts using predefined inclusion criteria. All publications describing the time to diagnosis and its associated factors in the contexts of breast or cervical cancer will be considered for inclusion. Evidence will be narratively synthesised and analysed using a predefined conceptual framework.

Ethics and dissemination
As this is a ScR of publicly available data, with no primary data collection, it will not require ethical approval. Findings will be disseminated widely through a peer-reviewed publication and forums such as conferences and community engagement sessions. This review will provide a user-friendly evidence summary for understanding the enormity of diagnostic delays and associated factors for breast and cervical cancers in LMICs, while helping to inform policy actions and implementation of interventions for addressing such delays.