Two decades of Tanzanian health policy

Tanzania has undertaken important health sector reforms in the new millennium, and the most recent Health Sector Strategic Plan (2021–26) lays out ambitious targets to achieve universal health coverage. Yet, women in Tanzania continue to face significant barriers in accessing healthcare and the country is grappling with important gender-biased health challenges disadvantaging women. The aims of this paper are two-fold. First, we examine the evolution of Tanzania’s health policy over the past two decades (2000–21) from the perspective of enhancing financial protection for working-age women. Second, we explore policy options for genderresponsive health insurance expansion in the context of Tanzania. Methodologically, the paper draws on a scoping study of diverse literature and data and a review of evidence from other contexts with public health insurance schemes. We find that Tanzania has a fragmented health system that relies on several independent schemes introduced throughout the years, characterized by insufficient risk-pooling. Such a system provides insufficient financial protection for workingage women and female-headed households, which are financially less secure than dual-earner households. Although expanding health insurance coverage represents a viable corrective measure, future reforms must account for women’s lower financial contribution capacity to enable equitable access. Additionally, the policy design requires gender-mainstreamed investments in awarenessraising, service quality, and benefit packages

Too many yet too few caesarean section deliveries in Bangladesh: Evidence from Bangladesh Demographic and Health Surveys data

Caesarean section (CS) use is rising rapidly in Bangladesh, though lack of CS use remains common among disadvantage women. This increases risks of long-term obstetric complications as well as maternal and child deaths among disadvantage women. We aimed to determine the interaction effects of women’s disadvantage characteristics on CS use in Bangladesh. For this we have analysed a total of 27,093 women’s data extracted from five rounds of Bangladesh Demographic and Health Survey conducted during 2004 and 2017/18. The outcome variable was CS use, coded as use (1) and non-use (0). The major exposure variables were individual level, household level, and community level characteristics. Multilevel logistic regression model was used to determine association of CS use with socio-demographic characteristics and the interactions of three variables: working status, wealth quintile, and place of residence. We found a 751% increase of CS use over the last 13 years—from 3.88% in 2004 to 33% in 2017/18. Nearly, 80% of the total CS operation occurred in the private health facilities followed by the government health facilities (15%). Women living in rural areas with no engagement in formal income generating activities showed a 11% (OR, 0.89, 95% CI, 0.71–0.99) lower use of CS in 2004. This association was further strengthened over time, and a 51% (OR, 0.49, 0.03–0.65) lower in CS use was reported in 2017/18. Similarly, around 12%-83% lower likelihoods of CS use were found among rural poor and poorer women. These indicate Bangladesh is facing a double burden of CS use, that is a group of women with improved socio-economic condition are using this life saving procedure without medical necessity while their counterpart of disadvantage characteristics could not access the service. Improved monitoring from the government along with support to use CS services for the disadvantage groups on necessity are important.

Inspirational Women in Surgery: Dr. Olive Kobusingye, Uganda

Dr. Olive Kobusingye has spent her career taking on an enormous challenge—improving trauma care in Uganda, in Africa, and worldwide. She was born in a village in southwestern Uganda, 5th in a family of six children. Her mother was a teacher and her father was a policeman and later a trader in agricultural produce. Both of her parents died young—her father when she was five and her mother when she was eleven. She went to all-girls missionary boarding schools until university. Her first ambition was to be an engineer, but she was talked out of it by her elder brother who was then at medical school. He told her that at Makerere University women did not do well in engineering no matter how bright they were. Medicine was her second choice.

Once at Makerere, she at first thought of going into forensic pathology and then psychiatry, but neither really caught her attention. Surgery was different. She saw patients brought in half dead and revived within a few hours of intervention. Her five years at medical school coincided with the five years that the National Resistance Army fought a civil war that left more than half a million Ugandans dead. She saw many victims of the war during her training. She did a rotating internship at Machakos General Hospital, in Kenya, to experience medicine in a more stable environment. It was here that she decided to pursue a career in surgery. Dr. Mohamad Alkama was head of surgery, and it was a joy to scrub for him. His operating lists included a great variety of surgeries, ranging from neurosurgery, orthopedics, general surgery and pediatric surgery. He did all of them with a positive attitude, always giving interns opportunities for hands-on experience during the surgery.

Two years later she returned to Uganda to begin her surgical residency and found that medical services were still quite poor. Shortages were a constant frustration—shortage of almost everything—sutures, equipment, anaesthesia, medicines, lab reagents. To compound the problem, AIDS was ravaging the country, putting medical workers at great risk. But, she felt herself very fortunate to have excellent surgeons as her teachers, especially Prof. JC Ssali who was her immediate supervisor, and who turned out to be a quieter, older version of Dr. Alkama.

Later when she decided to focus on accident & emergency surgery, the shortages did not let up, yet her patients could not wait for relatives to go and sell household property to buy medical supplies. The cost of mismanaged medical services in terms of lives needlessly lost was always “in her face”—especially the year she spent as the Acting Head of the Accident & Emergency at Mulago Hospital, the main hospital in the country. Frustrated at the many needless injuries, especially from road traffic crashes, she decided to take on trauma care and injury prevention as the focus of her career.

Over the ensuing two decades, she has been a major force in promoting both trauma care and injury prevention in low- and middle-income countries (LMICs) globally. She founded the Injury Prevention Center at Makere University, one of the first academic injury prevention centers in Africa. Her research addressed straightforward ways to improve care for the injured in LMICs, something that she realized was possible, despite the extreme resource limitations. A major scientific contribution was her development of the Kampala Trauma Score (KTS), a simple way to risk-adjust injured patients, especially in locations where it would be difficult and time consuming to use the more complex scales used in high-income countries. The KTS is now used around the world. She also co-developed a training course for teams working in emergency units—the Trauma Team Training course. She has looked for ways to improve trauma care broadly in many countries, spending 5 years as the WHO Regional Adviser on Injury for Africa, based in Brazzaville, Congo, providing input on trauma care to 46 African countries.

She has always had an ability to see beyond the immediate problems, to the bigger issues that hamper care in places like Uganda. She states: “In trauma, patients are still getting debilitating osteomyelitis because there is not enough saline to do a decent debridement. Patients are dying for lack of a chest tube. These problems are not for ‘the surgical community’ to resolve. They are political problems. Perhaps the surgical community needs to begin addressing upstream factors which make our practice of surgery an impossible task.” This has led her to write two books addressing such bigger factors, in medical care overall and in politics [1, 2].

Despite the numerous frustrations in her work, she maintains a hopeful outlook. “I did not foresee it back then, but the thing I am most proud of now is having spent time with students. Having taken the time to show younger doctors how to do procedures that truly mattered to patients’ recovery. Even with severe shortages, there is always something we can offer patients. Good listening and a thorough exam. Gadgets are great, and if one has them, they should definitely use them to the max, but nothing seems to be able to replace good clinical acumen yet.”

A systematic review of randomized control trials of HPV self-collection studies among women in sub-Saharan Africa using the RE-AIM framework

Introduction
Self-collection of samples for HPV testing may increase women’s access to cervical cancer screening in low- and middle-income settings. However, implementation remains poor in many regions. The purpose of this systematic review was to examine implementation data from randomized controlled trials evaluating human papillomavirus (HPV) self-collection testing among women in sub-Saharan Africa using the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance) framework.

Methods
We searched four electronic databases (PubMed, CINAHL, Web of Science, and Global Health) for pragmatic randomized controlled trials that promote HPV self-collection among women in sub-Saharan Africa. Study selection and data extraction were conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) checklist. Two researchers independently extracted information from each article using a RE-AIM data extraction tool. The reporting of RE-AIM dimensions was summarized and synthesized across included interventions.

Results
We identified 2008 citations, and eight studies were included. These reported on five unique interventions. The five interventions were conducted in five countries: Cameroon, Ethiopia, Kenya, Nigeria, and Uganda. Intervention reach (80%) was the most commonly reported RE-AIM dimension, followed by adoption (56%), efficacy/effectiveness (52%), implementation (47%), and maintenance (0%). All the interventions described increased uptake of HPV testing among study participants (effectiveness). However, the majority of the studies focused on reporting internal validity indicators such as inclusion criteria (100%) and exclusion criteria (100%), and few reported on external validity indicators such as participation rate (40%), intervention cost (40%), staff selection (20%), and cost of maintenance (0%).

Conclusions
Our review highlights the under-reporting of external validity indicators such as participation rate, intervention, and maintenance costs in studies of self-collection for HPV testing among women in SSA. Future research should focus on including factors that highlight internal validity factors and external validity factors to develop a greater understanding of ways to increase not only reach but also implementation and long-term maintenance of these interventions. Such data may advance the translation of HPV interventions into practice and reduce health disparities in SSA. Findings highlight the need for innovative tools such as participatory learning approaches or open challenges to expand knowledge and assessment of external validity indicators to ultimately increase the uptake of HPV testing among women in SSA.

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

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

Communication Intervention Using Digital Technology to Facilitate Informed Choices at Childbirth in the Context of the COVID-19 Pandemic: Protocol for a Randomized Controlled Trial

Background:
In Brazil and other low- and middle-income countries, excess interventions in childbirth are associated with an increase in preterm and early-term births, contributing to stagnant morbidity and mortality of mothers and neonates. The fact that women often report a negative experience with vaginal childbirth, with physical pain and feelings of unsafety, neglect, or abuse, may explain the high acceptability of elective cesarean sections. The recognition of information needs and of the right to informed choice during childbirth can help change this reality. The internet has been the main source of health information, but its quality is highly variable.

Objective:
This study aimed to develop and evaluate an information and communication strategy through a smartphone app with respect to childbirth, to facilitate informed choices for access to safer and evidence-based care in the context of the COVID-19 pandemic.

Methods:
A randomized controlled trial, with 2 arms (intervention and control) and a closed, blind, parallel design, will be conducted with a smartphone app designed for behavior and opinion research in Brazil, with women of reproductive age previously registered on the app. After completing an entry questionnaire to verify the eligibility criteria and obtaining ethical consent, approximately 20,000 participants will be randomly allocated to the intervention and control groups at a 1:1 ratio. Participants allocated to the intervention group will be invited to engage in a digital information and communication strategy, which is designed to expand evidence-based knowledge on the advantages and disadvantages of options for labor and childbirth and the safety of the care processes. The information is based on the guidelines of the Ministry of Health and the World Health Organization for a positive childbirth experience and has been updated to include the new challenges and disruptions in maternity care within the context of the COVID-19 pandemic. The control group will receive information regarding disposable and reusable diapers as a placebo intervention. The groups will be compared in their responses in generating the birth plan and the entry and exit questionnaires, regarding responses less or more aligned with the guidelines for a positive childbirth experience. A qualitative component to map information needs is included.

Results:
The digital trial started recruiting participants in late October 2020, and data collection has been projected to be complete by December 2020.

Conclusions:
This study will evaluate an innovative intervention that has the potential to promote better communication between women and providers, such that they can make better choices using an approach suitable for use during the COVID-19 pandemic

Women neurosurgeons around the world: a systematic review

OBJECTIVE
Gender disparities in neurosurgery have persisted even as the number of female medical students in many countries has risen. An understanding of the current gender distribution of neurosurgeons around the world and the possible factors contributing to country-specific gender disparities is an important step in improving gender equity in the field.

METHODS
The authors performed a systematic review of studies pertaining to women in neurosurgery. Papers listed in PubMed in the English language were collected. A modified grounded theory approach was utilized to systematically identify and code factors noted to contribute to gender disparities in neurosurgery. Statistical analysis was performed with IBM SPSS Statistics for Windows.

RESULTS
The authors identified 39 studies describing the density of women neurosurgeons in particular regions, 18 of which documented the proportion of practicing female neurosurgeons in a single or in multiple countries. The majority of these studies were published within the last 5 years. Eight factors contributing to gender disparity were identified, including conference representation, the proverbial glass ceiling, lifestyle, mentoring, discrimination, interest, salary, and physical burden.

CONCLUSIONS
The topic of women in neurosurgery has received considerable global scholarly attention. The worldwide proportion of female neurosurgeons varies by region and country. Mentorship was the most frequently cited factor contributing to noted gender differences, with lifestyle, the glass ceiling, and discrimination also frequently mentioned. Future studies are necessary to assess the influence of country-specific sociopolitical factors that push and pull individuals of all backgrounds to enter this field.

The Cervical Cancer (CC) Epidemiology and Human Papillomavirus (HPV) in the Middle East

Viral infections contribute 15–20 percent of all human cancers as a cause. Oncogenic virus infection may spur various stages of carcinogenesis. For several forms for HPV, about 15 associated with cancer. Following successful test techniques, cervical cancer remains a significant public health issue. Prevalence and mortality of per geographic area of cervical cancer were vastly different. The fourth most common cause of death from cancer among women is cervical cancer (CC). Human papillomavirus (HPV) infection in the cervix is the most significant risk factor for forming cervical cancer. Inflammation is a host-driven defensive technique that works rapidly to stimulate the innate immune response against pathogens such as viral infections. Inflammation is advantageous if it is brief and well-controlled; however, it can cause adverse effects if the inflammation is prolonged or is chronic in duration. HPV proteins are involved in the production of chronic inflammation, both directly and indirectly. Also, the age-specific prevalence of HPV differs significantly. Two peaks of HPV positive in younger and older people have seen in various populations. A variety of research has performed worldwide on the epidemiology of HPV infection and oncogenic properties due to specific HPV genotypes. Nevertheless, there are still several countries where population-dependent incidences have not yet identified. Additionally, the methods of screening for cervical cancer differ among countries.

Barriers to Women Entering Surgical Careers: A Global Study into Medical Student Perceptions

Background: Barriers to female surgeons entering the field are well documented in Australia, the USA and the UK, but how generalizable these problems are to other regions remains unknown.

Methods: A cross-sectional survey was developed by the International Federation of Medical Students’ Associations (IFMSA)’s Global Surgery Working Group assessing medical students’ desire to pursue a surgical career at different stages of their medical degree. The questionnaire also included questions on students’ perceptions of their education, resources and professional life. The survey was distributed via IFMSA mailing lists, conferences and social media. Univariate analysis was performed, and statistically significant exposures were added to a multivariate model. This model was then tested in male and female medical students, before a further subset analysis by country World Bank income strata.

Results: 639 medical students from 75 countries completed the survey. Mentorship [OR 3.42 (CI 2.29-5.12) p = 0.00], the acute element of the surgical specialties [OR 2.22 (CI 1.49-3.29) p = 0.00], academic competitiveness [OR 1.61 (CI 1.07-2.42) p = 0.02] and being from a high or upper-middle-income country (HIC and UMIC) [OR 1.56 (CI 1.021-2.369) p = 0.04] all increased likelihood to be considering a surgical career, whereas perceived access to postgraduate training [OR 0.63 (CI 0.417-0.943) p = 0.03], increased year of study [OR 0.68 (CI 0.57-0.81) p = 0.00] and perceived heavy workload [OR 0.47 (CI 0.31-0.73) p = 0.00] all decreased likelihood to consider a surgical career. Perceived quality of surgical teaching and quality of surgical services in country overall did not affect students’ decision to pursue surgery. On subset analysis, perceived poor access to postgraduate training made women 60% less likely to consider a surgical career [OR 0.381 (CI 0.217-0.671) p = 0.00], whilst not showing an effect in the men [OR 1.13 (CI 0.61-2.12) p = 0.70. Concerns about high cost of training halve the likelihood of students from low and low-middle-income countries (LICs and LMICs) considering a surgical career [OR 0.45 (CI 0.25-0.82) p = 0.00] whilst not demonstrating a significant relationship in HIC or UMIC countries. Women from LICs and LMICs were 40% less likely to consider surgical careers than men, when controlling for other factors [OR 0.59 CI (0.342-1.01 p = 0.053].

Conclusion: Perceived poor access to postgraduate training and heavy workload dissuade students worldwide from considering surgical careers. Postgraduate training in particular appears to be most significant for women and cost of training an additional factor in both women and men from LMICs and LICs. Mentorship remains an important and modifiable factor in influencing student’s decision to pursue surgery. Quality of surgical education showed no effect on student decision-making.

Not just numbers: beyond counting caesarean deliveries to understanding their determinants in Ghana using a population based cross-sectional study

Background
The increasing rate of caesarean deliveries (CD) has become a serious concern for public health experts globally. Despite this health concern, research on factors associated CD in many low- and -middle countries like Ghana is sparse. This study, therefore, assessed the prevalence and determinants of CD among child-bearing women aged 15–49  in Ghana.

Methods
The study used data from the 2014 Ghana Demographic and Health Survey. The analysis was limited to mothers (n = 2742) aged 15–49 , who had given birth in health facilities 5 years preceding the survey. Association between CD and its determinants was assessed by calculating adjusted odds ratios (AOR) with their respective 95% confidence intervals using a binary logistic regression.

Results
The percentage of mothers who delivered their babies through caesarean section (CS) was 18.5%. Using multivariable logistic regression, the results showed that women aged 45–49 (AOR = 10.5; 95% CI: 3.0–37.4), and women from a household that are headed by a female (AOR = 1.3; 95% CI = 1.1–1.7) had higher odds to deliver through CS. Women from the Upper East (AOR =0.4; 95% CI = 0.2–0.7) and Upper West (AOR = 0.4; 95% CI = 0.2–0.8) regions had lower odds to deliver their children through CS. Women with parity 4 or more (AOR = 0.3; 95% CI = 0.2–0.5) had lower odds of CD compared to those with parity 1. Women with female babies had lower odds (AOR = 0.8; CI = 0.7–0.9) of delivering them through CS compared to those with male children.

Conclusion
The percentage of women delivering babies through the CS in Ghana is high. The high rates of CD noted do not essentially indicate good quality care or services. Hence, health facilities offering this medical protocol need to adopt comprehensive and strict measures to ensure detailed medical justifications by doctors for performing these caesarean surgeries.