Health policy in low- and middle-income countries

Background:
Global climate change poses grave risks to population health, especially in low- and middle-income countries (LMICs). It both threatens the sustainability of nascent epidemiological transitions and raises prospects for counter-transitions driven by indirect climate impacts on mortality—such as those from reemerging infectious diseases—and by direct impacts of extreme climatic events.

Objective:
We investigate how the relationship between climate and mortality has changed as Antananarivo, Madagascar, progressed through the stages of the epidemiological transition, focusing on enteric infection mortality in children under five.

Methods:
Using death registration, precipitation, and temperature time-series data spanning over four decades, we model the climate–cause-specific mortality relationships during each stage of the epidemiological transition using generalized additive models.

Conclusions:
While childhood enteric infection mortality has become less sensitive to low rainfall and higher temperatures, it has become more sensitive to heavy rainfall. Mortality from other causes has also become less sensitive to high temperatures but has become slightly more sensitive to heavy rainfall while significantly more sensitive to low temperatures.

Contribution:
This is the first multidecade climate–mortality study of a city in sub-Saharan Africa outside of South Africa.

Introduction Obesity increases the risk of comorbidities and diabetes-related complications and, consequently, efforts to prevent and reduce excess weight in people with type 1 diabetes are essential. The aim of this systematic review and network meta-analysis is to assess the effect of adjunctive glucose-lowering drugs on body weight and other important health outcomes in people with type 1 diabetes. Methods and analysis This systematic review and network meta-analysis will include randomised controlled trials (RCTs) evaluating the use of adjunctive glucoselowering drugs for treatment of people with type 1 diabetes. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ClinicalTrials. gov and WHO International Clinical Trials Registry Platform will be searched from inception to present. Key eligibility criteria include: RCT study design; adult participants with type 1 diabetes; treatment with a glucose-lowering drug for ≥24 weeks; and comparison of the intervention to placebo, usual care or another glucoselowering drug. The primary outcome is change in body weight. Other major outcomes include change in HbA1c and total daily insulin dose and risk of hypoglycaemia and other adverse events. Dual study selection, data extraction and risk of bias assessment will be performed. Results from the meta-analysis will be presented as weighted mean differences for continuous outcomes and risk ratios for dichotomous outcomes. Sources of heterogeneity will be explored by subgroup and sensitivity analysis. A network meta-analysis for the primary outcome will be performed using an arm-based random-effects model based on the Bayesian framework while assessing for transitivity across studies and consistency between direct and indirect estimates. The overall quality of the evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach for each outcome. Ethics and dissemination No ethical assessment is required. The results of this review will be disseminated through peer-reviewed publication and conference presentation. PROSPERO registration number CRD42020158676

Gram-negative bacteria (GNB) are a major cause of neonatal sepsis in low-and middle-income countries (LMICs). Although the World Health Organization (WHO) reports that over 80% of these sepsis deaths could be prevented through improved treatment, the efficacy of the currently recommended firstand second-line treatment regimens for this condition is increasingly affected by high rates of drug resistance. Here we assess three well known antibiotics, fosfomycin, flomoxef and amikacin, in combination as potential antibiotic treatment regimens by investigating the drug resistance and genetic profiles of commonly isolated GNB causing neonatal sepsis in LMICs. The five most prevalent bacterial isolates in the NeoOBS study (NCT03721302) are Klebsiella pneumoniae, Acinetobacter baumannii, E. coli, Serratia marcescens and Enterobacter cloacae complex. Among these isolates, high levels of ESBL and carbapenemase encoding genes are detected along with resistance to ampicillin, gentamicin and cefotaxime, the current WHO recommended empiric regimens. The three new combinations show excellent in vitro activity against ESBL-producing K. pneumoniae and E. coli isolates. Our data should further inform and support the clinical evaluation of these three antibiotic combinations for the treatment of neonatal sepsis in areas with high rates of multidrugresistant Gram-negative bacteria.

Objective The primary objective was to evaluate factors influencing the cost of a 'hospital at home' (HAH) for geriatric patients in a Northeastern Mexican hospital. Secondarily to evaluate the per capita global costeffectiveness compared with traditional hospital care. Design This retrospective analysis examined the costs incurred by geriatric patients in an HAH programme from February to December 2022 Setting We collected data from clinical records and assessed medication and procedure costs through the hospital's financial department. Costs for traditionally hospitalised patients were reviewed for comparison. Participants Subjects of both genders aged 70 and older who were treated in HAH during 2022 and hospitalised subjects with the same age and gender treated in the same period. Intervention: NA Primary and secondary outcome measures Primary outcome: factors that influence costs in HAH. Secondary, global per capita cost comparison between HAH and hospital care. Results We examined the expenses associated with 416 home visits to 49 patients in the HAH programme. The main factors influencing the programme's overall cost were medical care and procedure-related disorders (β=0.333, p=0.002), sleep-regulators (β=0.561, p<0.001), laxatives (β=0.330, p=0.001) and anticoagulants (β=0.228, p=0.025). The HAH programme's per capita cost was three times lower compared with that of traditional hospital care and resulted in a 40% reduction in hospitalisation days. Conclusions This study highlights that the main factors influencing the HAH programme's costs include medical care and procedure-related disorders, as well as medication extensively used in the elderly population. Additionally, we demonstrated the cost-effectiveness of the HAH programme, which produces substantial savings and is a financially viable alternative to traditional hospital care.

Since 2005, health insurance (HI) coverage in India has significantly increased, largely because of the introduction of government-funded pro-poor insurance programs. As a result, the determinants of HI enrollment and their relative importance may have changed. Using National Family Health Survey (NFHS)-4 data, collected in 2015–2016, and employing a Probit regression model, we re-examine the determinants of household HI enrollment. Then, using a multinomial logistic regression model, we estimate the relative risk ratio for enrollment in different HI schemes. In comparison to the results on the determinants of HI enrollment using the NFHS data collected in 2005–2006, we find a decrease in the wealth gap in public HI enrollment. Nonetheless, disparities in enrollment remain, with some changes in those patterns. Households with low assets have lower enrollments in private and community-based health insurance (CBHI) programs. Households with a higher number of dependents have a higher ...

Psychodynamic psychiatry remains a challenging subject to teach in underserved areas, where enthusiasm to learn is substantial. Besides logistical and psychiatric workforce shortcomings, sensible cultural adaptations to make psychodynamic psychiatry relevant outside of high-income countries require creative effort. Innovative pedagogical methods that include carefully crafted mentoring and incorporate videoconferencing in combination with site visits can be implemented through international collaborations. Emphasis on mentoring is essential to adequately train future psychodynamic psychotherapy supervisors. Examples of World Psychiatric Association initiatives in countries such as Indonesia, Iran, Malaysia, and Thailand are presented as possible models to emulate elsewhere.

Aim: One of the causes for lower cure rates in acute childhood leukemia in low-and middle-income countries (LMIC) compared to high-income countries is abandonment from treatment. The International Society of Pediatric Oncology (SIOP) defines abandonment as failure to begin treatment or an absence of 4 weeks during treatment. The aim of this study was to evaluate the extent of abandonment among patients diagnosed with acute myeloid leukemia (AML) at the pediatric ward at a low-resource cancer center in India. Methods: Medical records of all patients, aged 0-15 years, diagnosed with AML between January 1, 2014, and March 31, 2015, at the hospital were reviewed. Age, sex, date of diagnosis, and survival during the short follow-up time after completed treatment and information regarding abandonment were collected. SIOP definition of abandonment was used. Eight patients were diagnosed with AML at the hospital whereof 65 met the inclusion criteria of this study. Results: Of the included 65 patients, 6 died before treatment could be initiated and 3 were referred to palliative care upfront. Thus, 56 patients were offered curatively intended treatment. Of these patients, six refused treatment at this stage and another five abandoned during therapy. Altogether, 11 children abandoned treatment. Conclusion: In this study, the abandonment rate from treatment of childhood AML was 20%, which is in concordance from other studies conducted in India and other LMIC, stating that abandonment is a problem and hindrance when treating with a curative intent.

Abstract
INTRODUCTION
Alzheimer's disease is an increasingly critical public health concern in aging populations. Characterized by progressive impairments, it can lead to dementia and significant dependence on family caregivers, who often face cognitive and behavioral challenges and heightened health risks. The study investigates the demands and unmet needs of these family caregivers using an electronic data-capture approach.

METHODS
This observational, descriptive, cross-sectional study was conducted in Brazil from February 2022 to January 2023. Non-professional dementia caregivers were surveyed through asynchronous digital data collection. A novel, context-specific questionnaire developed by an interdisciplinary expert group was administered, and a subset of randomly selected caregivers participated in focused interviews to enhance data quality.

RESULTS
Of 711 potential participants screened, 381 completed the questionnaire (53% response rate). Among them, 311 (82%) identified as non-professional caregivers. The results indicate that these caregivers often feel unprepared (46%), may have a negative self-perception of their role (39%), but also may feel rewarded with being a caregiver (44%). The primary needs expressed included additional assistance from others (87%) and emotional support (62%).

DISCUSSION
Findings indicate that care responsibilities were predominantly assumed by middle-aged female relatives, primarily in unpaid roles, with many providing more than 8 hours of direct care daily. A substantial proportion left their jobs to fulfill caregiving duties, underscoring the urgency of implementing policies that address the extensive needs of individuals with dementia and their caregivers. Given the complexity of dementia, public policies should be informed by rigorous situational analysis and delivered through targeted social, health, and educational programs that equip caregivers with effective management strategies and technologies while enhancing personalized emotional support systems.

HIGHLIGHTS
- Lack of preparedness: Brazilian family caregivers often feel unprepared for their responsibilities (33%), which may lead to negative self-satisfaction with their role as caregivers (38%).
- Employment impact: Nearly half of the respondents (43%) had to quit their jobs to take on caregiving responsibilities, and the vast majority (95%) did so without receiving any monetary compensation.
- Need for support: Major complaints from family caregivers include an often unmet need for help from others (57%) and the emotionally tiring routine of caregiving (85%).
- Duration of caregiving: The length of caregiving varied among participants, with 25% providing care for over 6 years. This highlights the long-term commitment often required in dementia cases.

Background: Cervical cancer is a major reason for morbidity and mortality in Low and Middle income countries. The National Programme for Prevention and Control of Cancers, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) sets out broad national guideline to implement Cervical cancer screening. However, an implementation strategy for cervical cancer screening is not in place for districts. Although opportunistic screening takes place, implementation is hindered by psychological and physical barriers for women, as well as insufficient capacity on the part of implementers. This qualitative study aims to identify the specific barriers that prevent the uptake of cervical cancer screening. Methods: Women who could benefit from cervical cancer program were interviewed to explore the factors that influenced their uptake of the cervical screening offered. Key informant interviews were conducted with implementers of the NPCDCS and with public health staff of three States (Himachal Pradesh, Meghalaya and Karnataka), to understand their perception of determinants of the utilization of screening services. Results: The general health concern among the participants was low, and routine check-ups were considered unimportant. Poor knowledge about cervical cancer, benefits of screening service availability, as well as a general sense of well-being, embarrassment or anxiety related to the screening procedure, fear of being judged for lack of modesty, and stigma were common barriers to screening uptake. In addition to a general unawareness of cervical cancer geographical inaccessibility of screening as a barrier to participate in cervical cancer screening, in certain regions. Conclusion: It is essential to increase the knowledge on cervical cancer and on the benefits of screening among Indian women. Providing information and cues to action by health workers and professionals can facilitate the decision to participate. Implementers need to be involved to ensure context specific implementation of the National programme to overcome these barriers.

Background: Itinerant migrants, particularly women and adolescent girls, are increasingly a significant category in West Africa due to climate change and political instability. This has led to a surge in cross-border migration into Ghana, potentially impacting their access to prenatal care. However, cultural and personal factors make female itinerant migrants (FIMs) less privileged and constrained in access to maternal care in Ghana. A lot of research has been conducted into female itinerant trade and retail businesses and the business environment, yet little is known about maternal healthcare services utilisation among FIMs in Ghana, with specific focus on antenatal care (ANC). Knowledge about the complexities around maternal care uptake among FIMs is important for policy and programming. Objective: We aimed to understand the factors faced by female itinerant migrants (also known as "Zabarima") in receiving health facility antenatal care in Wa municipality, Ghana. Methods: This was a qualitative exploratory study, involving 66 participants of 51 female itinerant migrants (FIMs), and 15 midwives. Of the total number of FIMs, 19 participated in both individual in-depth interviews and two focus group discussions. Participants were purposively selected to provide relevant data for the study. Written informed consent was obtained from all participants. Interviews and focus group discussions were audio-taped and transcribed. Transcripts were validated and coded using Mural and Dedoose qualitative analytical software/platforms. Based on Thaddeus and Maine's conceptualisation of the "three-delay" model, a consistent framework was created and applied to the data analysis. To develop themes around the "third delay," we used deductive coding. Both manual and computer coding were applied. We conducted both content and thematic analysis of the data. Results: From the iteration of the data together with priori codes relative to the "third delay" of the three-delay model, four broad themes emerged: "educational and ANC literacy of FIMs", "language barrier between provider and FIMs", "provider attitude and maltreatment of FIMs", and "discrimination and stigma". This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

More than one million people die every year in India due to tobacco use and in Australia it accounts for more than 8% of total disease and injury Considering the huge death, disease and injury burden of tobacco, the global community, under the auspices of the World Health Organization (WHO), adopted the Framework Convention on Tobacco Control (FCTC). Both the Indian and Australian Governments played constructive and leading roles in FCTC negotiations, supporting a strong and robust Treaty that incorporated effective evidence based tobacco control measures for reducing demand and supply of tobacco. Following the adoption of the Treaty, both India and Australia adopted stronger tobacco control regulations, but there are numerous instances where the tobacco industry posed hindrances in implementing effective and evidence-based tobacco control measures. These included violation of advertising bans and using tobacco packages as parallel marketing strategies. In order to alleviate tobacco industry interference and reduce the promotional function of packaging, several countries including New Zealand, Canada and the United Kingdom discussed, debated and planned introduction of plain packaging of tobacco products. However, Australia led the world by introducing plain packaging of tobacco products in 2011 -under legislation that prohibits the use of logos, colours, brand images or promotional information on tobacco product packaging. India occupies a unique position in tobacco control as the second largest producer and consumer of tobacco products in the world. The huge burden of tobacco use in India, aggressive marketing of tobacco products targeted to youth, and a delay in the introduction of large and strong pictorial health warnings merit advocacy for plain packaging of tobacco products in India as well. In recognition of this, the Australia India Institute (AII) supported the constitution of a Taskforce to examine the feasibility of introducing plain packaging in India. The Taskforce, comprising of many key tobacco control experts from both countries, has been instrumental in compiling the latest evidence and existing legislative and policy frameworks to support adoption of this strong tobacco control measure in India. It has been invaluable to have this joint Australia-India Taskforce to utilise the expertise and experience from Australia in plain packaging. In India we are confident that we have the key partners involved in facilitating this process and developing a policy that is appropriate and effective in this context. This Policy Document, developed by the Taskforce over a period of six months, includes comprehensive literature on plain packaging and highlights the challenges faced by Australia in introducing and standing firm on implementation of plain packaging. It aims to allay the concerns and myths about plain packaging, especially related to international and bilateral trade agreements. To substantiate the policy recommendations and future pathways on adoption of plain packaging in India, the AII also commissioned market research that lends substantial support, across demographic groups and key stakeholders, in favour of the plain packaging of tobacco products in India.

Background: Patient safety is an essential element for delivering quality of healthcare. Many studies focus on measuring patient safety from the healthcare provider's perspective to improve patient safety in healthcare facilities. However, patient participation may reduce medical errors and improve patient safety by providing information regarding the safety of their care. This study aimed to evaluate patient safety from the inpatients' perspective and the extent of the influence of the sociodemographic factors on their assessment.

Chest trauma is one of the most common surgical conditions seen in our teaching hospital at the University of Botswana and in the southern African region. [1] Therefore, intercostal chest drain (ICD) insertion is regarded as a core skill in the medical curriculum. During surgical rotations and assessments we observed varying exposure of students to surgical conditions, despite the high surgical disease burden, and also varying levels of competence in managing chest injuries. Simulation-based training plays a significant role in current surgical training practice, [2] and we hypothesised that chest trauma management, knowledge and skills may be improved by employing low-cost task trainers. Simulation describes a full-range use of physical objects (task trainers) or situations for mimicking real-life scenarios or functions during training. It plays a significant role in current health professions education, and was introduced to address the decreasing exposure to real patients in surgery [2,3] and improve teaching and assessment in medicine. [4] Simulation-based training and its assessment for both cognitive and psychomotor learning domains have been studied extensively. [5] This study employs a pre-and post-test design [6] to assess an educational intervention based on the Kirkpatrick evaluation model for training. [7] The Kirkpatrick model defines four evaluation levels. Levels 1 and 2 evaluate short-term outcomes, such as acceptability and change in level of knowledge and skills, while levels 3 and 4 evaluate behavioural change associated with training and the organisation's ultimate gain. We hypothesised that chest trauma management, knowledge and skills may be improved by employing simulation in the form of locally made lowcost task trainers. The overall purpose of this pilot study was to improve management of chest trauma. We included simulation in the previously theory-based chest trauma training module and thereafter tested trainees' knowledge and skills with regard to the effectiveness of the intervention. We also tested acceptance of this new simulation-based module. Methods Research setting The study was conducted at the University of Botswana's new Faculty of Medicine, where the competence-based curriculum employs a problembased learning approach and traditional patient encounters. Research design This study employed a quantitative pre-and post-test design. Population and sampling All medical students (n=41) were invited to take part in the study after their last surgical rotation and newer intern doctors (n=20) during their initial rotation-before being deployed to the surgical rotation. Using convenience sampling we included 35 medical students and 14 interns. There were 39 participants in the pre-test assessment and training; 14 completed all three sessions, i.e. the pre-test assessment, training and post-test assessment. Data collection instrument A checklist developed for the module was used for the pre-test and post-test assessments. Thirteen content-based items (total score of 22) evaluated the students' knowledge relating to the diagnosis and management of a chest injury (cognitive domain) and one item (total score of 3) evaluated their ability to perform the procedure correctly (psychomotor domain). A rating Background. To improve the management of chest trauma at the University of Botswana, Gaborone, Botswana, we incorporated simulation into a theorybased chest trauma module by developing procedural guides, checklists and low-cost simulation. Objectives. To assess the suitability of low-cost simulation-based training and its impact on students' proficiency, as well as its general acceptability. Methods. A total of 39 medical students who completed their surgical rotation and 20 intern doctors in their first clinical rotation participated. A checklist was used in a pre-and post-test design to assess procedural proficiency, and a rating system categorised scores. Thirteen content-based items assessed the students' knowledge relating to the diagnosis and management of a chest injury and one item assessed their ability to perform the procedure correctly. A questionnaire was administered after the second assessment to evaluate the acceptability of the training module. Findings were summarised by median, proportion and range, and pre-and post-test outcomes were compared by Student's paired t-test. Results. Pre-and post-test assessment scores differed significantly (median (range) 11.3 (4.5-21.0) and 19.5 (15.5-23.0), respectively (p<0.001)). The proportions of participants' scores categorised as 'full proficiency' rose from 7% to 42%, and 'reasonable proficiency' from 30% to 60%, while both 'some proficiency' and 'poor proficiency' decreased from 50% and 20% to 0%. Most (93%) participants 'strongly agreed' that the training module was acceptable. Conclusion. Our results demonstrate the suitability of low-cost simulation for training and assessment in resource-constrained settings.

Серцево-судинні захворювання (ССЗ) продовжують займати перше місце серед причин смертності праце­здатного населення, а їх поширеність вища в країнах з низьким та середнім рівнями доходу. В зв’язку з обмеженими фінансовими ресурсами цих країн виникає необхідність раціонального розподілу коштів, виділених на охорону здоров’я. Особливого значення в цих умовах набувають превентивна кардіологія та кардіореабілітація (КР). Мета – провести огляд наукової літератури, присвяченої економічній ефективності та організаційним аспектам реалізації програм КР у країнах з різним рівнем доходів; запропонувати модель КР для України. Матеріал і методи. Проведено огляд літератури з обраної теми в наукометричній базі даних MEDLINE та на офіційних електронних ресурсах міжнародних об’єднань кардіологів, лікарів фізичної та реабілітаційної медицини. Пошук проведено за ключовими словами: cardiac rehabilitation, cardiorehabilitation, cardiovascular rehabilitation, low/middle income country, core components, m...

Pandemics, often undocumented, cause fear and uncertainty among the public. The 2019 COVID-19 pandemic, first reported in Wuhan, China, was declared an International Public Health Emergency in January 2020. The Government of India took early warning seriously and implemented effective strategies to control the pandemic. This institute implemented steps for continuous patient care, health-care worker protection, and reviewed crisis management at administrative and clinical levels. This narrative observational review done during the period from March 2020 to December 2020, in an 840 bedded tertiary level academic institution of national importance under Govt of India in Eastern India with 4000 health-care workers serving the public with an average 3000 outpatient footfall and 100 admissions per day. This study was made to outline the challenges and strategies in managing the COVID-19 crisis in the hospital. All the circulars, minutes of meetings, E-mail communications, WhatsApp group communication, and feedback from patients and health-care workers were taken into consideration to collect the data for the study. It was found that there were approximately 47 circulars and minutes of meetings included in this study. Apart from several E-mail communications, nearly 10 WhatsApp groups were considered. The hospital implemented several infrastructural modifications for infection control in COVID-19 units, including continuous education and training for staff. Special services were implemented for sample collection, diagnostics, waste management, patient transportation, telemedicine, dead body management, dietary services, signages, emergency and critical care services, and administrative control room [Figure ].

Psychodynamic psychiatry remains a challenging subject to teach in underserved areas, where enthusiasm to learn is substantial. Besides logistical and psychiatric workforce shortcomings, sensible cultural adaptations to make psychodynamic psychiatry relevant outside of high-income countries require creative effort. Innovative pedagogical methods that include carefully crafted mentoring and incorporate videoconferencing in combination with site visits can be implemented through international collaborations. Emphasis on mentoring is essential to adequately train future psychodynamic psychotherapy supervisors. Examples of World Psychiatric Association initiatives in countries such as Indonesia, Iran, Malaysia, and Thailand are presented as possible models to emulate elsewhere.

Hypertension prevention and control are among the most important public health priorities. We evaluated the impacts of a workplace intervention project &quot;Stop Hypertension in Mobarakeh Steel Company&quot; (SHIMSCO) on controlling hypertension in industrial workers. The study was carried out in Mobarakeh Steel Company in Isfahan among 7286 male workers and employees. All individuals were evaluated for the presence of hypertension (HTN). According to examinations, 500 subjects with systolic blood pressure (SBP) ≥ 140 mmHg, and/or diastolic blood pressure (DBP) ≥ 90 mmHg, and/or those using antihypertensive medications were confirmed to have HTN and thus included in this study. They were questioned for sociodemographic characteristics, past medical history and medication use. They received an educational program including healthy lifestyle and self-care recommendations of HTN management and control as well as training for accurate blood pressure measurement and home monitoring for ...

ObjectivesIn low‐ to middle‐income countries, children from less‐deprived areas (from families of higher socio‐economic status [SES]) have superior muscular fitness than those from low‐SES groups. They are also taller and heavier, factors associated with muscular fitness. The purpose of this study was to identify any socio‐demographic differences in Colombian children&#39;s muscular fitness and examine how these conclusions can be modified by scaling for differences in body size.MethodsA total of 38,098 youths (46% girls), ninth grade students (aged 14–15 years), participated in a study of cross‐sectional design. We recorded SES and family incomes, stature, and mass. Standing broad jump and handgrip strength were used to assess muscular fitness. A multiplicative allometric model was adopted to adjust for body‐size differences.ResultsChildren from the mid‐ to high‐SES groups jumped significantly higher than children from the lowest SES group, although no SES group difference in grip ...

In general, rates of breast cancer are lower in low-income and middle-income countries (LMCs) than they are in more industrialised countries of North America and Europe. This lower incidence means that screening programmes aimed at early detection in asymptomatic women would have a lower yield-ie, substantially more women would need to be examined to find a true case of breast cancer. Because the average age of breast cancer is generally younger in LMCs, it has been suggested that breast-cancer screening programmes begin at an earlier age in these settings. However, the younger average age of breast cancer is mainly driven by the age distribution of the population, and fewer older women with breast cancer, rather than by higher age-specific incidence rates in younger women. Resources in LMCs might be better used to raise awareness and encourage more women with palpable breast lumps to seek and receive treatment in a timely manner.

Background and Aims
A growing body of literature on global health research has indicated a need for greater authorship equity, noting disproportionately high publishing rates by authors from high income countries. This study examined 11 years of clinical research publications in Pediatric Blood and Cancer (PBC), the official journal for the International Society of Pediatric Oncology and the American Society of Pediatric Hematology/Oncology to determine the distribution of authorship by country, income level, and World Health Organization region.

Methods
A multidisciplinary team of researchers extracted authorship data on all peer-reviewed, clinical research publications in PBC from 2011-2021. Submission type, country of data collection, country of the first affiliation of each author, study design, study topic, and author position for all authors (first, middle, senior, corresponding) from low-or middle-income countries (LMICs) were collected and analyzed using descriptive statistics.

Results
Of 4504 articles reviewed, only 13% (n=593) included at least one author from an LMIC. Of these, 483 had a first author from an LMIC and 459 had a senior author from an LMIC. The majority of the publications with authors from an LMIC were research articles (n=389/593), followed by brief reports (n=93/593), and critical reviews (n=33/593). The most LMIC authors by WHO region were the Americas (22%) and next Southeast Asia (21%).

Conclusions
Our findings are consistent with other studies on scientific authorship inequity, demonstrating an ongoing need to address multiple barriers to publication for researchers and clinicians living in LMICs. Meaningful inclusion and recognition of LMIC authors begin with an understanding of the structural inequities in research that perpetuate lack of diversity in the first place. PBC is uniquely poised to address equitable professional opportunity and recognition by drawing on emerging best practices to promote and support LMIC throughout the research pipeline.

Background Incomplete vital registration systems mean that causes of death during pregnancy and childbirth are poorly understood in low-income and middle-income countries. To inform global efforts to reduce maternal mortality, we compared physician review and computerised analysis of verbal autopsies (interpreting verbal autopsies [InterVA] software), to understand their agreement on maternal cause of death and circumstances of mortality categories (COMCATs) in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials. Methods The CLIP trials took place in India, Pakistan, and Mozambique, enrolling pregnant women aged 12-49 years between Nov 1, 2014, and Feb 28, 2017. 69 330 pregnant women were enrolled in 44 clusters (36 008 in the 22 intervention clusters and 33 322 in the 22 control clusters). In this secondary analysis of maternal deaths in CLIP, we included women who died in any of the 22 intervention clusters or 22 control clusters. Trained staff administered the WHO 2012 verbal autopsy after maternal deaths. Two physicians (and a third for consensus, if needed) reviewed trial surveillance data and verbal autopsies, and, in intervention clusters, community health worker-led visit data. They determined cause of death according to the WHO International Classification of Diseases-Maternal Mortality (ICD-MM). Verbal autopsies were also analysed by InterVA computer models (versions 4 and 5) to generate cause of death. COMCAT analysis was provided by InterVA-5 and, in India, by physician review of Maternal Newborn Health Registry data. Causes of death and COMCATs assigned by physician review, Inter-VA-4, and InterVA-5 were compared, with agreement assessed with Cohen's κ coefficient. Findings Of 61 988 pregnancies with successful follow-up in the CLIP trials, 143 maternal deaths were reported (16 deaths in India, 105 in Pakistan, and 22 in Mozambique). The maternal death rate was 231 (95% CI 193-268) per 100 000 identified pregnancies. Most deaths were attributed to direct maternal causes (rather than indirect or undetermined causes as per ICD-MM classification), with fair to good agreement between physician review and InterVA-4 (κ=0•56 [95% CI 0•43-0•66]) or InterVA-5 (κ=0•44 [0•30-0•57]), and InterVA-4 and InterVA-5 (κ=0•72 [0•60-0•84]). The top three causes of death were the same by physician review, InterVA-4, and InterVA-5 (ICD-MM categories obstetric haemorrhage, non-obstetric complications, and hypertensive disorders); however, attribution of individual patient deaths to obstetric haemorrhage varied more between methods (physician review, 38 [27%] deaths; InterVA-4, 69 [48%] deaths; and InterVA-5, 82 [57%] deaths), than did attribution to non-obstetric causes (physician review, 39 [27%] deaths; InterVA-4, 37 [26%] deaths; and InterVA-5, 28 [20%] deaths) or hypertensive disorders (physician review, 23 [16%] deaths; InterVA-4, 25 [17%] deaths; and InterVA-5, 24 [17%] deaths). Agreement for all nine ICD-MM categories was fair for physician review versus InterVA-4 (κ=0•48 [0•38-0•58]), poor for physician review versus InterVA-5 (κ=0•36 [0•27-0•46]), and good for InterVA-4 versus InterVA-5 (κ=0•69 [0•59-0•79]). The most commonly assigned COMCATs by InterVA-5 were emergencies (68 [48%] of 143 deaths) and health systems (62 [43%] deaths), and by physician review (India only) were health systems (seven [44%] of 16 deaths) and inevitability (five [31%] deaths); agreement between InterVA-5 and physician review (India data only) was poor (κ=0•04 [0•00-0•15]). Interpretation Our findings indicate that InterVA-5 is less accurate than InterVA-4 at ascertaining causes and circumstances of maternal death, when compared with physician review. Our results suggest a need to improve the next iteration of InterVA, and for researchers and clinicians to preferentially use InterVA-4 when recording maternal deaths. Funding University of British Columbia (grantee of the Bill & Melinda Gates Foundation).

This research paper aims to investigate the trends and patterns of smoking among students at Federal University Gusau. The study utilizes a quantitative research approach and a survey questionnaire as a research instrument. The sample size of the study is 250 students, selected through a random sampling technique. The findings reveal that a significant percentage of students at Federal University Gusau smoke, with male students more likely to smoke than female students. The study also identifies various factors that contribute to smoking, such as peer pressure, stress, and availability of cigarettes. The research concludes that there is a need for interventions that address the issue of smoking among students, such as awareness campaigns and cessation programs. The findings of this study may serve as a reference point for policymakers and stakeholders in developing strategies to curb smoking among students in the university setting.

Pandemics, often undocumented, cause fear and uncertainty among the public. The 2019 COVID-19 pandemic, first reported in Wuhan, China, was declared an International Public Health Emergency in January 2020. [1] The Government of India took early warning seriously and implemented effective strategies to control the pandemic. This institute implemented steps for continuous patient care, health-care worker protection, and reviewed crisis management at administrative and clinical levels. This narrative observational review done during the period from March 2020 to December 2020, in an 840 bedded tertiary level academic institution of national importance under Govt of India in Eastern India with 4000 health-care workers serving the public with an average 3000 outpatient footfall and 100 admissions per day. This study was made to outline the challenges and strategies in managing the COVID-19 crisis in the hospital. All the circulars, minutes of meetings, E-mail communications, WhatsApp group communication, and feedback from patients and health-care workers were taken into consideration to collect the data for the study. It was found that there were approximately 47 circulars and minutes of meetings included in this study. Apart from several E-mail communications, nearly 10 WhatsApp groups were considered. The hospital implemented several infrastructural modifications for infection control in COVID-19 units, including continuous education and training for staff. Special services were implemented for sample collection, diagnostics, waste management, patient transportation, telemedicine, dead body management, dietary services, signages, emergency and critical care services, and administrative control room [Figure 1].

Background Noncommunicable diseases (NCDs), including mental health, have become a major concern in low- and middle-income countries. Despite increased attention to them over the past decade, progress toward addressing NCDs has been slow. A lack of bold policy commitments has been suggested as one of the contributors to limited progress in NCD prevention and management. However, the policies of key global actors (bilateral, multilateral, and not-for-profit organisations) have been understudied. Methods This study aimed to map the key global actors investing in action regarding NCDs and review their policies to examine the articulation of priorities regarding NCDs. Narrative synthesis of 70 documents and 31 policy papers was completed, and related to data collated from the Global Health Data Visualisation Tool. Results In 2019 41% of development assistance for health committed to NCDs came from private philanthropies, while that for other global health priorities from this source was...

Background Incomplete vital registration systems mean that causes of death during pregnancy and childbirth are poorly understood in low-income and middle-income countries. To inform global efforts to reduce maternal mortality, we compared physician review and computerised analysis of verbal autopsies (interpreting verbal autopsies [InterVA] software), to understand their agreement on maternal cause of death and circumstances of mortality categories (COMCATs) in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials. Methods The CLIP trials took place in India, Pakistan, and Mozambique, enrolling pregnant women aged 12-49 years between Nov 1, 2014, and Feb 28, 2017. 69 330 pregnant women were enrolled in 44 clusters (36 008 in the 22 intervention clusters and 33 322 in the 22 control clusters). In this secondary analysis of maternal deaths in CLIP, we included women who died in any of the 22 intervention clusters or 22 control clusters. Trained staff administered the WHO 2012 verbal autopsy after maternal deaths. Two physicians (and a third for consensus, if needed) reviewed trial surveillance data and verbal autopsies, and, in intervention clusters, community health worker-led visit data. They determined cause of death according to the WHO International Classification of Diseases-Maternal Mortality (ICD-MM). Verbal autopsies were also analysed by InterVA computer models (versions 4 and 5) to generate cause of death. COMCAT analysis was provided by InterVA-5 and, in India, by physician review of Maternal Newborn Health Registry data. Causes of death and COMCATs assigned by physician review, Inter-VA-4, and InterVA-5 were compared, with agreement assessed with Cohen's κ coefficient. Findings Of 61 988 pregnancies with successful follow-up in the CLIP trials, 143 maternal deaths were reported (16 deaths in India, 105 in Pakistan, and 22 in Mozambique). The maternal death rate was 231 (95% CI 193-268) per 100 000 identified pregnancies. Most deaths were attributed to direct maternal causes (rather than indirect or undetermined causes as per ICD-MM classification), with fair to good agreement between physician review and InterVA-4 (κ=0•56 [95% CI 0•43-0•66]) or InterVA-5 (κ=0•44 [0•30-0•57]), and InterVA-4 and InterVA-5 (κ=0•72 [0•60-0•84]). The top three causes of death were the same by physician review, InterVA-4, and InterVA-5 (ICD-MM categories obstetric haemorrhage, non-obstetric complications, and hypertensive disorders); however, attribution of individual patient deaths to obstetric haemorrhage varied more between methods (physician review, 38 [27%] deaths; InterVA-4, 69 [48%] deaths; and InterVA-5, 82 [57%] deaths), than did attribution to non-obstetric causes (physician review, 39 [27%] deaths; InterVA-4, 37 [26%] deaths; and InterVA-5, 28 [20%] deaths) or hypertensive disorders (physician review, 23 [16%] deaths; InterVA-4, 25 [17%] deaths; and InterVA-5, 24 [17%] deaths). Agreement for all nine ICD-MM categories was fair for physician review versus InterVA-4 (κ=0•48 [0•38-0•58]), poor for physician review versus InterVA-5 (κ=0•36 [0•27-0•46]), and good for InterVA-4 versus InterVA-5 (κ=0•69 [0•59-0•79]). The most commonly assigned COMCATs by InterVA-5 were emergencies (68 [48%] of 143 deaths) and health systems (62 [43%] deaths), and by physician review (India only) were health systems (seven [44%] of 16 deaths) and inevitability (five [31%] deaths); agreement between InterVA-5 and physician review (India data only) was poor (κ=0•04 [0•00-0•15]). Interpretation Our findings indicate that InterVA-5 is less accurate than InterVA-4 at ascertaining causes and circumstances of maternal death, when compared with physician review. Our results suggest a need to improve the next iteration of InterVA, and for researchers and clinicians to preferentially use InterVA-4 when recording maternal deaths. Funding University of British Columbia (grantee of the Bill & Melinda Gates Foundation).

Background Most clinical guidelines are developed by high-income country institutions with little consideration given to either the evidence base for interventions in low- and middle-income countries (LMICs), or the specific challenges LMIC health systems may face in implementing recommendations. The aim of this study was to prioritize topics for future global surgery guidelines and then to develop a guideline for the top ranked topic. Methods A Delphi exercise identified and prioritized topics for guideline development. Once the top priority topic had been identified, relevant existing guidelines were identified and their recommendations were extracted. Recommendations were shortlisted if they were supported by at least two separate guidelines. Following two voting rounds, the final recommendations were agreed by an international guideline panel. The final recommendations were stratified by the guideline panel as essential (baseline measures that should be implemented as a priority...

Background Vietnam is in the process of an epidemiological transition, with cardiovascular disease (CVD) now ranked as the leading cause of death. The burden of CVD will continue to rise unless effective interventions for addressing its underlying risk factors are put in place. Objectives To assess the costs, health effects and cost-effectiveness of a set of personal and non-personal prevention strategies to reduce CVD in Vietnam, including mass media campaigns for reducing consumption of salt and tobacco, drugs for lowering blood pressure or cholesterol, and combined pharmacotherapy for people at varying levels of absolute risk of a cardiovascular event. Methods WHO-CHOICE methods and analytical models were employed, using local data to estimate the costs, effects and cost-effectiveness of 12 population and individual interventions implemented singly or in combination. Costs were measured in Vietnamese Dong for the year 2007 (discounted at a rate of 3% per year), while health effects were expressed in age-weighted and discounted disability-adjusted life years (DALYs) averted. Results A health education programme to reduce salt intake (VND 1 945 002 or US$118 per DALY averted) and individual treatment of systolic blood pressure above 160 mmHg (VND 1 281 596 or US$78 per DALY averted) were found to be the most cost-effective measures for population-and individual-based approaches, respectively. Where budget is very limited, a mass media education programme on salt intake and a combination mass media programme addressing salt intake, cholesterol and tobacco should be selected first. If more resources become available, greatest population health gains can be achieved via individual treatment of systolic blood pressure and the absolute risk approach to CVD prevention. Conclusions Contextualization of WHO-CHOICE using local data provides health decision-makers with more sound economic evidence for policy debates on prioritizing health interventions to reduce cardiovascular diseases in Vietnam. When used, cost-effectiveness analysis could increase efficiency in allocating scare resources.

Background Community health workers (CHWs) are well-positioned to play a pivotal role in fighting the pandemic at the community level. The Covid-19 outbreak has led to a lot of stress and anxiety among CHWs as they are expected to perform pandemic related tasks along with the delivery of essential healthcare services. In addition, movement restrictions, lockdowns, social distancing, and lack of protective gear have significantly affected CHWs’ routine workflow and performance. To optimize CHWs’ functioning, there is a renewed interest in supporting CHWs with digital technology to ensure an appropriate pandemic response. Discussion The current situation has necessitated the use of digital tools for the delivery of Covid-19 related tasks and other essential healthcare services at the community level. Evidence suggests that there has been a significant digital transformation to support CHWs in these critical times such as remote data collection and health assessments, the use of short ...

Using a large administrative data set from Chile, we find that, on average, boys perform better than girls in mathematics. In this paper, we document several features of their relative performance. First, we note that the gender gap appears to increase with age (it doubles between fourth grade and eighth grade). Second, we test whether commonly proposed explanations such as parental background and investment in the child, unobserved ability, and classroom environment (including teacher gender) help explain a substantial portion of the gap. While none of these explanations help in explaining a large portion of the gender gap, we show that boys and girls differ significantly in perceptions about their own ability in math. Conditional on math scores, girls are much more likely to state that they dislike math, or find math difficult, compared to boys. We highlight differences in self-assessed ability as areas for future research that might lead to a better understanding of the gender gap in math.

We confirm the presence of a gender gap in mathematics across many low-and middle-income countries using detailed, comparable test score data. Examining micro level data on school performance linked to household demographics we note that first, the gender gap appears to increase with age. Indeed, the gap nearly doubles when comparing 4th grade and 8th grade test scores. Second, we test whether commonly proposed explanations such as parental background and investments, unobserved ability, and classroom environment (including teacher gender) explain a substantial portion of the gap. While none of these explanations help in substantially explaining the gender gap we observe, we show that boys and girls differ significantly in perceptions about their own ability in math, conditional on math test scores. Girls are much more likely to state that they dislike math, or find math difficult compared to boys. We highlight differences in self-assessed ability as areas for future research that might lead to a better understanding of the gender gap in math.

Throughout much of the developing world, women tend to be disadvantaged in terms of job opportunities and wages (Sen 1999). This is at least partially due to a significant gender gap in educational levels that remains large in many countries (World Development Report 2012), q1 although it is reversed in the United States for recent cohorts (Goldin, Katz, and Kuziemko 2006). This gap is also potentially due to difference in the types of human capital women and men acquire, even conditional on the same level of education. For example, there is substantial evidence of a strong correlation between math test scores, mathbased curriculum, mathematical majors in college, and future income earned, suggesting that observed differences in math skills across genders can explain part of the wage gap. 1 It is therefore important for research to address the differences in the development of math skills and the determinants of math-related specializations and the role played by myriad factors starting from early childhood, such as parental investments, preferences, expectations and innate ability. Understanding when and how differences between men and women begin to Giacomo De Giorgi acknowledges financial support from the Spanish Ministry of Economy and Competitiveness, through the Severo Ochoa Programme for Centres of Excellence in R&D (SEV-2011-0075

The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research. NBER working papers are circulated for discussion and comment purposes. They have not been peer-reviewed or been subject to the review by the NBER Board of Directors that accompanies official NBER publications.

Throughout much of the developing world, women tend to be disadvantaged in terms of job opportunities and wages (Sen 1999). This is at least partially due to a significant gender gap in educational levels that remains large in many countries (World Development Report 2012), q1 although it is reversed in the United States for recent cohorts (Goldin, Katz, and Kuziemko 2006). This gap is also potentially due to difference in the types of human capital women and men acquire, even conditional on the same level of education. For example, there is substantial evidence of a strong correlation between math test scores, mathbased curriculum, mathematical majors in college, and future income earned, suggesting that observed differences in math skills across genders can explain part of the wage gap. 1 It is therefore important for research to address the differences in the development of math skills and the determinants of math-related specializations and the role played by myriad factors starting from early childhood, such as parental investments, preferences, expectations and innate ability. Understanding when and how differences between men and women begin to Giacomo De Giorgi acknowledges financial support from the Spanish Ministry of Economy and Competitiveness, through the Severo Ochoa Programme for Centres of Excellence in R&D (SEV-2011-0075

Using a large administrative data set from Chile, we find that, on average, boys perform better than girls in mathematics. In this paper, we document several features of their relative performance. First, we note that the gender gap appears to increase with age (it doubles between fourth grade and eighth grade). Second, we test whether commonly proposed explanations such as parental background and investment in the child, unobserved ability, and classroom environment (including teacher gender) help explain a substantial portion of the gap. While none of these explanations help in explaining a large portion of the gender gap, we show that boys and girls differ significantly in perceptions about their own ability in math. Conditional on math scores, girls are much more likely to state that they dislike math, or find math difficult, compared to boys. We highlight differences in self-assessed ability as areas for future research that might lead to a better understanding of the gender gap in math.

We confirm the presence of a gender gap in mathematics across many low-and middle-income countries using detailed, comparable test score data. Examining micro level data on school performance linked to household demographics we note that first, the gender gap appears to increase with age. Indeed, the gap nearly doubles when comparing 4th grade and 8th grade test scores. Second, we test whether commonly proposed explanations such as parental background and investments, unobserved ability, and classroom environment (including teacher gender) explain a substantial portion of the gap. While none of these explanations help in substantially explaining the gender gap we observe, we show that boys and girls differ significantly in perceptions about their own ability in math, conditional on math test scores. Girls are much more likely to state that they dislike math, or find math difficult compared to boys. We highlight differences in self-assessed ability as areas for future research that might lead to a better understanding of the gender gap in math.

This study aims to provide estimates, trends and projections of vision loss burden in Pakistan from 1990 to 2025. Global Burden of Diseases, Injuries, and Risk Factors Study (GBD 2017) was used to observe the vision loss burden in terms of prevalence and Years Lived with Disability (YLDs). As of 2017, out of 207.7 million people in Pakistan, an estimated 1.12 million (95% Uncertainty Interval [UI] 1.07-1.19) were blind (Visual Acuity [VA] <3/60), 1.09 million [0.93-1.24] people had severe vision loss (3/60�VA<6/60) and 6.79 million [6.00-7.74] people had moderate vision loss (6/60�VA<6/18). Presbyopia was found to be the most common ocular condition that affected an estimated 12.64 million [11.94-13.41] people (crude prevalence 6.08% [5.75-6.45]; 61% female). In terms of age-standardized YLDs rate, Pakistan is ranked fourth among other South Asian countries and twenty-first among other 42 low-middle income countries (classified by World Bank), with 552.98 YLDs [392.98-752.95] per 100,000. Compared with 1990, all-age YLDs count of blindness and vision impairment increased by 55% in 2017, which is the tenth highest increase among major health loss causes (such as dietary iron deficiency, headache disorders, low back pain etc.) in Pakistan. Moreover, our statistics show an increase in vision loss burden by 2025 for which Pakistan needs to make more efforts to encounter the growing burden of eye diseases.

Background Substandard medicines, whether the result of intentional manipulation or lack of compliance with good manufacturing practice (GMP) or good distribution practice (GDP), pose a significant potential threat to patient safety. Spontaneous adverse drug reaction reporting systems can contribute to identification of quality problems that cause unwanted and/or harmful effects, and to identification of clusters of lack of efficacy. In 2011, the Uppsala Monitoring Centre (UMC) constructed a novel algorithm to identify reporting patterns suggestive of substandard medicines in spontaneous reporting, and applied it to VigiBase Ò , the World Health Organization's global individual case safety report database. The algorithm identified some historical clusters related to substandard products, which were later able to be confirmed in the literature or by contact with national centres (NCs). As relevant and detailed information is often lacking in the VigiBase reports but might be available at the reporting NC, further evaluation of the algorithm was undertaken with involvement from NCs.

On a global scale, hypertension ranks third among the six major risk factors for cardiovascular disease. The risk of heart disease, stroke, and renal failure is all significantly increased by hypertension. We looked for papers on risk factors associated with hypertension in young adults on Google Scholar and PubMed. "Hypertension," "young adults," and "risk factors" were the search terms. Eligibility testing was done in a standardized, non-blinded way. The first author, year of publication, subject related to hypertension in young adults, and risk factors associated with hypertension in young adults were all retrieved from each paper. A PubMed search yielded 150 results. In all, 10 papers were considered in our review, which were published between 2017 and 2021. Most of the studies considered were carried out by foreign research groups. Adults who smoke, chew tobacco, drink alcohol, are obese, engage in sedentary behavior, consume too much salt, and have unhealthy lifestyles are at a higher risk of developing hypertension. In addition to these risk factors, there were additional important risk variables such as illiteracy, illness ignorance, a disregard for one's health, and a society that values men more than women. The way of life is radically altering because of people adjusting to Western culture. Smoking, drinking, being overweight, and eating too much salt are the primary risk factors for hypertension. This shows that in order to live a happier and healthier life, it is important to increase people's understanding of and attitudes toward the prevention and control of hypertension.

IntroductionIn older adults, dementia and depression are associated with individual distress and high societal costs. Music interventions such as group music therapy (GMT) and recreational choir singing (RCS) have shown promising effects, but their comparative effectiveness across clinical subgroups is unknown. This trial aims to determine effectiveness of GMT, RCS and their combination for care home residents and to examine heterogeneity of treatment effects across subgroups.Methods and analysisThis large, pragmatic, multinational cluster-randomised controlled trial with a 2×2 factorial design will compare the effects of GMT, RCS, both or neither, for care home residents aged 65 years or older with dementia and depressive symptoms. We will randomise 100 care home units with ≥1000 residents in total across eight countries. Each intervention will be offered for 6 months (3 months 2 times/week followed by 3 months 1 time/week), with extension allowed if locally available. The primary ...

There is a need to increase access to surgical treatments in African countries, but perioperative complications represent a major global health-care burden. There are few studies describing surgical outcomes in Africa. We did a 7-day, international, prospective, observational cohort study of patients aged 18 years and older undergoing any inpatient surgery in 25 countries in Africa (the African Surgical Outcomes Study). We aimed to recruit as many hospitals as possible using a convenience sampling survey, and required data from at least ten hospitals per country (or half the surgical centres if there were fewer than ten hospitals) and data for at least 90% of eligible patients from each site. Each country selected one recruitment week between February and May, 2016. The primary outcome was in-hospital postoperative complications, assessed according to predefined criteria and graded as mild, moderate, or severe. Data were presented as median (IQR), mean (SD), or n (%), and compared u...

Background: Cancer is the second leading cause of death globally accounting for more than half of deaths in Low- and Middle-Income Countries (LMICs). Cancer treatment is expensive and the high prices of cancer medicines have a huge impact on access in LMICs. Scarcity of pricing or affordability data is one of the major barriers in the development of effective and transparent pricing policies in LMICs. This study aimed to conduct a systematic review of the literature regarding pricing, availability, affordability, and access to anti-cancer medicines in LMICs.Method: A systematic search was conducted across six electronic databases: PubMed, Medline/CINAHL (EBSCO), Web of Science, Springer Links, Scopus, and Google Scholar. The literature (from 2015 to 2020) was reviewed to identify original research articles published in English.Results: A total of 13 studies were included in the review with some having multiple outcomes: five studies on pricing, four studies addressed affordability, ...

The support for this work provided by the ECD and Education Sections, UNICEF New York, is particularly appreciated. UNICEF thanks the LEGO Foundation for supporting the development of this paper, and for its generous contribution and strong partnership in the area of early childhood development and education. We thank Paula Lopez for the design. Disclaimer The opinions expressed in this paper are those of the contributors and do not necessarily reflect the policies or views of UNICEF. The text has not been edited to official publication standards and UNICEF accepts no responsibility for errors. Extracts from this paper may be freely reproduced with due acknowledgement.

The SDGs are a universal call to action by the United Nations General Assembly to end poverty, protect the planet and ensure that all people enjoy peace and prosperity. Goal 4 ensures that all girls and boys complete free primary and secondary schooling by 2030. For more information, see www.undp.org/content/undp/en/home/sustainabledevelopment-goals/goal-4-quality-education.html. Pre-primary education subsector: Pre-primary education is aimed at children below the age of entry to primary education, and may be referred to as early childhood development (ECD), early childhood education (ECE), play school, reception or preschool programmes. This subsector corresponds to the International Standard Classification of Education (ISCED) level 0. It can include two phases: (i) ECD, designed for children aged 0 to 2 years; and (ii) pre-primary education, designed for children from the age of 3 to the start of primary education. Such programmes are designed to support children's early cognitive, physical, social and emotional development and to introduce them to organized instruction outside the family context and prepare them for participation in primary education. Pre-primary workforce: The pre-primary workforce consists of individuals who share a dedication to improving the development and learning of pre-primary children in partnership with their families. Whatever their role, the members of this workforce share distinctive pre-primary competencies as well as the competencies and qualifications necessary for their specific responsibilities. 1 Competencies: Competencies are associated with the qualities of an individual practitioner, which can be acquired through training and professional preparation (i.e., the integration of knowledge, skills, attitudes and motivation). 2 Competencies refer to the requirements and expectations for what professionals should know and be able to do. 3 In general, there are two types: (i) competencies for professionals, and (ii) competencies for what training and professional development should impart. The first is essentially the 'professional competence profile', while the second is a 'training competence profile'. Pre-service or initial training: We use these terms interchangeably. Pre-service training is the training that an educator undergoes before taking up a post in ECE. Adapted pathways to qualification can be offered to low-qualified workers covering competencies that should have been developed through initial training. 4 Continuing professional development (CPD) or in-service training: We use these terms interchangeably. CPD refers to external and in-house training courses, team supervision, peer group learning sessions, mentoring, pedagogical guidance, coaching and counselling. 5 Reflective competencies: This is the ability of pre-primary professionals to reflect on their knowledge, skills and values, and to continually build on and improve the latter in order to improve their pedagogical practice. Reflective practice: This involves thinking about and analysing one's own practice to identify what drives children's learning and development. Reflective practice allows early childhood professionals (including teachers) to develop a critical understanding of their own practice, and to continue to develop the necessary skills, knowledge and approaches to achieve the best outcomes for children. Peer learning: In peer learning, staff involved in providing ECE share their knowledge about teaching and learning practice with their colleagues. Mentoring or coaching, pedagogical guidance and counselling: These forms of CPD are provided by a mentor, coach or counsellor who facilitates the practitioners' active reflection on their work. It is characterized by a focus on practice-based learning that takes place in constant dialogue with colleagues, parents and local communities. 6

Background Existing emergency general surgery (EGS) guidelines rarely include evidence from low- and middle-income countries (LMICs) and may lack relevance to low-resource settings. The aim of this study was to develop global guidelines for EGS that are applicable across all hospitals and health systems. Methods A systematic review and thematic analysis were performed to identify recommendations relating to undifferentiated EGS. Those deemed relevant across all resource settings by an international guideline development panel were included in a four-round Delphi prioritization process and are reported according to International Standards for Clinical Practice Guidelines. The final recommendations were included as essential (baseline measures that should be implemented as a priority) or desirable (some hospitals may lack relevant resources at present but should plan for future implementation). Results After thematic analysis of 38 guidelines with 1396 unique recommendations, 68 recom...

Children exposed to multiple adversities are at high risk of developing complex mental health and related problems, which are more likely to be met through integrated interprofessional working. Combining the expertise of different practitioners for interprofessional care is especially pertinent in low- and middle-income countries (LMIC) in the absence of specialist resources. The aim of this study was to work with practitioners who deliver care to vulnerable children in six LMIC (Turkey, Pakistan, Indonesia, Kenya, Rwanda, and Brazil) to understand their perspectives on the content of an interprofessional training programme in building resilience for these children. Seventeen participants from different professional backgrounds, who were in contact with vulnerable children were interviewed. A thematic analytic framework was used. Four themes were identified, which were the benefits of a tiered approach to training, challenges and limitations, perceived impact, and recommendations fo...

Background Incomplete vital registration systems mean that causes of death during pregnancy and childbirth are poorly understood in low-income and middle-income countries. To inform global efforts to reduce maternal mortality, we compared physician review and computerised analysis of verbal autopsies (interpreting verbal autopsies [InterVA] software), to understand their agreement on maternal cause of death and circumstances of mortality categories (COMCATs) in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials. Methods The CLIP trials took place in India, Pakistan, and Mozambique, enrolling pregnant women aged 12-49 years between Nov 1, 2014, and Feb 28, 2017. 69 330 pregnant women were enrolled in 44 clusters (36 008 in the 22 intervention clusters and 33 322 in the 22 control clusters). In this secondary analysis of maternal deaths in CLIP, we included women who died in any of the 22 intervention clusters or 22 control clusters. Trained staff administered the WHO 2012 verbal autopsy after maternal deaths. Two physicians (and a third for consensus, if needed) reviewed trial surveillance data and verbal autopsies, and, in intervention clusters, community health worker-led visit data. They determined cause of death according to the WHO International Classification of Diseases-Maternal Mortality (ICD-MM). Verbal autopsies were also analysed by InterVA computer models (versions 4 and 5) to generate cause of death. COMCAT analysis was provided by InterVA-5 and, in India, by physician review of Maternal Newborn Health Registry data. Causes of death and COMCATs assigned by physician review, Inter-VA-4, and InterVA-5 were compared, with agreement assessed with Cohen's κ coefficient. Findings Of 61 988 pregnancies with successful follow-up in the CLIP trials, 143 maternal deaths were reported (16 deaths in India, 105 in Pakistan, and 22 in Mozambique). The maternal death rate was 231 (95% CI 193-268) per 100 000 identified pregnancies. Most deaths were attributed to direct maternal causes (rather than indirect or undetermined causes as per ICD-MM classification), with fair to good agreement between physician review and InterVA-4 (κ=0•56 [95% CI 0•43-0•66]) or InterVA-5 (κ=0•44 [0•30-0•57]), and InterVA-4 and InterVA-5 (κ=0•72 [0•60-0•84]). The top three causes of death were the same by physician review, InterVA-4, and InterVA-5 (ICD-MM categories obstetric haemorrhage, non-obstetric complications, and hypertensive disorders); however, attribution of individual patient deaths to obstetric haemorrhage varied more between methods (physician review, 38 [27%] deaths; InterVA-4, 69 [48%] deaths; and InterVA-5, 82 [57%] deaths), than did attribution to non-obstetric causes (physician review, 39 [27%] deaths; InterVA-4, 37 [26%] deaths; and InterVA-5, 28 [20%] deaths) or hypertensive disorders (physician review, 23 [16%] deaths; InterVA-4, 25 [17%] deaths; and InterVA-5, 24 [17%] deaths). Agreement for all nine ICD-MM categories was fair for physician review versus InterVA-4 (κ=0•48 [0•38-0•58]), poor for physician review versus InterVA-5 (κ=0•36 [0•27-0•46]), and good for InterVA-4 versus InterVA-5 (κ=0•69 [0•59-0•79]). The most commonly assigned COMCATs by InterVA-5 were emergencies (68 [48%] of 143 deaths) and health systems (62 [43%] deaths), and by physician review (India only) were health systems (seven [44%] of 16 deaths) and inevitability (five [31%] deaths); agreement between InterVA-5 and physician review (India data only) was poor (κ=0•04 [0•00-0•15]). Interpretation Our findings indicate that InterVA-5 is less accurate than InterVA-4 at ascertaining causes and circumstances of maternal death, when compared with physician review. Our results suggest a need to improve the next iteration of InterVA, and for researchers and clinicians to preferentially use InterVA-4 when recording maternal deaths. Funding University of British Columbia (grantee of the Bill & Melinda Gates Foundation).

Background Hypertension is a major risk factor for cardiovascular disease (CVD). Despite advances in hypertension prevention and treatment, the proportion of patients who are aware, treated and controlled is low, particularly in low-income and middle-income countries (LMICs). We will evaluate an adapted version of a multilevel and multicomponent hypertension control program in Guatemala, previously proven effective and feasible in Argentina. The program components are: protocol-based hypertension treatment using a standardized algorithm; team-based collaborative care; health provider education; health coaching sessions; home blood pressure monitoring; blood pressure audit; and feedback. Methods Using a hybrid type 2 effectiveness-implementation design, we will evaluate clinical and implementation outcomes of the multicomponent program in Guatemala over an 18-month period. Through a cluster randomized trial, we will randomly assign 18 health districts to the intervention arm and 18 t...

Background Incomplete vital registration systems mean that causes of death during pregnancy and childbirth are poorly understood in low-income and middle-income countries. To inform global efforts to reduce maternal mortality, we compared physician review and computerised analysis of verbal autopsies (interpreting verbal autopsies [InterVA] software), to understand their agreement on maternal cause of death and circumstances of mortality categories (COMCATs) in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials. Methods The CLIP trials took place in India, Pakistan, and Mozambique, enrolling pregnant women aged 12-49 years between Nov 1, 2014, and Feb 28, 2017. 69 330 pregnant women were enrolled in 44 clusters (36 008 in the 22 intervention clusters and 33 322 in the 22 control clusters). In this secondary analysis of maternal deaths in CLIP, we included women who died in any of the 22 intervention clusters or 22 control clusters. Trained staff administered the WHO 2012 verbal autopsy after maternal deaths. Two physicians (and a third for consensus, if needed) reviewed trial surveillance data and verbal autopsies, and, in intervention clusters, community health worker-led visit data. They determined cause of death according to the WHO International Classification of Diseases-Maternal Mortality (ICD-MM). Verbal autopsies were also analysed by InterVA computer models (versions 4 and 5) to generate cause of death. COMCAT analysis was provided by InterVA-5 and, in India, by physician review of Maternal Newborn Health Registry data. Causes of death and COMCATs assigned by physician review, Inter-VA-4, and InterVA-5 were compared, with agreement assessed with Cohen's κ coefficient. Findings Of 61 988 pregnancies with successful follow-up in the CLIP trials, 143 maternal deaths were reported (16 deaths in India, 105 in Pakistan, and 22 in Mozambique). The maternal death rate was 231 (95% CI 193-268) per 100 000 identified pregnancies. Most deaths were attributed to direct maternal causes (rather than indirect or undetermined causes as per ICD-MM classification), with fair to good agreement between physician review and InterVA-4 (κ=0•56 [95% CI 0•43-0•66]) or InterVA-5 (κ=0•44 [0•30-0•57]), and InterVA-4 and InterVA-5 (κ=0•72 [0•60-0•84]). The top three causes of death were the same by physician review, InterVA-4, and InterVA-5 (ICD-MM categories obstetric haemorrhage, non-obstetric complications, and hypertensive disorders); however, attribution of individual patient deaths to obstetric haemorrhage varied more between methods (physician review, 38 [27%] deaths; InterVA-4, 69 [48%] deaths; and InterVA-5, 82 [57%] deaths), than did attribution to non-obstetric causes (physician review, 39 [27%] deaths; InterVA-4, 37 [26%] deaths; and InterVA-5, 28 [20%] deaths) or hypertensive disorders (physician review, 23 [16%] deaths; InterVA-4, 25 [17%] deaths; and InterVA-5, 24 [17%] deaths). Agreement for all nine ICD-MM categories was fair for physician review versus InterVA-4 (κ=0•48 [0•38-0•58]), poor for physician review versus InterVA-5 (κ=0•36 [0•27-0•46]), and good for InterVA-4 versus InterVA-5 (κ=0•69 [0•59-0•79]). The most commonly assigned COMCATs by InterVA-5 were emergencies (68 [48%] of 143 deaths) and health systems (62 [43%] deaths), and by physician review (India only) were health systems (seven [44%] of 16 deaths) and inevitability (five [31%] deaths); agreement between InterVA-5 and physician review (India data only) was poor (κ=0•04 [0•00-0•15]). Interpretation Our findings indicate that InterVA-5 is less accurate than InterVA-4 at ascertaining causes and circumstances of maternal death, when compared with physician review. Our results suggest a need to improve the next iteration of InterVA, and for researchers and clinicians to preferentially use InterVA-4 when recording maternal deaths. Funding University of British Columbia (grantee of the Bill & Melinda Gates Foundation).