The Millennium Declaration, adopted by the United Nations (UN) in 2000, set a series of Millennium Development Goals (MDGs) as priorities for UN member countries, committing governments to realising eight major MDGs and 18 associated targets by 2015. Progress towards these goals is being assessed by tracking a series of 48 technical indicators that have since been unanimously adopted by experts. This concept paper outlines the role member Health and Demographic Surveillance Systems (HDSSs) of the INDEPTH Network could play in monitoring progress towards achieving the MDGs. The unique qualities of the data generated by HDSSs lie in the fact that they provide an opportunity to measure or evaluate interventions longitudinally, through the long-term follow-up of defined populations.
This study explores stakeholder experiences and perspectives on end-of-trial obligations at the close of a phase II/III Pediatric Malaria Vaccine Trial (PMVT) [GSK/PATH-MVI RTS, S) (NCT00866619]. We conducted 52 key informant interviews with major stakeholders of an international multicentre PMVT in Ghana and Tanzania. The responses fell into four main themes: (a) Communicating End-of-Trial, (b) Maintaining Health Care Services, (c) Dissemination of Results, and (d) Post-Trial Access. Interviewee responses shared important practical experiences and insights that complement current thinking in the literature on research ethics guidance: (a) accompany end-of-trial communication with information on personal and family health care responsibilities, (b) establish public health indicators to measure the impact of research on a health care system, (c) design a gradual exit strategy with opportunities to address unplanned events, (d) endorse a principled approach of continuity of care when designing a health care service handover, and (e) devise an actionable post-trial treatment access pathway with diverse stakeholder representatives.
In line with the policy objectives of the United Nations Sustainable Development Goals, this commentary seeks to examine the extent to which provisions of international health research guidance promote capacity building and equitable partnerships in global health research. Our evaluation finds that governance of collaborative research partnerships, and in particular capacity building, in resource-constrained settings is limited but has improved with the implementation guidance of the International Ethical Guidelines for Health-related Research Involving Humans by The Council for International Organizations of Medical Sciences (CIOMS) (2016). However, more clarity is needed in national legislation, industry and ethics guidelines, and regulatory provisions to address the structural inequities and power imbalances inherent in international health research partnerships. Most notably, ethical partnership governance is not supported by the principal industry ethics guidelines - the International Conference on Harmonization Technical Requirements for Registration of Pharmaceutical for Human Use (ICH) Good Clinical Practice (ICH-GCP). Given the strategic value of ICH-GCP guidelines in defining the role and responsibility of global health research partners, we conclude that such governance should stipulate the minimal requirements for creating an equitable environment of inclusion, mutual learning, transparency and accountability. Procedurally, this can be supported by i) shared research agenda setting with local leadership, ii) capacity assessments, and iii) construction of a memorandum of understanding (MoU). Moreover, the requirement of capacity building needs to be coordinated amongst partners to support good collaborative practice and deliver on the public health goals of the research enterprise; improving local conditions of health and reducing global health inequality. In this respect, and in order to develop consistency between sources of research governance, ICH-GCP should reference CIOMS ethical guidelines as the established standard for collaborative partnership. Moreover, greater commitment and support should be given to co-ordinate, strengthen and enforce local laws requiring equitable research partnerships and health system strengthening.
This study explores ethical issues raised in providing medical care to participants and communities of low-resource settings involved in a Phase II/III pediatric malaria vaccine trial (PMVT). We conducted 52 key informant interviews with major stakeholders of an international multi-center PMVT (GSK/PATH-MVI RTS,S) (NCT00866619) in Ghana and Tanzania. Based on their stakeholder experiences, the responses fell into three main themes: (a) undue inducement, (b) community disparities, and (c) broad therapeutic misconceptions. The study identified the critical ethical aspects, from the perspectives of stakeholders, of delivering health care during a PMVT. The study showed that integrating research into health care services needs to be addressed in a manner that upholds the favorable risk–benefit ratio of research and attends to the health needs of local populations. The implementation of research should aim to improve local standards of care through building a collaborative agenda with local institutions and systems of health.
Knowledge and practices of rural South African populations with regard to antibiotic access and use (ABACUS) remain understudied. By using the case of four villages in the north east of the country, our aim was to investigate popular notions and social practices related to antibiotics to inform patient-level social interventions for appropriate antibiotic use. To achieve this, we investigated where community members (village residents) were accessing and sourcing medication, and what they understood antibiotics and antibiotic resistance (ABR) to be. Embedded within the multicountry ABACUS project, this qualitative study uses interviews and focus group discussions. A sample of 60 community members was recruited from the Agincourt Health and Demographic Surveillance System, situated in Mpumalanga Province, from April to August, 2017. We used the five abilities of seek, reach, pay, perceive, and engage in access to healthcare as proposed by Levesque's "Access to Healthcare" framework. Respondents reported accessing antibiotics prescribed from legal sources: by nurses at the government primary healthcare clinics or by private doctors dispensed by private pharmacists. No account of the illegal purchasing of antibiotics was described. There was a mix of people who finished their prescription according to the instructions and those who did not. Some people kept antibiotics for future episodes of infection. The concept of "ABR" was understood by some community members when translated into related Xitsonga words because of knowledge tuberculosis and HIV/AIDS treatment regimens. Our findings indicate that regulation around the sale of antibiotics is enforced. Safer use of antibiotics and why resistance is necessary to understand need to be instilled. Therefore, context-specific educational campaigns, drawing on people's understandings of antibiotics and informed by the experiences of other diseases, may be an important and deployable means of promoting the safe use of antibiotics.
Background In 2010, the government of Sierra Leone implemented the Free Health Care Initiative (FHCI) in the country with the objective of reducing the high maternal, infant, and child mortality rates and improving general health indicators. The objective of this study was to assess the trends in the prevalence of health care-seeking and to identify the determinants of healthcare service utilization by caregivers of children younger than five years. Methods The analysis of health-care-seeking behavior was done using data from four populationbased surveys in Sierra Leone before (2008) and after (2013, 2016, 2019) the FHCI was implemented. Care-seeking behavior was assessed with regard to caregivers seeking care for children under-five in the two weeks prior to each survey. We compared the percentages of healthcare-seeking behavior change and identify factors associated with healthcareseeking using a modified Poisson regression model with generalized estimating equations. Results In 2008, a total of 1208 children with fever were recorded, compared with 2823 children in 2013, 1633 in 2016, and 1464 in 2019. Care-seeking for children with fever was lowest in 2008 (51%; 95% CI (46.4-55.5)) than in 2013 (71.5%; 95% CI (68.4-74.5)), 2016 (70.3%; 95% CI (66.6-73.8)), and 2019 (74.6%; 95% CI (71.6-77.3)) (p < 0.001). Care-seeking in 2013, 2016 and 2019 was at least 1.4 time higher than in 2008 (p < 0.001) after adjusting for mother's age, wealth, religion, education level, household head and the child's age. Careseeking was lowest for children older than 12 months, mothers older than 35 years, children living in the poorest households, and in the northern region. A trend was observed for the sex of the household head. The level of care-seeking was lowest when the household head was a man. Conclusions The increase in healthcare-seeking for children under-five with fever followed the introduction of the FHCI in Sierra Leone. Care-seeking for fever varied by the child's age, caregiver's age, household wealth, the sex ...
The International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) is a global network of research centers that conduct longitudinal health and demographic evaluation of populations in low- and middle-income countries (LMICs) currently in 52 health and demographic surveillance system (HDSS) field sites situated in sub-Saharan Africa (14 countries), Asia (India, Bangladesh, Thailand, Vietnam, and Indonesia), and Oceania (Papua New Guinea). Through this network of HDSS field sites, INDEPTH is capable of producing reliable longitudinal data about the lives of people in the research communities as well as how development policies and programs affect those lives. The aim of the INDEPTH Data Repository is to enable INDEPTH member centers and associated researchers to contribute and share fully documented, high-quality datasets with the scientific community and health policy makers.
Registration of births, recording deaths by age, sex and cause, and calculating mortality levels and differentials are fundamental to evidence-based health policy, monitoring and evaluation. Yet few of the countries with the greatest need for these data have functioning systems to produce them despite legislation providing for the establishment and maintenance of vital registration. Sample vital registration (SVR), when applied in conjunction with validated verbal autopsy procedures and implemented in a nationally representative sample of population clusters represents an affordable, cost-effective, and sustainable short- and medium-term solution to this problem. SVR complements other information sources by producing age-, sex-, and cause-specific mortality data that are more complete and continuous than those currently available. The tools and methods employed in an SVR system, however, are imperfect and require rigorous validation and continuous quality assurance; sampling strategies for SVR are also still evolving. Nonetheless, interest in establishing SVR is rapidly growing in Africa and Asia. Better systems for reporting and recording data on vital events will be sustainable only if developed hand-in-hand with existing health information strategies at the national and district levels; governance structures; and agendas for social research and development monitoring. If the global community wishes to have mortality measurements 5 or 10 years hence, the foundation stones of SVR must be laid today.
Background: Antimicrobial misuse is common in low-income and middle-income countries (LMICs), and this practice is a driver of antibiotic resistance. We compared community-based antibiotic access and use practices across communities in LMICs to identify contextually specific targets for interventions to improve antibiotic use practices. Methods: We did quantitative and qualitative assessments of antibiotic access and use in six LMICs across Africa (Mozambique, Ghana, and South Africa) and Asia (Bangladesh, Vietnam, and Thailand) over a 2·5-year study period (July 1, 2016–Dec 31, 2018). We did quantitative assessments of community antibiotic access and use through supplier mapping, customer exit interviews, and household surveys. These quantitative assessments were triangulated with qualitative drug supplier and consumer interviews and discussions. Findings: Vietnam and Bangladesh had the largest proportions of non-licensed antibiotic dispensing points. For mild illness, drug stores were the most common point of contact when seeking antibiotics in most countries, except South Africa and Mozambique, where public facilities were most common. Self-medication with antibiotics was found to be widespread in Vietnam (55·2% of antibiotics dispensed without prescription), Bangladesh (45·7%), and Ghana (36·1%), but less so in Mozambique (8·0%), South Africa (1·2%), and Thailand (3·9%). Self-medication was considered to be less time consuming, cheaper, and overall, more convenient than accessing them through health-care facilities. Factors determining where treatment was sought often involved relevant policies, trust in the supplier and the drug, disease severity, and whether the antibiotic was intended for a child. Confusion regarding how to identify oral antibiotics was revealed in both Africa and Asia. Interpretation: Contextual complexities and differences between countries with different incomes, policy frameworks, and cultural norms were revealed. These contextual differences render a single strategy inadequate and instead necessitate context-tailored, integrated intervention packages to improve antibiotic use in LMICs as part of global efforts to combat antibiotic resistance.
For the poorest of our world, non-communicable diseases and injuries (NCDIs) account for more than a third of their burden of disease; this burden includes almost 800000 deaths annually among those aged younger than 40 years, more than HIV, tuberculosis, and maternal deaths combined. • Despite already living in abject poverty, between 19 million and 50 million of the poorest billion spend a catastrophic amount of money each year in direct out-of-pocket costs on health care as a result of NCDIs. • Progressive implementation of affordable, cost-effective, and equitable NCDI interventions between 2020 and 2030 could save the lives of more than 4·6 million of the world's poorest, including 1·3 million who would otherwise die before the age of 40 years. • To avoid needless death and suffering, and to reduce the risk of catastrophic health spending, essential NCDI services must be financed through pooled, public resources, either from increased domestic funding or external funds. • National governments should set and adjust priorities based on the best available local data on NCDIs and the specific needs of the worst off. • International development assistance for health should be augmented and targeted to ensure that the poorest families affected by NCDIs are included in progress towards universal health care.
