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Definitions of health literacy have evolved from notions of health-related literacy to a multidimensional concept that incorporates the importance of social and cultural knowledge, practices and contexts. This evolution is evident in the development of instruments that seek to measure health literacy in different ways. Health literacy measurement is important for global health because diverse stakeholders, including the WHO, use these data to inform health practice and policy, and to understand sources of inequity. In this Practice paper, we explore the potential for negative consequences, bias and epistemic injustice to occur when health literacy instruments are used across settings without due regard for the lived experiences of people in various contexts from whom data are collected. A health literacy measurement approach that is emic-sensitive, strengths based and solution oriented is needed to minimise biased data interpretation and use and to avoid epistemic injustice. Definitions of health literacy have evolved from notions of health-related literacy to a multidimensional concept that incorporates the importance of social and cultural knowledge, practices and contexts. This evolution is evident in the development of instruments that seek to measure health literacy in different ways. Health literacy measurement is important for global health because diverse stakeholders, including the WHO, use these data to inform health practice and policy, and to understand sources of inequity. In this Practice paper, we explore the potential for negative consequences, bias and epistemic injustice to occur when health literacy instruments are used across settings without due regard for the lived experiences of people in various contexts from whom data are collected. A health literacy measurement approach that is emic-sensitive, strengths based and solution oriented is needed to minimise biased data interpretation and use and to avoid epistemic injustice.

IntroductionWomen and children bear a substantial burden of the impact of conflict and instability. The number of people living in humanitarian and fragile settings (HFS) has increased significantly over the last decade. The provision of essential maternal and newborn healthcare by midwives is crucial everywhere, especially in HFS. There is limited knowledge about the interventions, support systems and enabling environments that enhance midwifery care in these settings. The aim of this paper is to identify the factors affecting an enabling environment for midwives in HFS and to explore the availability and effectiveness of support systems for midwives.MethodsA structured systematic review was undertaken to identify peer-reviewed primary research articles published between 1995 and 2020.ResultsIn total, 24 papers were included from Afghanistan, Bangladesh, Nigeria, Democratic Republic of Congo, South Sudan and Sudan, Ethiopia, Pakistan, Uganda and Liberia. There were two broad themes: (1) the facilitators of, and barriers to, an enabling environment, and (2) the importance of effective support systems for midwives. Facilitators were: community involvement and engagement and an adequate salary, incentives or benefits. Barriers included: security and safety concerns, culture and gender norms and a lack of infrastructure and supplies. Support systems were: education, professional development, supportive supervision, mentorship and workforce planning.ConclusionMore efforts are needed to develop and implement quality midwifery services in HFS. There is an urgent need for more action and financing to ensure better outcomes and experiences for all women, girls and families living in these settings.PROSPERO registration numberCRD42021226323.

ObjectiveTo understand how, and under what circumstances community participation in water and sanitation interventions impacts the availability of safe water and sanitation, a change in health status or behaviour and the longevity of water, sanitation and hygiene (WASH) resources and services.DesignRealist review.Data sourcesPubMed, Web of Science and Scopus databases were used to identify papers from low-income and middle-income countries from 2010 to 2020.Eligibility criteria for selecting studiesCriteria were developed for papers to be included. The contribution of each paper was assessed based on its relevance and rigour (eg, can it contribute to context, mechanism or outcome, and is the method used to generate that information credible).AnalysisInductive and deductive coding was used to generate context–mechanism–outcome configurations.Results73 studies conducted in 29 countries were included. We identified five mechanisms that explained the availability, change and longevity outcomes: (1) accountability (policies and procedures to hold communities responsible for their actions and outcomes of an intervention), (2) diffusion (spread of an idea or behaviour by innovators over time through communication among members of a community), (3) market (the interplay between demand and supply of a WASH service or resource), (4) ownership (a sense of possession and control of the WASH service or resource) and (5) shame (a feeling of disgust in one’s behaviour or actions). Contextual elements identified included community leadership and communication, technical skills and knowledge, resource access and dependency, committee activity such as the rules and management plans, location and the level of community participation.ConclusionsThe findings highlight five key mechanisms impacted by 19 contextual factors that explain the outcomes of community water and sanitation interventions. Policymakers, programme implementers and institutions should consider community dynamics, location, resources, committee activity and practices and nature of community participation, before introducing community water and sanitation interventions.

IntroductionHandover is the system by which the responsibility for immediate and ongoing care is transferred between healthcare professionals and can be an area of risk. The Royal College of Physicians (RCP) has recommended improvement and standardisation of handover. Locally, national training surveys have reported poor feedback regarding handover at Glasgow Royal Infirmary.AimTo improve and standardise handover from weekday to weekend teams.MethodsThe Plan–Do–Study–Act (PDSA) quality improvement framework was used. Interventions were derived from a driver diagram after consultation with relevant stakeholders. Four PDSA cycles were completed over a 4-month period:PDSA cycle 1—Introduction of standardised paper form on three wards.PDSA cycle 2—Introduction of electronic handover system on three wards.PDSA cycle 3—Expansion of electronic handover to seven wards.PDSA cycle 4—Expansion of electronic handover to all non-receiving medical wards.The outcome of interest was the percentage of patients with full information handed over based on a six-point scale derived from the RCP. Data were collected weekly throughout the study period.Results18 data collection exercises were performed including 525 patients. During the initial phase there was an improvement in handover quality with 0/28 (0%) at baseline having all six points completed compared with 13/48 (27%) with standardised paper form and 21/42 (50%) with the electronic system (pConclusionA standardised electronic handover system was successfully introduced to downstream medical wards over a short time period. This led to an in improvement in the quality of handover in the initial wards involved. When expanded to a greater number of wards there was still an improvement in quality but to a lesser degree.

BackgroundThere are few examples of the practical application of the concepts of social accountability, as defined by the World Bank and WHO, to health system change. This paper describes a robust approach led by First Nations Health Authority and the Rural Coordination Centre of British Columbia. This was achieved using partnerships in British Columbia, Canada, where the health system features inequities in service and outcomes for rural and Indigenous populations. Social accountability is achieved when all stakeholders come together simultaneously as partners and agree on a path forward. This approach has enabled socially accountable healthcare, effecting change in the healthcare system by addressing the needs of the population.InnovationOur innovative approach uses social accountability engagement to counteract persistent health inequities. This involves an adaptation of the Boelen Health Partnership model (policymakers, health administrators, health professionals, academics and community members) extended by addition of linked sectors (eg, industry and not-for-profits) to the ‘Partnership Pentagram Plus’. We used appreciative inquiry and deliberative dialogue focused on the rural scale and integrating Indigenous ways of knowing along with western scientific traditions (‘two-eyed seeing’). Using this approach, partners are brought together to identify common interests and direction as a learning community. Equitable engagement and provision of space as ‘peers’ and ‘partners’ were key to this process. Groups with varying perspectives came together to create solutions, building on existing strengths and new collaborative approaches to address specific issues in the community and health services delivery. A resulting provincial table reflecting the Pentagram Plus model has fostered policies and practices over the last 3 years that have resulted in meaningful collaborations for health service change.ConclusionThis paper presents the application of the ‘Partnership Pentagram Plus’ approach and uses appreciative inquiry and deliberative dialogue to bring about practical and positive change to rural and Indigenous communities.

The Welsh Transplantation and Immunogenetics Laboratory (WTAIL) is responsible for managing patient work-up for haematopoietic stem cell transplantation (HSCT), the only potentially curative option for many haematological and non-haematological conditions. Work-up requires regular communication between WTAIL and the transplanting clinicians, facilitated by weekly multidisciplinary team (MDT) meetings, to agree decisions and proceed through each work-up stage. Effective communication and minimising error are critical, as transplanting cells from a suboptimal donor could have severe or fatal consequences for the patient. We reviewed our HSCT patient management and identified issues including staff dissatisfaction with the inefficiency of the current (paper-based) system and concern about the potential for incidents caused by errors in manual transcription of patient information and tracking clinical decisions. Another driver for change was the COVID-19 pandemic, which prevented the usual face-to-face MDT meetings in which staff would show clinicians the paper records and reports; the shift to online MDT required new ways of sharing data. In this project we developed a new central reference point for our patient management data along with electronic patient summary sheets, designed with an eye to improving safety and efficiency. Over several improvement cycles we tested and refined the summary sheets with staff and clinicians and experimented with videoconferencing to facilitate data sharing. We conducted interviews with staff from which we concluded that the new process successfully reduced transcription and duplication and improved communication with the clinicians during the pandemic. Despite an increase in workload due to build-up of active patient work-up cases during the pandemic, staff reported that the new summaries enabled them to cope well. A key initiative was creation of a ‘Task and Finish’ group that helped establish continual improvement culture and identified additional areas for improvement which have been followed up in further improvement projects.

IntroductionCommunities of practice are used for knowledge sharing and learning in health settings. However, more needs to be known to understand how they work, if they work different in different settings and what outcomes they might generate. Of particular interest is their potential role in health literacy development.Methods and analysisThis realist review will be undertaken in seven stages, aiming to develop a framework to show how the various contexts of communities of practice in health settings trigger mechanisms that lead to improved health literacy outcomes. The first stage of a realist review is considered important as it clarifies the scope of the review, yet it is rarely elaborated in detail. This paper describes this first stage in detail and shows how scoping techniques can support drafting an initial framework which can guide the rest of the review. After the initial scoping review, the subsequent stages follow an iterative and recurring process (until saturation is reached) that includes searching and appraising evidence, extracting and organising results, and analysing and summarising. The review will then generate conclusions and recommendations for stakeholders seeking to use communities of practice for their health literacy challenges. Findings of the scoping review are presented in this paper as part of the methods description to show the relevance of conducting a scoping review prior to a realist review.Ethics and disseminationEthical review is not required for this review. Experts and stakeholders will be involved in the process after the first stage to increase the quality of the process and to ensure practical relevance and uptake. This review focuses on communities of practice and health literacy, yet findings will likely be relevant for other health settings. Findings will be disseminated through stakeholders, publications, presentations and formal and informal reports.

Animal ethics committees (AECs) typically focus on the welfare of animals used in experiments, neglecting the potential welfare impact of that animal use on the animal laboratory personnel. Some of this work, particularly the killing of animals, can impose significant psychological burdens that can diminish the well-being of laboratory animal personnel, as well as their capacity to care for animals. We propose that AECs, which regulate animal research in part on the basis of reducing harm, can and ought to require that these harms to researchers are reduced as well. The paper starts by presenting evidence of these burdens and their harm, giving some examples showing how they may be mitigated. We then argue that AECs are well placed to account for these harms to personnel and ought to use their power to reduce their occurrence. We conclude by responding to four potential objections: (1) that this problem should be addressed through health and safety administration, not research ethics administration; (2) that the proposal is unjustifiably paternalistic; (3) that these harms to laboratory animal personnel ought to occur, given their treatment of animals; and (4) that mitigating them may lead to worse treatment of research animals.

Research in the quality and safety field often necessitates an approach that supports the development of an in-depth understanding of how a complex phenomenon occurs, or how an intervention works. Realist review is an increasingly popular form of evidence synthesis that provides a theory-driven, interpretive approach to secondary research. Realist reviews offer quality and safety researchers the opportunity to draw on diverse types of evidence to develop explanatory theory about how, when and for whom interventions ‘work’ or outcomes occur. The approach is flexible, iterative and practical, typically drawing on the experience of policymakers, practitioners and patients throughout the review. With the increasing use of realist reviews, some common misconceptions about the approach have become evident in the literature. This paper introduces what is involved when planning and conducting a realist review, and where the approach can offer most value, as well as outlining common challenges that researchers may face when adopting the approach, and recommended solutions. Our aim is to support researchers who are considering conducting a realist review to understand the key principles and concepts involved, and how they can go about producing high-quality work.

IntroductionDespite growing consensus on the need for equitable data sharing, there has been very limited discussion about what this should entail in practice. As a matter of procedural fairness and epistemic justice, the perspectives of low-income and middle-income country (LMIC) stakeholders must inform concepts of equitable health research data sharing. This paper investigates published perspectives in relation to how equitable data sharing in global health research should be understood.MethodsWe undertook a scoping review (2015 onwards) of the literature on LMIC stakeholders’ experiences and perspectives of data sharing in global health research and thematically analysed the 26 articles included in the review.ResultsWe report LMIC stakeholders’ published views on how current data sharing mandates may exacerbate inequities, what structural changes are required in order to create an environment conducive to equitable data sharing and what should comprise equitable data sharing in global health research.ConclusionsIn light of our findings, we conclude that data sharing under existing mandates to share data (with minimal restrictions) risks perpetuating a neocolonial dynamic. To achieve equitable data sharing, adopting best practices in data sharing is necessary but insufficient. Structural inequalities in global health research must also be addressed. It is thus imperative that the structural changes needed to ensure equitable data sharing are incorporated into the broader dialogue on global health research.

Over 30 million people worldwide have taken a commercial at-home DNA test, because they were interested in their genetic ancestry, disease predisposition or inherited traits. Yet, these consumer DNA data are also increasingly used for a very different purpose: to identify suspects in criminal investigations. By matching a suspect’s DNA with DNA from a suspect’s distant relatives who have taken a commercial at-home DNA test, law enforcement can zero in on a perpetrator. Such forensic use of consumer DNA data has been performed in over 200 criminal investigations. However, this practice of so-called investigative genetic genealogy (IGG) raises ethical concerns. In this paper, we aim to broaden the bioethical analysis on IGG by showing the limitations of an individual-based model. We discuss two concerns central in the debate: privacy and informed consent. However, we argue that IGG raises pressing ethical concerns that extend beyond these individual-focused issues. The very nature of the genetic information entails that relatives may also be affected by the individual customer’s choices. In this respect, we explore to what extent the ethical approach in the biomedical genetic context on consent and consequences for relatives can be helpful for the debate on IGG. We argue that an individual-based model has significant limitations in an IGG context. The ethical debate is further complicated by the international, transgenerational and commercial nature of IGG. We conclude that IGG should not only be approached as an individual but also—and perhaps primarily—as a collective issue.There are no data in this work.

Health policy and systems research (HPSR) is critical in developing health systems to better meet the health needs of their populations. The highly contextualised nature of health systems point to the value of local knowledge and the need for context-embedded HPSR. Despite such need, relatively few individuals, groups or organisations carry out HPSR, particularly in low-income and middle-income countries. Greater effort is required to strengthen capacity for, and build the field of, HPSR by capturing the multilevel and nuanced representation of HPSR across contexts. No comprehensive frameworks were found that inform systemic HPSR capacity strengthening. Existing literature on capacity strengthening for health research and development tends to focus on individual-level capacity with less attention to collective, organisational and network levels. This paper proposes a comprehensive framework for systemic capacity strengthening for HPSR, uniquely drawing attention to the blurred boundaries and amplification potential for synergistic capacity strengthening efforts across the individual, organisational and network levels. Further, it identifies guiding values and principles that consciously acknowledge and manage the power dynamics inherent to capacity strengthening work. The framework was developed drawing on available literature and was peer-reviewed by the Board and Thematic Working Groups of Health Systems Global. While the framework focuses on HPSR, it may provide a useful heuristic for systemic approaches to capacity strengthening more generally; facilitate its mainstreaming within organisations and networks and help maintain a focused approach to, and structure repositories of resources on, capacity strengthening.

‘The problem with…’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended, but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution. Healthcare-associated infections (HCAIs) are the most common adverse events affecting patients.1 The pathogens responsible are often carried on health workers’ hands, and on the evidence of epidemiological and microbiological studies, in theory hand hygiene ought to break the chain of infection.2 The WHO3 promotes ‘My Five Moments for Hand Hygiene’4 as a ‘time-space’ framework to identify points in the sequence of care when hand hygiene should occur to prevent transmission. The Five Moments conceptualise risk in relation to two virtual areas: the patient zone and the healthcare zone.4 The patient zone comprises the patient and their immediate surroundings: intact skin and all inanimate surfaces in direct contact with the patient and all the surfaces handled by healthcare workers. The healthcare zone comprises everything outside the patient zone. Except for the original definition of zones provided by Sax et al ,4 no other definition of patient and healthcare zones appears to exist. The model assumes that the healthcare zone is contaminated with potentially harmful micro-organisms (ie, those able to cause exogenous infection and/or resistant to antimicrobials). The Five Moments are the dominant paradigm used to organise practice, policy and research in relation to hand hygiene. In this paper we identify five ‘inconvenient truths’ limiting the Five Moments: (1) the development of the Five Moments did not include the perspectives of stakeholders; (2) it is not always possible to implement Five Moments for all patients all the time; (3) the patient zone is not a fixed entity; (4) the Five Moments overlook barriers that reduce hand hygiene adherence; and (5) adherence to the Five Moments …

IntroductionUniversal availability and affordability of essential medicines are determined by effective design and implementation of relevant policies, typically involving multiple stakeholders. This paper examined stakeholder engagements, powers and resultant influences over design and implementation of four medicines pricing policies in Ghana: Health Commodity Supply Chain Master Plan, framework contracting for high demand medicines, Value Added Tax (VAT) exemptions for selected essential medicines, and ring-fencing medicines for local manufacturing.MethodsData were collected using reviews of policy documentation (n=16), consultative meetings with key policy actors (n=5) and in-depth interviews (n=29) with purposefully identified national-level policymakers, public and private health professionals including members of the National Medicine Pricing Committee, pharmaceutical wholesalers and importers. Data were analysed using thematic framework.ResultsA total of 46 stakeholders were identified, including representatives from the Ministry of Health, other government agencies, development partners, pharmaceutical industry and professional bodies. The Ministry of Health coordinated policy processes, utilising its bureaucratic mandate and exerted high influences over each policy. Most stakeholders were highly engaged in policy processes. Whereas some led or coproduced the policies in the design stage and participated in policy implementation, others were consulted for their inputs, views and opinions. Stakeholder powers reflected their expertise, bureaucratic mandates and through participation in national level consultation meetings, influences policy contents and implementation. A wider range of stakeholders were involved in the VAT exemption policies, reflecting their multisectoral nature. A minority of stakeholders, such as service providers were not engaged despite their interest in medicines pricing, and consequently did not influence policies.ConclusionsStakeholder powers were central to their engagements in, and resultant influences over medicine pricing policy processes. Effective leadership is important for inclusive and participatory policymaking, and one should be cognisant of the nature of policy issues and approaches to policy design and implementation.

IntroductionHealth and Demographic Surveillance Systems (HDSS) collect data on births, deaths and migration from relatively small, geographically defined populations primarily in Africa and Asia. HDSS occupy a grey area between research, healthcare and public health practice and it is unclear how ethics guidance that rely on a research-practice distinction apply to HDSS. This topic has received little attention in the literature. In this paper, based on empirical research across sub-Saharan Africa, we map out key ethical issues for HDSS and assess the relevance of current ethics guidance in relation to these findings.MethodsWe conducted a qualitative study across seven HDSS sites in sub-Saharan Africa, including individual in-depth interviews and informal discussions with 68 research staff, document reviews and non-participant observations of surveillance activities. Qualitative data analysis drew on a framework approach led by a priori and emergent themes, drawing on the wider ethics and social science literature.ResultsThere were diverse views on core ethical issues in HDSS, including regarding the strengths and challenges of community engagement, informed consent and data sharing processes. A key emerging issue was unfairness in the overall balance of benefits and burdens for residents and front-line staff when compared with other stakeholders, particularly given the socioeconomic contexts in which HDSS are generally conducted.ConclusionWe argue that HDSS operate as non-traditional epidemiologic research projects but are often governed using ethics guidance developed for traditional forms of health research. There is a need for specific ethics guidance for HDSS which prioritises considerations around fairness, cost-effectiveness, ancillary care responsibilities, longitudinality and obligations of the global community to HDSS residents.

This paper explores the quality and usefulness of ethical guidance for humanitarian aid workers and their agencies. We focus specifically on public health emergencies, such as COVID-19. The authors undertook a literature review and gathered empirical data through semi-structured focus group discussions amongst front-line workers from health clinics in Cox's Bazar, Bangladesh and in the Abyei Special Administrative Area, South Sudan. The purpose of the project was to identify how front-line workers respond to ethical challenges, including any informal or local decision-making processes, support networks, or habits of response.The research findings highlighted a dissonance between ethical guidance and the experiences of front-line humanitarian health workers. They suggest the possibility: (1) that few problems confronting front-line workers are conceived, described, or resolved as ethical problems; and (2) of significant dissonance between available, allegedly practically oriented guidance (often produced by academics in North America and Europe), and the immediate issues confronting front-line workers. The literature review and focus group data suggest a real possibility that there is, at best, a significant epistemic gulf between those who produce ethical guidelines and those engaged in real-time problem solving at the point of contact with people. At worst they suggest a form of epistemic control-an imposition of cognitive shapes that shoehorn the round peg of theoretical preoccupations and the disciplinary boundaries of western academies into the square hole of front-line humanitarian practice. [Abstract copyright: © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.]

IntroductionHealth researchers from low-income and middle-income countries (LMICs) are under-represented in the academic literature. Scientific writing and publishing interventions may help researchers publish their findings; however, we lack evidence about the prevalence and effectiveness of such interventions. This review describes interventions for researchers in LMICs aimed at strengthening capacity for writing and publishing academic journal articles.MethodsWe followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to report literature searches in PubMed, Embase, Global Health, Scopus and ERIC. Our keywords included LMICs, low-income and middle-income countries, health research and writing/publication support interventions, with no restrictions on publication date. Our screening process consisted of title screening, abstract review and full-text review. We collected information about the content, implementation and evaluation of each intervention, if included.ResultsWe identified 20 interventions designed to strengthen capacity for scientific writing and publishing. We summarised information from the 14 interventions that reported submitted or published papers as outcomes separately, reasoning that because they provide quantifiable metrics of success, they may offer particular insights into intervention components leading to publication. The writing and publishing components in this ‘Publications Reported’ group were an average length of 5.4 days compared with 2.5 days in the other group we refer to as ‘Other Interventions.’ Whereas all 14 Publications Reported interventions incorporated mentors, only two of five in the Other Interventions group incorporated mentors. Across interventions, leaders expressed the importance of a high ratio of mentors to participants, the need to accommodate time demands of busy researchers, and the necessity of a budget for open access fees and high-quality internet connectivity.ConclusionWriting and publishing interventions in LMICs are an underutilised opportunity for capacity strengthening. To facilitate the implementation of high-quality interventions, future writing and publishing interventions should share their experiences by publishing detailed information about the approach and effectiveness of the interventions.

The fair distribution of health resources is critical to health justice. But distributing healthcare equitably requires careful attention to the existing distribution of other resources, and the economic system which produces these inequalities. Health is strongly determined by socioeconomic factors, such as the effects of racism on the health of communities of colour, as well as the broader market-oriented healthcare and pharmaceutical systems that put the pursuit of profit above the alleviation of suffering. Two papers in this issue confront health injustices at different scales, and make far-reaching recommendations for more just healthcare allocation policies.

Cancer registries are an important part of the public health infrastructure, since they allow to monitor the temporal trends of this illness as well as facilitate epidemiological research. In order to effectively set up such registries, it is necessary to create a system of data collection that permits to record health-related information from patients who are diagnosed with cancer. Given the sensitive nature of such data, it is debated whether their recording should be based on consent or whether alternative arrangements are possible (eg, opt-out systems where information is automatically collected but patients can later withdraw). In the recent reform of the Swiss cancer registration legislation, the lawmaker set out to implement rules about the recording of data in cancer registries that would allegedly go beyond a consent-based model, in order to balance accurate registration with respect of patient rights. However, by analysing the operational norms of the new legislation and comparing them with those of other systems, it emerges that the Swiss rules de facto closely resemble a system of registration based on informed consent—in partial contradiction with the objective pursued by the lawmaker. In this paper, we show how the details of a policy are crucial to determine its true nature and we highlight some critical elements—from an ethical standpoint—of the recently reformed Swiss policy on cancer registration.

ObjectiveOwing to its potential human, social and economic costs, antimicrobial resistance (AMR) is frequently referred to as a threat to health security. Simultaneously, health security and the preservation of antimicrobials are often described as a global public good. However, how the term ‘public good’ is used in the context of health security, and the values that underpin it, remains ambiguous. Policymaking is never value-free, and a better examination of such values is critical to understanding how issues such as AMR are problematised and how policy decisions are informed.DesignWe used McDougall’s version of critical interpretive synthesis to capture the recurring concepts and arguments within public policy, political science and applied ethics literature on AMR. Articles were analysed by identifying recurring ideas and developing themes across the literature.ResultsA total of 77 papers were included in our review. In the context of health security and AMR, the concept of ‘public good’ appears to be used interchangeably with ‘common good’, reflecting confusion, but sometimes meaningful differences, regarding how antimicrobials, as a good, are conceived. Main approaches to addressing AMR are statism, globalism and regionalism, which appeal to different values in guiding policymakers. Common justificatory values underpinning preservation of antimicrobials as a public good were prevention of harm, solidarity, justice and rights.ConclusionThe findings suggest that within the literature there is a lack of conceptual clarity as to whether antimicrobials constitute a public good or a common good. Moreover, the way in which antimicrobials are conceived and the approaches through which AMR as a threat to health security is addressed appear to be grounded in values that are often implicit. Being explicit about the values that underpin AMR and health security is not simply an intellectual exercise but has very real policy and programmatic implications.

ObjectivesWe explore the cost of care of type 2 diabetes mellitus (T2DM) using time-driven activity-based costing (TDABC) and connect that cost to resulting patient health outcomes.DesignWe construct six care pathways varying from low-risk to high-risk patients over a 12-month cycle of care. We collect time, resource and cost data on activities in each care pathway and compute a time-driven estimate of cost. Use of patient outcome data highlights the health outcomes achieved.SettingPrimary, secondary and tertiary care.ParticipantsMedical staff involved in the care of patients with T2DM.Primary and secondary measuresPrimary: resources consumed to provide T2DM care. Secondary: health outcomes for representative patient within each patient category.ResultsBy computing cost of T2DM care and associated complications of chronic kidney disease, active foot disease, moderate risk of active foot disease and myocardial infarction, we show that when patients develop acute complications, significant costs are incurred, as compared with the cost of maintaining a patient at low or moderate risk. Variance analysis further informs decision making by showing the need to have the right personnel doing the right tasks at the right time to control costs.ConclusionsA TDABC approach facilitates an understanding of the drivers of cost in chronic illness care. Our paper highlights the stages in the care pathway where different settings, decision making and a more optimal use of resources could assist with achievement of better patient outcomes.

The COVID-19 pandemic is an unprecedented global crisis in which governments had to act in a situation of rapid change and substantial uncertainty. The governments of Germany, Sweden and the UK have taken different paths allowing learning for future pandemic preparedness. To help inform discussions on preparedness, inspired by resilience frameworks, this paper reviews governance structures, and the role of science and the media in the COVID-19 response of Germany, Sweden and the UK in 2020. We mapped legitimacy, interdependence, knowledge generation and the capacity to deal with uncertainty.Our analysis revealed stark differences which were linked to pre-existing governing structures, the traditional role of academia, experience of crisis management and the communication of uncertainty—all of which impacted on how much people trusted their government. Germany leveraged diversity and inclusiveness, a ‘patchwork quilt’, for which it was heavily criticised during the second wave. The Swedish approach avoided plurality and largely excluded academia, while in the UK’s academia played an important role in knowledge generation and in forcing the government to review its strategies. However, the vivant debate left the public with confusing and rapidly changing public health messages. Uncertainty and the lack of evidence on how best to manage the COVID-19 pandemic—the main feature during the first wave—was only communicated explicitly in Germany. All country governments lost trust of their populations during the epidemic due to a mix of communication and transparency failures, and increased questioning of government legitimacy and technical capacity by the public.

ObjectivesPrimary care networks (PCNs) were introduced in the National Health Service (NHS) in England in 2019 to improve integrated care for patients and help address financial and workforce sustainability issues in general practice. The purpose of this study was to collect early evidence on their implementation and development, including motivations to participate and what enables or inhibits progress. This paper considers the core characteristics of PCNs, and how this informs their management.DesignA qualitative mixed-methods rapid evaluation was conducted across four case study sites in England, informed by a literature review and stakeholder workshop. Data collection comprised interviews, non-participant observation of meetings, an online survey and documentary review.ResultsGeneral practitioners (GPs) are motivated to participate in PCNs for their potential to improve patient care, enable better coordinated services and enhance financial and workforce sustainability within primary care. However, PCNs also have an almost mandatory feel, based on the national policy context and significant financial incentives associated with joining them. PCNs offer potential to bring GPs together to work towards common goals, deliver national priorities and respond rapidly to local needs.ConclusionsPCNs face similar challenges to other meso-level primary care organisations internationally, as they respond to local and national priorities and operate in a context of multiple goals and interests. In managing these organisations, it is important to find a balance between local and national autonomy, decision making and control.

BackgroundThe success of payment for performance (P4P) schemes relies on their ability to generate sustainable changes in the behaviour of healthcare providers. This paper examines short-term and longer-term effects of P4P in Tanzania and the reasons for these changes.MethodsWe conducted a controlled before and after study and an embedded process evaluation. Three rounds of facility, patient and household survey data (at baseline, after 13 months and at 36 months) measured programme effects in seven intervention districts and four comparison districts. We used linear difference-in-difference regression analysis to determine programme effects, and differential effects over time. Four rounds of qualitative data examined evolution in programme design, implementation and mechanisms of change.ResultsProgramme effects on the rate of institutional deliveries and antimalarial treatment during antenatal care reduced overtime, with stock out rates of antimalarials increasing over time to baseline levels. P4P led to sustained improvements in kindness during deliveries, with a wider set of improvements in patient experience of care in the longer term. A change in programme management and funding delayed incentive payments affecting performance on some indicators. The verification system became more integrated within routine systems over time, reducing the time burden on managers and health workers. Ongoing financial autonomy and supervision sustained motivational effects in those aspects of care giving not reliant on funding.ConclusionOur study adds to limited and mixed evidence documenting how P4P effects evolve over time. Our findings highlight the importance of undertaking ongoing assessment of effects over time.

ObjectivesCOVID-19 has altered health sector capacity in low-income and middle-income countries (LMICs). Cost data to inform evidence-based priority setting are urgently needed. Consequently, in this paper, we calculate the full economic health sector costs of COVID-19 clinical management in 79 LMICs under different epidemiological scenarios.MethodsWe used country-specific epidemiological projections from a dynamic transmission model to determine number of cases, hospitalisations and deaths over 1 year under four mitigation scenarios. We defined the health sector response for three base LMICs through guidelines and expert opinion. We calculated costs through local resource use and price data and extrapolated costs across 79 LMICs. Lastly, we compared cost estimates against gross domestic product (GDP) and total annual health expenditure in 76 LMICs.ResultsCOVID-19 clinical management costs vary greatly by country, ranging between ConclusionsWe present the first dataset of COVID-19 clinical management costs across LMICs. These costs can be used to inform decision-making on priority setting. Our results show that COVID-19 clinical management costs in LMICs are substantial, even in scenarios of moderate social distancing. Low-income countries are particularly vulnerable and some will struggle to cope with almost any epidemiological scenario. The choices facing LMICs are likely to remain stark and emergency financial support will be needed.

Power is a growing area of study for researchers and practitioners working in the field of health policy and systems research (HPSR). Theoretical development and empirical research on power are crucial for providing deeper, more nuanced understandings of the mechanisms and structures leading to social inequities and health disparities; placing contemporary policy concerns in a wider historical, political and social context; and for contributing to the (re)design or reform of health systems to drive progress towards improved health outcomes. Nonetheless, explicit analyses of power in HPSR remain relatively infrequent, and there are no comprehensive resources that serve as theoretical and methodological starting points. This paper aims to fill this gap by providing a consolidated guide to researchers wishing to consider, design and conduct power analyses of health policies or systems. This practice article presents a synthesis of theoretical and conceptual understandings of power; describes methodologies and approaches for conducting power analyses; discusses how they might be appropriately combined; and throughout reflects on the importance of engaging with positionality through reflexive praxis. Expanding research on power in health policy and systems will generate key insights needed to address underlying drivers of health disparities and strengthen health systems for all.

IntroductionThe Children and Young People’s Health Partnership (CYPHP) Evelina London Model of Care is a new approach to integrated care delivery for children and young people (CYP) with common health complaints and chronic conditions. CYPHP includes population health management (services shaped by data-driven understanding of population and individual needs, applied in this case to enable proactive case finding and tailored biopsychosocial care), specialist clinics with multidisciplinary health teams and training resources for professionals working with CYP. This complex health system strengthening programme has been implemented in South London since April 2018 and will be evaluated using a cluster randomised controlled trial with an embedded process evaluation. This protocol describes the within-trial and beyond-trial economic evaluation of CYPHP.Methods and analysisThe economic evaluation will identify, measure and value resources and health outcome impacts of CYPHP compared with enhanced usual care from a National Health Service/Personal Social Service and a broader societal perspective. The study population includes 90 000 CYP under 16 years of age in 23 clusters (groups of general practitioner (GP) practices) to assess health service use and costs, with more detailed cost-effectiveness analysis of a targeted sample of 2138 CYP with asthma, eczema or constipation (tracer conditions). For the cost-effectiveness analysis, health outcomes will be measured using the Paediatric Quality of Life Inventory and quality-adjusted life years (QALYs) using the Child Health Utility 9 Dimensions (CHU-9D) measure. To account for changes in parental well-being, the Warwick-Edinburg Mental Well-being Scale will be integrated with QALYs in a cost–benefit analysis. The within-trial economic evaluation will be complemented by a novel long-term model that expands the analytical horizon to 10 years. Analyses will adhere to good practice guidelines and National Institute for Health and Care Excellence public health reference case.Ethics and disseminationThe study has received ethical approval from South West-Cornwall and Plymouth Research Ethics Committee (REC Reference: 17/SW/0275). Results will be submitted for publication in peer-reviewed journals, made available in briefing papers for local decision-makers, and provided to the local community through website and public events. Findings will be generalisable to community-based models of care, especially in urban settings.Trial registration numberNCT03461848.

This paper describes the lessons from scaling up a verbal autopsy (VA) intervention to improve data about causes of death according to a nine-domain framework: governance, design, operations, human resources, financing, infrastructure, logistics, information technologies and data quality assurance. We use experiences from China, Myanmar, Papua New Guinea, Philippines and Solomon Islands to explore how VA has been successfully implemented in different contexts, to guide other countries in their VA implementation. The governance structure for VA implementation comprised a multidisciplinary team of technical experts, implementers and staff at different levels within ministries. A staged approach to VA implementation involved scoping and mapping of death registration processes, followed by pretest and pilot phases which allowed for redesign before a phased scale-up. Existing health workforce in countries were trained to conduct the VA interviews as part of their routine role. Costs included training and compensation for the VA interviewers, information technology (IT) infrastructure costs, advocacy and dissemination, which were borne by the funding agency in early stages of implementation. The complexity of the necessary infrastructure, logistics and IT support required for VA increased with scale-up. Quality assurance was built into the different phases of the implementation. VA as a source of cause of death data for community deaths will be needed for some time. With the right technical and political support, countries can scale up this intervention to ensure ongoing collection of quality and timely information on community deaths for use in health planning and better monitoring of national and global health goals.

ObjectiveInequality is deeply embedded in our economic structures—it is necessary to address these economic inequalities if we are to reduce health inequalities. An inclusive economic approach was conceptualised as a way to reduce these economic inequalities, although the attributes of this approach are unclear. Public health practitioners are increasingly asked to provide a health perspective on the economic recovery plans in the light of the COVID-19 pandemic. This paper aims to identify the attributes of an inclusive economy to enable the public health profession to influence an inclusive economic recovery.ApproachWe conducted a rapid review of grey and peer-reviewed literature to identify the attributes of an inclusive economy as currently defined in the literature.Attributes of an inclusive economyTwenty-two concepts were identified from 56 reports and articles. These were collapsed into four distinct attributes of an inclusive economy: (1) an economy that is designed to deliver inclusion and equity, (2) equitable distribution of the benefits from the economy (eg, assets, power, value), (3) equitable access to the resources needed to participate in the economy (eg, health, education), and (4) the economy operates within planetary boundaries.ConclusionAs economies are (re)built following the COVID-19 pandemic, these attributes of an inclusive economy—based on the current literature—can be used to develop, and then monitor progress of, economic policy that will reduce health inequalities, improve health and mitigate against climate change.

IntroductionEffective public financial management (PFM) ensures public health funds are used to deliver services in the best way possible. Given the global call for universal health coverage, and concerns about the management of public funds in many low-income and middle-income countries, PFM has become an important area of research. South Africa has a robust PFM framework, that is generally adhered to, and yet financial outcomes have remained poor. In this paper, we describe how a South African provincial department of health tried to strengthen its PFM processes by deploying finance managers into service delivery units, involving service delivery managers in the monthly finance meeting, using a weekly committee to review expenditure requests and starting a weekly managers’ ‘touch-base’ meeting. We assess whether these strategies strengthened collaboration and trust and how this impacted on PFM.MethodThis research used a case study design with ethnographic methods. Semi-structured interviews (n=30) were conducted with participant observations. Thematic analysis was used to identify emergent themes and collaborative public management theory was then used to frame the findings. The authors used reflexive methods, and member checking was conducted.ResultsThe deployment of staff and touch-base meeting illustrated the potential of multidisciplinary teams when members share power, and the importance of impartial leadership when trying to achieve consensus on how to prioritise resource use. However, the service delivery and finance managers did not manage to collaborate in the monthly finance meeting to develop realistic budgets, or to reprioritise expenditure when required. The resulting mistrust threatened to derail the other strategies, highlighting how critical trust is for collaboration.ConclusionEffective PFM requires authentic collaboration between service delivery and finance managers; formal processes alone will not achieve this. We recommend more opportunities for ‘boundary crossing’, embedding finance managers in service delivery units and impartial effective leadership.

IntroductionThe COVID-19 pandemic has had a significant impact on the physical and mental functioning of healthcare professionals, especially those working on the ‘frontline’, and other hospital workers. At the onset of the crisis, various interventions were introduced to promote resilience and offer mental support to these professionals. However, it is unknown whether the interventions will meet the needs of professionals as the COVID-19 pandemic continues.The goal of this exploratory study is to gain insight in factors that protect the vitality and resilience of Dutch hospital employees during the so-called ‘second wave’ of the COVID-19 pandemic. This paper describes the study protocol.Methods and analysisThis exploratory study applies a mixed-methods design, using both quantitative and qualitative methods of data collection and analysis. The first part of the study (substudy I) consists of surveys among doctors and nurses in COVID-19 departments and non-COVID-19 departments, and other professionals in the hospital (ie, managers and homeworkers) in 2020 and 2021. The second part of the study (substudy II) consists of focus groups and interviews among professionals of the intensive care unit, COVID-19 departments and infection prevention units.Ethics and disseminationThe research protocol for this study has been approved by the Medical Ethics Committee (MEC-2020-0705). The outcomes of this study will be used to develop and implement interventions to support hospital employees maintaining their vitality and resilience during and after the COVID-19 pandemic. Employees with vitality experience less work-related stress and make a positive contribution to healthcare quality.

ObjectiveThis paper describes the development of a tool for assessing organisational readiness to conduct knowledge translation (KT) among academic institutions in low-income and middle-income countries (LMICs).DesignA literature review and stakeholder consultation process were conducted to identify constructs relevant for assessing KT readiness in LMICs. These were face-validated with LMIC stakeholders and organised into a Likert-scale questionnaire.ParticipantsThe questionnaire was distributed to researchers based at six LMIC academic institutions and members of a global knowledge-to-action thematic working group.Outcome measuresAn exploratory factor analysis was used to identify underlying dimensions for assessing institutional readiness to conduct KT.Results111 respondents with varied KT experiences from 10 LMICs were included in the analysis. We selected 5 factors and 23 items, with factor loadings from 0.40 to 0.77. These factors include (1) institutional climate, (2) organisation change efficacy, (3) prioritisation and cosmopolitanism, (4) self-efficacy, and (5) financial resources. These factors accounted for 69% of the total variance, with Cronbach’s alpha coefficients of 0.78, 0.73, 0.62, 0.68 and 0.52, respectively.ConclusionsThis study identifies a tool for assessing readiness of LMIC academic institutions to conduct KT and unique opportunities for building capacity. The organisational focus of these factors underscores the need for strategies that address organisational systems and structures in addition to individual skills. Future research will be conducted to understand determinants of these factors and develop a comprehensive set of capacity building strategies responsive to academic institutions in LMICs.

Mobile phones are increasingly used to facilitate in-service training for frontline health workers (FLHWs). Mobile learning (mLearning) programmes have the potential to provide FLHWs with high quality, inexpensive, standardised learning at scale, and at the time and location of their choosing. However, further research is needed into FLHW engagement with mLearning content at scale, a factor which could influence knowledge and service delivery. Mobile Academy is an interactive voice response training course for FLHWs in India, which aims to improve interpersonal communication skills and refresh knowledge of preventative reproductive, maternal, neonatal and child health. FLHWs dial in to an audio course consisting of 11 chapters, each with a 4-question true/false quiz, resulting in a cumulative pass/fail score. In this paper, we analyse call data records from the national version of Mobile Academy to explore coverage, user engagement and completion. Over 158 596 Accredited Social Health Activists (ASHAs) initiated the national version, while 111 994 initiated the course on state-based platforms. Together, this represents 41% of the estimated total number of ASHAs registered in the government database across 13 states. Of those who initiated the national version, 81% completed it; and of those, over 99% passed. The initiation and completion rates varied by state, with Rajasthan having the highest initiation rate. Many ASHAs made multiple calls in the afternoons and evenings but called in for longer durations earlier in the day. Findings from this analysis provide important insights into the differential reach and uptake of the programme across states.

A prominent view on personal identity over time, Jeff McMahan’s ‘Embodied Mind Account’ (2002) holds that we cease to exist only once our brains can no longer sustain the basic capacity to uphold consciousness. One of the many implications of this view on identity persistence is that we continue to exist throughout even the most severe cases of dementia, until our consciousness irreversibly shuts down. In this paper, I argue that, while the most convincing of prominent accounts of personal identity over time, McMahan’s account faces serious challenges in explanatory power of dementias and related neurodegenerative conditions. Particularly, this becomes visible in the face of emerging methods for neural tissue regeneration, and the possibility of ‘re-emerging patients’. I argue that medical professionals’ neglecting qualitative aspects of identity risks resulting in grave misunderstandings in decision-making processes, and ethically objectionable outcomes in future practices. Finally, I propose revisions which could potentially salvage the great benefits that Embodied Mind Theory still can bring to the field of dementia care in terms of understanding life, death, and identity across the lifespan.

Computer-assisted telephone interviews (CATI) through mobile phones are a low-cost, rapid and safe way to collect data. However, decisions for how such mobile phone surveys are designed and implemented, and their data analysed, can have implications for the sample reached, and in turn affect the generalisability of sample estimates. In this practice paper, we propose a framework for extending the use of CATI–mobile phone surveys in India, which can be applied broadly to future surveys conducted using this method. Across the stages of design, implementation and analysis, we outline challenges in ensuring that the data collected through such surveys are representative and provide recommendations for reducing non-coverage and non-response errors, thereby enabling practitioners in India to use CATI–mobile phone surveys to estimate population statistics with lower bias. We support our analysis by drawing on primary data that we collected in five mobile phone surveys across nine Indian states in 2020. Our recommendations can help practitioners in India improve the representativeness of data collected through mobile phone surveys and generate more accurate estimates.

Clinical research conducted to Good Clinical Practice (GCP) standards is increasingly being undertaken in resource-constrained low-income and middle-income countries (LMICs) settings. This presents unique challenges that differ from those faced in high-income country (HIC) contexts, due to a dearth of infrastructure and unique socio-cultural contexts. Field experiences by research teams working in these LMIC contexts are thus critical to advancing knowledge on successful research conduct in these settings. The Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine has operated in The Gambia, a resource-constrained LMIC for over 70 years and has developed numerous research support platforms and systems. The unit was the lead clinical collaborator in a recently completed Expanded Program on Immunization Consortium (EPIC) study, involving a multicountry collaboration across five countries including the USA, Canada, Belgium, Papua New Guinea and The Gambia. The EPIC study recruited and completed follow-up of 720 newborn infants over 2 years. In this paper, we provide in-depth field experience covering challenges faced by the Gambian EPIC team in the conduct of this study. We also detail some reflections on these challenges. Our findings are relevant to the international research community as they highlight practical day-to-day challenges in conducting GCP standard clinical research in resource-constrained LMIC contexts. They also provide insights on how study processes can be adapted early during research planning to mitigate challenges.

ObjectiveEssential medicines lists have been created and used globally in countries that range from low-income to high-income status. The aim of this paper is to compare the essential medicines list of high-income countries with each other, the WHO’s Model List of Essential Medicines and the lists of countries of other income statuses.DesignHigh-income countries were defined by World Bank classification. High-income essential medicines lists were assessed for medicine inclusion and were compared with the subset of high-income countries, the WHO’s Model List and 137 national essential medicines lists. Medicine lists were obtained from the Global Essential Medicines database. Countries were subdivided by income status, and the groups’ most common medicines were compared. Select medicines and medicine classes were assessed for inclusion among high-income country lists.ResultsThe 21 high-income countries identified were most like each other when compared with other lists. They were more like upper middle-income countries and least like low-income countries. There was significant variability in the number of medicines on each list. Less than half (48%) of high-income countries included a newer diabetes medicines in their list. Most countries (71%) included naloxone while every country including at least one opioid medicine. More than half of the lists (52%) included a medicine that has been globally withdrawn or banned.ConclusionEssential medicines lists of high-income countries are similar to each other, but significant variations in essential medicine list composition and specifically the number of medications included were noted. Effective medicines were left off several countries’ lists, and globally recalled medicines were included on over half the lists. Comparing the essential medicines lists of countries within the same income status category can provide a useful subset of lists for policymakers and essential medicine list creators to use when creating or maintaining their lists.

IntroductionIschaemic heart disease (IHD) is one of the leading causes of death and disease burden in India affecting all age groups. To reduce the deaths and tackle the burden of existing IHD, the government approach has been mostly through the National Health Policy (2017) and National Programme for Prevention and Control of Diabetes, Cardiovascular diseases and Stroke. This paper offers a protocol for the systematic review of studies exploring the factors influencing service readiness of the public health system of India to tackle the burden of IHD.Methods and analysisElectronic databases of Embase (Ovid), AMED (Ovid), HMIC (Ovid), BNI (ProQuest), CINAHL (EBSCO), EMCARE (Ovid), PsycINFO (ProQuest), MEDLINE/PubMed and Web of Science (Clarivate Analytics) will be searched till 2020 for primary studies. Grey literature will be accessed through OpenGrey, TRIP Medical, WHO database, MoHFW website, Open Government Data (OGD) Platform of India and Google Scholar (between 2010 and 2020). Primary studies meeting the eligibility criteria and grey literature published in English between 2010 and 2020 will be included. Data will be analysed through a conceptual framework, and the primary outcome will constitute both quantitative and qualitative data. The quality of included studies will be assessed based on study design. Data will be managed on the COVIDENCE platform. All authors will be involved in data extraction, quality appraisal, data synthesis and formulation of the final draft.Ethics and disseminationThis study, being a systematic review, does not involve any clinical trial, primary data collection or empirical study involving humans or animals. Therefore, no ethical permissions were sought by reviewers.PROSPERO registration numberCRD42020219490.

The globe is gripped by the COVID-19 pandemic. Mass population vaccination is seen as the solution. As vaccines become available, governments aim to deploy them as rapidly as possible. It is important, therefore, that the efficiency of vaccination processes is optimal.Operations management is concerned with improving processes and comprises systematic approaches such as Lean. Lean focuses explicitly on process efficiency through the elimination of non-value adding steps to optimise processes for those who use and depend on them.Technology-enhanced learning can be a strategy to build improvement capability at scale. A massive online programme to build capability in Lean has been developed by the regulator of England's National Health Service. Beta testing of this programme has been used by some test sites to refine their COVID-19 vaccination processes. The paper presents a case example of massive online learning supporting the use of Lean in the day-to-day operations management of COVID-19 vaccine processes.The case example illustrates the challenges that vaccination processes may present and the need for responsive and effective operations management. Building capability to respond rapidly and systematically in dynamic situations to optimise flow, safety and patient experience may be beneficial.Given the national imperative to achieve mass vaccination as rapidly as possible, systematic improvement methods such as Lean may have a contribution to make. Massive online programmes, such as that described here, may help with this effort by achieving timely knowledge transfer at large scale.

Health management information systems (HMIS) are a crucial source of timely health statistics and have the potential to improve reporting in low-income countries. However, concerns about data quality have hampered their widespread adoption in research and policy decisions. This article presents results from a data verification study undertaken to gain insights into the quality of HMIS data in Ethiopia. We also provide recommendations for working with HMIS data for research and policy translation. We linked the HMIS to the 2016 Emergency Obstetric and Newborn Care Assessment, a national census of all health facilities that provided maternal and newborn health services in Ethiopia. We compared the number of visits for deliveries and caesarean sections (C-sections) reported in the HMIS in 2015 (January–December) to those found in source documents (paper-based labour and delivery and operating theatre registers) in 2425 facilities across Ethiopia. We found that two-thirds of facilities had ‘good’ HMIS reporting for deliveries (defined as reporting within 10% of source documents) and half had ‘very good’ reporting (within 5% of source documents). Results were similar for reporting on C-section deliveries. We found that good reporting was more common in urban areas (OR: 1.30, 95% CI 1.06 to 1.59), public facilities (OR: 2.95, 95% CI 1.38 to 6.29) and in hospitals compared with health centres (OR: 1.71, 95% CI 1.13 to 2.61). Facilities in the Somali and Afar regions had the lowest odds of good reporting compared with Addis Ababa and were more likely to over-report deliveries in the HMIS. Further work remains to address remaining discrepancies in the Ethiopian HMIS. Nonetheless, our findings corroborate previous data verification exercises in Ethiopia and support greater use and uptake of HMIS data for research and policy decisions (particularly, greater use of HMIS data elements (eg, absolute number of services provided each month) rather than coverage indicators). Increased use of these data, combined with feedback mechanisms, is necessary to maintain data quality.

ObjectiveTo identify the risk factors associated with complaints, malpractice claims and impaired performance in medical practitioners.DesignSystematic review.Data sourcesOvid-Medline, Ovid Embase, Scopus and Cochrane Central Register of Controlled Trials were searched from 2011 until March 2020. Reference lists and Google were also handsearched.ResultsSixty-seven peer-reviewed papers and three grey literature publications from 2011 to March 2020 were reviewed by pairs of independent reviewers. Twenty-three key factors identified, which were categorised as demographic or workplace related. Gender, age, years spent in practice and greater number of patient lists were associated with higher risk of malpractice claim or complaint. Risk factors associated with physician impaired performance included substance abuse and burn-out.ConclusionsIt is likely that risk factors are interdependent with no single factor as a strong predictor of a doctor’s risk to the public. Risk factors for malpractice claim or complaint are likely to be country specific due to differences in governance structures, processes and funding. Risk factors for impaired performance are likely to be specialty specific due to differences in work culture and access to substances. New ways of supporting doctors might be developed, using risk factor data to reduce adverse events and patient harm.PROSPERO registration numberPROSPERO registration number: CRD42020182045.

Chronic kidney disease (CKD) is a global public health problem, seemingly affecting individuals from low-income and-middle-income countries (LMICs) disproportionately, especially in sub-Saharan Africa. Despite the growing evidence pointing to an increasing prevalence of CKD across Africa, there has not been an Africa-wide concerted effort to provide reliable estimates that could adequately inform health services planning and policy development to address the consequences of CKD. Therefore, we established the CKD in Africa (CKD-Africa) Collaboration. To date, the network has curated data from 39 studies conducted in 12 African countries, totalling 35 747 participants, of which most are from sub-Saharan Africa. We are, however, continuously seeking further collaborations with other groups who have suitable data to grow the network. Although many successful research consortia exist, few papers have been published (with none from Africa) detailing the challenges faced and lessons learnt in setting up and managing a research consortium. Drawing on our experience, we describe the steps taken and the key factors required to establish a functional collaborative consortium among researchers in Africa. In addition, we present the challenges we encountered in building our network, how we managed those challenges and the benefit of such a collaboration for Africa. Although the CKD-Africa Collaboration is focused primarily on CKD research, many of the lessons learnt can be applied more widely in public health research in LMICs.

Interspecialty referrals for increasingly complex hospital inpatients are common and miscommunication often leads to delays in patient care. In a district general hospital, a web-based system generated an email referral, which lacked visibility and tracking/audit of the process, with no record generated automatically in paper inpatient notes or electronic patient records (EPR). We aimed to improve the visibility and safety of the interspecialty referral system.We canvassed stakeholders, informally and via an online satisfaction survey, collecting qualitative and quantitative data about attitudes to the existing system, generating ideas for change. We process mapped the system, identifying points of weakness. We adapted our EPR system, using a work-around solution, to develop a form that could be emailed from the EPR. This generated a permanent record within the EPR and an electronic record of the referral having been sent. We measured the visibility of referrals and responses within the EPR. We generated an online training ‘how-to’ video and reaudited stakeholder satisfaction.There was a significant increase in the proportion of junior doctors satisfied or very satisfied with the interspecialty referral system (27/31 postintervention; 87.1% vs 26/55 preintervention; 47%; pWe developed a more visible and reliable interspecialty referral system, adapting existing EPR capabilities, which was popular with users and led to cultural change in interspecialty referral responders. A formal EPR redesign, informed by our project, is in development.