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Introduction: As low-income countries (LICs) shoulder a disproportionate share of the world's burden of critical illnesses, they must continue to build critical care capacity outside conventional intensive care units (ICUs) to address mortality and morbidity, including on general medical wards. A lack of data on the ability to treat critical illness, especially in non-ICU settings in LICs, hinders efforts to improve outcomes. Methods: This was a secondary analysis of the cross-sectional Malawi Emergency and Critical Care (MECC) survey, administered from January to February 2020, to a random sample of nine public sector district hospitals and all four central hospitals in Malawi. This analysis describes inputs, systems, and barriers to care in district hospitals compared to central hospital medical wards, including if any medical wards fit the World Federation of Intensive and Critical Care Medicine (WFSICCM) definition of a level 1 ICU. We grouped items into essential care bundles for service readiness compared using Fisher's exact test. Results: From the 13 hospitals, we analysed data from 39 medical ward staff members through staffing, infrastructure, equipment, and systems domains. No medical wards met the WFSICCM definition of level 1 ICU. The most common barriers in district hospital medical wards compared to central hospital wards were stock-outs (29%, Cl: 21% to 44% vs 6%, Cl: 0% to 13%) and personnel shortages (40%, Cl: 24% to 67% vs 29%, Cl: 16% to 52%) but central hospital wards reported a higher proportion of training barriers (68%, Cl: 52% to 73% vs 45%, Cl: 29% to 60%). No differences were statistically significant. Conclusion: Despite current gaps in resources to consistently care for critically ill patients in medical wards, this study shows that with modest inputs, the provision of simple life-saving critical care is within reach. Required inputs for care provision can be informed from this study. [ABSTRACT FROM AUTHOR]

This qualitative study documented the effects of uterine fibroids on the suffering of women in Haiti. It makes a unique contribution by re-socializing this disease, by making visible the social inequalities and what is at stake for the women, for their families, and for healthcare delivery. Uterine fibroid is a benign tumor of the uterus, common in gynecology, but profoundly malignant in how it affects women's lives. Little has been reported on their lived experiences. Haiti has historical, social, and economic factors that hinder the search for treatment. The study explores how and why patients seek surgical care for uterine fibroids at Mirebalais University Hospital. Seventeen in-depth interviews with patients and seven accompanying family members were conducted and recorded in Creole and translated into English, along with participant observations in two patients' homes. Content and narrative analysis were done iteratively, and the processual ethnographic method was used to relate our findings to Haitian history, to the context of the study, and to future implications. The women's experience of accompaniment, their suffering in their pèlerinage (care-seeking journey), and the troubling social impact of uterine fibroids make it a socially malignant illness. The study shows that it is critical to address the suffering of women afflicted with uterine fibroids by strengthening the Haitian health system, improving economic advantages, and establishing ways for them to gain access to social goods and participate in community activities. [ABSTRACT FROM AUTHOR]

Despite high health expenditures, Lesotho had some of the world's worst health indicators between 2000 and 2014. Official development assistance tripled from $37 to $107 million. PEPFAR funding rose from $3.8 to $32.4 million. Yet, deaths from TB, HIV, infant mortality, and maternal mortality remained unchanged. Lesotho had declining health outcomes amidst increased disease-focused financing and several large infrastructure projects. A World Bank loan financed the state-of-the-art Mamohato Hospital, and the U.S.-supported $362.5 million Millennium Challenge Corporation Project supported primary and secondary health infrastructure. This analysis uses the WHO Health Systems Framework to explore the unintended consequences of health financing on Lesotho's health outcomes. The WHO Health Systems Framework can be used to optimize health financing through investments in health service delivery, health workforce, health information, essential medicines, leadership, and equitable financial strategies. This approach can support governments to achieve universal health coverage and develop comprehensive health systems. [ABSTRACT FROM AUTHOR]

In 2000, all 191 United Nations member states agreed to work toward the achievement of a set of health and development goals by 2015. The achievement of these eight goals, the Millennium Development goals (MDGs) is highly dependent on improving the status of women, who play a key role in health and education in families and communities around the world. Yet structural violence, defined as the systematic exclusion of a group from the resources needed to develop their full human potential, remains a significant barrier against women's development and threatens the achievement of the MDGs. Although sound evidence has long existed for improving women's survival, the will to address women's health concretely and holistically is only recently gaining the advocacy needed to change policy. Concrete examples of the integration of approaches to mitigate structural violence within the delivery of health services do exist and should be incorporated into global advocacy for women's health. [ABSTRACT FROM AUTHOR]

In many developing countries, Directly Observed Therapy (DOT) for tuberculosis has been undertaken mainly in the clinic setting. However, clinic-based DOT may create a high patient load in already overburdened health facilities and increase barriers to care by requiring patients to travel to clinic frequently for therapy. Community-based DOT (CBDOT) may overcome some of these problems. This aims of this review are (a) to describe the main features of CBDOT programs, and (b) to compare features and outcomes of CBDOT programs that do and do not offer financial reward for CBDOT providers. Ten major features define CBDOT program structure and function. Programs that paid their CBDOT providers tended to differ from unpaid programs based on all of these features. CBDOT programs in which providers received financial reward had success rates of 85.7 versus 77.6% in programs without financial reward for providers. This difference was not statistically significant. CBDOT programs fall into two major archetypes, which differ in their structure and possibly in their outcomes. [ABSTRACT FROM AUTHOR]

As HIV treatment is scaled-up in resource-poor settings, the timely identification of persons with HIV infection remains an important challenge. Most people with HIV are unaware of their status, and those who are often present late in the course of their illness. Free-standing voluntary counseling and testing sites often have poor uptake of testing. We aimed to evaluate a 'providerinitiated' HIV testing strategy in a primary care clinic in rural resource-poor Haiti by reviewing the number of visits made to clinic before an HIV test was performed in those who were ultimately found to have HIV infection. In collaboration with the Haitian Ministry of Health, a nongovernmental organization (Partners In Health) scaled up HIV care in central Haiti by reinforcing primary care clinics, instituting provider-initiated HIV testing and by providing HIV treatment in the context of primary medical care, free of charge to patients. Among a cohort of people with HIV infection, we assessed retrospectively for delays in or 'missed opportunities' for diagnosis of HIV by the providers in one clinic. Of the first 117 patients diagnosed with HIV in one clinic, 100 (85%) were diagnosed at the first medical encounter. Median delay in diagnosis for the remaining 17 was only 62 days (IQR 19 - 122; range 1 - 272). There was no statistical difference in CD4 cell count between those with and without a delay. 3787 HIV tests were performed in the period reviewed. Provider-initiated testing was associated with high volume uptake of HIV testing and minimal delay between first medical encounter and diagnosis of HIV infection. In scale up of HIV care, providerinitiated HIV testing at primary care clinics can be a successful strategy to identify patients with HIV infection. [ABSTRACT FROM AUTHOR]

Three decades ago, the world's ministries of health declared primary health care-the delivery of basic preventive and curative services-a top priority. Since then, however the world's poorest countries have not met most primary health care goals. Twenty-six years after the Declaration of Alma Ata, we are said to be living in a time of "limited resources," a phrase that construes various health interventions as competing priorities. As HIV has become the leading infectious cause of adult death in much of the world, it is difficult to argue that AIDS prevention and care are not ranking priorities for primary health care, yet precisely such arguments have held sway among international health policy makers. We present new information emerging from the scale-up of an established and integrated AIDS prevention-and- care program, based initially in a squatter settlement in central Haiti, to a second site in rural Haiti. The program includes robust prevention efforts as well as community-based therapy for advanced AIDS; three related components-women's health and active case finding and therapy for tuberculosis and sexually transmitted infections-were central to this effort. We tracked changes in key indices over the 14 months following the introduction of these services to a public clinic in central Haiti. We found that integrated AIDS prevention and care, including the use of antiretroviral agents, to be feasible in resource-poor settings and that such efforts may have favorable and readily measured impact on a number of primary health care goals, including vaccination, family planning, tuberculosis case finding and cure, and health promotion. Other collateral benefits, though less readily measured, include improved staff morale and enhanced confidence in public health and medicine. We conclude that improving AIDS prevention and treatment can help to reinvigorate flagging efforts to promote universal primary health care. [ABSTRACT FROM AUTHOR]

Focuses on the WHO/UNAIDS "3 by 5" initiative, which has the goal of getting three million people on antiretroviral treatment before the end of 2005. Cost of the initiative; Number of countries targeted for the program; Idea that the human-rights based approach will provide universal access to AIDS treatment; The need for massive financial assistance from international agencies and the donor community; The rights-based goals of the 1978 Alma-Ata declaration; Idea that the distribution of resources for health has been determined by the market economics; Assertion that government structures have to reflect the population's need; The responsibility for assuring universal rights to health care.

Discusses community-based approaches to AIDS prevention in resource-poor settings such as Haiti. Issue of access to highly-active antiretroviral therapy (HAART); Topic of directly observed therapy with HAART (DOT-HAART); Expansion of the HIV Equity Initiative; Objections to the use of HAART in resource-poor settings; Idea of rethinking costs and benefits.

The article presents the authors' comments on the need to strengthen the health system in Africa following the west African Ebola virus disease epidemic which resulted in over 11000 deaths. The authors note that the global health community is concerned on the need for greater investment in health-system strengthening to reduce the impact of similar outbreaks in the future.