The political dimension of sexual rights:Commentary on the paper by Chandra-Mouli et al.: a never-before opportunity to strengthen investment and action on adolescent contraception, and what we must do to make full use of it

BACKGROUND: The recent commentary article in this journal by Chandra-Mouli et al. speaks of a never-before opportunity to strengthen investment and action on adolescent contraception. We endorse the positive 'can-do' tone of the article, but noticed that at least four issues, which in our view are crucial, merit a comment. MAIN BODY: First of all, the article suggests that there is some sort of shared interest, based on a presumed global consensus around the use of contraceptives by adolescents - which is not the case: sexual rights are controversial. Secondly, for real progress in adolescent contraception to occur, we believe it is critical to thoroughly investigate and mention the factors, including political ones, that would need to be overcome. Thirdly, new avenues need to be explored that allow for accurate and positive teaching of adolescents about contraception in socio-cultural and political environments that are ambivalent about the issue. Fourthly, barriers at the global level that we already know of should not be silenced. There is sufficient evidence to call upon donors and international agencies to choose position and stop obstructing women's - including young women's - access to a broad range of contraceptives. The 'She Decides' movement is a heartening example. CONCLUSION: It is crucial to acknowledge the political dimension of sexual rights. It requires solutions not only at national levels, but also at the global level

Global Surgery – Informing National Strategies for Scaling Up Surgery in Sub-Saharan Africa

Abstract Surgery has the potential to address one of the largest, neglected burdens of disease in low- and middle-income countries (LMICs), especially in sub-Saharan Africa (SSA). The Lancet Commission on Global Surgery (LCoGS) has provided a blueprint for a systems approach to making safe emergency and elective surgery accessible and affordable and has started to enable African governments to develop national surgical plans. This editorial outlines an important gap, which is the need for surgical systems research, especially at district hospitals which are the first point of surgical care for rural communities, to inform the implementation of country plans. Using the Lancet Commission as a starting point and illustrated by two European Union (EU) funded research projects, we point to the need for implementation research to develop and evaluate contextualised strategies. As illustrated by the case study of Zambia, coordination by global and external stakeholders can enable governments to lead national scale-up of essential surgery, supported by national partners including surgical specialist associations

Government or Donor: The Budget for HIV/AIDS Control and Financial Commitment in Bandung City, Indonesia

The number of HIV/AIDS cases in Indonesia has steadily increased since 1987. West Java Province, especially Bandung City, had the highest HIV/AIDS cases among other districts/cities in 2016. Some stakeholders' interventions overlap with others, leading to inefficient use of the limited government budget and flattening international donor funding. This study aimed to estimate the HIV/AIDS budget in Bandung City and then segregate the share of the budget by funding source and objectives. This study was a part of the Priority Setting Involving Stakeholder Using Multiple Criteria (PRISMA) project in 2017 to prioritize HIV/AIDS interventions knowing that Bandung City had the highest HIV/AIDS cases. Data from several institutions and relevant budget allocations were obtained before (2016) and after (2018-2019) the PRISMA project. HIV/AIDS control programs in Bandung City largely depend on international funding: 49% in 2016 (~USD208,898), 85% in 2018 (~USD386,132), and 71% in 2019 (~USD389,943) for a total of ~USD1,433,216. The largest budget was allocated to core interventions, with prevention dominating the budget since 2018. The budget allocated for prevention increased significantly from 2016-2019, most likely under the influence of the PRISMA project

Mapping of research on maternal health interventions in low- and middle-income countries: a review of 2292 publications between 2000 and 2012

Background: Progress in achieving maternal health goals and the rates of reductions in deaths from individual conditions have varied over time and across countries. Assessing whether research priorities in maternal health align with the main causes of mortality, and those factors responsible for inequitable health outcomes, such as health system performance, may help direct future research. The study thus investigated whether the research done in low- and middle-income countries (LMICs) matched the principal causes of maternal deaths in these settings. Methods: Systematic mapping was done of maternal health interventional research in LMICs from 2000 to 2012. Articles were included on health systems strengthening, health promotion; and on five tracer conditions (haemorrhage, hypertension, malaria, HIV and other sexually transmitted infections (STIs)). Following review of 35,078 titles and abstracts in duplicate, data were extracted from 2292 full-text publications. Results: Over time, the number of publications rose several-fold, especially in 2004–2007, and the range of methods used broadened considerably. More than half the studies were done in sub-Saharan Africa (55.4 %), mostly addressing HIV and malaria. This region had low numbers of publications per hypertension and haemorrhage deaths, though South Asia had even fewer. The proportion of studies set in East Asia Pacific dropped steadily over the period, and in Latin America from 2008 to 2012. By 2008–2012, 39.1 % of articles included health systems components and 30.2 % health promotion. Only 5.4 % of studies assessed maternal STI interventions, diminishing with time. More than a third of haemorrhage research included health systems or health promotion components, double that of HIV research. Conclusion: Several mismatches were noted between research publications, and the burden and causes of maternal deaths. This is especially true for South Asia; haemorrhage and hypertension in sub-Saharan Africa; and for STIs worldwide. The large rise in research outputs and range of methods employed indicates a major expansion in the number of researchers and their skills. This bodes well for maternal health if variations in research priorities across settings and topics are corrected

Priority setting for universal health coverage: We need evidence-informed deliberative processes, not just more evidence on cost-effectiveness

Priority setting of health interventions is generally considered as a valuable approach to support low- and middle-income countries (LMICs) in their strive for universal health coverage (UHC). However, present initiatives on priority setting are mainly geared towards the development of more cost-effectiveness information, and this evidence does not sufficiently support countries to make optimal choices. The reason is that priority setting is in reality a value-laden political process in which multiple criteria beyond cost-effectiveness are important, and stakeholders often justifiably disagree about the relative importance of these criteria. Here, we propose the use of ‘evidence-informed deliberative processes’ as an approach that does explicitly recognise priority setting as a political process and an intrinsically complex task. In these processes, deliberation between stakeholders is crucial to identify, reflect and learn about the meaning and importance of values, informed by evidence on these values. Such processes then result in the use of a broader range of explicit criteria that can be seen as the product of both international learning (‘core’ criteria, which include eg, cost-effectiveness, priority to the worse off, and financial protection) and learning among local stakeholders (‘contextual’ criteria). We believe that, with these evidence-informed deliberative processes in place, priority setting can provide a more meaningful contribution to achieving UHC

Priority Setting for Universal Health Coverage: We Need Evidence-Informed Deliberative Processes, Not Just More Evidence on Cost-Effectiveness

Priority setting of health interventions is generally considered as a valuable approach to support low- and middle-income countries (LMICs) in their strive for universal health coverage (UHC). However, present initiatives on priority setting are mainly geared towards the development of more cost-effectiveness information, and this evidence does not sufficiently support countries to make optimal choices. The reason is that priority setting is in reality a value-laden political process in which multiple criteria beyond cost-effectiveness are important, and stakeholders often justifiably disagree about the relative importance of these criteria. Here, we propose the use of ‘evidence-informed deliberative processes’ as an approach that does explicitly recognise priority setting as a political process and an intrinsically complex task. In these processes, deliberation between stakeholders is crucial to identify, reflect and learn about the meaning and importance of values, informed by evidence on these values. Such processes then result in the use of a broader range of explicit criteria that can be seen as the product of both international learning (‘core’ criteria, which include eg, cost-effectiveness, priority to the worse off, and financial protection) and learning among local stakeholders (‘contextual’ criteria). We believe that, with these evidence-informed deliberative processes in place, priority setting can provide a more meaningful contribution to achieving UHC

Critical shortage of capacity to deliver safe paediatric surgery in sub-Saharan Africa: evidence from 67 hospitals in Malawi, Zambia, and Tanzania

IntroductionPaediatric surgical care is a significant challenge in Sub-Saharan Africa (SSA), where 42% of the population are children. Building paediatric surgical capacity to meet SSA country needs is a priority. This study aimed to assess district hospital paediatric surgical capacity in three countries: Malawi, Tanzania and Zambia (MTZ).MethodsData from 67 district-level hospitals in MTZ were collected using a PediPIPES survey tool. Its five components are procedures, personnel, infrastructure, equipment, and supplies. A PediPIPES Index was calculated for each country, and a two-tailed analysis of variance test was used to explore cross-country comparisons.ResultsSimilar paediatric surgical capacity index scores and shortages were observed across countries, greater in Malawi and less in Tanzania. Almost all hospitals reported the capacity to perform common minor surgical procedures and less complex resuscitation interventions. Capacity to undertake common abdominal, orthopaedic and urogenital procedures varied—more often reported in Malawi and less often in Tanzania. There were no paediatric or general surgeons or anaesthesiologists at district hospitals. General medical officers with some training to do surgery on children were present (more often in Zambia). Paediatric surgical equipment and supplies were poor in all three countries. Malawi district hospitals had the poorest supply of electricity and water.ConclusionsWith no specialists in district hospitals in MTZ, access to safe paediatric surgery is compromised, aggravated by shortages of infrastructure, equipment and supplies. Significant investments are required to address these shortfalls. SSA countries need to define what procedures are appropriate to national, referral and district hospital levels and ensure that an appropriate paediatric surgical workforce is in place at district hospitals, trained and supervised to undertake these essential surgical procedures so as to meet population needs