Context and Priorities for Health Systems Strengthening for Pain and Disability in Low- and Middle-Income Countries: A Secondary Qualitative Study and Content Analysis of Health Policies.

Musculoskeletal (MSK) health impairments contribute substantially to the pain and disability burden in low- and middle-income countries (LMICs), yet health systems strengthening (HSS) responses are nascent in these settings. We aimed to explore the contemporary context, framed as challenges and opportunities, for improving population-level prevention and management of MSK health in LMICs using secondary qualitative data from a previous study exploring HSS priorities for MSK health globally and (2) to contextualize these findings through a primary analysis of health policies for integrated management of non-communicable diseases (NCDs) in select LMICs. Part 1: 12 transcripts of interviews with LMIC-based key informants (KIs) were inductively analysed. Part 2: systematic content analysis of health policies for integrated care of NCDs where KIs were resident (Argentina, Bangladesh, Brazil, Ethiopia, India, Kenya, Malaysia, Philippines and South Africa). A thematic framework of LMIC-relevant challenges and opportunities was empirically derived and organized around five meta-themes: (1) MSK health is a low priority; (2) social determinants adversely affect MSK health; (3) healthcare system issues de-prioritize MSK health; (4) economic constraints restrict system capacity to direct and mobilize resources to MSK health; and (5) build research capacity. Twelve policy documents were included, describing explicit foci on cardiovascular disease (100%), diabetes (100%), respiratory conditions (100%) and cancer (89%); none explicitly focused on MSK health. Policy strategies were coded into three categories: (1) general principles for people-centred NCD care, (2) service delivery and (3) system strengthening. Four policies described strategies to address MSK health in some way, mostly related to injury care. Priorities and opportunities for HSS for MSK health identified by KIs aligned with broader strategies targeting NCDs identified in the policies. MSK health is not currently prioritized in NCD health policies among selected LMICs. However, opportunities to address the MSK-attributed disability burden exist through integrating MSK-specific HSS initiatives with initiatives targeting NCDs generally and injury and trauma care

Scalable object-based load balancing in multi-tier architectures

An exponential growth in internet usage and penetration amongst the general population has led to an ever increasing demand for e-commerce applications and other internet-based services. E-commerce applications must provide high levels of service that include reliability, low response times and scalability. Most e-commerce applications follow a multi-tier architecture. As they are highly dynamic and data-intensive, the database is often a bottleneck in the whole system as most systems deploy multiple application servers in the replicated application tier, while only deploying a single database as managing a replicated database is not a trivial task. Hence, in order to achieve scalability, caching of data at the application server is an attractive option.In this thesis, we develop effective load balancing and caching strategies for read-only transaction workloads that help scaling multi-tier architectures and improve their performance. Our strategies have several special features. Firstly, our strategies take into account statistics about the objects of the cache, such as access frequency. Secondly, our algorithms that generate the strategies, despite being object-aware, are generic in nature, and thus, not limited to any specific type of applications. The main objective is to direct a request to an appropriate application server so that there is a high probability that the objects required to serve that request can be accessed from the cache, avoiding a database access. We have developed a whole suite of strategies, which differ in the way they assign objects and requests to application servers. We use distributed caching so as to make better utilization of the aggregate cache capacity of the application servers. Experimental results show that our strategies are promising and help to improve performance.Une croissance exponentielle de l'utilisation d'Internet et sa pénétration dans la population générale ont conduit à une demande toujours croissante d'applications de commerce électronique et d'autres services basés sur l'internet. Les applications de commerce électronique doivent fournir des niveaux élevés de services qui comprennent la fiabilité, un court temps de réponse et de la variabilité dimensionnelle. La plupart des applications de commerce électronique suivent une architecture multi-niveau. Comme elles sont très dynamiques et possèdent une forte intensité de données, la base de données est souvent un goulot d'étranglement dans le système en entier comme la plupart des systèmes déploient des serveurs d'applications multiples dans l'application tierce reproduite. D'un autre côté, le déploiement d'une base de données unique pour la gestion d'une base de données répliquée n'est pas une tâche simple. Ainsi, afin de parvenir à une variabilité dimensionnelle, la mise en cache des données au serveur d'applications est une option attrayante.Dans cette thèse, nous développons un équilibrage de charge efficace et des stratégies de mise en cache qui aident à échelonner les architectures multi-niveaux et à améliorer leurs performances. Nos stratégies ont plusieurs caractéristiques particulières. Premièrement, nos stratégies prennent en compte les statistiques sur les objets de la mémoire cache, comme la fréquence d'accès. Deuxièmement, nos algorithmes qui génèrent les stratégies, tout en étant conscients des objets, sont de nature générique, et donc, ne se limitent pas à un type spécifique d'applications. L'objectif principal est de diriger une requête au serveur d'applications approprié afin qu'il y ait une forte probabilité que les objets requis pour servir cette demande puissent être consultés à partir de la mémoire cache, évitant un accès à la base de données. Nous avons développé toute une série de stratégies qui différent dans leur façon d'assigner des objets et des requêtes aux serveurs d'applications. Nous utilisons une mise en cache distribuée de manière à mieux utiliser la capacité totale de la mémoire cache des serveurs d'applications. Les résultats expérimentaux montrent que nos stratégies sont prometteuses et permettent d'améliorer les performances

Emergency care in South Asia: Challenges and opportunities

One of the striking deficiencies in the current health delivery structure is lack of focus on emergency care in primary health systems, which are ill-equipped to offer appropriate care in emergency situations resulting in a high burden of preventable deaths and disability. Emergency medical systems (EMS) encompass a much wider spectrum from recognition of the emergency, access to the system, provision of pre-hospital care, through definitive hospital care. The burden of death and disability resulting from lack of appropriate emergency care is very high in low- and middle-income countries. In South Asia, health services in general, and emergency care in particular, have failed to attract priority, investments and efforts for a variety of reasons. It has to be emphasized that integrating EMS with other health system components improves health care for the entire community, including children, the elderly, and other vulnerable groups with special needs. Out-of-facility care is an integral component of the health care system in South Asia. EMS focuses on out-of-facility care and also supports efforts to implement cost-effective community health care. There is a possibility of integration of other health services and programmes with an innovative, cost-effective EMS in the region

Strengthening care of injured children globally

Part of the solution to the growing problem of child injury is to strengthen the care that injured children receive. This paper will point out the potential health gains to be made by doing this and will then review recent advances in the care of injured children in individual institutions and countries. It will discuss how these individual efforts have been aided by increased international attention to trauma care. Although there are no major, well-funded global programmes to improve trauma care, recent guidance documents developed by WHO and a broad network of collaborators have stimulated increased global attention to improving planning and resources for trauma care. This has in turn led to increased attention to strengthening trauma care capabilities in countries, including needs assessments and implementation of WHO recommendations in national policy

Emergency medical systems in low- and middle-income countries: recommendations for action.

Emergency medical care is not a luxury for rich countries or rich individuals in poor countries. This paper makes the point that emergency care can make an important contribution to reducing avoidable death and disability in low- and middle-income countries. But emergency care needs to be planned well and supported at all levels--at the national, provincial and community levels--and take into account the entire spectrum of care, from the occurrence of an acute medical event in the community to the provision of appropriate care at the hospital. The mix of personnel, materials, and health-system infrastructure can be tailored to optimize the provision of emergency care in settings with different levels of resource availability. The misconception that emergency care cannot be cost effective in low-income settings is demonstrably inaccurate. Emergencies occur everywhere, and each day they consume resources regardless of whether there are systems capable of achieving good outcomes. With better planning, the ongoing costs of emergency care can result in better outcomes and better cost-effectiveness. Every country and community can and should provide emergency care regardless of their place in the ratings of developmental indices. We make the case for universal access to emergency care and lay out a research agenda to fill the gaps in knowledge in emergency care

A checklist for trauma quality improvement meetings: A process improvement study

Background: Each year approximately five million people die from injuries. In countries where systems of trauma care have been introduced, death and disability have decreased. A major component of developed trauma systems is a trauma quality improvement (TQI) program and trauma quality improvement meeting (TQIM). Effective TQIMs improve trauma care by identifying and fixing problems. But globally, TQIMs are absent or unstructured in most hospitals providing trauma care. The aim of this study was to implement and evaluate a checklist for a structured TQIM. Methods: This project was conducted as a prospective before-and-after study in four major trauma centres in India. The intervention was the introduction of a structured TQIM using a checklist, introduced with a workshop. This workshop was based on the World Health Organization (WHO) TQI Programs short course and resources, plus the developed TQIM checklist. Pre- and post-intervention data collection occurred at all meetings in which cases of trauma death were discussed. The primary outcome was TQIM Checklist compliance, defined by the discussion of, and agreement upon each of the following: preventability of death, identification of opportunities to improve care and corrective actions and a plan for closing the loop. Results: There were 34 meetings in each phase, with 99 cases brought to the pre-intervention phase and 125 cases brought to the post-intervention phase. There was an increase in the proportion of cases brought to the meeting for which preventability of death was discussed (from 94% to 100%, p = 0.007) and agreed (from 7 to 19%, OR 3.7; 95% CI:1.4–9.4, p = 0.004) and for which a plan for closing the loop was discussed (from 2% to 18%, OR 10.9; 95% CI:2.5–47.6, p < 0.001) and agreed (from 2% to 18%, OR 10.9; 95% CI:2.5–47.6, p < 0.001). Conclusion: This study developed, implemented and evaluated a TQIM Checklist for improving TQIM processes. The introduction of a TQIM Checklist, with training, into four Indian trauma centres, led to more structured TQIMs, including increased discussion and agreement on preventability of death and plans for loop closure. A TQIM Checklist should be considered for all centres managing trauma patients.This project was part of the Australia-India Trauma Systems Collaboration (AITSC), funded by the Indian (Department of Science and Technology) and Australian (Department of Industry, Innovation and Science) governments through the Australia India Strategic Research Fund Grand Challenge scheme

‘It’s about time’. Dissemination and evaluation of a global health systems strengthening roadmap for musculoskeletal health – insights and future directions

Actions towards the health-related Sustainable Development Goal 3.4 typically focus on non-communicable diseases (NCDs) associated with premature mortality, with less emphasis on NCDs associated with disability, such as musculoskeletal conditions—the leading contributor to the global burden of disability. Can systems strengthening priorities for an underprioritised NCD be codesigned, disseminated and evaluated? A ‘roadmap’ for strengthening global health systems for improved musculoskeletal health was launched in 2021. In this practice paper, we outline dissemination efforts for this Roadmap and insights on evaluating its reach, user experience and early adoption. A global network of 22 dissemination partners was established to drive dissemination efforts, focussing on Africa, Asia and Latin America, each supported with a suite of dissemination assets. Within a 6-month evaluation window, 52 Twitter posts were distributed, 2195 visitors from 109 countries accessed the online multilingual Roadmap and 138 downloads of the Roadmap per month were recorded. Among 254 end users who answered a user-experience survey, respondents ‘agreed’ or ‘strongly agreed’ the Roadmap was valuable (88.3%), credible (91.2%), useful (90.1%) and usable (85.4%). Most (77.8%) agreed or strongly agreed they would adopt the Roadmap in some way. Collection of real-world adoption case studies allowed unique insights into adoption practices in different contexts, settings and health system levels. Diversity in adoption examples suggests that the Roadmap has value and adoption potential at multiple touchpoints within health systems globally. With resourcing, harnessing an engaged global community and establishing a global network of partners, a systems strengthening tool can be cocreated, disseminated and formatively evaluated