In the eye of the beholder: To make global health estimates useful, make them more socially robust

A plethora of new development goals and funding institutions have greatly increased the demand for internationally comparable health estimates in recent years, and have brought important new players into the field of health estimate production. These changes have rekindled debates about the validity and legitimacy of global health estimates. This paper draws on country case studies and personal experience to support our opinion that the production and use of estimates are deeply embedded in specific social, economic, political and ideational contexts, which differ at different levels of the global health architecture. Broadly, most global health estimates tend to be made far from the local contexts in which the data upon which they are based are collected, and where the results of estimation processes must ultimately be used if they are to make a difference to the health of individuals. Internationally standardised indicators are necessary, but they are no substitute for data that meet local needs, and that fit with local ideas of what is credible and useful. In other words, data that are both technically and socially robust for those who make key decisions about health. We suggest that greater engagement of local actors (and local data) in the formulation, communication and interpretation of health estimates would increase the likelihood that these data will be used by those most able to translate them into health gains for the longer term. Besides strengthening national information systems, this requires ongoing interaction, building trust and establishing a communicative infrastructure. Local capacities to use knowledge to improve health must be supported

What Makes a National Pharmaceutical Track and Trace System Succeed?

__Background:__ Track and trace systems are increasingly being implemented as a technological solution to secure pharmaceutical supply chains. Turkey was the first country to implement a full pharmaceutical track and trace system throughout the entire regulated domestic supply chain. This article explores the emergence and functioning of this system and the consequences for substandard and falsified medicine with a focus on the underlying political and economic factors. __Methods:__ This study uses an explanatory case study approach that combined interviews with purposefully selected key informants and document analyses. __Results:__ The main drivers for implementing the pharmaceutical track and trace system in Turkey centered on the elimination of reimbursement fraud and the prevention of falsified medicine in the regulated supply chain. Although stakeholders experienced both physical and software-related problems in implementation, the alignment of incentives of all stakeholders with the power of the state, along with leeway for adaptations, ultimately resulted in a successful process. This track and trace system provides a clean regulated supply chain, minimizes reimbursement fraud, facilitates fast market recalls, and can flag likely medicine shortages. Staff previously engaged in pharmacy inspections now concentrate on ensuring production quality, which reduces the risk of substandard medicines. __Conclusions:__ In Turkey, 4 factors drove the successful implementation of pharmaceutical track and trace: the political determination to eliminate reimbursement fraud, a large pharmaceutical market dominated by a single payer, medicine reimbursement being contingent on verified dispensing and prescription, and flexibility to adapt the system according to the needs of stakeholders during implementation

Which health research gets used and why? An empirical analysis of 30 cases

Background: While health research is considered essential for improving health worldwide, it remains unclear how it is best organized to contribute to health. This study examined research that was part of a Ghanaian-Dutch research program that aimed to increase the likelihood that results would be used by funding research that focused on national research priorities and was led by local researchers. The aim of this study was to map the contribution of this research to action and examine which features of research and translation processes were associated with the use of the results. Methods: Using Contribution Mapping, we systematically examined how 30 studies evolved and how results were used to contribute to action. We combined interviews with 113 purposively selected key informants, document analysis and triangulation to map how research and translation processes evolved and contributions to action were realized. After each case was analysed separately, a cross-case analysis was conducted to identify patterns in the association between features of research processes and the use of research. Results: The results of 20 of the 30 studies were used to contribute to action within 12 months. The priority setting and proposal selection process led to the funding of studies which were from the outset closely aligned with health sector priorities. Research was most likely to be used when it was initiated and conducted by people who were in a position to use their results in their own work. The results of 17 out of 18 of these user-initiated studies were translated into action. Other features of research that appeared to contribute to its use were involving potential key users in formulating proposals and developing recommendations. Conclusions: Our study underlines the importance of supporting research that meets locally-expressed needs and that is led by people embedded in the contexts in which results can be used. Supporting the involvement of health sector professionals in the design, conduct and interpretation of research appears to be an especially worthwhile investment

Identifying market risk for substandard and falsified medicines

__Introduction:__ Substandard and falsified medicines undermine health systems. We sought to unravel the political and economic factors which drive the production of these products, and to explain how they reach patients. __Methods:__ We conducted in-depth case studies in China, Indonesia, Turkey and Romania. We reviewed academic papers and press reports (n = 840), developing semi-structured questionnaires. We interviewed regulators, policy-makers, pharmaceutical manufacturers, physicians, pharmacists, patients and academics (n=88). We coded data using NVivo software, and developed an analytic framework to assess national risks for substandard and falsified medicines. We tested the framework against cases reported to the World Health Organization, from countries at all income levels. __Results:__ We found that increasing political commitment to provision of universal health coverage has led to public procurement policies aimed at lowering prices of medical products. In response, legitimate, profit-driven pharmaceutical companies protect their margins by cutting costs, or withdrawing from less profitable markets, while distributors engage in arbitrage. Meanwhile, health providers sometimes protect profits by 'upselling' patients to medicines not covered by insurers. Cost-cutting can undermine quality assurance, leading to substandard or degraded medicines. Other responses contribute to shortages, irrational demand and high prices. All of these provide market opportunities for producers of falsified products; they also push consumers outside of the regular supply chain, providing falsifiers with easy access to customers. The analytic framework capturing these interactions explained cases in most high and middle-income settings; additional factors operate in the poorest countries. __Conclusions:__ Most efforts to secure medicine quality currently focus on product regulation. However, our research suggests market mechanisms are key drivers for poor quality medicines, including where political commitments to universal health coverage are under-resourced. We have developed a framework to guide country-specific, system-wide analysis. This can flag risks and pinpoint specific actions to protect medicine quality, and thus health

Reaching rural communities through 'Healthy Entrepreneurs': a cross-sectional exploration of community health entrepreneurship's role in sexual and reproductive health

The purpose of the current study was to explore the association between community health entrepreneurship and the sexual and reproductive health status of rural households in West-Uganda. We collected data using digital surveys in a cluster-randomized cross-sectional cohort study. The sample entailed 1211 household members from 25 randomly selected villages within two subcounties, of a rural West-Ugandan district. The association between five validated sexual and reproductive health outcome indicators and exposure to community health entrepreneurship was assessed using wealth-adjusted mixed-effects logistic regression models. We observed that households living in an area where community health entrepreneurs were active reported more often to use at least one modern contraceptive method [odds ratios (OR): 2.01, 95% CI: 1.30-3.10] had more knowledge of modern contraceptive methods (OR: 7.75, 95% CI: 2.81-21.34), knew more sexually transmitted infections (OR: 1.86, 95% CI: 1.14-3.05), and mentioned more symptoms of sexually transmitted infections (OR: 1.83, 95% CI: 1.18-2.85). The association between exposure to community health entrepreneurship and communities' comprehensive knowledge of HIV/AIDS was more ambiguous (OR: 1.27, 95% CI: 0.97-1.67). To conclude, households living in areas where community health entrepreneurs were active had higher odds on using modern contraceptives and had more knowledge of modern contraceptive methods, sexually transmitted infections and symptoms of sexually transmitted infections. This study provides the first evidence supporting the role of community health entrepreneurship in providing rural communities with sexual and reproductive health care

The church and paediatric HIV care in rural South Africa

Religion has substantial – positive and negative – influence on South Africa’s HIV context. This qualitative study explored possibilities for positive church engagement in paediatric HIV care in a rural district in Limpopo Province, South Africa. Opinions, attitudes and experiences of various stakeholders including religious leaders, healthcare workers and people infected/affected with/by HIV were investigated through participant observation, semi-structured interviews and focus group discussions. During the research the original focus on paediatric HIV care shifted to HIV care in general in reaction to participant responses. Participants identified three main barriers to positive church engagement in HIV care: (a) stigma and disclosure; (b) sexual associations with HIV and (c) religious beliefs and practices. All participant groups appreciated the opportunity and relevance of strengthening church involvement in HIV care. Opportunities for positive church engagement in HIV care that participants identified included: (a) comprehensive and holistic HIV care when churches and clinics collaborate; (b) the wide social reach of churches and (c) the safety and acceptance in churches. Findings indicate that despite barriers great potential exists for increased positive church engagement in HIV care in rural South Africa. Recommendations include increased medical knowledge and dialogue on HIV/AIDS within church settings, and increased collaboration between churches and the medical sector

Disclosure of human immunodeficiency virus status to children in South Africa: A comprehensive analysis

Background: The extent of disclosure of HIV status to children and adolescents and the context facilitating their disclosure process have received little attention. Objectives: To assess disclosure and provide a comprehensive analysis of characteristics associated with disclosure to children (3–14 years) receiving antiretroviral treatment in a South African semi-urban clinic. Methods: This cross-sectional study used structured interview administered questionnaires which were supplemented with medical record data. Predictors included child, caregiver, clinical and socio-economic characteristics, viral suppression, immune response, adherence, health-related quality of life and family functioning. Results: We included 190 children of whom 45 (23.7%) received disclosure about their HIV status, of whom 28 (14.7%) were partially disclosed and 17