An economic perspective on Malawi's medical "brain drain"

BACKGROUND: The medical "brain drain" has been described as rich countries "looting" doctors and nurses from developing countries undermining their health systems and public health. However this "brain-drain" might also be seen as a success in the training and "export" of health professionals and the benefits this provides. This paper illustrates the arguments and possible policy options by focusing on the situation in one of the poorest countries in the world, Malawi. DISCUSSION: Many see this "brain drain" of medical staff as wrong with developed countries exploiting poorer ones. The effects are considerable with Malawi facing high vacancy rates in its public health system, and with migration threatening to outstrip training despite efforts to improve pay and conditions. This shortage of staff has made it more challenging for Malawi to deliver on its Essential Health Package and to absorb new international health funding. Yet, without any policy effort Malawi has been able to demonstrate its global competitiveness in the training ("production") of skilled health professionals. Remittances from migration are a large and growing source of foreign exchange for poor countries and tend to go directly to households. Whilst the data for Malawi is limited, studies from other poor countries demonstrate the power of remittances in significantly reducing poverty. Malawi can benefit from the export of health professionals provided there is a resolution of the situation whereby the state pays for training and the benefits are gained by the individual professional working abroad. Solutions include migrating staff paying back training costs, or rich host governments remitting part of a tax (e.g. income or national insurance) to the Malawi government. These schemes would allow Malawi to scale up training of health professionals for local needs and to work abroad. SUMMARY: There is concern about the negative impacts of the medical "brain-drain". However a closer look at the evidence for and against the medical "brain-drain" in Malawi suggests that there are potential gains in managing medical migration to produce outcomes that are beneficial to individuals, households and the country. Finally we present several policy options

Cesarean section: More than a maternal health issue

A cesarean section (CS) can be a lifesaving intervention when medically indicated, but it may also lead to adverse short- and long-term health effects for women and childre

Exploring the impact of health worker strikes on maternal and child health in a Kenyan county

Background: Studies of the impact of health care workers’ strikes tend to look at facility-level activity rather than populations, with evidence from low and middle-income countries relatively sparse. This study explored the effect of national strikes on maternal and child health. It looked at the impact on health system activity in both public and non-public sectors (e.g. private, faith-based), on health promotion investments like immunisation, and on disease detection like post-partum haemorrhage (PPH). A 100 day doctors’ strike started in December 2016, a 150 day nurses strike from June 2017 and then the clinical officers for 21 days that September. Methods: Time series descriptive analysis of attendance data from the Kenyan Health Management Information System (public, non-public sector facilities). The setting was Kilifi, a coastal county in Kenya with a population of about 1.5 million. Results: Along the care pathway from antenatal, postnatal and out-patient child health clinics, activity levels dropped markedly in the public sector with only partial compensatory increases in non-public sector activity. The number of fully immunised children fell during the nurses strike as did women seen with PPH during all strikes. These health care strikes caused signifcant adverse health impacts at the time and potentially inter-generationally as exemplifed by the fall in antenatal haematinics supplementation and syphilis testing. Some post-strike ‘’catch-up” activity occurred, however this may have been too late in some instances. Conclusions: Policy-makers at national and county level need to ensure population health is protected at times of strikes and ideally resolve disputes without such action. Not to do so risks major negative effects on maternal and child health. Increased use of the non-public health sector could be done by the authorities in mitigation should strikes occur again

Digital News Media Coverage on Sexual and Gender-Based Violence in Kenya: Scoping the Impact of the COVID-19 Pandemic

Background: Sexual and gender-based violence (SGBV) in Kenya is frequently covered in digital news media. As a powerful influencer of public opinion, news media coverage can have a significant societal impact. This scoping review identifies the extent, nature, and themes of all available digital news media coverage on SGBV in Kenya from June 2019 to July 2020. It analyzes changes in coverage since the start of the COVID-19 pandemic. Method: The methodological framework for scoping reviews developed by Arksey and O’Malley (2005) guided the scoping review. The selected articles were analyzed using NVivo. Results: Analysis of the 340 included articles indicates clear trends in news media coverage on SGBV in Kenya. Before the COVID-19 pandemic, trends include high numbers of news reports, feature articles, and opinion pieces on SGBV, female genital mutilation (FGM) as the most covered form of SGBV, and opinion pieces in line with the Kenya Vision 2030 agenda. Since the implementation of the COVID-19 mitigation measures in Kenya, trends include an increase in news media coverage on SGBV, extensive reporting on the causes of the rise in SGBV cases in Kenya, and increased media attention for domestic and sexual violence. Conclusions: Analysis of the news media coverage demonstrates the health advocacy/ agenda-setting role of the media. The increased reporting on SGBV since the implementation of the COVID-19 mitigation measures could facilitate broad-based awareness

The impact of COVID-19 mitigation measures on sexual and reproductive health in low- and middle-income countries: a rapid review

Pandemic mitigation measures can have a negative impact on access and provision of essential healthcare services including sexual and reproductive health (SRH) services. This rapid review looked at the literature on the impact of COVID-19 mitigation measures on SRH and gender-based violence (GBV) on women in low- and middle-income countries (LMIC) using WHO rapid review guidance. We looked at relevant literature published in the English language from January 2020 to October 2021 from LMICs using WHO rapid review methods. A total of 114 articles were obtained from PubMed, Google Scholar and grey literature of which 20 met the eligible criteria. Our review found that there was an overall reduction in; (a) uptake of services as shown by lower antenatal, postnatal and family planning clinic attendance, (b) service delivery as shown by reduced health facility deliveries, and post abortion care services and (c) reproductive health outcomes as shown by an increase in incidence of GBV especially intimate partner violence. COVID-19 mitigation measures negatively impact SRH of women in LMICs. Findings from this review could inform policy makers in the health sector to recognize the potential adverse effects of COVID-19 responses on SRH in the country, and therefore implement mitigation measure

Intimate partner violence against adolescents and young women in sub-Saharan Africa: who is most vulnerable?

Background: Intimate partner violence (IPV) is a global public health and human rights issue that affects millions of women and girls. While disaggregated national statistics are crucial to assess inequalities, little evidence exists on inequalities in exposure to violence against adolescents and young women (AYW). The aim of this study was to deter- mine inequalities in physical or sexual IPV against AYW and beliefs about gender based violence (GBV) in sub-Saharan Africa (SSA). Methods: We used data from the most recent Demographic and Health Surveys (DHS) conducted in 27 countries in SSA. Only data from surveys conducted after 2010 were included. Our analysis focused on married or cohabiting AYW aged 15–24 years and compared inequalities in physical or sexual IPV by place of residence, education and wealth. We also examined IPV variations by AYW’s beliefs about GBV and the association of country characteristics such as gender inequality with IPV prevalence. Results: The proportion of AYW reporting IPV in the year before the survey ranged from 6.5% in Comoros to 43.3% in Gabon, with a median of 25.2%. Overall, reported IPV levels were higher in countries in the Central Africa region than other sub-regions. Although the prevalence of IPV varied by place of residence, education and wealth, there was no clear pattern of inequalities. In many countries with high prevalence of IPV, a higher proportion of AYW from rural areas, with lower education and from the poorest wealth quintile reported IPV. In almost all countries, a greater pro- portion of AYW who approved wife beating for any reason reported IPV compared to their counterparts who disap- proved wife beating. Reporting of IPV was weakly correlated with the Gender Inequality Index and other societal level variables but was moderately positively correlated with adult alcohol consumption (r = 0.48) and negative attitudes towards GBV (r = 0.38). Conclusion: IPV is pervasive among AYW, with substantial variation across and within countries reflecting the role of contextual and structural factors in shaping the vulnerability to IPV. The lack of consistent patterns of inequalities by the stratifiers within countries shows that IPV against women and girls cuts across socio-economic boundaries sug- gesting the need for comprehensive and multi-sectoral approaches to preventing and responding to IPV

Inequalities in early marriage, childbearing and sexual debut among adolescents in sub-Saharan Africa

Background: Adolescent sexual and reproductive health (ASRH) is a major public health concern in sub-Saharan Africa (SSA). However, inequalities in ASRH have received less attention than many other public health priority areas, in part due to limited data. In this study, we examine inequalities in key ASRH indicators. Methods: We analyzed national household surveys from 37 countries in SSA, conducted during 1990–2018, to exam- ine trends and inequalities in adolescent behaviors related to early marriage, childbearing and sexual debut among adolescents using data from respondents 15–24 years. Survival analyses were conducted on each survey to obtain estimates for the ASRH indicators. Multilevel linear regression modelling was used to obtain estimates for 2000 and 2015 in four subregions of SSA for all indicators, disaggregated by sex, age, household wealth, urban–rural residence and educational status (primary or less versus secondary or higher education). Results: In 2015, 28% of adolescent girls in SSA were married before age 18, declined at an average annual rate of 1.5% during 2000–2015, while 47% of girls gave birth before age 20, declining at 0.6% per year. Child marriage was rare for boys (2.5%). About 54% and 43% of girls and boys, respectively, had their sexual debut before 18. The declines were greater for the indicators of early adolescence (10–14 years). Large differences in marriage and childbearing were observed between adolescent girls from rural versus urban areas and the poorest versus richest households, with much greater inequalities observed in West and Central Africa where the prevalence was highest. The urban– rural and wealth-related inequalities remained stagnant or widened during 2000–2015, as the decline was relatively slower among rural and the poorest compared to urban and the richest girls. The prevalence of the ASRH indicators did not decline or increase in either education categories. Conclusion: Early marriage, childbearing and sexual debut declined in SSA but the 2015 levels were still high, especially in Central and West Africa, and inequalities persisted or became larger. In particular, rural, less educated and poorest adolescent girls continued to face higher ASRH risks and vulnerabilities. Greater attention to disparities in ASRH is needed for better targeting of interventions and monitoring of progress

Interventions to reduce unnecessary caesarean sections in healthy women and babies

Optimising the use of caesarean section (CS) is of global concern. Underuse leads to maternal and perinatal mortality and morbidity. Conversely, overuse of CS has not shown benefits and can create harm. Worldwide, the frequency of CS continues to increase, and interventions to reduce unnecessary CSs have shown little success. Identifying the underlying factors for the continuing increase in CS use could improve the efficacy of interventions. In this Series paper, we describe the factors for CS use that are associated with women, families, health professionals, and health-care organisations and systems, and we examine behavioural, psychosocial, health system, and financial factors. We also outline the type and effects of interventions to reduce CS use that have been investigated. Clinical interventions, such as external cephalic version for breech delivery at term, vaginal breech delivery in appropriately selected women, and vaginal birth after CS, could reduce the frequency of CS use. Approaches such as labour companionship and midwife-led care have been associated with higher proportions of physiological births, safer outcomes, and lower health-care costs relative to control groups without these interventions, and with positive maternal experiences, in high-income countries. Such approaches need to be assessed in middle-income and low-income countries. Educational interventions for women should be complemented with meaningful dialogue with health professionals and effective emotional support for women and families. Investing in the training of health professionals, eliminating financial incentives for CS use, and reducing fear of litigation is fundamental. Safe, private, welcoming, and adequately resourced facilities are needed. At the country level, effective medical leadership is essential to ensure CS is used only when indicated. We conclude that interventions to reduce overuse must be multicomponent and locally tailored, addressing women’s and health professionals’ concerns, as well as health system and financial factors

Cesarean section : more than a maternal health issue

A cesarean section (CS) can be a lifesaving intervention when medically indicated, but it may also lead to adverse short- and long-term health effects for women and children