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Jordan K, Lewis TP, Roberts B. Quality in crisis: a systematic review of the quality of health systems in humanitarian settings. Confl Health 2021; 15:7. [PMID: 33531065 PMCID: PMC7851932 DOI: 10.1186/s13031-021-00342-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 01/22/2021] [Indexed: 12/03/2022] Open
Abstract
Background There is a growing concern that the quality of health systems in humanitarian crises and the care they provide has received little attention. To help better understand current practice and research on health system quality, this paper aimed to examine the evidence on the quality of health systems in humanitarian settings. Methods This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. The context of interest was populations affected by humanitarian crisis in low- and middle- income countries (LMICs). We included studies where the intervention of interest, health services for populations affected by crisis, was provided by the formal health system. Our outcome of interest was the quality of the health system. We included primary research studies, from a combination of information sources, published in English between January 2000 and January 2019 using quantitative and qualitative methods. We used the High Quality Health Systems Framework to analyze the included studies by quality domain and sub-domain. Results We identified 2285 articles through our search, of which 163 were eligible for full-text review, and 55 articles were eligible for inclusion in our systematic review. Poor diagnosis, inadequate patient referrals, and inappropriate treatment of illness were commonly cited barriers to quality care. There was a strong focus placed on the foundations of a health system with emphasis on the workforce and tools, but a limited focus on the health impacts of health systems. The review also suggests some barriers to high quality health systems that are specific to humanitarian settings such as language barriers for refugees in their host country, discontinued care for migrant populations with chronic conditions, and fears around provider safety. Conclusion The review highlights a large gap in the measurement of quality both at the point of care and at the health system level. There is a need for further work particularly on health system measurement strategies, accountability mechanisms, and patient-centered approaches in humanitarian settings. Supplementary Information The online version contains supplementary material available at 10.1186/s13031-021-00342-z.
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Affiliation(s)
- Keely Jordan
- Department of Health Policy, New York University School of Global Public Health, 665 Broadway, New York, NY, 10012, USA.
| | - Todd P Lewis
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Bayard Roberts
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Tosif S, Jatobatu A, Maepioh A, Gray A, Gilbert K, Hodgson J, Duke T. Implementation Lessons from a Multifaceted National Newborn Program in Solomon Islands: A Mixed-Methods Study. Am J Trop Med Hyg 2020; 102:667-675. [PMID: 31971147 PMCID: PMC7056423 DOI: 10.4269/ajtmh.19-0631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/24/2019] [Indexed: 11/07/2022] Open
Abstract
Multifaceted interventions are important in improving neonatal quality of care and health outcomes. This study describes the implementation of an intervention to improve the quality of newborn care in Solomon Islands, a small island developing state and lower middle-income country in the Western Pacific. Inputs included training, equipment provision, and healthcare system organizational changes. For evaluation, we used a mixed-methods design, using quantitative (audits of health facility equipment, structure, and organization) and qualitative (semi-structured interviews and focused group discussions with healthcare workers) methods. Participants highlighted the practical, interactive, coaching style of training and its short duration as positive features in establishing skills. Training had indirect impacts through improving culture of the workplace, and the evaluation provided a valuable opportunity for reflection of the implementation process for healthcare workers. Facility limitations from equipment deficits and poor condition of clinical areas had implications by limiting the provision of quality care, as well as contributing to healthcare workers feeling undervalued. Resuscitation of a nonbreathing baby was a stressful experience for many health workers, compounded by geographic isolation and feeling unsupported. Our findings highlight the importance of training methodology, impact from structural limitations, and experience of resuscitation for the healthcare worker. Attention to these factors may help the design and implementation of newborn care programs in similar contexts.
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Affiliation(s)
- Shidan Tosif
- Centre for International Child Health, Murdoch Children’s Research Institute, Royal Children’s Hospital Melbourne, University of Melbourne, Parkville VIC, Australia
| | - Anna Jatobatu
- Reproductive and Child Health Department, Ministry of Health and Medical Services, Honiara, Solomon Islands
| | - Anita Maepioh
- Department of Obstetrics and Gynaecology, National Referral Hospital, Honiara, Solomon Islands
| | - Amy Gray
- Centre for International Child Health, Murdoch Children’s Research Institute, Royal Children’s Hospital Melbourne, University of Melbourne, Parkville VIC, Australia
| | - Katherine Gilbert
- Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Parkville VIC, Australia
| | - Jan Hodgson
- Department of Paediatrics, University of Melbourne, Parkville VIC, Australia
| | - Trevor Duke
- Centre for International Child Health, Murdoch Children’s Research Institute, Royal Children’s Hospital Melbourne, University of Melbourne, Parkville VIC, Australia
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Tosif S, Nasi T, Gray A, Sadr-Azodi N, Ogaoga D, Duke T. Assessment of the quality of neonatal care in the Solomon Islands. J Paediatr Child Health 2018; 54:165-171. [PMID: 28905447 DOI: 10.1111/jpc.13686] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/15/2017] [Accepted: 07/21/2017] [Indexed: 01/01/2023]
Abstract
AIM To identify strengths and obstacles for improving the quality of newborn care in the Solomon Islands. Improving the quality of newborn care is a priority in the Sustainable Development Goals and the Action Plan for Healthy Newborns in the Western Pacific. The neonatal mortality rate in the Solomon Islands, a lower-middle-income country, has improved slower than overall child mortality. In 2013, neonatal mortality (13.2/1000) constituted 44% of under-5 deaths (30.1/1000). METHODS A cross-sectional study of newborn care in five provincial hospitals using a World Health Organization assessment tool for hospital quality of care. Twelve months of neonatal records of the National Referral Hospital (NRH) labour ward and nursery were audited. RESULTS Essential medications and basic equipment were generally available. Challenges included workforce shortages and lack of expertise, high costs, organisation and maintenance of equipment, infection control and high rates of stillbirth. Over 12 months at the NRH labour ward, there were 5412 live births, 65 (1.2%) 'fresh' stillbirths and 96 (1.8%) 'macerated' stillbirths. Over the same period, there were an associated 779 nursery admissions, and the main causes of mortality were complications of prematurity, birth asphyxia, congenital abnormalities and sepsis. Total neonatal mortality at NRH was 16 per 1000 live births, and 77% of deaths occurred in the first 3 days of life. CONCLUSIONS Infrastructure limitations, technical maintenance and equipment organisation were obstacles to newborn care. Greater health-care worker knowledge and skills for early essential newborn care, infection control and management of newborn complications is needed.
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Affiliation(s)
- Shidan Tosif
- Centre for International Child Health, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Titus Nasi
- Department of Paediatrics, National Referral Hospital, Honiara, Solomon Islands
| | - Amy Gray
- Centre for International Child Health, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Nahad Sadr-Azodi
- Child Survival and Development, United Nations Children's Fund, Suva, Fiji
| | - Divi Ogaoga
- Reproductive and Child Health Division, Ministry of Health and Medical Services, Honiara, Solomon Islands
| | - Trevor Duke
- Centre for International Child Health, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
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Duke T, Cheema B. Paediatric emergency and acute care in resource poor settings. J Paediatr Child Health 2016; 52:221-6. [PMID: 27062627 DOI: 10.1111/jpc.13105] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 11/26/2015] [Accepted: 12/03/2015] [Indexed: 11/29/2022]
Abstract
Acute care of seriously ill children is a global public health issue, and there is much scope for improving quality of care in hospitals at all levels in many developing countries. We describe the current state of paediatric emergency and acute care in the least developed regions of low and middle income countries and identify gaps and requirements for improving quality. Approaches are needed which span the continuum of care: from triage and emergency treatment, the diagnostic process, identification of co-morbidities, treatment, monitoring and supportive care, discharge planning and follow-up. Improvements require support and training for health workers and quality processes. Effective training is that which is ongoing, combining good technical training in under-graduate courses and continuing professional development. Quality processes combine evidence-based guidelines, essential medicines, appropriate technology, appropriate financing of services, standards and assessment tools and training resources. While initial emergency treatment is based on common clinical syndromes, early differentiation is required for specific treatment, and this can usually be carried out clinically without expensive tests. While global strategies are important, it is what happens locally that makes a difference and is too often neglected. In rural areas in the poorest countries in the world, public doctors and nurses who provide emergency and acute care for children are revered by their communities and demonstrate daily that much can be carried out with little.
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Affiliation(s)
- Trevor Duke
- Centre for International Child Health, Department of Paediatrics, University of Melbourne, MCRI, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Baljit Cheema
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
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Duke T, Kado JH, Auto J, Amini J, Gilbert K. Closing the gaps in child health in the Pacific: an achievable goal in the next 20 years. J Paediatr Child Health 2015; 51:54-60. [PMID: 25586845 PMCID: PMC4309470 DOI: 10.1111/jpc.12804] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2014] [Indexed: 01/15/2023]
Abstract
It is not inconceivable that by 2035 the substantial gaps in child health across the Pacific can close significantly. Currently, Australia and New Zealand have child mortality rates of 5 and 6 per 1000 live births, respectively, while Pacific island developing nations have under 5 mortality rates ranging from 13 to 16 (Vanuatu, Fiji and Tonga) to 47 and 58 per 1000 live births (Kiribati and Papua New Guinea, respectively). However, these Pacific child mortality rates are falling, by an average of 1.4% per year since 1990, and more rapidly (1.9% per year) since 2000. Based on progress elsewhere, there is a need to (i) define the specific things needed to close the gaps in child health; (ii) be far more ambitious and hopeful than ever before; and (iii) form a new regional compact based on solidarity and interdependence.
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Affiliation(s)
- Trevor Duke
- Centre for International Child Health, Department of Paediatrics, University of MelbourneMelbourne, Victoria, Australia,Royal Children's Hospital, Murdoch Childrens Research InstituteMelbourne, Victoria, Australia,School of Medicine and Health Science, University of Papua New GuineaPort Moresby, Fiji,Correspondence: Professor Trevor Duke, Centre for International Child Health, Department of Paediatrics, University of Melbourne, Parkville, Vic. 3052, Australia. Fax: 9345 6667;
| | - Joseph H Kado
- Department of Paediatrics, Colonial War Memorial HospitalSuva, Fiji
| | - James Auto
- Medical School, University of FijiLautoka, Fiji
| | - James Amini
- Department of Paediatrics, Port Moresby General HospitalPort Moresby, Fiji
| | - Katherine Gilbert
- Centre for Health Economics, Monash UniversityMelbourne, Victoria, Australia
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Abstract
Quality improvement (QI) is described as being about changing the way in which patient care is delivered. It is more than just a theoretical framework against which innovations can be introduced; it is about a rigorous patient-centric approach to the design and delivery of care. In this paper we will explore some of the practicalities of delivering quality improvement in paediatrics and child health, and explain why it is an approach that we all must take.
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Affiliation(s)
- R E Klaber
- Department of Paediatrics, Imperial College Healthcare NHS Trust, , London, UK
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Duke T, Peel D, Graham S, Howie S, Enarson PM, Jacobson R. Oxygen concentrators: a practical guide for clinicians and technicians in developing countries. ACTA ACUST UNITED AC 2013; 30:87-101. [DOI: 10.1179/146532810x12637745452356] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Colquhoun S, Ogaoga D, Tamou M, Nasi T, Subhi R, Duke T. Child health nurses in the Solomon Islands: lessons for the Pacific and other developing countries. HUMAN RESOURCES FOR HEALTH 2012; 10:45. [PMID: 23171144 PMCID: PMC3545833 DOI: 10.1186/1478-4491-10-45] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 11/09/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To understand the roles of nurses with advanced training in paediatrics in the Solomon Islands, and the importance of these roles to child health. To understand how adequately equipped child health nurses feel for these roles, to identify the training needs, difficulties and future opportunities. DESIGN Semi-structured interviews. SETTINGS Tertiary hospital, district hospitals and health clinics in the Solomon Islands. PARTICIPANTS Twenty-one paediatric nurses were interviewed out of a total of 27 in the country. RESULTS All nurses were currently employed in teaching, clinical or management areas. At least one or two nurses were working in each of 7 of the 9 provinces; in the two smaller provinces there were none. Many nurses were sole practitioners in remote locations without back-up from doctors or other experienced nurses; all had additional administrative or public health duties. Different types of courses were identified: a residential diploma through the University of Papua New Guinea or New Zealand and a diploma by correspondence through the University of Sydney. CONCLUSIONS Child health nurses in the Solomon Islands fulfill vital clinical, public health, teaching and administrative roles. Currently they are too few in number, and this is a limiting factor for improving the quality of child health services in that country. Current methods of training require overseas travel, or are expensive, or lack relevance, or remove nurses from their work-places and families for prolonged periods of time. A local post-basic child health nursing course is urgently needed, and models exist to achieve this.
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Affiliation(s)
- Samantha Colquhoun
- Centre for International Child Health, University of Melbourne, Royal Children's Hospital, MCRI,, 50 Flemington Road, Parkville,, 3052, Melbourne, Australia
| | | | | | | | - Rami Subhi
- Centre for International Child Health, University of Melbourne, Royal Children's Hospital, MCRI,, 50 Flemington Road, Parkville,, 3052, Melbourne, Australia
| | - Trevor Duke
- Centre for International Child Health, University of Melbourne, Royal Children's Hospital, MCRI,, 50 Flemington Road, Parkville,, 3052, Melbourne, Australia
- School of Medicine and Health Sciences, University of Papua New Guinea, Papua New Guinea
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Lind A, Edward A, Bonhoure P, Mustafa L, Hansen P, Burnham G, Peters DH. Quality of outpatient hospital care for children under 5 years in Afghanistan. Int J Qual Health Care 2011; 23:108-16. [PMID: 21242157 PMCID: PMC3115619 DOI: 10.1093/intqhc/mzq081] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2010] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE To determine the quality of outpatient hospital care for children under 5 years in Afghanistan. DESIGN Case management observations were conducted on 10-12 children under five selected by systematic random sampling in 31 outpatient hospital clinics across the country, followed by interviews with caretakers and providers. MAIN OUTCOME MEASURES Quality of care defined as adherence to the clinical standards described in the Integrated Management of Childhood Illness. RESULTS Overall quality of outpatient care for children was suboptimal based on patient examination and caretaker counseling (median score: 27.5 on a 100 point scale). Children receiving care from female providers had better care than those seen by male providers (OR: 6.6, 95% CI: 2.0-21.9, P = 0.002), and doctors provided better quality of care than other providers (OR: 2.7, 95% CI: 1.1-6.4, P = 0.02). The poor were more likely to receive better care in hospitals managed by non-governmental organizations than those managed by other mechanisms (OR: 15.2, 95% CI: 1.2-200.1, P = 0.04). CONCLUSIONS Efforts to strengthen optimal care provision at peripheral health clinics must be complemented with investments at the referral and tertiary care facilities to ensure care continuity. The findings of improved care by female providers, doctors and NGO's for poor patients, warrant further empirical evidence on care determinants. Optimizing care quality at referral hospitals is one of the prerequisites to ensure service utilization and outcomes for the achievement of the Child health Millennium Development Goals for Afghanistan.
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Affiliation(s)
- Allison Lind
- University of Washington School of Nursing, Seattle, WA, USA
| | - Anbrasi Edward
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Philippe Bonhoure
- European Commission Directorate-General for Humanitarian Aid and Civil Protection, India
| | | | | | - Gilbert Burnham
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David H. Peters
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Theodoratou E, Al-Jilaihawi S, Woodward F, Ferguson J, Jhass A, Balliet M, Kolcic I, Sadruddin S, Duke T, Rudan I, Campbell H. The effect of case management on childhood pneumonia mortality in developing countries. Int J Epidemiol 2010; 39 Suppl 1:i155-71. [PMID: 20348118 PMCID: PMC2845871 DOI: 10.1093/ije/dyq032] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND With the aim of populating the Lives Saved Tool (LiST) with parameters of effectiveness of existing interventions, we conducted a systematic review of the literature assessing the effect of pneumonia case management on mortality from childhood pneumonia. METHODS This review covered the following interventions: community case management with antibiotic treatment, and hospital treatment with antibiotics, oxygen, zinc and vitamin A. Pneumonia mortality outcomes were sought where available but data were also recorded on secondary outcomes. We summarized results from randomized controlled trials (RCTs), cluster RCTs, quasi-experimental studies and observational studies across outcome measures using standard meta-analysis methods and used a set of standardized rules developed for the purpose of populating the LiST with required parameters, which dealt with the issues of comparability of the studies in a uniform way across a spectrum of childhood conditions. RESULTS We estimate that community case management of pneumonia could result in a 70% reduction in mortality from pneumonia in 0-5-year-old children. In contrast treatment of pneumonia episodes with zinc and vitamin A is ineffective in reducing pneumonia mortality. There is insufficient evidence to make a quantitative estimate of the effect of hospital case management on pneumonia mortality based on the published data. CONCLUSION The available evidence reinforces the effectiveness of community and hospital case management with World Health Organization-recommended antibiotics and the lack of effect of zinc and vitamin A supportive treatment for children with pneumonia. Evidence from one trial demonstrates the effectiveness of oxygen therapy but further research is required to give higher quality evidence so that an effect estimate can be incorporated into the LiST model. We identified no trials that separately evaluated the effectiveness of other supportive care interventions. The summary estimates of effect on pneumonia mortality will inform the LiST model.
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Campbell H, Duke T, Weber M, English M, Carai S, Tamburlini G. Global initiatives for improving hospital care for children: state of the art and future prospects. Pediatrics 2008; 121:e984-92. [PMID: 18381526 PMCID: PMC2655645 DOI: 10.1542/peds.2007-1395] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Deficiencies in the quality of health care are major limiting factors to the achievement of the Millennium Development Goals for child and maternal health. Quality of patient care in hospitals is firmly on the agendas of Western countries but has been slower to gain traction in developing countries, despite evidence that there is substantial scope for improvement, that hospitals have a major role in child survival, and that inequities in quality may be as important as inequities in access. There is now substantial global experience of strategies and interventions that improve the quality of care for children in hospitals with limited resources. The World Health Organization has developed a toolkit that contains adaptable instruments, including a framework for quality improvement, evidence-based clinical guidelines in the form of the Pocket Book of Hospital Care for Children, teaching material, assessment, and mortality audit tools. These tools have been field-tested by doctors, nurses, and other child health workers in many developing countries. This collective experience was brought together in a global World Health Organization meeting in Bali in 2007. This article describes how many countries are achieving improvements in quality of pediatric care, despite limited resources and other major obstacles, and how the evidence has progressed in recent years from documenting the nature and scope of the problems to describing the effectiveness of innovative interventions. The challenges remain to bring these and other strategies to scale and to support research into their use, impact, and sustainability in different environments.
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Affiliation(s)
- Harry Campbell
- Public Health Sciences, Institute of Genomics and Molecular Medicine, College of Medicine and Vet Medicine University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, United Kingdom.
| | - Trevor Duke
- Centre for International Child Health, Melbourne University and Department of Pediatrics, Royal Children’s Hospital, Parkville, Victoria, Australia
| | - Martin Weber
- Department of Child and Adolescent Health & Development, World Health Organization, Geneva, Switzerland
| | - Mike English
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Susanne Carai
- Department of Child and Adolescent Health & Development, World Health Organization, Geneva, Switzerland
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