Treatment of Febrile illness with artemisinin combination therapy: prevalence and predictors in five African household surveys

Exploring medicine classification and accessibility: a qualitative study

Background

Brunei Darussalam's medicine control governance landscape is complex, driven by legislative directives and directed by the Brunei Darussalam Medicines Control Authority (BDMCA). While the medicine dispensing system in Brunei Darussalam, across both governmental and private sectors, is a critical component of the nation's healthcare, it remains under-researched, leaving gaps in understanding its distinctions, challenges, and opportunities. This study aimed to explore deep into the perspectives of pharmacists regarding the medicine dispensing systems in Brunei Darussalam, medicine accessibility, the classification and regulation of medicines, and the growing role of pharmacists.

Methods

Using a narrative qualitative approach, we conducted in-depth one-on-one interviews with six pharmacists, delving into their personal experiences with topics such as medicine classification and the broader systems for medication provision. The collected narratives were analysed through a rigorous thematic analysis, following the framework established by Braun & Clarke.

Results

Five themes emerged from the data: nuances of Brunei Darussalam's medicine dispensing landscape across both public and private sectors; accessibility and regulatory framework of medicines both in Brunei Darussalam and abroad; prospective implementations to enhance the current system; and the evolving role and expectations of pharmacists in the current healthcare environment. Notably, a significant contribution of this study was the illumination of the differential perspectives between pharmacists operating in governmental versus private contexts.

Conclusion

This study sheds light on the previously under-explored domain of Brunei Darussalam's medicine control governance and medicine dispensing system. By drawing from the first-hand experiences of practicing pharmacists, it offers actionable insights that could guide future policy developments, optimise medicine dispensation and regulation, and shape the evolving role of pharmacists in Brunei Darussalam.

A one health approach to tackling AMR and why gender matters: findings from pastoralist communities in Tanzania

Introduction

Inappropriate use of antimicrobials is a major driver of AMR in low-resource settings, where the regulation of supply for pharmaceuticals is limited. In pastoralist settings in Tanzania, men and women face varying degrees of exposure to antibiotics due to gender relations that shape access and use of antimicrobials. For example, critical limitations in healthcare systems in these settings, including inadequate coverage of health services put people at risk of AMR, as families routinely administer self-treatment at home with antimicrobials. However, approaches to understanding AMR drivers and risk distribution, including the One Health approach, have paid little attention to these gender considerations. Understanding differences in access and use of antimicrobials can inform interventions to reduce AMR risk in community settings. This paper focuses on the gendered risk of AMR through a study of gender and social determinants of access to and use of antimicrobials in low-resource pastoralist settings in Tanzania.

Methods

A mixed methods approach involving household surveys, interviews and ethnographic participant observation in homes and sites of healthcare provision was used, to investigate access and administration of antibiotics in 379 adults in Naiti, Monduli district in northern Tanzania. A purposive sampling technique was used to recruit study participants and all data was disaggregated by sex, age and gender.

Results

Gender and age are significantly associated with the use of antibiotics without a prescription in the study population. Young people aged 18-24 are more likely to use unprescribed antibiotics than older people and may be at a higher risk of AMR. Meanwhile, although more men purchase unprescribed antibiotics than women, the administration of these drugs is more common among women. This is because men control how women use drugs at the household level.

Discussion

AMR interventions must consider the critical importance of adopting and implementing a gender-sensitive One Health approach, as gender interacts with other social determinants of health to shape AMR risk through access to and use of antimicrobials, particularly in resource-limited pastoralist settings.

Enhancing resilience in transnational E-commerce supply chains: Critical factors, perspectives and strategic action plan

This study develops a hybrid model to investigate the factors affecting transnational e-commerce supply chain resilience (TNSCRE) by integrating the Entropy Weight Method (EWM), Simple Additive Weighting (SAW), and Interpretive Structural Modeling (ISM). The study identifies 36 critical factors categorized under supply chain adaptability, supply chain efficiency, and supply chain evolution, and five criteria are used to rank these factors. The EWM is used to calculate the relative weights of the criteria, and the SAW method is used to rank the factors based on their weighted scores. The ISM is then used to evaluate the interrelationships among the key factors. The research highlights the significance of several factors, such as the speed of supply chain disruption recovery, interactive collaboration, and response time to supply chain disruption. Sensitivity analysis was performed to assess the robustness of the findings. Finally, a SWOT analysis is conducted to develop a strategic action plan for addressing these significant factors. The study provides a comprehensive understanding of the factors that impact TNSCRE from the perspective of multiple stakeholders. The findings can help e-commerce business owners improve their existing supply chain resilience and achieve sustainable growth in the context of globalization.

Comparing pharmacy practice in health facilities with and without pharmaceutically trained dispensers: a post intervention study in Tanzania

Background

The critical shortage of comprehensively trained healthcare staff in Tanzania affects the capacity to deliver essential health services, attain universal health coverage and compromises health outcomes. There is a specific lack of suitably trained pharmaceutical professionals, thus, an increase in the use of unqualified or poorly trained staff. Following the introduction of a one-year pharmacy dispenser course intervention, this study explored the impact that the new cadre of graduates had on pharmacy practice compared to healthcare facilities with non-pharmacy trained dispensers (NPTDs).

Methods

A post intervention assessment was conducted in 2021 using questionnaires formulated to measure indicators of Good Pharmacy Practice, comparing 29 public health facilities employing pharmacy-trained dispensers (PTD) with 32 public health facilities with NPTDs in Dodoma, Shinyanga and Morogoro regions of Tanzania. Data were collected by experienced pharmacists or pharmaceutical technicians and subsequently aggregated and statistically analysed.

Results

The dispensing times for medicines were found to be the same for PTDs and the NPTDs (2 min). There were no statistically significant differences in the adequacy of labelling elements between PTDs and NPTDs. Patients' level of knowledge of the medicines dispensed to them, from both PTDs and NPTDs, showed no difference. Moreover, no differences were observed in storage practice and documentation performance, records of dispensed medicines, handling of medicines and the dispensing area cleanliness between both groups. Overall, facilities with PTDs averaged a higher availability of tracer medicines (77%) than those with NPTDs (70%), however, availability of health commodities in all health facilities in the three regions was low and there was no statistically significant difference between both groups.

Conclusion

The study showed no significant difference in performance of pharmacy practice between PTDs and NPTDs despite the former undertaking a one-year training course intended to improve knowledge and skills. Practice application not only depends on effective training but on the working environment. Clear job descriptions, appropriate tools and references to guide, Standard Operating Procedures, acceptance by management of the training undertaken to actively encourage recruits to apply these new skills could improve PTDs performance. Training and knowledge alone do not seem to lead to better practice and performance.

Determine the perceived level of involvement and factors affecting diabetes management by community pharmacy professionals at drug retails in northwestern amhara region, Ethiopia

Background

Pharmacists in community drug retail outlets (CDROs) have significant involvement in diabetes prevention and management by providing more direct interventions in medication education, preventive measures, and disease management. This study examined the perceived level of involvement of community pharmacy professionals (CPPs) in diabetes management at CDROs in Northwest Ethiopia.

Methods

A multicenter cross-sectional study was conducted among CPPs in Northwest Ethiopia between September 1 and 30, 2022. The Statistical Package for Social Science (SPSS) version 26 was used to analyzed the data, which had been gathered using a self-administered structured questionnaire. An independent sample t-test and one-way ANOVA were used to examine the mean perceived involvement score difference between CPPs. The association between CPPs' involvement and other sociodemographic variables was examined using linear regression analysis. At a 95% confidence interval (CI), a p-value <0.05 was considered statistically significant.

Results

The study included 184 (94.3%) of 195 CPPs approached. The overall mean perceived involvement score of CPPs in diabetes management was 3.80 ± 0.63 out of 5. CPPs with a bachelor's degree or higher [β = 3.065, 95% CI: 2.704, 3.641; p < 0.001], CPPs with a higher monthly income (≥5000 ETB) [β = 0.242, 95% CI: 0.112, 0.596; p = 0.034], and those who provided more than 8 hours of service per day [β = 0.163, 95% CI: 0.051, 0.332; p = 0.043] had higher perceived involvement in the management of diabetes compared with their counterparts.

Conclusions

This study found that most CPPs had a high level of perceived involvement in diabetes management. Higher educational backgrounds, a higher monthly salary, and working longer hours were associated with an increased level of perceived involvement. Promoting the educational background of CPPs may be crucial to enhance their active involvement in the management of diabetes.

Access to Medicines and Pharmaceutical Policy in Saudi Arabia: A Scoping Review

Introduction

This scoping review includes studies on pharmaceutical access, shortages, generics, availability, pharmacoeconomics, and pricing restrictions. The study's findings may aid in developing excellent pharmaceutical and access policies in the country.

Objective

To conduct a scoping review documenting access to medicines and Pharmaceutical Policy in Saudi Arabia.

Methodology

The PRISMA-ScR guidelines were used to perform a scoping review. The articles were screened using databases from Google Scholar, EBSCO, Science Direct, and the University of Huddersfield Library. The selection, aims, results, and conclusion of each original research publication published between 2010 and 2022 were evaluated. To categorize the articles, a theme analysis was done.

Results

This study includes nineteen publications. The chosen articles revealed four themes. Among these topics were: Access to medications 36.84% Pharmacoeconomic 36.84%), which were the predominant theme followed by Generic Medicines 15.80%, and Cancer drug financing 10.54%. There are myriad challenges related to high-cost medicines. Access restrictions to medications have significant effects on patient morbidity and mortality; as a result, policy decision-makers frequently consider this issue. Access to medicines suffers budgetary limitations and the increasing cost of innovative medicines. Access to medicines for all patients could be significantly impacted by delays in patient access to new therapies.

Conclusion

The available evidence revealed that Saudi Arabia's healthcare system has numerous issues ranging from cancer drug financing, medicine shortages, and access issue. In order to achieve the highest health standards possible, it is crucial that each individual has access to medicines and has the financial, physical, and social means to do so. However, the price of some medications can be prohibitive for people who need to obtain them. The study's outcomes could help the country develop pharmaceutical and access policies related to medicines.

Gender and urban-rural influences on antibiotic purchasing and prescription use in retail drug shops: a one health study

INTRODUCTION

Few studies have reported antibiotic purchases from retail drug shops in relation to gender in low and middle-income countries (LMICs). Using a One Health approach, we aimed to examine gender dimensions of antibiotic purchases for humans and animals and use of prescriptions in retail drug shops in Bangladesh.

METHODS

We conducted customer observations in 20 drug shops in one rural and one urban area. Customer gender, antibiotic purchases, and prescription use were recorded during a four-hour observation (2 sessions of 2 hours) in each shop. We included drug shops selling human medicine (n = 15); animal medicine (n = 3), and shops selling both human and animal medicine (n = 2).

RESULTS

Of 582 observations, 31.6% of drug shop customers were women. Women comprised almost half of customers (47.1%) in urban drug shops but only 17.2% of customers in rural drug shops (p < 0.001). Antibiotic purchases were more common in urban than rural shops (21.6% versus 12.2% of all transactions, p = 0.003). Only a quarter (26.0%) of customers who purchased antibiotics used a prescription. Prescription use for antibiotics was more likely among women than men (odds ratio (OR) = 4.04, 95% CI 1.55, 10.55) and more likely among urban compared to rural customers (OR = 4.31 95% CI 1.34, 13.84). After adjusting for urban-rural locality, women remained more likely to use a prescription than men (adjusted OR = 3.38, 95% CI 1.26, 9.09) but this was in part due to antibiotics bought by men for animals without prescription. Customers in drug shops selling animal medicine had the lowest use of prescriptions for antibiotics (4.8% of antibiotic purchases).

CONCLUSION

This study found that nearly three-quarters of all antibiotics sold were without prescription, including antibiotics on the list of critically important antimicrobials for human medicine. Men attending drug shops were more likely to purchase antibiotics without a prescription compared to women, while women customers were underrepresented in rural drug shops. Antibiotic stewardship initiatives in the community need to consider gender and urban-rural dimensions of drug shop uptake and prescription use for antibiotics in both human and animal medicine. Such initiatives could strengthen National Action Plans.

Improving WHO's understanding of WHO guideline uptake and use in Member States: a scoping review

BACKGROUND

WHO publishes public health and clinical guidelines to guide Member States in achieving better health outcomes. Furthermore, WHO's Thirteenth General Programme of Work for 2019-2023 prioritizes strengthening its normative functional role and uptake of normative and standard-setting products, including guidelines at the country level. Therefore, understanding WHO guideline uptake by the Member States, particularly the low- and middle-income countries (LMICs), is of utmost importance for the organization and scholarship.

METHODS

We conducted a scoping review using a comprehensive search strategy to include published literature in English between 2007 and 2020. The review was conducted between May and June 2021. We searched five electronic databases including CINAHL, the Cochrane Library, PubMed, Embase and Scopus. We also searched Google Scholar as a supplementary source. The review adhered to the PRISMA-ScR (PRISMA extension for scoping reviews) guidelines for reporting the searches, screening and identification of evaluation studies from the literature. A narrative synthesis of the evidence around key barriers and challenges for WHO guideline uptake in LMICs is thematically presented.

RESULTS

The scoping review included 48 studies, and the findings were categorized into four themes: (1) lack of national legislation, regulations and policy coherence, (2) inadequate experience, expertise and training of healthcare providers for guideline uptake, (3) funding limitations for guideline uptake and use, and (4) inadequate healthcare infrastructure for guideline compliance. These challenges were situated in the Member States' health systems. The findings suggest that governance was often weak within the existing health systems amongst most of the LMICs studied, as was the guidance provided by WHO's guidelines on governance requirements. This challenge was further exacerbated by a lack of accountability and transparency mechanisms for uptake and implementation of guidelines. In addition, the WHO guidelines themselves were either unclear and were technically challenging for some health conditions; however, WHO guidelines were primarily used as a reference by Member States when they developed their national guidelines.

CONCLUSIONS

The challenges identified reflect the national health systems' (in)ability to allocate, implement and monitor the guidelines. Historically this is beyond the remit of WHO, but Member States could benefit from WHO implementation guidance on requirements and needs for successful uptake and use of WHO guidelines.

The Impact of COVID-19 on Pharmaceutical Shortages and Supply Disruptions for Non-Communicable Diseases Among Public Hospitals of South West, Oromia, Ethiopia

Background

COVID-19 is a pandemic disease that has led to inequitable supply and shortages of essential medicines worldwide due to decreased production capacity, export bans, and national stockpiling which are affecting the global pharmaceutical supply chain. Access to essential pharmaceuticals is dependent on well-functioning supply chain systems that move medicines from the manufacturer to end users at service delivery point.

Objective

To assess impact of Covid-19 pandemic disease on pharmaceutical shortages and supply disruptions for non-communicable diseases among public hospitals of South West, Oromia, Ethiopia.

Methods and Materials

A multi-institutional cross sectional study design was employed. Quantitative and qualitative methods were utilized concurrently to gather data from four public hospital warehouses, dispensaries, patients, and local health authorities from March 1–30, 2021 in Ilu-Ababor and Buno-Bedelle Zones, Oromia, Ethiopia. Data were analyzed by using SPSS (version 23.0). A semi-structured interview guide was used to gather qualitative information from key informants from DTC members, patients, and local health authorities and finally analyzed through thematic approach.

Results

From six public hospitals in the two zones; cost of medicine increased more in Dedesa hospital compared to the other public hospital found in that zone and the effect of Covid-19 on essential medicines used for treatment of non-communicable diseases was less in Darimu Hospital. Stock status of PFSA and transportation were the major challenges during the procurement process due to Covid-19 pandemic disease. Among the EMs assessed at public hospitals, drugs used for cardiovascular diseases were out of stock for more than 90 days while anti-asthma drugs were out of stock for less than 40 days.

Conclusion

The availability of essential medicine was low and there was also poor inventory management practice in some of the public hospitals during Covid-19 pandemic in the study period.

Evaluating the impacts of COVID-19 outbreak on supply chain risks by modified failure mode and effects analysis: a case study in an automotive company

Supply chains have been facing many disruptions due to natural and man-made disasters. Recently, the global pandemic caused by COVID-19 outbreak, has severely hit trade and investment worldwide. Companies around the world faced significant disruption in their supply chains. This study aims to explore the impacts of COVID-19 outbreak on supply chain risks (SCRs). Based on a comprehensive literature review on supply chain risk management, 70 risks are identified and listed in 7 categories including demand, supply, logistics, political, manufacturing, financial and information. Then, a modified failure mode and effects analysis (FMEA) is proposed to assess the identified SCRs, which integrates FMEA and best-worst method to provide a double effectiveness. The results demonstrate the efficiency of the proposed method, and according to the main findings, "insufficient information about demand quantities", "shortages on supply markets", "bullwhip effect", "loss of key suppliers", "transportation breakdowns", "suppliers", "on-time delivery", "government restrictions", "suppliers' temporary closure", "market demand change" and "single supply sourcing" are the top 10 SCRs during the COVID-19 outbreak, respectively. Finally, the practical implications are discussed and useful managerial insights are recommended.

How are global health policies transferred to sub-Saharan Africa countries? A systematic critical review of literature

Background

Most sub-Saharan Africa countries adopt global health policies. However, mechanisms with which policy transfers occur have largely been studied amongst developed countries and much less in low- and middle- income countries. The current review sought to contribute to literature in this area by exploring how health policy agendas have been transferred from global to national level in sub-Saharan Africa. This is particularly important in the Sustainable Development Goals (SDGs) era as there are many policy prepositions by global actors to be transferred to national level for example the World Health Organization (WHO) policy principles of health financing reforms that advance Universal Health Coverage (UHC).

Methods

We conducted a critical review of literature following Arksey and O’Malley framework for conducting reviews. We searched EBSCOhost, ProQuest, PubMed, Scopus, Web of Science and Google scholar for articles. We combined the concepts and synonyms of “policy transfer” with those of “sub-Saharan Africa” using Boolean operators in searching databases. Data were analyzed thematically, and results presented narratively.

Results

Nine articles satisfied our eligibility criteria. The predominant policy transfer mechanism in the health sector in sub-Saharan Africa is voluntarism. There are cases of coercion, however, even in the face of coercion, there is usually some level of negotiation. Agency, context and nature of the issue are key influencers in policy transfers. The transfer is likely to be smooth if it is mainly technical and changes are within the confines of a given disease programmatic area. Policies with potential implications on bureaucratic and political status quo are more challenging to transfer.

Conclusion

Policy transfer, irrespective of the mechanism, requires local alignment and appreciation of context by the principal agents, availability of financial resources, a coordination platform and good working relations amongst stakeholders. Potential effects of the policy on the bureaucratic structure and political status are also important during the policy transfer process.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-022-00821-9.

Comparison of Prices and Affordability of Cancer Medicines in 16 Countries in Europe and Latin America

BACKGROUND

There are concerns that high prices of cancer medicines may limit patient access. Since information on prices for cancer medicines and their impact on affordability is lacking for several countries, particularly for lower income countries, this study surveys prices of originator cancer medicines in Europe and Latin America and assesses their affordability.

METHODS

For 19 cancer medicines, public procurement and ex-factory prices, as of 2017, were surveyed in five Latin American (LATAM) countries (Brazil, Chile, Colombia, Mexico, and Peru) and 11 European countries (Austria, France, Germany, Greece, Hungary, the Netherlands, Poland, Romania, Spain, Sweden, and the UK). Price data (public procurement prices in LATAM and ex-factory prices in Europe) in US dollar purchasing power parities (PPP) were analyzed per defined daily dose. Affordability was measured by setting medicines prices in relation to national minimum wages.

RESULTS

The prices of cancer medicines varied considerably between countries. In European countries with higher levels of income, PPP-adjusted prices tended to be lower than in European countries of lower income and LATAM countries. Except for one medicine, all surveyed medicines were considered unaffordable in most countries. In European countries of lower income and LATAM countries, more than 15 days' worth of minimum wages would be required by a worker to purchase one defined daily dose of several of the studied medicines.

CONCLUSIONS

The high prices and large unaffordability of cancer medicines call for strengthening pricing policies with the aim of ensuring affordable treatment in cancer care.

Barriers and facilitators for integration of guidelines on operating health shops: a case of family planning services

Background

The Zambia Medicines Regulatory Authority (ZAMRA) piloted the implementation of Guidelines on Operating Health Shops in Zambia in 2016, with a view to making basic medicines more accessible to communities. The guidelines aim to transform ordinary drug shops into health shops, which are dispensing facilities permitted to sell a ZAMRA-prescribed list of medicines over the counter. However, studies that explore the integration and uptake of guidelines into the health system are lacking. This study aims to inform future improved implementation of these guidelines by examining the current acceptability of guidelines within the Zambian health system, especially in relation to family planning services.

Methodology

Data collected through documentary review, key informant interviews with district pharmacists, staff from ZAMRA and in-depth interviews with 24 health shop owners and dispensers were analyzed using thematic analysis. A conceptual framework on the integration of health innovations into health systems guided the analysis.

Results

The Guidelines on Operating Health Shops were implemented to address the problem of inadequate access to quality medicines especially in rural areas. Factors that facilitated the acceptability of the guidelines included their perceived relevance and simplicity, comprehensive training and improved knowledge among health shop operators on the guidelines, development of a governance and reporting structure or steering committee at the national level as well as perceived improved health outcomes at the community level. Factors that hindered acceptability of the guidelines included the high cost of implementing them, a restricted list of drugs which affected consumer choice, limited communication between the local council and the operators of health shops, health shop owners not owning the health shop premises restricting their ability to adapt the building, and cultural norms which constrained uptake of family planning services.

Conclusion

In addition to training, facilitating the acceptability of the guidelines among health shop owners requires paying attention to operational issues such as location, ownership of the shop, size of infrastructure as well as financial costs of implementing guidelines through decentralizing the registration process and thus reducing the cost of registration. It is also important to have effective communication strategies between operators and the regulators of health shops.

Availability and Utilization of the WHO-Recommended Lifesaving Medicines for Under-Five Children at University of Gondar Comprehensive Specialized Hospital, Amhara Region, Ethiopia

According to the World Health Organization report, 5.4 million under-five children died, which is similar to under-five mortality rate of 39 deaths per 1000 live births. This rate is higher in sub-Saharan Africa with 76 deaths per 1000 live births. More than 1 out of every 2 deaths is because of diseases that can be managed with drug of low-cost and high quality. Institutional-based cross-sectional survey was conducted from January to February 2021, at the University of Gondar Comprehensive Specialized Hospital. Statistical Package for the Social Sciences software version 24 was used for data analysis. The results were presented using Figures, tables, and texts according to the nature of the data. The overall average availability of priority medicines was 75% on the day of visit and the average stock-out duration in the last 6 months was 23.85 days. Availability and utilization of priority medicines for the management of antiretroviral infections, Vitamin A deficiency, malaria, and diarrheal cases were high, whereas availability and utilization of suggested medication for neonatal sepsis were very low. A significant proportion of priority diseases was managed by non-priority medications. Medicines supply sources of the country, ministry of health, policymakers as well as facility managers should work in collaboration toward ensuring sustainable and consistent availability of priority medicines through the country. Continues in-service training of healthcare professionals is also mandatory to update themselves with newly developed guidelines, standards, and recommendations.

Challenges in Treatment for Fever among School-Age Children and Adults in Malawi

Prompt and effective treatment is key to malaria control and prevention, as it reduces disease morbidity and mortality and minimizes the number of transmission reservoirs. Transmission reduction may be particularly important among school-age children (SAC, 5-15 years old), who have the highest prevalence of Plasmodium falciparum infection in southern Malawi. We hypothesized that one factor contributing to this difference in prevalence is that SAC are less likely to seek appropriate treatment for fever than children younger than 5 years. In this study, we assessed treatment-seeking behaviors of people of all ages between 2012 and 2014 in Malawi. During each of the five cross-sectional surveys, all members of ∼900 households reported on fever and treatment-seeking in the previous 2 weeks. Multilevel logistic regression was used to analyze predictors of whether febrile people sought treatment and whether they did so at formal (government/private clinics) or informal sources (primarily shops). Twenty-two percent of participants (3,579/16,621) reported fever, and 2,715 of those (75.9%) sought treatment. Seeking treatment exclusively from local shops remains a common practice, although use of recommended diagnostic testing and antimalarial drugs was infrequently reported there. Although SAC were not significantly less likely than children aged < 5 years to seek treatment, SAC and adults (age ≥ 16 years) were significantly less likely to use formal sources. Our results indicate that encouraging treatment at government/private clinics and increasing retail access to appropriate antimalarial testing and treatment, especially among SAC, could help remedy inadequate treatment of symptomatic disease and potentially reduce Plasmodium transmission in Malawi.

Challenges and opportunities towards the road of universal health coverage (UHC) in Nepal: a systematic review

BACKGROUND

Universal health coverage (UHC) assures all types of health service and protects all citizens financially in any conditions due to illness. Globally, the UN sustainable development goal (SDG) provides high priority for UHC as a health related goal. The National health system of Nepal has prioritized in similar way. The aim of this study is to explore the challenges and opportunities on the road to UHC in Nepal.

METHOD

We used varieties of search terminologies with popular search engines like PubMed, Google, Google Scholar, etc. to identify studies regarding Nepal's progress towards UHC. Reports of original studies, policies, guidelines and government manuals were taken from the web pages of Ministry of Health and its department/division. Searches were designed to identify the status of service coverage on UHC, financial protection on health particularly, health insurance coverage with its legal status. Other associated factors related to UHC were also explored and presented in Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart.

RESULTS

We found 14 studies that were related to legal assurance, risk pulling and financing of health service, 11 studies associated to UHC service coverage status and, 7 articles linked to government stewardship, health system and governance on health care. Constitutional provision, global support, progress on the health insurance act, decentralization of health service to the grass root level, positive trends of increasing service coverage are seen as opportunities. However, existing volunteer types of health insurance, misleading role of trade unions and high proportion of population outside the country are main challenges. The political commitment under the changing political context, a sense of national priority and international support were identified as the facilitating factors towards UHC.

CONCLUSION

To achieve UHC, service and population coverage of health services has to be expanded along with financial protection for marginalized communities. Government stewardship, support of stakeholders and fair contribution and distribution of resources by appropriate health financing modality can speed up the path of UHC in Nepal.

Household beliefs about malaria testing and treatment in Western Kenya: the role of health worker adherence to malaria test results

Background

Although use of malaria diagnostic tests has increased in recent years, health workers often prescribe anti-malarial drugs to individuals who test negative for malaria. This study investigates how health worker adherence to malaria case management guidelines influences individuals’ beliefs about whether their illness was malaria, and their confidence in the effectiveness of artemisinin-based combination therapy (ACT).

Methods

A survey was conducted with 2065 households in Western Kenya about a household member’s treatment actions for a recent febrile illness. The survey also elicited the individual’s (or their caregiver’s) beliefs about the illness and about malaria testing and treatment. Logistic regressions were used to test the association between these beliefs and whether the health worker adhered to malaria testing and treatment guidelines.

Results

Of the 1070 individuals who visited a formal health facility during their illness, 82% were tested for malaria. ACT rates for malaria-positive and negative individuals were 89 and 49%, respectively. Overall, 65% of individuals/caregivers believed that the illness was “very likely” malaria. Individuals/caregivers had higher odds of saying that the illness was “very likely” malaria when the individual was treated with ACT, and this was the case both among individuals not tested for malaria [adjusted odds ratio (AOR) 3.42, 95% confidence interval (CI) [1.65 7.10], P = 0.001] and among individuals tested for malaria, regardless of their test result. In addition, 72% of ACT-takers said the drug was “very likely” effective in treating malaria. However, malaria-negative individuals who were treated with ACT had lower odds of saying that the drugs were “very likely” effective than ACT-takers who were not tested or who tested positive for malaria (AOR 0.29, 95% CI [0.13 0.63], P = 0.002).

Conclusion

Individuals/caregivers were more likely to believe that the illness was malaria when the patient was treated with ACT, regardless of their test result. Moreover, malaria-negative individuals treated with ACT had lower confidence in the drug than other individuals who took ACT. These results suggest that ensuring health worker adherence to malaria case management guidelines will not only improve ACT targeting, but may also increase patient/caregivers’ confidence in malaria testing and treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-017-1993-7) contains supplementary material, which is available to authorized users.

Disparities between malaria infection and treatment rates: Evidence from a cross-sectional analysis of households in Uganda

Background

In Sub-Saharan Africa, both under-treatment and over-treatment of malaria are common since illnesses are often diagnosed and treated on the basis of symptoms. We investigate whether malaria treatment rates among febrile individuals correspond to observed patterns of malaria infection by age and by local prevalence.

Methods and findings

We use data on treatment of febrile illnesses from a household survey that was conducted between March and May 2012 in 92 villages in six districts in Eastern Uganda. All household members were also tested for malaria using a rapid diagnostic test. We show that both the age of the febrile individual and the village prevalence rate are strongly associated with the odds that a febrile patient was infected with malaria, but not with the odds of ACT treatment. Compared to individuals who were aged 15 or above, febrile individuals aged 5–14 had 3.21 times the odds of testing positive for malaria (95% CI: [2.36 4.37], P<0·001), and febrile individuals who were under age 5 had 2.66 times the odds of testing positive for malaria (95% CI: [1.99 3.56], P<0·001). However, ACT treatment rates for febrile illnesses were not significantly higher for either children ages 5–14 (Unadjusted OR: 1.19, 95% CI: [0.88 1.62], P = 0.255) or children under the age of 5 (Unadjusted OR: 1.24, 95% CI: [0.92 1.68], P = 0·154). A one standard deviation increase in the village malaria prevalence rate was associated with a 2.03 times higher odds that a febrile individual under the age of five tested positive for malaria (95% CI: [1.63 2.54], p<0·001), but was not significantly associated with the odds of ACT treatment (Un-adjusted OR: 0.83, 95% CI: [0.66 1.05], P = 0·113). We present some evidence that this discrepancy may be because caregivers do not suspect a higher likelihood of malaria infection, conditional on fever, in young children or in high-prevalence villages.

Conclusion

Our findings suggest that households have significant mis-perceptions about malaria likelihood that may contribute to the under-treatment of malaria. Policies are needed to encourage caregivers to seek immediate diagnostic testing and treatment for febrile illnesses, particularly among young children.

Low Seroprevalence of Brucellosis in Humans and Small Ruminants in the Gambia

Background

Brucellosis is a worldwide zoonosis with significant impact on rural livelihoods and a potentially underestimated contributor to febrile illnesses. The aim of this study was to estimate the seroprevalence of brucellosis in humans and small ruminants in The Gambia.

Methods

The study was carried out in rural and urban areas. In 12 rural villages in Kiang West district, sera were collected from humans (n = 599) and small ruminants (n = 623) from the same compounds. From lactating small ruminants, milk samples and vaginal swabs were obtained. At the urban study sites, sera were collected from small ruminants (n = 500) from slaughterhouses and livestock markets. Information on possible risk factors for seropositivity was collected through questionnaires. Sera were screened for antibodies against Brucella spp. with the Rose Bengal Test, ELISA and Micro Agglutination Test (human sera only). PCR was performed on 10 percent of the milk samples and vaginal swabs from small ruminants.

Results

One human and 14 sheep sera were positive by the Rose Bengal Test. The rest were negative in all serological tests used. The PCR results were all negative.

Conclusions

The results suggest that brucellosis is currently not a generalized problem in humans or small ruminants in The Gambia.

Travelers' health problems and behavior: prospective study with post-travel follow-up

Background

The annual number of international tourist arrivals has recently exceeded one billion, yet surprisingly few studies have characterized travelers’ behavior, illness, and risk factors in a prospective setting. Particularly scarce are surveys of data spanning travel, return, and follow-up of the same cohort.

This study examines behavior and illness among travelers while abroad, after return home, and at follow-up. Patterns of behavior connected to type of travel and illness are characterized so as to identify risk factors and provide background data for pre-travel advice.

Methods

Volunteers to this prospective cohort study were recruited at visits to a travel clinic prior to departure. Data on the subjects’ health and behavior were collected by questionnaires before and after journeys and over a three-week follow-up. In addition, the subjects were asked to fill in health diaries while traveling.

Results

The final study population consisted of 460 subjects, 79 % of whom reported illness during travel or on arrival: 69 % had travelers’ diarrhea (TD), 17 % skin problems, 17 % fever, 12 % vomiting, 8 % respiratory tract infection, 4 % urinary tract infection, 2 % ear infection, 4 % gastrointestinal complaints other than TD or vomiting, and 4 % other symptoms. Of all subjects, 10 % consulted a doctor and 0.7 % were hospitalized; 18 % took antimicrobials, with TD as the most common indication (64 %). Ongoing symptoms were reported by 25 % of all travelers upon return home.

During the three-week follow-up (return rate 51 %), 32 % of respondents developed new-onset symptoms, 20 % visited a doctor and 1.7 % were hospitalized.

Factors predisposing to health problems were identified by multivariable analysis: certain regions (Southern Asia, South-Eastern Asia, and Eastern Africa), female gender, young age, and long travel duration.

Conclusions

Despite proper preventive measures like vaccinations, malaria prophylaxis, and travel advice, the majority of our subjects fell ill during or after travel. As the symptoms mostly remained mild, health care services were seldom needed. Typical traveler profiles were identified, thereby providing a tool for pre-travel advice. The finding that one third reported new-onset illness during follow-up attests to the importance of advising clients on potential post-travel health problems already during pre-travel visits.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1682-0) contains supplementary material, which is available to authorized users.

The Relationship between Poverty and Healthcare Seeking among Patients Hospitalized with Acute Febrile Illnesses in Chittagong, Bangladesh

Delays in seeking appropriate healthcare can increase the case fatality of acute febrile illnesses, and circuitous routes of care-seeking can have a catastrophic financial impact upon patients in low-income settings. To investigate the relationship between poverty and pre-hospital delays for patients with acute febrile illnesses, we recruited a cross-sectional, convenience sample of 527 acutely ill adults and children aged over 6 months, with a documented fever ≥38.0°C and symptoms of up to 14 days’ duration, presenting to a tertiary referral hospital in Chittagong, Bangladesh, over the course of one year from September 2011 to September 2012. Participants were classified according to the socioeconomic status of their households, defined by the Oxford Poverty and Human Development Initiative’s multidimensional poverty index (MPI). 51% of participants were classified as multidimensionally poor (MPI>0.33). Median time from onset of any symptoms to arrival at hospital was 22 hours longer for MPI poor adults compared to non-poor adults (123 vs. 101 hours) rising to a difference of 26 hours with adjustment in a multivariate regression model (95% confidence interval 7 to 46 hours; P = 0.009). There was no difference in delays for children from poor and non-poor households (97 vs. 119 hours; P = 0.394). Case fatality was 5.9% vs. 0.8% in poor and non-poor individuals respectively (P = 0.001)—5.1% vs. 0.0% for poor and non-poor adults (P = 0.010) and 6.4% vs. 1.8% for poor and non-poor children (P = 0.083). Deaths were attributed to central nervous system infection (11), malaria (3), urinary tract infection (2), gastrointestinal infection (1) and undifferentiated sepsis (1). Both poor and non-poor households relied predominantly upon the (often informal) private sector for medical advice before reaching the referral hospital, but MPI poor participants were less likely to have consulted a qualified doctor. Poor participants were more likely to attribute delays in decision-making and travel to a lack of money (P<0.001), and more likely to face catastrophic expenditure of more than 25% of monthly household income (P<0.001). We conclude that multidimensional poverty is associated with greater pre-hospital delays and expenditure in this setting. Closer links between health and development agendas could address these consequences of poverty and streamline access to adequate healthcare.