Technologies for global health

Male Gender and Arterial Hypertension are Plaque Predictors at Coronary Computed Tomography Angiography

BACKGROUND

Systemic Arterial Hypertension (SAH) is one of the main risk factors for Coronary Artery Disease (CAD), in addition to male gender. Differences in coronary artery lesions between hypertensive and normotensive individuals of both genders at the Coronary Computed Tomography Angiography (CCTA) have not been clearly determined.

OBJECTIVE

To Investigate the calcium score (CS), CAD extent and characteristics of coronary plaques at CCTA in men and women with and without SAH.

METHODS

Prospective cross-sectional study of 509 patients undergoing CCTA for CAD diagnosis and risk stratification, from November 2011 to December 2012, at Instituto de Cardiologia Dante Pazzanese. Individuals were stratified according to gender and subdivided according to the presence (HT +) or absence (HT-) of SAH.

RESULTS

HT+ women were older (62.3 ± 10.2 vs 57.8 ± 12.8, p = 0.01). As for the assessment of CAD extent, the HT+ individuals of both genders had significant CAD, although multivessel disease is more frequent in HT + men. The regression analysis for significant CAD showed that age and male gender were the determinant factors of multivessel disease and CS ≥ 100. Plaque type analysis showed that SAH was a predictive risk factor for partially calcified plaques (OR = 3.9).

CONCLUSION

Hypertensive men had multivessel disease more often than women. Male gender was a determinant factor of significant CAD, multivessel disease, CS ≥ 100 and calcified and partially calcified plaques, whereas SAH was predictive of partially calcified plaques.

The global inventor gap: distribution and equality of world-wide inventive effort, 1990-2010

Applying distance-to-frontier analysis, we have used 2.9 million patents and population data to assess whether the relative capacity of world countries and major regions to create new knowledge and technology has become globally more equal or less equal between 1990 and 2010. We show with the Gini coefficient that the global distribution of inventors has become more equal between major countries and regions. However, this trend has been largely due to the improved performance of only two major countries, China and India. The worst performing regions, totalling a population of almost 2 billion, are actually falling behind. Our results suggest that substantial parts of the global population have fallen further behind countries at the global frontier in their ability to create new knowledge and inventions, and that the catch-up among the least developed and middle-income countries is highly uneven, prompting questions about the nature and future of the global knowledge economy.

Priorities in lower limb prosthetic service delivery based on an international survey of prosthetists in low- and high-income countries

BACKGROUND

Prosthetic services, including the provision of an appropriate prosthesis, are a crucial part of the rehabilitation process for individuals with lower limb amputations. However, globally there exist unique challenges in the delivery of prosthetic services that are limiting rehabilitation outcomes and consequently the well-being and socio-economic status of individuals with lower limb amputations.

OBJECTIVES

The objective of this work was to explore the issues related to the provision of appropriate prosthetic technologies and to compare these across different economies of the world.

STUDY DESIGN

Cross-sectional survey.

METHODS

An online survey was developed and distributed to prosthetic practitioners providing services in countries around the world. An open-coding thematic content analysis procedure was applied to extract key themes from the data.

RESULTS

The response codes defined three overall themes of lower limb prosthetic delivery, and several key differences between higher and lower income countries emerged. Namely, a higher emphasis on part/material availability, practitioner training and durability in lower income countries was found. High costs were an issue raised by practitioners in all countries.

CONCLUSION

Practitioners around the world share many of the same concerns; however, some lower income countries face important and pressing issues that limit their ability to provide adequate prosthetic services.

CLINICAL RELEVANCE

This work highlights the most crucial service and technology-related needs, as perceived by trained prosthetic practitioners, of populations requiring lower limb prosthetic treatment around the world. Additionally, the results may be used to prioritize prosthetic-related health-care initiatives led by other researchers, governments and organizations working to improve services internationally.

An augmented SMS intervention to improve access to antenatal CD4 testing and ART initiation in HIV-infected pregnant women: a cluster randomized trial

BACKGROUND

Less than one-third of HIV-infected pregnant women eligible for combination antiretroviral therapy (ART) globally initiate treatment prior to delivery, with lack of access to timely CD4 results being a principal barrier. We evaluated the effectiveness of an SMS-based intervention to improve access to timely antenatal ART.

METHODS

We conducted a stepped-wedge cluster randomized trial of a low-cost programmatic intervention in 20 antenatal clinics in Gaborone, Botswana. From July 2011-April 2012, 2 clinics were randomly selected every 4 weeks to receive an ongoing clinic-based educational intervention to improve CD4 collection and to receive CD4 results via an automated SMS platform with active patient tracing. CD4 testing before 26 weeks gestation and ART initiation before 30 weeks gestation were assessed.

RESULTS

Three-hundred-sixty-six ART-naïve women were included, 189 registering for antenatal care under Intervention and 177 under Usual Care periods. Of CD4-eligible women, 100 (59.2%) women under Intervention and 79 (50.6%) women under Usual Care completed CD4 phlebotomy before 26 weeks gestation, adjusted odds ratio (aOR, adjusted for time that a clinic initiated Intervention) 0.87 (95% confidence interval [CI]0.47-1.63, P = 0.67). The SMS-based platform reduced time to clinic receipt of CD4 test result from median of 16 to 6 days (P<0.001), was appreciated by clinic staff, and was associated with reduced operational cost. However, rates of ART initiation remained low, with 56 (36.4%) women registering under Intervention versus 37 (24.2%) women under Usual Care initiating ART prior to 30 weeks gestation, aOR 1.06 (95%CI 0.53-2.13, P = 0.87).

CONCLUSIONS

The augmented SMS-based intervention delivered CD4 results more rapidly and efficiently, and this type of SMS-based results delivery platform may be useful for a variety of tests and settings. However, the intervention did not appear to improve access to timely antenatal CD4 testing or ART initiation, as obstacles other than CD4 impeded ART initiation during pregnancy.

The Health Impact Fund: how might it work for novel anticoagulants in atrial fibrillation?

Cardiovascular diseases represent the greatest burden of global disease. Spending on cardiovascular diseases is higher than for other diseases, with the majority being spent on drugs. Therefore, these drugs and these diseases are hugely important to health systems, society, and pharmaceutical companies. The Health Impact Fund represents a new mechanism by which pharmaceutical innovators would be rewarded on the basis of the health impact of their new drugs. This review illustrates the concept of the Health Impact Fund using the example of novel anticoagulants for prevention of stroke and thromboembolism in atrial fibrillation. By considering existing data and the current situation for novel anticoagulants, we suggest that epidemiologic data and modeling techniques can be used to predict future trends in disease and the health impact of new drugs. The Health Impact Fund may offer potential benefits to pharmaceutical companies, patients, and governments and warrants proper investigation.

Redistributing prostheses – from Britain to Sri Lanka

How used British mobility devices are being turned into brand new limbs for Sri Lankans.

Determining the utility and durability of medical equipment donated to a rural clinic in a low-income country

BACKGROUND

Health centers in low-income countries often depend on donations to provide appropriate diagnostic equipment. However, donations are sometimes made without an understanding of the recipient's needs, practical constraints or sustainability of supplies.

METHODS

We donated a set of physical diagnostic equipment, non-invasive instrument tests and laboratory supplies to a rural health center in the Democratic Republic of Congo. We collected information on the usage and durability of equipment and supplies for each patient encounter over a 1-year period.

RESULTS

We recorded 913 patient encounters. The most commonly used physical diagnostic equipment were the stethoscope (98.9%; 903/913), thermometer (81.7%; 746/913), adult scale (81.4%; 744/913), stop watch (62.6%; 572/913), adult sphygmomanometer (55.8%; 510/913), infant scale (24.9%; 228/913), measuring tape (24.3%; 222/913) and fetoscope (23.8%; 218/913). The most commonly used laboratory tests were the blood smear for malaria (53.7%; 491/913), hematocrit (23.5%; 215/913), urinalysis (20.1%; 184/913) and sputum stain for TB (13.3%; 122/913). With the exception of a penlight and solar lantern, all equipment remained functional.

CONCLUSIONS

This study adds valuable information about the utility and durability of equipment supplied to a health center in the Democratic Republic of Congo. Our results might aid in determining the appropriateness of donated medical equipment in similar settings. The selection of donated goods should be made with knowledge of the context in which it will be used, and utilization should be monitored.

A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS – Practical systematic RevIew of Self-Management Support for long-term conditions

Background

Despite robust evidence concerning self-management for some long-term conditions (LTCs), others lack research explicitly on self-management and, consequently, some patient groups may be overlooked.

Aim

To undertake a rapid, systematic overview of the evidence on self-management support for LTCs to inform health-care commissioners and providers about what works, for whom, and in what contexts.

Methods

Self-management is ‘the tasks . . . individuals must undertake to live with one or more chronic conditions . . . [including] . . . having the confidence to deal with medical management, role management and emotional management of their conditions’. We convened an expert workshop and identified characteristics of LTCs potentially of relevance to self-management and 14 diverse exemplar LTCs (stroke, asthma, type 2 diabetes mellitus, depression, chronic obstructive pulmonary disease, chronic kidney disease, dementia, epilepsy, hypertension, inflammatory arthropathies, irritable bowel syndrome, low back pain, progressive neurological disorders and type 1 diabetes mellitus). For each LTC we conducted systematic overviews of systematic reviews of randomised controlled trials (RCTs) of self-management support interventions (‘quantitative meta-reviews’); and systematic overviews of systematic reviews of qualitative studies of patients’ experiences relating to self-management (‘qualitative meta-reviews’). We also conducted an original systematic review of implementation studies of self-management support in the LTCs. We synthesised all our data considering the different characteristics of LTCs. In parallel, we developed a taxonomy of the potential components of self-management support.

Results

We included 30 qualitative systematic reviews (including 515 unique studies), 102 quantitative systematic reviews (including 969 RCTs), and 61 studies in the implementation systematic review. Effective self-management support interventions are multifaceted, should be tailored to the individual, their culture and beliefs, a specific LTC and position on the disease trajectory, and underpinned by a collaborative/communicative relationship between the patient and health-care professional (HCP) within the context of a health-care organisation that actively promotes self-management. Self-management support is a complex intervention and although many components were described and trialled in the studies no single component stood out as more important than any other. Core components include (1) provision of education about the LTC, recognising the importance of understanding patients’ pre-existing knowledge and beliefs about their LTC; (2) psychological strategies to support adjustment to life with a LTC; (3) strategies specifically to support adherence to treatments; (4) practical support tailored to the specific LTC, including support around activities of daily living for disabling conditions, action plans in conditions subject to marked exacerbations, intensive disease-specific training to enable self-management of specific clinical tasks; and (5) social support as appropriate. Implementation requires a whole-systems approach which intervenes at the level of the patient, the HCP and the organisation. The health-care organisation is responsible for providing the means (both training and time/material resources) to enable HCPs to implement, and patients to benefit from, self-management support, regularly evaluating self-management processes and clinical outcomes. More widely there is a societal need to address public understanding of LTCs. The lack of public story for many conditions impacted on patient help-seeking behaviour and public perceptions of need.

Conclusions

Supporting self-management is inseparable from the high-quality care for LTCs. Commissioners and health-care providers should promote a culture of actively supporting self-management as a normal, expected, monitored and rewarded aspect of care. Further research is needed to understand how health service managers and staff can achieve this culture change in their health-care organisations.

Study registration

This study is registered as PROSPERO CRD42012002898.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Developing sustainable global health technologies: insight from an initiative to address neonatal hypothermia

Relative to drugs, diagnostics, and vaccines, efforts to develop other global health technologies, such as medical devices, are limited and often focus on the short-term goal of prototype development instead of the long-term goal of a sustainable business model. To develop a medical device to address neonatal hypothermia for use in resource-limited settings, we turned to principles of design theory: (1) define the problem with consideration of appropriate integration into relevant health policies, (2) identify the users of the technology and the scenarios in which the technology would be used, and (3) use a highly iterative product design and development process that incorporates the perspective of the user of the technology at the outset and addresses scalability. In contrast to our initial idea, to create a single device, the process guided us to create two separate devices, both strikingly different from current solutions. We offer insights from our initial experience that may be helpful to others engaging in global health technology development.

Online social networking services in the management of patients with diabetes mellitus: systematic review and meta-analysis of randomised controlled trials

AIMS

Social networking services (SNS) can facilitate real-time communication and feedback of blood glucose and other physiological data between patients and healthcare professionals. This systematic review and meta-analysis aims to summarise the current evidence surrounding the role of online social networking services in diabetes care.

METHODS

We performed a systematic literature review of the Medline, EMBASE and PsychINFO databases of all studies reporting HbA1c (glycated haemoglobin) as a measure of glycaemic control for social networking services in diabetes care. HbA1c, clinical outcomes and the type of technology used were extracted. Study quality and publication bias were assessed.

RESULTS

SNS interventions beneficially reduced HbA1c when compared to controls, which was confirmed by sensitivity analysis. SNS interventions also significantly improved systolic and diastolic blood pressure, triglycerides and total cholesterol. Subgroup analysis according to diabetes type demonstrated that Type 2 diabetes patients had a significantly greater reduction in HbA1c than those with Type 1 diabetes.

CONCLUSIONS

Online SNS provide a novel, feasible approach to improving glycaemic control, particularly in patients with Type 2 diabetes. Further mechanistic and cost-effectiveness studies are required to improve our understanding of SNS and its efficacy in diabetes care.

Medical device procurement in low- and middle-income settings: protocol for a systematic review

BACKGROUND

Medical device procurement processes for low- and middle-income countries (LMICs) are a poorly understood and researched topic. To support LMIC policy formulation in this area, international public health organizations and research institutions issue a large body of predominantly grey literature including guidelines, manuals and recommendations. We propose to undertake a systematic review to identify and explore the medical device procurement methodologies suggested within this and further literature. Procurement facilitators and barriers will be identified, and methodologies for medical device prioritization under resource constraints will be discussed.

METHODS/DESIGN

Searches of both bibliographic and grey literature will be conducted to identify documents relating to the procurement of medical devices in LMICs. Data will be extracted according to protocol on a number of pre-specified issues and variables. First, data relating to the specific settings described within the literature will be noted. Second, information relating to medical device procurement methodologies will be extracted, including prioritization of procurement under resource constraints, the use of evidence (e.g. cost-effectiveness evaluations, burden of disease data) as well as stakeholders participating in procurement processes. Information relating to prioritization methodologies will be extracted in the form of quotes or keywords, and analysis will include qualitative meta-summary. Narrative synthesis will be employed to analyse data otherwise extracted. The PRISMA guidelines for reporting will be followed.

DISCUSSION

The current review will identify recommended medical device procurement methodologies for LMICs. Prioritization methods for medical device acquisition will be explored. Relevant stakeholders, facilitators and barriers will be discussed. The review is aimed at both LMIC decision makers and the international research community and hopes to offer a first holistic conceptualization of this topic.

How to transform the practice of engineering to meet global health needs

More of the world's population has access to cell phones than to basic sanitation facilities, a gap that can only be closed if the engineering and international aid communities adopt new approaches to design for scarcity and scalability.

World health dilemmas: Orphan and rare diseases, orphan drugs and orphan patients

According to global annual estimates hunger/malnutrition is the major cause of death (36 of 62 million). Cardiovascular diseases and cancer (5.44 of 13.43 million) are the major causes of death in developed countries, while lower respiratory tract infections, human immunodeficiency virus infection/acquired immunodeficiency syndrome, diarrhoeal disease, malaria and tuberculosis (10.88 of 27.12 million) are the major causes of death in developing countries with more than 70% of deaths occurring in children. The majority of approximately 800 million people with other rare diseases, including 100000 children born with thalassaemia annually receive no treatment. There are major ethical dilemmas in dealing with global health issues such as poverty and the treatment of orphan and rare diseases. Of approximately 50000 drugs about 10% are orphan drugs, with annual sales of the latter approaching 100 billion USD. In comparison, the annual revenue in 2009 from the top 12 pharmaceutical companies in Western countries was 445 billion USD and the top drug, atorvastatin, reached 100 billion USD. In the same year, the total government expenditure for health in the developing countries was 410 billion USD with only 6%-7% having been received as aid from developed countries. Drugs cost the National Health Service in the United Kingdom more than 20 billion USD or 10% of the annual health budget. Uncontrollable drug prices and marketing policies affect global health budgets, clinical practice, patient safety and survival. Fines of 5.3 billion USD were imposed on two pharmaceutical companies in the United States, the regulatory authority in France was replaced and clinicians were charged with bribery in order to overcome recent illegal practises affecting patient care. High expenditure for drug development is mainly related to marketing costs. However, only 2 million USD was spent developing the drug deferiprone (L1) for thalassaemia up to the stage of multicentre clinical trials. The criteria for drug development, price levels and use needs to be readdressed to improve drug safety and minimise costs. New global health policies based on cheaper drugs can help the treatment of many categories of orphan and rare diseases and millions of orphan patients in developing and developed countries.

Density-based separation in multiphase systems provides a simple method to identify sickle cell disease

Although effective low-cost interventions exist, child mortality attributable to sickle cell disease (SCD) remains high in low-resource areas due, in large part, to the lack of accessible diagnostic methods. The presence of dense (ρ > 1.120 g/cm(3)) cells is characteristic of SCD. The fluid, self-assembling step-gradients in density created by aqueous multiphase systems (AMPSs) identifies SCD by detecting dense cells. AMPSs separate different forms of red blood cells by density in a microhematocrit centrifuge and provide a visual means to distinguish individuals with SCD from those with normal hemoglobin or with nondisease, sickle-cell trait in under 12 min. Visual evaluation of a simple two-phase system identified the two main subclasses of SCD [homozygous (Hb SS) and heterozygous (Hb SC)] with a sensitivity of 90% (73-98%) and a specificity of 97% (86-100%). A three-phase system identified these two types of SCD with a sensitivity of 91% (78-98%) and a specificity of 88% (74-98%). This system could also distinguish between Hb SS and Hb SC. To the authors' knowledge, this test demonstrates the first separation of cells by density with AMPSs, and the usefulness of AMPSs in point-of-care diagnostic hematology.

Challenges and frugal remedies for lowering facility based neonatal mortality and morbidity: a comparative study

Millennium development goal target on infant mortality (MDG4) by 2015 would not be realised in some low-resource countries. This was in part due to unsustainable high-tech ideas that have been poorly executed. Prudent but high impact techniques could have been synthesised in these countries. A collaborative outreach was initiated to devise frugal measures that could reduce neonatal deaths in Nigeria. Prevailing issues of concern that could militate against neonatal survival within care centres were identified and remedies were proffered. These included application of (i) recycled incubator technology (RIT) as a measure of providing affordable incubator sufficiency, (ii) facility-based research groups, (iii) elective training courses for clinicians/nurses, (iv) independent local artisans on spare parts production, (v) power-banking and apnoea-monitoring schemes, and (v) 1/2 yearly failure-preventive maintenance and auditing system. Through a retrospective data analyses 4 outreach centres and one "control" were assessed. Average neonatal mortality of centres reduced from 254/1000 to 114/1000 whilst control remained at 250/1000. There was higher relative influx of incubator-dependent-neonates at outreach centres. It was found that 43% of mortality occurred within 48 hours of presentation (d48) and up to 92% of d48 were of very-low birth parameters. The RIT and associated concerns remedies have demonstrated the vital signs of efficiency that would have guaranteed MDG4 neonatal component in Nigeria.

Surgical care in low and middle-income countries: burden and barriers

Surgically correctable pathology accounts for a sizeable proportion of the overall global burden of disease. Over the last decade the role of surgery in the public health agenda has increased in prominence and attempts to quantify surgical capacity suggest that it is a significant public health issue, with a great disparity between high-income, and low- and middle-income countries (LMICs). Although barriers such as accessibility, availability, affordability and acceptability of surgical care hinder improvements in LMICs, evidence suggests that interventions to improve surgical care in these settings can be cost-effective. Currently, efforts to improve surgical care are mainly coordinated by academia and intuitions with strong surgical and global health interests. However, with the involvement of various international organisations, policy makers, healthcare managers and other stakeholders, a collaborative approach can be achieved in order to accelerate progress towards improved and sustainable surgical care. In this article, we discuss the current burden of global surgical disease and explore some of the barriers that may be encountered in improving surgical capacity in LMICs. We go on to consider the role that international organisations can have in improving surgical care globally. We conclude by discussing surgery as a global health priority and possible solutions to improving surgical care globally.

Mobile phone intervention reduces perinatal mortality in zanzibar: secondary outcomes of a cluster randomized controlled trial

Background

Mobile phones are increasingly used in health systems in developing countries and innovative technical solutions have great potential to overcome barriers of access to reproductive and child health care. However, despite widespread support for the use of mobile health technologies, evidence for its role in health care is sparse.

Objective

We aimed to evaluate the association between a mobile phone intervention and perinatal mortality in a resource-limited setting.

Methods

This study was a pragmatic, cluster-randomized, controlled trial with primary health care facilities in Zanzibar as the unit of randomization. At their first antenatal care visit, 2550 pregnant women (1311 interventions and 1239 controls) who attended antenatal care at selected primary health care facilities were included in this study and followed until 42 days after delivery. Twenty-four primary health care facilities in six districts were randomized to either mobile phone intervention or standard care. The intervention consisted of a mobile phone text message and voucher component. Secondary outcome measures included stillbirth, perinatal mortality, and death of a child within 42 days after birth as a proxy of neonatal mortality.

Results

Within the first 42 days of life, 2482 children were born alive, 54 were stillborn, and 36 died. The overall perinatal mortality rate in the study was 27 per 1000 total births. The rate was lower in the intervention clusters, 19 per 1000 births, than in the control clusters, 36 per 1000 births. The intervention was associated with a significant reduction in perinatal mortality with an odds ratio (OR) of 0.50 (95% CI 0.27-0.93). Other secondary outcomes showed an insignificant reduction in stillbirth (OR 0.65, 95% CI 0.34-1.24) and an insignificant reduction in death within the first 42 days of life (OR 0.79, 95% CI 0.36-1.74).

Conclusions

Mobile phone applications may contribute to improved health of the newborn and should be considered by policy makers in resource-limited settings.

Trial Registration

ClinicalTrials.gov NCT01821222; http://www.clinicaltrials.gov/ct2/show/NCT01821222 (Archived by WebCite at http://www.webcitation.org/6NqxnxYn0).

Mobile phones improve antenatal care attendance in Zanzibar: a cluster randomized controlled trial

BACKGROUND

Applying mobile phones in healthcare is increasingly prioritized to strengthen healthcare systems. Antenatal care has the potential to reduce maternal morbidity and improve newborns' survival but this benefit may not be realized in sub-Saharan Africa where the attendance and quality of care is declining. We evaluated the association between a mobile phone intervention and antenatal care in a resource-limited setting. We aimed to assess antenatal care in a comprehensive way taking into consideration utilisation of antenatal care as well as content and timing of interventions during pregnancy.

METHODS

This study was an open label pragmatic cluster-randomised controlled trial with primary healthcare facilities in Zanzibar as the unit of randomisation. 2550 pregnant women (1311 interventions and 1239 controls) who attended antenatal care at selected primary healthcare facilities were included at their first antenatal care visit and followed until 42 days after delivery. 24 primary health care facilities in six districts were randomized to either mobile phone intervention or standard care. The intervention consisted of a mobile phone text-message and voucher component. Primary outcome measure was four or more antenatal care visits during pregnancy. Secondary outcome measures were tetanus vaccination, preventive treatment for malaria, gestational age at last antenatal care visit, and antepartum referral.

RESULTS

The mobile phone intervention was associated with an increase in antenatal care attendance. In the intervention group 44% of the women received four or more antenatal care visits versus 31% in the control group (OR, 2.39; 95% CI, 1.03-5.55). There was a trend towards improved timing and quality of antenatal care services across all secondary outcome measures although not statistically significant.

CONCLUSIONS

The wired mothers' mobile phone intervention significantly increased the proportion of women receiving the recommended four antenatal care visits during pregnancy and there was a trend towards improved quality of care with more women receiving preventive health services, more women attending antenatal care late in pregnancy and more women with antepartum complications identified and referred. Mobile phone applications may contribute towards improved maternal and newborn health and should be considered by policy makers in resource-limited settings.

Prioritizing investments in innovations to protect women from the leading causes of maternal death

PATH, an international nonprofit organization, assessed nearly 40 technologies for their potential to reduce maternal mortality from postpartum hemorrhage and preeclampsia and eclampsia in low-resource settings. The evaluation used a new Excel-based prioritization tool covering 22 criteria developed by PATH, the Maternal and Neonatal Directed Assessment of Technology (MANDATE) model, and consultations with experts. It identified five innovations with especially high potential: technologies to improve use of oxytocin, a uterine balloon tamponade, simplified dosing of magnesium sulfate, an improved proteinuria test, and better blood pressure measurement devices. Investments are needed to realize the potential of these technologies to reduce mortality.

mHealth Series: mHealth project in Zhao County, rural China - Description of objectives, field site and methods

Background

We set up a collaboration between researchers in China and the UK that aimed to explore the use of mHealth in China. This is the first paper in a series of papers on a large mHealth project part of this collaboration. This paper included the aims and objectives of the mHealth project, our field site, and the detailed methods of two studies.

Field site

The field site for this mHealth project was Zhao County, which lies 280 km south of Beijing in Hebei Province, China.

Methods

We described the methodology of two studies: (i) a mixed methods study exploring factors influencing sample size calculations for mHealth–based health surveys and (ii) a cross–over study determining validity of an mHealth text messaging data collection tool. The first study used mixed methods, both quantitative and qualitative, including: (i) two surveys with caregivers of young children, (ii) interviews with caregivers, village doctors and participants of the cross–over study, and (iii) researchers’ views. We combined data from caregivers, village doctors and researchers to provide an in–depth understanding of factors influencing sample size calculations for mHealth–based health surveys. The second study, a cross–over study, used a randomised cross–over study design to compare the traditional face–to–face survey method to the new text messaging survey method. We assessed data equivalence (intrarater agreement), the amount of information in responses, reasons for giving different responses, the response rate, characteristics of non–responders, and the error rate.

Conclusions

This paper described the objectives, field site and methods of a large mHealth project part of a collaboration between researchers in China and the UK. The mixed methods study evaluating factors that influence sample size calculations could help future studies with estimating reliable sample sizes. The cross–over study comparing face–to–face and text message survey data collection could help future studies with developing their mHealth tools.

The Integrated Behavioural Model for Water, Sanitation, and Hygiene: a systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-restricted settings

BACKGROUND

Promotion and provision of low-cost technologies that enable improved water, sanitation, and hygiene (WASH) practices are seen as viable solutions for reducing high rates of morbidity and mortality due to enteric illnesses in low-income countries. A number of theoretical models, explanatory frameworks, and decision-making models have emerged which attempt to guide behaviour change interventions related to WASH. The design and evaluation of such interventions would benefit from a synthesis of this body of theory informing WASH behaviour change and maintenance.

METHODS

We completed a systematic review of existing models and frameworks through a search of related articles available in PubMed and in the grey literature. Information on the organization of behavioural determinants was extracted from the references that fulfilled the selection criteria and synthesized. Results from this synthesis were combined with other relevant literature, and from feedback through concurrent formative and pilot research conducted in the context of two cluster-randomized trials on the efficacy of WASH behaviour change interventions to inform the development of a framework to guide the development and evaluation of WASH interventions: the Integrated Behavioural Model for Water, Sanitation, and Hygiene (IBM-WASH).

RESULTS

We identified 15 WASH-specific theoretical models, behaviour change frameworks, or programmatic models, of which 9 addressed our review questions. Existing models under-represented the potential role of technology in influencing behavioural outcomes, focused on individual-level behavioural determinants, and had largely ignored the role of the physical and natural environment. IBM-WASH attempts to correct this by acknowledging three dimensions (Contextual Factors, Psychosocial Factors, and Technology Factors) that operate on five-levels (structural, community, household, individual, and habitual).

CONCLUSIONS

A number of WASH-specific models and frameworks exist, yet with some limitations. The IBM-WASH model aims to provide both a conceptual and practical tool for improving our understanding and evaluation of the multi-level multi-dimensional factors that influence water, sanitation, and hygiene practices in infrastructure-constrained settings. We outline future applications of our proposed model as well as future research priorities needed to advance our understanding of the sustained adoption of water, sanitation, and hygiene technologies and practices.

Developing global health technology standards: what can other industries teach us?

BACKGROUND

There is a lack of effective and affordable technologies to address health needs in the developing world. One way to address problems of innovation and affordability is to design global health technologies to follow agreed-upon standards. This Debate article argues that we can better develop standards for global health technologies if we learn lessons from other industries.

DISCUSSION

The article's Background section begins by explaining why standards are needed in global health. For example, if global health technologies can be modularized into independent interfacing parts, these parts can then interact via well-defined standards in a "plug and play" fashion. This can avoid development of mutually incompatible solutions by different organizations, speed the pace of innovation, unlock health systems from single providers and approaches, and lower barriers to entry. The Background then gives a brief primer on standards and discusses incentives for health standards. The article's Discussion section begins with brief relevant cases of standards development from other industries, including electricity, container shipping, CD standards, Universal Serial Bus (USB), and the Internet. It then explores lessons from these and other industries that suggest how to develop standards for global health technologies. The remainder of the Discussion considers intellectual property and regulatory issues and standards-based global health business models, and ends with a checklist of considerations for health standards development leaders. (The associated Additional file discusses observations from standards development for cell phones and semiconductors, as well as challenges in the standards development process itself.) Throughout the article, point-of-care diagnostics are used as an illustrative example. An initiative is already underway to explore standardized diagnostics platforms.

SUMMARY

This Debate article aims to convince the reader that standards can benefit global health technologies if we learn lessons from other industries. The article draws from historical examples and the authors' experiences to suggest principles, challenges, and opportunities in developing these standards. If implemented well, standardized platforms can lower barriers to entry, improve affordability, and create a vibrant ecosystem of innovative new global health technologies.

Mapping of available health research and development data: what's there, what's missing, and what role is there for a global observatory?

The need to align investments in health research and development (R&D) with public health demands is one of the most pressing global public health challenges. We aim to provide a comprehensive description of available data sources, propose a set of indicators for monitoring the global landscape of health R&D, and present a sample of country indicators on research inputs (investments), processes (clinical trials), and outputs (publications), based on data from international databases. Total global investments in health R&D (both public and private sector) in 2009 reached US$240 billion. Of the US$214 billion invested in high-income countries, 60% of health R&D investments came from the business sector, 30% from the public sector, and about 10% from other sources (including private non-profit organisations). Only about 1% of all health R&D investments were allocated to neglected diseases in 2010. Diseases of relevance to high-income countries were investigated in clinical trials seven-to-eight-times more often than were diseases whose burden lies mainly in low-income and middle-income countries. This report confirms that substantial gaps in the global landscape of health R&D remain, especially for and in low-income and middle-income countries. Too few investments are targeted towards the health needs of these countries. Better data are needed to improve priority setting and coordination for health R&D, ultimately to ensure that resources are allocated to diseases and regions where they are needed the most. The establishment of a global observatory on health R&D, which is being discussed at WHO, could address the absence of a comprehensive and sustainable mechanism for regular global monitoring of health R&D.

The link between information and communication technologies and global public health: pushing forward

.Global public health (GPH) continues to be a challenging field. It focuses on health-related issues that transcend national boundaries and thus requires global cooperation for implementing solutions to public health problems. Information and communication technologies (ICTs) have the potential to contribute to GPH by improving the quality of healthcare services. The purpose of this commentary article is to discuss the nature and characteristics of the existing link between ICTs and GPH. The key underlying questions discussed in this article are (a) whether ICTs can truly reduce the burden of current GPH problems and (b) how to effectively achieve it. We selected three widely recognized GPH challenges: diarrheal disease among children under 5 years old, malaria, and type 2 diabetes mellitus. These are considered to be examples of salient global issues that, despite the availability of cost-effective preventive and therapeutic interventions, still remain a major burden of morbidity and mortality worldwide. We conclude that there is a growing global interest in ICT-related solutions in GPH. We recommend the development of more transparent frameworks, more theory-informed solutions, and clearer translational links between ICTs and GPH matters. Ten further specific recommendations are also discussed in this article.

Systematic Review of Economic Evaluation Literature in Ghana: Is Health Technology Assessment the Future?

OBJECTIVES

In many countries, such as Ghana, there is an increasing impetus to use economic evaluation to allow more explicit and transparent health care priority setting. An important question for policymakers in low-income countries, however, is whether it is possible to introduce economic evaluation data into health care priority-setting decisions.

METHODS

This article systematically reviewed the literature on economic evaluation on medical devices and pharmaceuticals in Ghana published between 1997 and 2012. Its aim was to analyze the quantity, quality, and targeting of economic evaluation studies that relate to medical devices and pharmaceuticals and provide a framework for those conducting similar health technology assessment reviews in similar contexts.

RESULTS

The review revealed that the number of publications reporting economic evaluations was minimal with regard to medical devices and pharmaceuticals.

CONCLUSIONS

With the introduction of the National Health Insurance Scheme since 2004 policymakers are confronted with the challenge of allocating scarce resources rationally. Priority setting therefore has to be guided by a sound knowledge of the costs of providing health services. The need for economic evaluation is thus important. More costing studies were found; there were very few cost-effectiveness analysis studies. If economic evaluation is useful for policymakers only when performed correctly and reported accurately, these findings depict barriers to using economic evaluation to assist decision-making processes in Ghana; hence, there is a need for an independent health technology assessment unit.

Shared learning in an interconnected world: innovations to advance global health equity

The notion of "reverse innovation"--that some insights from low-income countries might offer transferable lessons for wealthier contexts--is increasingly common in the global health and business strategy literature. Yet the perspectives of researchers and policymakers in settings where these innovations are developed have been largely absent from the discussion to date. In this Commentary, we present examples of programmatic, technological, and research-based innovations from Rwanda, and offer reflections on how the global health community might leverage innovative partnerships for shared learning and improved health outcomes in all countries.

Applying rapid 'de-facto' HTA in resource-limited settings: experience from Romania

BACKGROUND

In attempting to constrain healthcare expenditure growth, health technology assessment (HTA) can enable policy-makers to look beyond budget impact and facilitate more rational decision-making. However lack of technical capacity and poor governance can limit use in some countries. Undertaking de facto HTA by adapting decisions taken in countries with established processes is a method that may be applied while building domestic HTA capacity. We explored the potential for applying this approach in Romania.

METHODS

As part of a review of the basic health benefits available to insured Romanians we examined the listing process and content of the Romanian drug reimbursement formulary. We assessed value for money indirectly by drawing on appraisals by UK's NICE, and for products considered cost effective in the UK, adjusting prices by the ratio of Romanian per capita GDP to UK per capita GDP.

FINDINGS

We found more than 30 of the top 50 medicines on the Romanian formulary unlikely to be cost-effective, suggesting that existing external reference pricing mechanisms may not be delivering good value for money.

CONCLUSIONS

While not taking into account local costs or treatment patterns, absent local considerations of value for money, this method offers a guide for both drug selection and pricing. Until robust local HTA processes are established this approach could support further analysis of existing prices and pricing mechanisms. Applied more generally, it is arguably preferable to external reference pricing, product delisting or arbitrary price cuts, and may support the future development of more rigorous, evidence-based decision-making.

The blood supply in Sub-Saharan Africa: needs, challenges, and solutions

Sub-Saharan Africa (SSA) is burdened with a growing population and poor health care resources. Transfusion medicine is uniquely affected for SSA as a result of a combination of factors which put tremendous pressure on the blood supply. In this review, we consider these factors including: malaria, sickle cell anemia, transfusion medicine infrastructure, and past transfusion medicine policies including those which are tied to foreign aid, such as a VNRD-only practice. We also consider how SSA can overcome some of these hurdles to achieve a safe and adequate blood supply for its people through the advent of new vaccines, medications, infrastructure development, policy changes, and education.

Universal health coverage in Turkey: enhancement of equity

Turkey has successfully introduced health system changes and provided its citizens with the right to health to achieve universal health coverage, which helped to address inequities in financing, health service access, and health outcomes. We trace the trajectory of health system reforms in Turkey, with a particular emphasis on 2003-13, which coincides with the Health Transformation Program (HTP). The HTP rapidly expanded health insurance coverage and access to health-care services for all citizens, especially the poorest population groups, to achieve universal health coverage. We analyse the contextual drivers that shaped the transformations in the health system, explore the design and implementation of the HTP, identify the factors that enabled its success, and investigate its effects. Our findings suggest that the HTP was instrumental in achieving universal health coverage to enhance equity substantially, and led to quantifiable and beneficial effects on all health system goals, with an improved level and distribution of health, greater fairness in financing with better financial protection, and notably increased user satisfaction. After the HTP, five health insurance schemes were consolidated to create a unified General Health Insurance scheme with harmonised and expanded benefits. Insurance coverage for the poorest population groups in Turkey increased from 2·4 million people in 2003, to 10·2 million in 2011. Health service access increased across the country-in particular, access and use of key maternal and child health services improved to help to greatly reduce the maternal mortality ratio, and under-5, infant, and neonatal mortality, especially in socioeconomically disadvantaged groups. Several factors helped to achieve universal health coverage and improve outcomes. These factors include economic growth, political stability, a comprehensive transformation strategy led by a transformation team, rapid policy translation, flexible implementation with continuous learning, and simultaneous improvements in the health system, on both the demand side (increased health insurance coverage, expanded benefits, and reduced cost-sharing) and the supply side (expansion of infrastructure, health human resources, and health services).

Innovative newborn health technology for resource-limited environments

OBJECTIVES

To review medical devices addressing newborn health in resource-poor settings, and to identify existing and potential barriers to their actual and efficient use in these settings.

METHODS

We searched Pubmed as our principal electronic reference library and dedicated databases such as Maternova and the Maternal and Neonatal Directed Assessment of Technology. We also researched standard public search engines. Studies and grey literature reports describing devices for use in a low- or middle-income country context were eligible for inclusion.

RESULTS

Few devices are currently described in the peer-reviewed medical or public health literature. The majority of newborn-specific devices were found in the grey literature. Most sources described infant warmers, neonatal resuscitators, and phototherapy devices. Other devices address the diagnosis of infectious diseases, monitoring of oxygen saturation, assisted ventilation, prevention of mother-to-child transmission of HIV, assisted childbirth, weight or temperature assessment, and others.

CONCLUSION

Many medical devices designed for newborns in the developing world are under development or in the early stages of production, but the vast majority of them are not available when and where they are needed. Making them available to mothers, newborns, and birth attendants in resource-limited countries at the time and place of birth will require innovative and creative production, distribution, and implementation approaches.

Cost-effectiveness of a new internet-based monitoring tool for neonatal post-discharge home care

BACKGROUND

The application of information and communication technologies in nursing care is becoming more widespread, but few applications have been reported in neonatal care. A close monitoring of newborns within the first weeks of life is crucial to evaluating correct feeding, growth, and health status. Conventional hospital-based postdischarge monitoring could be improved in terms of costs and clinical effectiveness by using a telemedicine approach.

OBJECTIVE

To evaluate the cost-effectiveness of a new Internet-based system for monitoring low-risk newborns after discharge compared to the standard hospital-based follow-up, with specific attention to prevention of emergency department (ED) visits in the first month of life.

METHODS

We performed a retrospective cohort study of two low-risk newborn patient groups. One group, born between January 1, 2011, and June 30, 2011, received the standard hospital-based follow-up visit within 48 hours after discharge. After implementing an Internet-based monitoring system, another group, born between July 19, 2011, and January 19, 2012, received their follow-up with this system.

RESULTS

A total of 18 (15.8%) out of 114 newborns who received the standard hospital-based follow-up had an ED visit in the first month of life compared with 5 (5.6%; P=.026) out of 90 infants who were monitored by the Internet-based system. The cost of the hospital-based follow-up was 182.1€ per patient, compared with 86.1€ for the Internet-based follow-up.

CONCLUSION

Our Internet-based monitoring approach proved to be both more effective and less costly than the conventional hospital-based follow-up, particularly through reducing subsequent ED visits.