Barriers to the success of an electronic pharmacovigilance reporting system in Kenya: an evaluation three years post implementation

Community health worker payment processes: a qualitative assessment of experiences in two Indian states

Community health worker (CHWs) remuneration has received some attention in terms of the design of incentives, however, there is a lack of systematic data on the processes by which CHWs are paid. We aimed to study existing payment processes including the role of digitization and its effects on CHW experiences with receiving full and timely compensation, and identify barriers and facilitators to the payment process. We studied payment processes for the Accredited Social Health Activist (ASHA) in India in two states with varying levels of performance and payment systems and conducted 53 in-depth interviews and eight focus group discussions across three categories of respondents (37 ASHA workers, 46 supervisors, and 34 managers/health system leaders). The data was coded thematically using inductive and deductive coding methods organized around five steps of the payment process: (i) recording of work, (ii) claim submission, (iii) claim verification, (iv) claim processing, and (v) payment disbursement. We observed complex sub-processes within each stage of the payment process that adversely impacted payment timelines, CHW workload, and motivation, even where digital tools provide support. Local administrative initiative and positive organizational culture overcame these challenges to standardize and simplify processes for recording work, submitting claims, and maintaining adequate funds, facilitating timely payments. Complete digitization of disbursement through the public financial management system improved timeliness, transparency, and satisfaction among CHWs compared to earlier cash and cheque-based payments. The potential digitization of service delivery records for claim submission was met with mixed perceptions among CHWs and their supervisors. Our study contributes to the body of knowledge on CHW compensation by delineating the processes by which financial incentives are paid and offering insights for low and middle-income countries to improve the efficiency of payment systems.

"We have been so patient because we know where we are coming from" Exploring the acceptability and feasibility of a mobile electronic medical record system designed for community-based antiretroviral therapy in Lilongwe, Malawi

Background

Mobile health (mHealth) is reshaping healthcare delivery, especially in HIV management. The World Health Organization advocates for mHealth to provide healthcare workers (HCWs) with real-time data, enhancing patient care. However, in Malawi's Lighthouse Trust antiretroviral therapy (ART) clinic, the nurse-led community-based ART (NCAP) program faces hurdles with data management due to lack of access to electronic medical records systems (EMRS) in the community setting. EMRS is not typically available in differentiated service delivery settings where reliable power and internet are often unavailable. We used human-centered design (HCD) processes to create a mobile EMRS prototype, the Community-based ART Retention and Suppression (CARES) app. We explore progress to simplify workflow for HCWs and improve client care.

Methods

To evaluate the CARES app's feasibility and acceptability among NCAP HCWs, we conducted in-depth interviews among 15 NCAP HCWs. We used a rapid qualitative analysis approach guided by the extended Technology Acceptance Model. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Results

As a likely result of HCD, HCWs demonstrated high expectations for the CARES app to improve healthcare delivery and data management. However, challenges such as app performance, data integration, and system navigation were significant barriers to acceptance or feasibility. Despite challenges, HCWs remained optimistic about the potential for CARES to enhance NCAP clinical decision-making and data flow. HCWs emphasized the need for continuous training and stakeholder engagement, improved infrastructure, data security protections, and establishing the CARES app and EMRS integration to facilitate CARES' longterm success at scale.

Conclusion

The study's findings underscore the importance of HCD for mHealth buy-in. As HCWs were invested in CARES success, they remained optimistic that the app could enhance NCAP services if user experience and app performance improved. Incorporation of HCW feedback would help deliver beyond the promise of CARES.

Barriers and facilitators for the sustainability of digital health interventions in low and middle-income countries: A systematic review

Background

Digital health interventions (DHIs) have increased exponentially all over the world. Furthermore, the interest in the sustainability of digital health interventions is growing significantly. However, a systematic synthesis of digital health intervention sustainability challenges is lacking. This systematic review aimed to identify the barriers and facilitators for the sustainability of digital health intervention in low and middle-income countries.

Methods

Three electronic databases (PubMed, Embase and Web of Science) were searched. Two independent reviewers selected eligible publications based on inclusion and exclusion criteria. Data were extracted and quality assessed by four team members. Qualitative, quantitative or mixed studies conducted in low and middle-income countries and published from January 2000 to May 2022 were included.

Results

The sustainability of digital health interventions is very complex and multidimensional. Successful sustainability of digital health interventions depends on interdependent complex factors that influence the implementation and scale-up level in the short, middle and long term. Barriers identified among others are associated with infrastructure, equipment, internet, electricity and the DHIs. As for the facilitators, they are more focused on the strong commitment and involvement of relevant stakeholders: Government, institutional, sectoral, stakeholders' support, collaborative networks with implementing partners, improved satisfaction, convenience, privacy, confidentiality and trust in clients, experience and confidence in using the system, motivation and competence of staff. All stakeholders play an essential role in the process of sustainability. Digital technology can have long term impacts on health workers, patients, and the health system, by improving data management for decision-making, the standard of healthcare service delivery and boosting attendance at health facilities and using services. Therefore, management changes with effective monitoring and evaluation before, during, and after DHIs are essential.

Conclusion

The sustainability of digital health interventions is crucial to maintain good quality healthcare, especially in low and middle-income countries. Considering potential barriers and facilitators for the sustainability of digital health interventions should inform all stakeholders, from their planning until their scaling up. Besides, it would be appropriate at the health facilities level to consolidate facilitators and efficiently manage barriers with the participation of all stakeholders.

Challenges and lessons learned from four years of planning and implementing pharmacovigilance enhancement in sub-Saharan Africa

Pharmacovigilance (PV) systems in many countries in sub-Saharan Africa (SSA) are not fully functional. The spontaneous adverse events (AE) reporting rate in SSA is lower than in any other region of the world, and healthcare professionals (HCPs) in SSA countries have limited awareness of AE surveillance and reporting procedures. The GSK PV enhancement pilot initiative, in collaboration with PATH and national PV stakeholders, aimed to strengthen passive safety surveillance through a training and mentoring program of HCPs in healthcare facilities in three SSA countries: Malawi, Côte d’Ivoire, and Democratic Republic of Congo (DRC). Project implementation was country-driven, led by the Ministry of Health via the national PV center or department, and was adapted to each country’s needs. The implementation phase for each country was scheduled to last 18 months. At project start, low AE reporting rates reflected that awareness of PV practices was very low among HCPs in all three countries, even if a national PV center already existed. Malawi did not have a functional PV system nor a national PV center prior to the start of the initiative. After 18 months of PV training and mentoring of HCPs, passive safety surveillance was enhanced significantly as shown by the increased number of AE reports: from 22 during 2000–2016 to 228 in 18 months to 511 in 30 months in Malawi, and ~ 80% of AE reports from trained healthcare facilities in Côte d’Ivoire. In DRC, project implementation ended after 7 months because of the SARS-CoV-2 pandemic. Main challenges encountered were delayed AE report transmission (1–2 months, due mainly to remoteness of healthcare facilities and complex procedures for transmitting reports to the national PV center), delayed or no causality assessment due to lack of expertise and/or funding, negative perceptions among HCPs toward AE reporting, and difficulties in engaging public health programs with the centralized AE reporting processes. This pilot project has enabled the countries to train more HCPs, increased reporting of AEs and identified KPIs that could be flexibly replicated in each country. Country ownership and empowerment is essential to sustain these improvements and build a stronger AE reporting culture.

Pharmacovigilance in emerging economies: modeling interaction among barriers

Purpose

The main purpose of this paper is to identify and rank various barriers to pharmacovigilance (PV) in context of emerging economies and examine their interrelationships using the interpretive structural modeling (ISM) approach. The result is a model that offers insights about how to achieve rational and safe use of medicines and ensure patient safety as realized through robust national PV systems.

Design/methodology/approach

The paper develops a model to analyze the interactions among PV barriers using the ISM approach. Based on input from clinical and medical product development experts, PV barriers in emerging economies were identified and reviewed. The hierarchical interrelationships among these PV barriers were analyzed in context of their driving/dependence powers.

Findings

Findings of the study identify key PV barriers—lack of resources/infrastructure, weak legislation, unfair burden of disease, lack of PV capacity, training, and enforcement authority—that drive, or strongly influence, other barriers and thwart implementation of robust national PV systems in emerging economies. Pharmaceutical industry factors were PV barriers that were identified as autonomous, implying their relative disconnection from other barriers, and patient PV practices barrier was strongly dependent on other barriers.

Research limitations/implications

The paper offers policy- and decision-makers alike with a framework to support further research into interdependencies among key PV barriers in emerging economies. It can serve as an impetus for further research with potential to broadening the understanding of how and why PV systems may be rendered ineffective. Future studies can be planned to apply the ISM approach to study PV barriers in the context of developed economies and draw lessons and implications for policy- and decision-makers by contrasting results from these studies.

Practical implications

This paper contributes to the understanding of the multifaceted nature of PV and its barriers. The proposed approach gives public health decision-makers a better comprehension of driver PV barriers that have most influence on others versus dependent PV barriers, which are most influenced by others. Also, knowledge, attitude and practices of patients and caregivers can also be critical PV barriers in emerging economies. This information can be instrumental for public health policymakers, government entities, and health/PV practitioners to identify the PV barriers that they should prioritize for improvement and how to manage trade-offs between these barriers.

Social implications

PV barriers in emerging economies, as compared to developed economies, are inherently different and need to be examined in their specific context. The hierarchical ISM model suggests that resources and regulation initiatives by governments in emerging economies lead to through informed/enabled pharmaceutical supply chain players and eventually drive PV-specific knowledge, attitude, and practice outcomes improvements across their populace.

Originality/value

This paper highlights the deployment of ISM approach as a health policy decision support tool in the identifying and ranking barriers to effective PV systems in emerging economies, in terms of their contextual relationships, to achieve a better understanding as to how these interrelationships can affect national PV system outcomes.

The Development of a Pharmacovigilance System in Bahrain

Introduction

Aim

Objectives

Methodology

Results

An investigation of pharmacovigilance and reporting of adverse drug reactions in hospitals: a cross-sectional study in China

BACKGROUND

Pharmacovigilance is a science that plays a significant role in reducing ADRs and helps predict adverse reactions to drugs in community. To safely use drugs in treatment and prevention of disease, adverse drug reaction has been paid more attention.

OBJECTIVES

To evaluate the future needs of existing systems, the paper investigated the current state of pharmacovigilance and the reporting of ADR in Chinese hospitals.

METHODS

This cross-sectional, questionnaire-based study involved 10,063 pharmacists, doctors, and nurses from primary, secondary, and tertiary hospitals in all 31 provinces of China. It was commissioned by the National Centre for ADR Monitoring of China and conducted in March 2020. Three areas were assessed: sociodemographic characteristics of participants, awareness of the pharmacovigilance system, and the current state of hospitals' reporting of ADRs. Chi-square tests were used to calculate P values.

RESULTS

Health care professionals had heard the term "pharmacovigilance" previously (89.40%) and knew the reporting object (68.47%), content (65.94%), and range (64.83%) of pharmacovigilance. Most hospitals dispatched responsible professionals (87.64%) and departments (86.25%) to monitor ADR reporting. A total of 58.66% of tertiary medical, 45.25% of secondary, and 38.90% of primary hospitals extracted ADRs from a hospital information system. Moreover, 53.09% of tertiary medical, 38.93% of secondary, and 23.89% of primary hospitals had established a prescription automatic screening system to warn about risks for ADRs. Health care professionals' reports (99.92%) and patient feedback (77.99%) were included in most hospitals' ADR reporting.

CONCLUSIONS

Chinese health care professionals generally have good awareness of pharmacovigilance, and pharmacovigilance is relatively more advanced in China compared to other developing countries.

Guiding axes for drug safety management of pharmacovigilance centres during the COVID-19 era

The COVID-19 pandemic presents several challenges to the organisation and workflow of pharmacovigilance centres as a result of the massive increase in reports, the need for quick detection, processing and reporting of safety issues and the management of these within the context of lack of complete information on the disease. Pharmacovigilance centres permanently monitor the safety profile of medicines, ensuring risk management to evaluate the benefit-risk relationship. However, traditional pharmacovigilance approaches of spontaneous reporting, are not suitable in the context of a pandemic; the scientific community and regulators need information on a near real-time point. The aim of this commentary is to suggest six interrelated multidimensional guiding axes for drug safety management by pharmacovigilance centres during the COVID-19 pandemic. This working plan can increase knowledge on COVID-19 and associated therapeutic approaches, support decisions by the regulatory authorities, oppose fake news and promote more efficient public health protection.

Direct reporting of adverse drug reactions by healthcare consumers in Africa: a narrative review

Background The challenges of under-reporting of adverse drug reactions have been identified as a major setback for the pharmacovigilance system worldwide. Direct reporting by health care consumers has been adopted in some developed and developing countries with a positive impact in improving pharmacovigilance activities through increased reporting rate. There are limited reports on direct reporting and its outcome in Africa. Aim of the review The study aimed to identify and present the available evidence on direct reporting of adverse drug reactions by healthcare consumers in Africa. Methods A review guided by Cochrane handbook was conducted. Electronic scientific databases such as PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase and Cochrane Library were searched. Google scholar, general Google search engine, the website for the regulatory resources for Africa and World Health Organisation-Uppsala Monitoring were also searched for available guidelines, documents and publications. The review period was January 1992 to October 2019. The results were analysed descriptively. Results This study identified 16 African countries that have included healthcare consumers as eligible to report adverse drug reactions in their policy/guidelines. There is low awareness of healthcare consumers on pharmacovigilance system. Eight (8) out of thirty-six (36) African countries that are members of the World Health Organisation Programme for International Drug Monitoring have formally launched direct reporting by healthcare consumers which are 14.2% of African countries. There is a wide range of difference between the rate of adverse drug reactions report submitted by health care consumers as compared with healthcare workers. Paper form, text messages, telephone and web application-based reporting system have been used by different countries that have launched direct reporting. Poor infrastructure, low awareness and lack of a reporting culture are major challenges while the availability of common reporting methods is a potential opportunity of promoting direct reporting in African countries. Conclusions Few African countries have adopted and launched direct reporting. Reporting rate through direct methods is still relatively low when compared with reporting by healthcare workers. Published legal framework, policies, guidelines and studies on direct reporting are limited. Availability of a system and reporting method are opportunities to improve and overcome probable challenges.

Development and Usability Testing of the Society for Pediatric Anesthesia Pedi Crisis Mobile Application

When life-threatening, critical events occur in the operating room, the fast-paced, high-distraction atmosphere often leaves little time to think or deliberate about management options. Success depends on applying a team approach to quickly implement well-rehearsed, systematic, evidence-based assessment and treatment protocols. Mobile devices offer resources for readily accessible, easily updatable information that can be invaluable during perioperative critical events. We developed a mobile device version of the Society for Pediatric Anesthesia 26 Pediatric Crisis paper checklists-the Pedi Crisis 2.0 application-as a resource to support clinician responses to pediatric perioperative life-threatening critical events. Human factors expertise and principles were applied to maximize usability, such as by clustering information into themes that clinicians utilize when accessing cognitive aids during critical events. The electronic environment allowed us to feature optional diagnostic support, optimized navigation, weight-based dosing, critical institution-specific phone numbers pertinent to emergency response, and accessibility for those who want larger font sizes. The design and functionality of the application were optimized for clinician use in real time during actual critical events, and it can also be used for self-study or review. Beta usability testing of the application was conducted with a convenience sample of clinicians at 9 institutions in 2 countries and showed that participants were able to find information quickly and as expected. In addition, clinicians rated the application as slightly above "excellent" overall on an established measure, the Systems Usability Scale, which is a 10-item, widely used and validated Likert scale created to assess usability for a variety of situations. The application can be downloaded, at no cost, for iOS devices from the Apple App Store and for Android devices from the Google Play Store. The processes and principles used in its development are readily applicable to the development of future mobile and electronic applications for the field of anesthesiology.

Development of a pharmacovigilance system in a resource-limited country: the experience of the Democratic Republic of Congo

Implementation of pharmacovigilance (PV) systems in resource-limited countries is a real endeavor. Despite country- and continent-specific challenges, the Democratic Republic of the Congo (DRC) has been able to develop one of the most active PV systems in the sub-Saharan Africa. The World Health Organization (WHO) regional Office identified the DRC experience to set up a PV system for antimalarial drugs safety monitoring as a ‘best practice’ that needed to be documented in order to help DRC improve its PV system and to be scaled up in other African countries. In response to the WHO request, a best practices and bottlenecks analysis was conducted in 2015. This analysis was updated in 2018 in the light of the minimum requirements of the WHO to set up a PV system taking into account other guidance for PV systems. The following themes were retained for analysis: (1) creation of the national PV center; (2) implementation of PV in the health system; (3) data collection and analysis; (4) collaboration with public health programs; (5) collaboration with the National Regulatory Authority. Lessons learnt from the DRC experience show that it is possible to implement PV systems in order to promote patients’ safety in resource limited sub-Saharan African countries with no guaranteed funding. The ability of national PV centers to collaborate with Public health stakeholders, including public health authorities at all levels as well as public health programs, and to use existing health information systems are considered the main key to success and may substantially reduce the cost of PV activities.