The Impacts of Donor Transitions on Health Systems in Middle-Income Countries: A Scoping Review

As countries graduate from low-income to middle-income status, many face losses in development assistance for health and must ‘transition’ to greater domestic funding of their health response. If improperly managed, donor transitions in middle-income countries (MICs) could present significant challenges to global health progress. No prior knowledge synthesis has comprehensively surveyed how donor transitions can affect health systems in MICs. We conducted a scoping review using a structured search strategy across five academic databases and 37 global health donor and think tank websites for literature published between January 1990 and October 2018. We used the World Health Organization health system ‘building blocks’ framework to thematically synthesize and structure the analysis. Following independent screening, 89 publications out of 11 236 were included for data extraction and synthesis. Most of this evidence examines transitions related to human immunodeficiency virus/Acquired Immune Deficiency Syndrome (AIDS; n = 45, 50%) and immunization programmes (n = 14, 16%), with a focus on donors such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (n = 26, 29%) and Gavi, the Vaccine Alliance (n = 15, 17%). Donor transitions are influenced by the actions of both donors and country governments, with impacts on every component of the health system. Successful transition experiences show that leadership, planning, and pre-transition investments in a country’s financial, technical, and logistical capacity are vital to ensuring smooth transition. In the absence of such measures, shortages in financial resources, medical product and supply stock-outs, service disruptions, and shortages in human resources were common, with resulting implications not only for programme continuation, but also for population health. Donor transitions can affect different components of the health system in varying and interconnected ways. More rigorous evaluation of how donor transitions can affect health systems in MICs will create an improved understanding of the risks and opportunities posed by donor exits.

Unexpectedly high occurrence of Escherichia coli and Staphylococcus aureus isolates from raw milk in Ilam, Western Iran

Raw milk contains diverse nutritional components that provide a suitable medium for spoilage and the growth of potentially pathogenic microorganisms. Unpasteurized milk consumption by a large number of people can threaten health and increase public concerns. In this study, sixty-two raw cow’s milk samples were collected from the dairy farms of Ilam, Western Iran. All samples were collected in sterilized containers and were transferred via ice boxes to the laboratory. Isolates were then identified by standard methods. Totally, 88.7% (n=55) of samples were contaminated. Our study also showed that Escherichia coli had a high prevalence among isolates (43: 69.4%), while Klebsiella pneumoniae and Klebsiella planticola showed the lowest prevalence (1: 1.6%). Staphylococcus aureus was also detected in 17.7% (n=11) of samples. The raw milk microbial contamination is complex. Some of the microorganisms threaten public health via different traits, therefore it is recommended that raw milk consumption should be avoided.

Psychomotor delay, a possible rare presentation of moyamoya disease

Moyamoya disease is a rare, chronic cerebrovascular occlusive disease of unknown etiology. It is characterized by progressive stenosis of the arteries of the circle of Willis leading to ischemic strokes in young people and cerebral hemorrhage, which is more frequent in adults. Secondarily, an abnormal network of fine collateral vessels arises at the base of the brain. The term moyamoya refers to the angiographic appearance of the cerebral vasculature. We present such a disease in an 18-month-old Iranian girl with global developmental delay, which is a very rare presentation of moyamoya disease. She was diagnosed by magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA).

Glycemic optimization may reduce lipid peroxidation independent of weight and blood lipid changes in Type 2 diabetes mellitus

The aim of this study was to determine the effect of diet-therapy on lipid peroxidation in patients with Type 2 diabetes mellitus (T2DM). Fifteen T2DM patients of both sexes, aged between 35-70 years, were given the diet suggested for patients with diabetes by the American Diabetic Association. This diet comprised 50-60% carbohydrate, 10-15% protein, 20-30% fat and about 35 g fiber was given for weight maintenance. Weight and body mass index did not change significantly during 8 weeks of study. Also, no statistically significant difference was observed in serum total cholesterol, triglycerides, LDL- and HDL-cholesterol from before to after dietary intervention. However, the levels of fasting blood sugar, HbA1c and malondialdehyde were lowered significantly after dietary intervention. It was concluded that glycemic optimization, independent of weight and blood lipid profile, through a well-designed diet is likely to be the most effective factor in reducing the process of oxidative stress in T2DM. This may have preventive implications for such diabetic complications as atherosclerosis.

Effect of thiazides on serum calcium

A retrospective study of 22 hypertensive patients who were treated with thiazide diuretics for 2 to 12 yr revealed that 36% developed transient, self-limited asymptomatic elevations of serum calcium which occurred at varying periods of therapy and returned to normal within 2 to 4 wk despite continued administration of thiazides. These episodes of hypercalcemia correlated positively with increases in total protein, albumin, and globulin. The same phenomenon of intermittent hypercalcemia occurred in a prospective study of 11 patients but not in control subjects. The mean serum total calcium of the prospectively studied hydrochlorothiazide-treated patients was found to be higher than the nonthiazide control group. This difference was due to increased protein-bound calcium. The total proteins, serum albumin, and serum beta globulins of the treated group were higher, probably due to depletion of extracellular fluid. The presence of slightly elevated serum calcium in a patient treated with thiazides appears to be a common phenomenon and, unless it is marked, should not necessarily be construed as indicating covert hyperparathyroidism.

Paradoxical effect of salmon calcitonin on serum calcium: studies in intact and thyroparathyroidectomized men and dogs

Total serum calcium of normal men, a hypoparathyroid man, two thyroparathyroidectomized men, and intact and thyroparathyroidectomized dogs were studied at multiple intervals following the acute administration of synthetic salmon calcitonin. Calcitonin produced marked fluctuations in serum calcium in one normal man and a biphasic hypocalcaemic response in another. In four of five intact dogs, calcitonin caused absolute or relative hypercalcaemia. In contrast, administration of calcitonin to thyroparathyroidectomized dogs caused a hypocalcaemia with less fluctuations and with no periods of hypercalcaemia. It is possible that some of the paradoxical responses of serum calcium induced by exogenous calcitonin are due to overcompensation by parathyroid hormone. However, other mechanisms may be involved. Our findings indicate that when the disturbing influence is sufficiently great, the control of serum calcium is not as well modulated as previously suspected. In addition, our findings of paradoxically hypercalcaemic responses to calcitonin indicates that the pathophysiologic interpretation of serum calcium at any single moment in time following the administration of this hormone to either intact or thyroparathyroidectomized men or dogs is a precarious endeavour.