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Objective: To investigate self reported practice and actual practice of private pharmacy staff in relation to drug regulations and provision of prednisolone (a prescription-only corticosteroid) on request to treat lower back pain. Method: Sixty private pharmacies in Hanoi were randomly selected. Self reported practice was assessed through interviews with pharmacy staff using a questionnaire; actual practice was assessed with the Simulated Client Method with 5 encounters in each pharmacy (a total of 295 encounters). Results: Sixty percent of the pharmacy staff interviewed said that they would not dispense corticosteroids without prescription and 60% could mention some adverse effects. In practice all but one pharmacy dispensed corticosteroids without prescription in 76 % of all the encounters. Questions and advice given to the clients were associated with significantly lower dispensing of corticosteroids. Conclusion: The low compliance with prescription regulations and the discrepancy between stated practice and actual practice raises concerns. This study indicates that commercial pressures exceed the deterrent effect of current drug regulations and their implementation and hence enforcement of regulations needs to be improved.

The Global South nations and their statehoods have presented a driving force of economic and social development through most of the written history of humankind. China and India have been traditionally accounted as the economic powerhouses of the past. In recent decades, we have witnessed reestablishment of the traditional world economic structure as per Agnus Maddison Project data. These profound changes have led to accelerated real GDP growth across many LMICs and emerging countries of the Global South. This evolution had a profound impact on an evolving health financing landscape. This review revealed hidden patterns and explained the driving forces behind the political economy of health spending in these vast world regions. The medical device and pharmaceutical industry play a crucial role in addressing the unmet medical needs of rising middle class citizens across Asia, Latin America, and Africa. Domestic manufacturing has only been partially meeting this ever rising demand for medical services and medicines. The rest was complemented by the participation of multinational pharmaceutical industry, whose focus on investment into East Asia and ASEAN nations remains part of long-term market access strategies. Understanding of the past remains essential for the development of successful health strategies for the present. Political economy has been driving the evolution of health financing landscape since the establishment of early modern health systems in these countries. Fiscal gaps these governments face in diverse ways might be partially overcome with the spreading of cost-effectiveness based decision-making and health technology assessment capacities. The considerable remaining challenges ranging from insufficient reimbursement rates, large out-of-pocket spending, and lengthy lag in the introduction of cutting-edge technologies such as monoclonal antibodies, biosimilars, or targeted oncology agents, might be partially resolved only in the long run.

Health and Demographic Surveillance Systems (HDSS) have been developed in several low- and middle-income countries (LMICs) in Africa and Asia. This paper reviews their history, state of the art and future potential and highlights substantial areas of contribution by the late Professor Peter Byass.Historically, HDSS appeared in the second half of the twentieth century, responding to a dearth of accurate population data in poorly resourced settings to contextualise the study of interventions to improve health and well-being. The progress of the development of this network is described starting with Pholela, and progressing through Gwembe, Balabgarh, Niakhar, Matlab, Navrongo, Agincourt, Farafenni, and Butajira, and the emergence of the INDEPTH Network in the early 1990'sThe paper describes the HDSS methodology, data, strengths, and limitations. The strengths are particularly their temporal coverage, detail, dense linkage, and the fact that they exist in chronically under-documented populations in LMICs where HDSS sites operate. The main limitations are generalisability to a national population and a potential Hawthorne effect, whereby the project itself may have changed characteristics of the population.The future will include advances in HDSS data harmonisation, accessibility, and protection. Key applications of the data are to validate and assess bias in other datasets. A strong collaboration between a national HDSS network and the national statistics office is modelled in South Africa and Sierra Leone, and it is possible that other low- to middle-income countries will see the benefit and take this approach.

Adequate infection control plays a key role in preventing healthcare-associated infections (HAIs). This study aimed to explore staff perceptions of hospital infection control in a rural and an urban hospital in Vietnam. Individual interviews were conducted with hospital managers, and focus group discussions were conducted with doctors, nurses and cleaning workers separately. Content analysis was applied. An interview guide including discussion points on HAIs, hand hygiene and healthcare waste management was used. Generally, the staff were knowledgeable of hospital infection control, but they were not aware of the situation in their own hospital, and infection control practices in the hospitals remained poor. Reported difficulties in infection control included lack of resources, poor awareness and patient overload. A main theme emerged: 'Making data on HAIs available for health workers can improve their awareness and motivate them to put their existing knowledge into practice, thus decreasing the know-do gap in infection control'. This could be a feasible intervention to improve infection control practice in the hospitals with limited resources, high workload and patient overload.

Staff practice, driven by knowledge, plays a decisive role in hospital infection control. This study aimed to assess and compare knowledge and self-reported practices of infection control among various occupational groups in a rural and an urban hospital in Vietnam. Questionnaires consisting of items on knowledge and practices were collected from 339 hospital staff with varying occupations. For analysis, total knowledge or practice score ranged from 0-15. Mood's median test was performed to compare median scores. Post-hoc analysis of ordinal logistic regression models was applied to test differences in scores among occupational groups. The majority of hospital staff had good or adequate knowledge (median score: rural = 11.8; urban = 12), but the score range was wide (1.4-14.5). Self-reported practices in the urban hospital were likely to be better than in the rural one (p = 0.003). Self-reported practices yet not completely satisfactory, indicating the need for continuing professional development in both settings. Overall, cleaners had lower scores than both physicians and nurses, highlighting the need for tailored education in this topic. Future infection control strategies within the hospitals might want to assess the difference between the staff's self-reported practice and their actual real practice. These findings can be of value in many other similar settings.

In many low- and middle-income countries (LMICs), a poor link between antibiotic policies and practices exists. Numerous contextual factors may influence the degree of antibiotic access, appropriateness of antibiotic provision, and actual use in communities. Therefore, improving appropriateness of antibiotic use in different communities in LMICs probably requires interventions tailored to the setting of interest, accounting for cultural context. Here we present the ABACUS study (AntiBiotic ACcess and USe), which employs a unique approach and infrastructure, enabling quantitative validation, contextualization of determinants, and cross-continent comparisons of antibiotic access and use. The community infrastructure for this study is the INDEPTH-Network (International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries), which facilitates health and population research through an established health and demographic surveillance system. After an initial round of formative qualitative research with community members and antibiotic suppliers in three African and three Asian countries, household surveys will assess the appropriateness of antibiotic access, provision and use. Results from this sample will be validated against a systematically conducted inventory of suppliers. All potential antibiotic suppliers will be mapped and characterized. Subsequently, their supply of antibiotics to the community will be measured through customer exit interviews, which tend to be more reliable than bulk purchase or sales data. Discrepancies identified between reported and observed antibiotic practices will be investigated in further qualitative interviews. Amartya Sen's Capability Approach will be employed to identify the conversion factors that determine whether or not, and the extent to which appropriate provision of antibiotics may lead to appropriate access and use of antibiotics. Currently, the study is ongoing and expected to conclude by 2019. ABACUS will provide important new insights into antibiotic practices in LMICs to inform social interventions aimed at promoting optimal antibiotic use, thereby preserving antibiotic effectiveness., Competing Interests: Competing interests: No competing interests were disclosed.

The environmental spread of antibiotic-resistant bacteria has been recognised as a growing public health threat for which hospitals play a significant role. The aims of this study were to investigate the prevalence of antibiotic resistance and antibiotic resistance genes (ARGs) in Escherichia coli isolates from hospital wastewater in Vietnam. Wastewater samples before and after treatment were collected using continuous sampling every month over a year. Standard disk diffusion and E-test were used for antibiotic susceptibility testing. Extended-spectrum beta-lactamase (ESBL) production was tested using combined disk diffusion. ARGs were detected by polymerase chain reactions. Resistance to at least one antibiotic was detected in 83% of isolates; multidrug resistance was found in 32%. The highest resistance prevalence was found for co-trimoxazole (70%) and the lowest for imipenem (1%). Forty-three percent of isolates were ESBL-producing, with the bla TEM gene being more common than bla CTX-M . Co-harbouring of the bla CTX-M , bla TEM and qepA genes was found in 46% of isolates resistant to ciprofloxacin. The large presence of antibiotic-resistant E. coli isolates combined with ARGs in hospital wastewater, even post-treatment, poses a threat to public health. It highlights the need to develop effective processes for hospital wastewater treatment plants to eliminate antibiotic resistant bacteria and ARGs., Competing Interests: The authors declare no conflicts of interest.

Background: Appropriate antibiotic use is vital to effectively contain antibiotic resistance and improve global health. Acute respiratory infections (ARIs) remain the leading cause of disease and death in children under five in low-income countries., Objective: To evaluate a multi-faceted intervention targeting health-care-providers' (HCPs) knowledge, practical competences and practices regarding antibiotic use for ARIs., Methods: A multi-faceted educational intervention with a two-armed randomised controlled design targeting HCPs treating ARIs in children was conducted in Bavi district, a rural district in Northern Vietnam in 2010-2011. Thirty-two communes of the district were randomized into two arms, with 144 HCPs in the intervention arm and 160 in the control arm. The intervention, conducted over seven months, comprised: (i) education regarding appropriate-antibiotic use, (ii) case scenario discussion and (iii) poster distribution. Questionnaires to assess knowledge and dispensing/prescribing forms to assess practice were completed before-and after interventions. The main outcome measures were differences in improvement in knowledge and practice in the intervention and control group, respectively., Results: Knowledge improved in the intervention group for ARI aetiology by 28% (Δ Decrement control arm 10%), antibiotic use for mild ARIs by 15% (Δ Decrement control arm 13%) and for severe ARIs by 14% (Δ Improvement control arm 29%). Practical competence for a mild ARI case scenario improved in the intervention and control groups by 20% and 11%, respectively. Total knowledge score increased statistically in the intervention group (Δ mean improvement 1.17); less so in the control group (Δ mean improvement 0.48). Practice regarding antibiotics for mild ARIs improved by 28% in the intervention group (Δ Decrement control arm 3%)., Conclusions: The intervention significantly improved HCPs' knowledge of ARIs and practice of antibiotic use in treatment of ARIs. We suggest mixed method assessment and long-term follow-up of these interventions to enable better appreciation of the effects and effect sizes of our interventions.