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Background: Giving birth in a healthcare facility with the guidance of skilled healthcare providers allows access to necessary medical interventions. Ethiopia has implemented several strategies to enhance institutional delivery and decrease maternal mortality; however, the rate of institutional delivery remains low. This study examines the role of distance to healthcare institutions on institutional delivery in Ethiopia, and how this has changed over time., Method: This study used data from two rounds of the Ethiopian Demographic and Health Survey (2011 and 2016), a spatial database detailing the locations of healthcare facilities, and Ethiopian road network data. The sample included 22,881 women who delivered within the 5 years preceding each survey and lived in 1,295 villages. Bivariate and multivariable logistic regression analyses were used to investigate how the distance to health facilities and other potential determinants influenced institutional delivery trends., Results: The rate of institutional deliveries in Ethiopia has increased from 10% in 2011 to 26% in 2016. Likewise, the average transportation distance to health facilities has decreased from 22.4 km in 2011 to 20.2 km in 2016 at the national level. Furthermore, a one-kilometer increase in the distance to the nearest health facility was associated with a 1% decrease in the likelihood of delivering at a health facility in 2016 (odds ratio (OR) = 0.99, 95% CI [0.98-0.99], p < 0.05). Additionally, mothers who are more educated, have completed more antenatal care visits, live in wealthier households in more urban areas, and cohabit with more educated husbands are more likely to deliver at healthcare facilities. These variables showed consistent relevance in both survey rounds, suggesting that key determinants remained largely unchanged throughout the study period., Conclusion: The impact of distance from health facilities on institutional delivery in Ethiopia remains evident, although its influence is relatively modest. The other factors, including education, antenatal care, socioeconomic status, urban residence, and partner education, remained consistent between the two surveys. These determinants have consistently influenced institutional delivery, highlighting the importance of a comprehensive approach that addresses both access to and socioeconomic factors to improve maternal and infant health across the country., Competing Interests: The authors declare that they have no competing interests., (© 2024 Sebsibe and Kebede.)

Background: The Sustainable Development Goal Three has prioritised reducing maternal, under-5 and neonatal mortalities as core global health policy objectives. The place, where expectant mothers choose to deliver their babies has a direct effect on maternal health outcomes. In sub-Saharan Africa, existing literature has shown that some women attend antenatal care during pregnancy but choose to deliver their babies at home. Using the Andersen and Newman Behavioural Model, this study explored the institutional and socio-cultural factors motivating women to deliver at home after attending antenatal care., Methods: A qualitative, exploratory, cross-sectional design was deployed. Data were collected from a purposive sample of 23 women, who attended antenatal care during pregnancy but delivered their babies at home, 10 health workers and 17 other community-level stakeholders. The data were collected through semi-structured interviews, which were audio-recorded, transcribed and thematically analysed., Results: In line with the Andersen and Newman Model, the study discovered that traditional and religious belief systems about marital fidelity and the role of the gods in childbirth, myths about consequences of facility-based delivery, illiteracy, and weak women's autonomy in healthcare decision-making, predisposed women to home delivery. Home delivery was also enabled by inadequate midwives at health facilities, the unfriendly attitude of health workers, hidden charges for facility-based delivery, and long distances to healthcare facilities. The fear of caesarean section, also created the need for women who attended antenatal care to deliver at home., Conclusion: The study has established that socio-cultural and institutional level factors influenced women's decisions to deliver at home. We recommend a general improvement in the service delivery capacity of health facilities, and the implementation of collaborative educational and women empowerment programmes by stakeholders, to strengthen women's autonomy and reshape existing traditional and religious beliefs facilitating home delivery., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Colorectal cancer (CRC) care costs the Australian healthcare system more than any other cancer. We estimated costs and days in hospital for CRC cases, stratified by site (colon/rectal cancer) and disease stage, to inform detailed analyses of CRC-related healthcare., Methods: Incident CRC patients were identified using the Australian 45 and Up Study cohort linked with cancer registry records. We analysed linked hospital admission records, emergency department records, and reimbursement records for government-subsidised medical services and prescription medicines. Cases' health system costs (2020 Australian dollars) and hospital days were compared with those for cancer-free controls (matched by age, sex, geography, smoking) to estimate excess resources by phase of care, analysed by sociodemographic, health, and disease characteristics., Results: 1200 colon and 546 rectal cancer cases were diagnosed 2006-2013, and followed up to June 2016. Eighty-nine percent of cases had surgery, chemotherapy or radiotherapy, and excess costs were predominantly for hospitalisations. Initial phase (12 months post-diagnosis) mean excess health system costs were $50,434 for colon and $60,877 for rectal cancer cases, with means of 16 and 18.5 excess hospital days, respectively. The annual continuing mean excess costs were $6,779 (colon) and $8,336 (rectal), with a mean of 2 excess hospital days each. Resources utilised (costs and days) in these phases increased with more advanced disease, comorbidities, and younger age. Mean excess costs in the year before death were $74,952 (colon) and $67,733 (rectal), with means of 34 and 30 excess hospital days, respectively-resources utilised were similar across all characteristics, apart from lower costs for cases aged ≥75 at diagnosis., Conclusions: Health system costs and hospital utilisation for CRC care are greater for people with more advanced disease. These findings provide a benchmark, and will help inform future cost-effectiveness analyses of potential approaches to CRC screening and treatment., Competing Interests: The authors have declared that no competing interests exist.

Objectives: To date, many artificial intelligence (AI) systems have been developed in healthcare, but adoption has been limited. This may be due to inappropriate or incomplete evaluation and a lack of internationally recognised AI standards on evaluation. To have confidence in the generalisability of AI systems in healthcare and to enable their integration into workflows, there is a need for a practical yet comprehensive instrument to assess the translational aspects of the available AI systems. Currently available evaluation frameworks for AI in healthcare focus on the reporting and regulatory aspects but have little guidance regarding assessment of the translational aspects of the AI systems like the functional, utility and ethical components., Methods: To address this gap and create a framework that assesses real-world systems, an international team has developed a translationally focused evaluation framework termed 'Translational Evaluation of Healthcare AI (TEHAI)'. A critical review of literature assessed existing evaluation and reporting frameworks and gaps. Next, using health technology evaluation and translational principles, reporting components were identified for consideration. These were independently reviewed for consensus inclusion in a final framework by an international panel of eight expert., Results: TEHAI includes three main components: capability, utility and adoption. The emphasis on translational and ethical features of the model development and deployment distinguishes TEHAI from other evaluation instruments. In specific, the evaluation components can be applied at any stage of the development and deployment of the AI system., Discussion: One major limitation of existing reporting or evaluation frameworks is their narrow focus. TEHAI, because of its strong foundation in translation research models and an emphasis on safety, translational value and generalisability, not only has a theoretical basis but also practical application to assessing real-world systems., Conclusion: The translational research theoretic approach used to develop TEHAI should see it having application not just for evaluation of clinical AI in research settings, but more broadly to guide evaluation of working clinical systems., Competing Interests: Competing interests: SR holds Directorship in Medi-AI. PM is cofounder of BrainX and BrainX Community. EC sits on the Board of Evidentli., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The built environment has been integral to response to the global pandemic of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). In particular, engineering controls to mitigate risk of exposure to SARS-CoV-2 and other newly emergent respiratory pathogens in the future will be important. Anticipating emergence from this pandemic, or at least adaptation given increasing administration of effective vaccines, and the safety of patients, personnel, and others in health care facilities remain the core goals. This article summarizes known risks and highlights prevention strategies for daily care as well as response to emergent infectious diseases and this parapandemic phase., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Transgender and gender diverse (TGD) people experience significant barriers to accessing affirming health services. There is a paucity of literature examining how both community members and health care professionals (HCPs) understand potential causes and solutions for these barriers, particularly in non-urban settings., Objective: We present the first systematic examination of perspectives from community members and HCPs regarding barriers to and solutions for promoting access to gender-affirming health care., Design: Study activities were conducted through the Plan and Act for Transgender Health (PATH) Project, a health needs assessment of TGD people. Community members in the catchment area were recruited to participate in focus group discussions about access to gender-affirming health care and optimal health service delivery models in March-October 2019. HCPs were recruited to participate in focus group discussions or in-depth interviews about experiences working with TGD clients. Data were analyzed using an inductive grounded theory approach., Setting: 25 rural counties in Massachusetts, New York, Connecticut, Vermont, and New Hampshire., Participants: Study participants included 61 adult TGD community members and 23 HCPs working in the catchment area., Results: Both community members and HCPs spoke of the need for connectedness and linkages among disparate health system components for gender-affirming health care. Participants expressed this priority through calls for systems-level improvements within existing services (e.g., expanded data collection, expanded mental health services, inclusive and affirming health care environments, and TGD staff). They also expressed the need for expanded TGD community outreach and engagement (e.g., incorporation of a patient feedback process, TGD health navigators, and resource mapping)., Limitations: Findings specifically reflect the perspectives of community members and HCPs in the rural New England area. Furthermore, the study sample was predominantly White non-Hispanic., Conclusion: Interventions to achieve accessible gender-affirming health care must address the diverse perspectives and needs of both community members and HCPs., Competing Interests: The authors have declared that no competing interests exist.

Background: Reimbursements for professional services performed by clinicians are under constant scrutiny. The value of a vascular surgeon's services as measured by work relative value units (wRVUs) and professional reimbursement has decreased for some of the most common procedures performed. Hospital reimbursements, however, often remain stable or increases. We sought to evaluate fistulagrams as a case study and hypothesized that while wRVUs and professional reimbursements decrease, hospital reimbursements for these services increased over the same time period., Methods: Medicare 5% claims data were reviewed to identify all fistulagrams with or without angioplasty or stenting performed between 2015 and 2018 using current procedural terminology codes. Reimbursements were classified into 3 categories: medical center (reimbursements made to a hospital for a fistulagram performed as an outpatient procedure), professional (reimbursement for fistulagrams based on compensation for procedures: work RVUs, practice expense RVU, malpractice expense RVU), and office-based laboratory (OBL, reimbursement for fistulagrams performed in an OBL setting). Medicare's Physician Fee Schedule was used to calculate wRVU and professional reimbursement. Medicare's Hospital Outpatient Prospective Payment System-Ambulatory Payment Classification was used to calculate hospital outpatient reimbursement., Results: From 2015 to 2018, we identified 1,326,993 fistulagrams. During this study period, vascular surgeons experienced a 25% increase in market share for diagnostic fistulagrams. Compared with 2015, total professional reimbursements from 2017 to 2018 for all fistulagram procedures decreased by 41% (-$10.3 million) while OBL reimbursement decreased 29% (-$42.5 million) and wRVU decreased 36%. During the same period, medical center reimbursement increased by 6.6% (+$14.1 million)., Conclusions: Vascular surgeons' contribution to a hospital may not be accurately reflected through traditional RVU metrics alone. Vascular surgeons performed an increasing volume of fistulagram procedures while experiencing marked reductions in wRVU and reimbursement. Medical centers, on the other hand, experienced an overall increase in reimbursement during the same time period. This study highlights that professional reimbursements, taken in isolation and without consideration of medical center reimbursement, undervalues the services and contributions provided by vascular surgeons., (Copyright © 2020. Published by Elsevier Inc.)

The risk of overwhelming hospitals from multiple waves of COVID-19 is yet to be quantified. Here, we investigate the impact of different scenarios of releasing strong measures implemented around the U.S. on COVID-19 hospitalized cases and the risk of overwhelming the hospitals while considering resources at the county level. We show that multiple waves might cause an unprecedented impact on the hospitals if an increasing number of the population becomes susceptible and/or if the various protective measures are discontinued. Furthermore, we explore the ability of different mitigation strategies in providing considerable relief to hospitals. The results can help planners, policymakers, and state officials decide on additional resources required and when to return to normalcy., Competing Interests: No authors have competing interests.

Background: Geographical accessibility to healthcare is an important component of infectious disease dynamics. Timely access to health facilities can prevent disease progression and enables disease notification through surveillance systems. The importance of accounting for physical accessibility in response to infectious diseases is increasingly recognized. Yet, there is no comprehensive review of the literature available on infectious diseases in relation to geographical accessibility to care. Therefore, we aimed at evaluating the current state of knowledge on the effect of geographical accessibility to health care on infectious diseases in low- and middle-income countries., Methods and Findings: A search strategy was developed and conducted on Web of Science and PubMed on 4 March 2019. New publications were checked until May 28, 2020. All publication dates were eligible. Data was charted into a tabular format and descriptive data analyses were carried out to identify geographical regions, infectious diseases, and measures of physical accessibility among other factors. Search queries in PubMed and Web of Science yielded 560 unique publications. After title and abstract screening 99 articles were read in full detail, from which 64 articles were selected, including 10 manually. Results of the included publications could be broadly categorized into three groups: (1) decreased spatial accessibility to health care was associated with a higher infectious disease burden, (2) decreased accessibility was associated to lower disease reporting, minimizing true understanding of disease distribution, and (3) the occurrence of an infectious disease outbreak negatively impacted health care accessibility in affected regions. In the majority of studies, poor geographical accessibility to health care was associated with higher disease incidence, more severe health outcomes, higher mortality, and lower disease reporting. No difference was seen between countries or infectious diseases., Conclusions: Currently, policy-makers and scientists rely on data collected through passive surveillance systems, introducing uncertainty on disease estimates for remote communities. Our results highlight the need for increasing integration of geographical accessibility measures in disease risk modelling, allowing more realistic disease estimates and enhancing our understanding of true disease burden. Additionally, disease risk estimates could be used in turn to optimize the allocation of health services in the prevention and detection of infectious diseases., Competing Interests: The authors have declared that no competing interests exist.

Background: Maternal and child health care services are available in both public and private facilities in Nepal. Studies have not yet looked at trends in maternal and child health service use over time in Nepal. This paper assesses trends in and determinants of visiting private health facilities for maternal and child health needs using nationally representative data from the last three successive Nepal Demographic Health Surveys (NDHS)., Methods: Data from the NDHS conducted in 2006, 2011, and 2016 were used. Maternal and child health-seeking was established using data on place of antenatal care (ANC), place of delivery, and place of treatment for child diarrhoea and fever/cough. Logistic regression models were fitted to identify trends in and determinants of health-seeking at private facilities., Results: The results indicate an increase in the use of private facilities for maternal and child health care over time. Across the three survey waves, women from the highest wealth quintile had the highest odds of accessing ANC services at private health facilities (AOR = 3.0, 95% CI = 1.53, 5.91 in 2006; AOR = 5.6, 95% CI = 3.51, 8.81 in 2011; AOR = 6.0, 95% CI = 3.78, 9.52 in 2016). Women from the highest wealth quintile (AOR = 3.3, 95% CI = 1.54, 7.09 in 2006; AOR = 7.3, 95% CI = 3.91, 13.54 in 2011; AOR = 8.3, 95% CI = 3.97, 17.42 in 2016) and women with more years of schooling (AOR = 1.2, 95% CI = 1.17, 1.27 in 2006; AOR = 1.1, 95% CI = 1.04, 1.14 in 2011; AOR = 1.1, 95% CI = 1.07, 1.16 in 2016) were more likely to deliver in private health facilities. Likewise, children belonging to the highest wealth quintile (AOR = 8.0, 95% CI = 2.43, 26.54 in 2006; AOR = 6.4, 95% CI = 1.59, 25.85 in 2016) were more likely to receive diarrhoea treatment in private health facilities., Conclusions: Women are increasingly visiting private health facilities for maternal and child health care in Nepal. Household wealth quintile and more years of schooling were the major determinants for selecting private health facilities for these services. These trends indicate the importance of collaboration between private and public health facilities in Nepal to foster a public private partnership approach in the Nepalese health care sector.

Background and Aims: Potential role of health literacy in determining adherence to COVID-19 preventive behavior, pharmacological, and lifestyle management among diagnosed patients of chronic diseases during nationwide lockdown is inadequately investigated., Methods: A cross-sectional study was conducted from May-August 2020 among diagnosed patients of chronic diseases residing in a COVID-19 hotspot of urban Jodhpur, Rajasthan, and availing health services from primary care facility. Telephonic interviews of participants were conducted to determine their health literacy using HLS-EU-Q47 questionnaire, adherence to COVID-19 preventive behaviour as per World Health Organization recommendations, and compliance to prescribed pharmacological and physical activity recommendations for chronic disease., Results: All the 605 diagnosed patients of chronic diseases availing services from primary care facility were contacted for the study, yielding response rate of 68% with 412 agreeing to participate. Insufficient health literacy was observed for 65.8% participants. Only about half of participants had scored above median for COVID-19 awareness (55.1%) and preventive behavior (45.1%). Health literacy was observed to be significant predictor of COVID-19 awareness [aOR: 3.53 (95% CI: 1.81-6.88)]; COVID-19 preventive behavior [aOR: 2.06, 95%CI; 1.14-3.69] and compliance to pharmacological management [aOR: 3.05; 95% CI: 1.47-6.35] but not for physical activity., Conclusion: COVID-19 awareness, preventive behavior, and compliance to pharmacological management is associated with health literacy among patients of chronic disease availing services from primary health facility. Focusing on health literacy could thus be an essential strategic intervention yielding long term benefits., Competing Interests: Declaration of competing interest There are no conflicts of interest associated with this publication, and there has been no financial support for this publication. As corresponding author, I confirm the same. We hope you find our work suitable for publication., (Copyright © 2020 Diabetes India. Published by Elsevier Ltd. All rights reserved.)

Importance: Federally qualified health centers (FQHCs) receive federal funding to serve medically underserved areas and provide a range of services including comprehensive primary care, enabling services, and behavioral health care. Greater funding for FQHCs could increase the local availability of clinic-based care and help reduce more costly resource use, such as emergency department visits (ED)., Objective: To examine the impact of funding increases for FQHCs after the ACA on the use of FQHCs and EDs., Methods: Retrospective study using the Massachusetts All Payer Claims Database (APCD) 2010-2013 that included APCD enrollees in 559 Massachusetts ZIP codes (N = 6,173,563 in 2010). We calculated shift-share predictions of changes in FQHC funding at the ZIP code-level for FQHCs that received Community Health Center funds in any year, 2010-13 (N = 31). Outcomes were the number of ZIP code enrollees with visits to FQHCs and EDs, overall and for emergent and non-emergent diagnoses., Results: In 2010, 4% of study subjects visited a FQHC, and they were more likely to be younger, have Medicaid, and live in low-income areas. We found that a standard deviation increase in prior year FQHC funding (+31 percentage point (pp)) at the ZIP code level was associated with a 2.3pp (95% CI 0.7pp to 3.8pp) increase in enrollees with FQHC visits and a 1.3pp (95% CI -2.3pp to -0.3pp) decrease in enrollees with non-emergent ED visits, but no significant change in emergent ED visits (0.3pp, 95% CI -0.8pp to 1.4pp)., Conclusions: We found that areas exposed to greater FQHC funding increases had more growth in the number of enrollees seen by FQHCs and greater reductions in ED visits for non-emergent conditions. Investment in FQHCs could be a promising approach to increase access to care for underserved populations and reduce costly ED visits, especially for primary care treatable or non-emergent conditions., Competing Interests: The authors have declared that no competing interests exist.

Background: Good nutrition and healthy growth during the first 1000days have lasting benefit throughout life. For this, equally important is the structural readiness of health facilities. However, structural readiness and nutrition services provision during the first 1000 days in Ethiopia is not well understood. The present study was part of a broader implementation research aimed at developing model nutrition districts by implementing evidence based, high impact and cost-effective package of nutrition interventions through the continuum of care. This study was aimed at assessing structural readiness of health facilities and the extent of nutrition service provision in the implementation districts., Methods: This assessment was conducted in four districts of Ethiopia. We used mixed method; a quantitative study followed by qualitative exploration. The quantitative part of the study addressed two-dimensions, structural readiness and process of nutrition service delivery. The first dimension assessed attributes of context in which care is delivered by observing availability of essential logistics. The second dimension assessed the service provision through direct observation of care at different units of health facilities. For these dimensions, we conducted a total of 380 observations in 23 health centers and 33 health posts. The observations were conducted at the Integrated Management of Neonatal and Childhood Illnesses unit, immunization unit, Antenatal care unit and Postnatal care unit. The qualitative part included a total of 60 key informant interviews with key stakeholders and service providers., Result: We assessed structural readiness of 56 health facilities. Both quantitative and qualitative findings revealed poor structural readiness and gap in nutrition services provision. Health facilities lack essential logistics which was found to be more prominent at health posts compared to health centers. The process evaluation showed a critical missed opportunity for anthropometric assessment and preventive nutrition counselling at different contact points. This was particularly prominent at immunization unit (where only 16.4% of children had their weight measured and only 16.2% of mothers with children under six month of age were counselled about exclusive breastfeeding). Although 90.4% of pregnant women who came for antenatal care were prescribed iron and folic acid supplementation, only 57.7% were counselled about the benefit and 42.4% were counselled about the side effect. The qualitative findings showed major service provision bottlenecks including non-functionality of the existing district nutrition coordination body and technical committees, training gaps, staff shortage, high staff turnover resulting in work related burden, fatigue and poor motivation among service providers., Conclusion: We found a considerable poor structural readiness and gaps in delivering integrated nutrition services with a significant missed opportunity in nutrition screening and counselling. Ensuring availability of logistics and improving access to training might improve delivery of nutrition services. In addition, ensuring adequate human resource might reduce missed opportunity and enable providers to provide a thorough preventive counselling service., Competing Interests: The authors have declared that no competing interests exist.

Because severe acute respiratory coronavirus virus 2 (SARS-CoV-2) spreads easily and healthcare workers are at increased risk of both acquiring and transmitting infection, all healthcare facilities must rapidly and rigorously implement the full hierarchy of established infection controls: source control (removal or mitigation of infection sources), engineering and environmental controls, administrative controls, and personal protective equipment.

Background: People with chronic conditions have complex healthcare needs that lead to challenges for adequate healthcare provision. Current healthcare services do not always respond adequately to their needs. A modular perspective, in particular providing visualization of the modular service architecture, is promising for improving the responsiveness of healthcare services to the complex healthcare needs of people with chronic conditions. The modular service architecture provides a comprehensive representation of the components and modules of healthcare provision. In this study, we explore this further in a qualitative multiple case study on healthcare provision for children with Down syndrome in the Netherlands., Methods: Data collection for four cases involved 53 semi-structured interviews with healthcare professionals and 21 semi-structured interviews with patients (the parents of children with Down syndrome as proxy). In addition, we gathered data by means of practice observations and analysis of relevant documents. The interviews were audio-recorded, transcribed verbatim and analyzed utilizing the Miles and Huberman approach., Results: Our study shows that the perspectives on healthcare provision of professionals and patients differ substantially. The visualization of the modular service architecture that was based on the healthcare professionals' perspective provided a complete representation of (para)medical outcomes relevant to the professionals' own discipline. In contrast, the modular service architecture based on the patients' perspective, which we define as a person-centered modular service architecture, provided a representation of the healthcare service that was primarily based on functional outcomes and the overall wellbeing of the patients., Conclusion: Our study shows that visualization of the modular service architecture can be a useful tool to better address the complex needs and requirements of people with a chronic condition. We suggest that a person-centered modular service architecture that focuses on functional outcomes and overall wellbeing, enables increased responsiveness of healthcare services to people with complex healthcare needs and provision of truly person-centered care., Competing Interests: The authors have declared that no competing interests exist.

Background: Though long-acting reversible contraceptives (LARCs) are highly effective, have minimal side effects, require minimal follow-up, and are low cost, only 10% of contraceptives used in Ethiopia are LARCs. The reason for this low uptake is not understood at the country or regional level. Therefore, this study identified determinants of LARC utilization in Northwest Ethiopia., Methods: A facility-based unmatched case control study, using LARC users as cases and short- acting reversible contraception (SARC) users as controls, had been conducted at fourteen public health institutions in Northwest Ethiopia. A systematic random sampling technique was used to select participants with a 1:2 case to control ratio (n = 1167). Binary logistic regression analysis was used to identify determinants of LARC utilization among family planning service users., Results: Wealth status [AOR:1.87, 95%CI (1.08, 3.24)], history of abortion [AOR:2.69, 95%CI (1.41, 5.12)], limiting family size [AOR: 2.38, 95%CI (1.01, 5.62)], good knowledge about LARCs [AOR: 2.52, 95%CI (1.17, 5.41)], method convenience [AOR: 0.23, 95%CI (0.16, 0.34)], good availability of method [AOR:0.10 (0.05, 0.19)], less frequent visits to health facility [AOR:2.95, 95% CI(1.89, 4.62)], health care providers advice [AOR:10.69, 95%CI (3.27, 34.87)], partner approval [AOR:0.66, 95%CI (0.45, 0.97)], and favorable attitude towards LARCs [AOR:13.0, 95%CI (8.60, 19.72)] were significantly associated with LARC utilization., Conclusion: Professional support, favorable attitude towards LARC use, high economic status, history of abortion, advantage of less frequent visits, having good knowledge towards LARC and interest of limiting births were significantly associated with LARC Utilization. On the other hand, perceived method convenience, and contraception availability were inversely associated with it. Family planning education about the benefits of LARC should be done by health providers and media. Male involvement in the counselling and decision making about the advantage of using LARC may improve the negative influence of partners on LARC utilization. It is also recommended that, future qualitative research further explore perceptions of LARC use., Competing Interests: The authors have declared that no competing interests exist.

Background: A routine health information system is one of the essential components of a health system. Interventions to improve routine health information system data quality and use for decision-making in low- and middle-income countries differ in design, methods, and scope. There have been limited efforts to synthesise the knowledge across the currently available intervention studies. Thus, this scoping review synthesised published results from interventions that aimed at improving data quality and use in routine health information systems in low- and middle-income countries., Method: We included articles on intervention studies that aimed to improve data quality and use within routine health information systems in low- and middle-income countries, published in English from January 2008 to February 2020. We searched the literature in the databases Medline/PubMed, Web of Science, Embase, and Global Health. After a meticulous screening, we identified 20 articles on data quality and 16 on data use. We prepared and presented the results as a narrative., Results: Most of the studies were from Sub-Saharan Africa and designed as case studies. Interventions enhancing the quality of data targeted health facilities and staff within districts, and district health managers for improved data use. Combinations of technology enhancement along with capacity building activities, and data quality assessment and feedback system were found useful in improving data quality. Interventions facilitating data availability combined with technology enhancement increased the use of data for planning., Conclusion: The studies in this scoping review showed that a combination of interventions, addressing both behavioural and technical factors, improved data quality and use. Interventions addressing organisational factors were non-existent, but these factors were reported to pose challenges to the implementation and performance of reported interventions., Competing Interests: The authors have declared that no competing interests exist.

The spatial distributions of diverse facilities are often understood in terms of the optimization of the commute distance or the economic profit. Incorporating more general objective functions into such optimization framework may be useful, helping the policy decisions to meet various social and economic demands. As an example, we consider how hospitals should be distributed to minimize the total fatalities of tuberculosis (TB). The empirical data of Korea shows that the fatality rate of TB in a district decreases with the areal density of hospitals, implying their correlation and the possibility of reducing the nationwide fatalities by adjusting the hospital distribution across districts. Approximating the fatality rate by the probability of a patient not to visit a hospital in her/his residential district for the duration period of TB and evaluating the latter probability in the random-walk framework, we obtain the fatality rate as an exponential function of the hospital density with a characteristic constant related to each district's effective lattice constant estimable empirically. This leads us to the optimal hospital distribution which finds the hospital density in a district to be a logarithmic function of the rescaled patient density. The total fatalities is reduced by 13% with this optimum. The current hospital density deviates from the optimized one in different manners from district to district, which is analyzed in the proposed model framework. The assumptions and limitations of our study are also discussed.

While transition of donor programs to national control is increasingly common, there is a lack of evidence about the consequences of transition for private health care providers. In 2015, President's Emergency Plan for AIDS Relief (PEPFAR) identified 734 facilities in Uganda for transition from PEPFAR support, including 137 private not-for-profits (PNFP) and 140 private for-profits (PFPs). We sought to understand the differential impacts of transition on facilities with differing ownership statuses. We used a survey conducted in mid-2017 among 145 public, 29 PNFP and 32 PFP facilities reporting transition from PEPFAR. The survey collected information on current and prior PEPFAR support, service provision, laboratory services and staff time allocation. We used both bivariate and logistic regression to analyse the association between ownership and survey responses. All analyses adjust for survey design. Public facilities were more likely to report increased disruption of sputum microscopy tests following transition than PFPs [odds ratio (OR) = 5.85, 1.79-19.23, P = 0.005]. Compared with public facilities, PNFPs were more likely to report declining frequency of supervision for human immunodeficiency virus (HIV) since transition (OR = 2.27, 1.136-4.518, P = 0.022). Workers in PFP facilities were more likely to report reduced time spent on HIV care since transition (OR = 6.241, 2.709-14.38, P < 0.001), and PFP facilities were also more likely to discontinue HIV outreach following transition (OR = 3.029, 1.325-6.925; P = 0.011). PNFP facilities' loss of supervision may require that public sector supervision be extended to them. Reduced HIV clinical care in PFPs, primarily HIV testing and counselling, increases burdens on public facilities. Prior PFP clients who preferred the confidentiality and service of private facilities may opt to forgo HIV testing altogether. Donors and governments should consider the roles and responses of PNFPs and PFPs when transitioning donor-funded health programs., (© The Author(s) 2019. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Background: Carbapenemase-producing Enterobacteriaceae (CPE) are an important and increasing threat to public health. In hospitals and long-term care facilities, carriers should be identified to prevent transmission; however, guidelines for infection control are not applicable to all types of care homes., Aim: To report the outbreak investigation of a VIM-metallo-β-lactamase-producing Escherichia coli in a Dutch residential care home, where residents lived in private apartments but also used shared facilities., Methods: Contact and environmental screening rounds were performed to assess carriage and colonization rates. Due to the domestic characteristics of the home, customized infection control measures were needed. A bundle of interventions was implemented, including contact precautions, improved hygiene and education., Findings: In total, eight CPE carriers, including the index case, were identified among 110 residents. VIM-CPE spread was associated with the use of shared toilets in communal areas. Seven months after the first finding, all carriers were found to be VIM-negative, and after 1 year, VIM CPE was no longer detectable in the environment., Conclusion: A customized bundled approach was needed to control the outbreak successfully. Current guidelines should be adapted to be suitable for all types of residential care homes in order to combat the spread of multi-resistant pathogens effectively., (Copyright © 2019 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: Stillbirth is a major adverse perinatal outcome especially in low and middle income countries across the globe. Certain factors relating to mothers from such countries may be associated with this adverse condition., Objectives: To determine the prevalence of stillbirth and also explore the maternal socio-demographic factors associated with stillbirth among mothers in rural communities in Anambra Central Senatorial District of Anambra State Nigeria who gave birth between January 2012 and December 2016., Methods: All case files of mothers who were delivered of their babies were accessed at the sampled health facilities in the district. Data were collected using a structured proforma. A total of 313 stillbirth cases were recorded across the health facilities from 2012-2016., Results: The highest prevalence of stillbirth was recorded in 2012 (38.07 per 1,000 total births). The prevalence of stillbirth was significantly associated with the maternal level of education, occupation, age and type of health facility the mother utilized (p<0.05)., Conclusions: We recommend that women empowerment should be a priority at both family and community levels to enable women to seek and obtain necessary care during pregnancy and delivery., (© 2019 Anyichie et al.)

Aims: The purpose of this study was to compare outcomes associated with medical management of ST-elevation myocardial infarction and non-ST-elevation myocardial infarction patients presenting to hospitals with and without onsite catheterization facilities., Methods: All patients ( n =25,921) with ST-elevation myocardial infarction ( n =10,563) or non-ST-elevation myocardial infarction ( n =15,358) in Alberta, Canada between April 2010-March 2016 were categorized according to availability of catheterization facilities at the hospital they presented to and their management strategy (medically managed without coronary angiography or medically managed after coronary angiography)., Results: Overall, 51% presented to hospitals without catheterization facilities; and 34% were managed medically (18% without coronary angiography, and 16% after coronary angiography). Rates of medical management were higher at hospitals without versus those with catheterization facilities (43% vs. 24%, p <0.01). However, both the rate of presentation to hospitals without catheterization facilities (70% non-ST-elevation myocardial infarction, 24% ST-elevation myocardial infarction, p <0.01) and medical management (45% non-ST-elevation myocardial infarction, 18% ST-elevation myocardial infarction, p <0.01) differed by myocardial infarction type. The lack of catheterization facilities at the presenting hospital had no association with in-hospital mortality in patients medically managed without coronary angiography, but was associated with a lower risk of mortality among patients medically managed after coronary angiography. However, the latter benefit was restricted to non-ST-elevation myocardial infarction patients only (adjusted hazard ratio 0.43, 95% confidence interval: 0.25-0.76)., Conclusion: The availability of catheterization facilities at the hospital at which non-ST-elevation myocardial infarction and ST-elevation myocardial infarction patients presented influenced their likelihood of being medically managed, but was not associated with adverse short- or long-term mortality outcomes.

Introduction: Patient Safety Culture is based on learning from incidents, developing preventive strategies to reduce the likelihood to happen and recognizing and accompanying those who have suffered unnecessary and involuntary harm derived from the health care received. To go ahead on patient safety culture entails facilitating the implementation of these behaviors and attitudes in healthcare professionals. Objective was to describe the regulations of some autonomous communities and national proposals for regulations changes., Material and Methods: Search of normative changes made in the autonomous communities of Catalonia, Navarra and the Basque Country. Proposals for legislative changes at national level were agreed., Results: Activities and normative changes made in the autonomous communities of Catalonia, Navarre and the Basque Country are described and proposals for normative changes at the national level at short-term and long-term changes are made. In such a way that it is easier to advance in creating culture of patient safety in the whole National Health System CONCLUSION: Currently there is no global regulation that facilitates to advance in patient safety culture. Changes at the national legislation level are essential. It is at the Inter-territorial Council where the proposed legislative amendment should be defined, promoted by the representatives of the health systems of the autonomous communities., (Copyright © 2019 FECA. Publicado por Elsevier España, S.L.U. All rights reserved.)

Aim: The industry of unproven stem cell clinics has rapidly mushroomed throughout the USA, posing risks to patients and the research field. In this study, the aim was to better define how this industry changes. Methods: I analyzed a large cohort of US stem cell clinic firms and their distinct clinic locations as defined in 2015-2016 for their status now in 2019. Results: About a quarter of the firms no longer marketed stem cells. Some lacked active websites, while others dropped stem cell services. Even so, the total number of clinics in this group increased because some firms greatly expanded their clinic numbers. Conclusion: Overall, the unproven clinic industry is a moving target requiring ongoing study and regulatory oversight.

Background: A hospital is an unfamiliar place to patients because of its style, atmosphere, and procedures. These hospital characteristics cause patients to become confused about responding to protocols, which slows down the procedural flows. Some additional information technology infrastructure facilities and human resources may be needed to solve these problems. However, this solution needs high investment and cannot guarantee an accuracy of information sent to patients. To handle this limitation, EasyHos has been developed to help patients recognize their status (for example, "waiting for an appointment at 11am") during their stay in a hospital using all existing infrastructure and hospital data and without changing existing hospital's process., Objective: The objective of this study was to provide a design of the EasyHos system and the case study in hospitals in Thailand. The design is usable and repeatable for small- and medium-sized hospitals where internet infrastructure is in place., Methods: The EasyHos system has been designed based on existing infrastructure, hospital data and hospital processes. The main components include mobile devices, existing hospital data, wireless communication network. The EasyHos was deployed at 2 hospitals in Thailand, one small and the other with a medium size. The experimental process was focused on solving the problem of unfamiliarity in the hospital. The criteria and pretest conditions regarding the unexpected problem have been defined before the experiment., Results: The results are presented in terms of criteria, pretest conditions, posttest conditions in the hospitals. The posttest conditions show the experimental results and impact of the system on users such as hospital nurses/staff and patients. For example, the questions from patients were reduced by 83.3% after using EasyHos system while nurses/hospital staff had 5 min more to do their routine work each day. In addition, another impact is that hospitals can create new information values from existing data, which now can be visible and valuable to patients., Conclusions: Hospitals' unexpected problems have been reduced by the EasyHos system. The EasyHos system has been developed with self-service and patient-centered concepts to assist patients with necessary information. The system makes interaction easier for nurses/hospital staff members and patients working or waiting in the hospital. The nurses/hospital staff members would have more time to do their routine works. Hospitals can easily set up the EasyHos system, which will have a low or nearly zero implementation cost., (©Chalee Vorakulpipat, Ekkachan Rattanalerdnusorn, Soontorn Sirapaisan, Visut Savangsuk, Natsuda Kasisopha. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 22.07.2019.)

Background: Strong primary health care (PHC) is essential for achieving universal health coverage, but in many low- and middle-income countries (LMICs) PHC services are of poor quality. Facility management is hypothesized to be critical for improving PHC performance, but evidence about management performance and its associations with PHC in LMICs remains limited., Methods: We quantified management performance of PHC facilities in Ghana and assessed the experiences of women who sought care at sampled facilities. Using multi-level models, we examined associations of facility management with five process outcomes and eight experiential outcomes., Findings: On a scale of 0 to 1, the average overall management score in Ghana was 0·76 (IQR = 0·68-0·85). Facility management was significantly associated with one process outcome and three experiential outcomes. Controlling for facility characteristics, facilities with management scores at the 90th percentile (management score = 0·90) had 22% more essential drugs compared to facilities with management scores at the 10th percentile (0·60) (p = 0·002). Positive statistically non-significant associations were also seen with three additional process outcomes-integration of family planning services (p = 0·054), family planning types provided (p = 0·067), and essential equipment availability (p = 0·104). Compared to women who sought care at facilities with management scores at the 10th percentile, women who sought care at facilities at the 90th percentile reported 8% higher ratings of trust in providers (p = 0·028), 15% higher ratings of ease of following provider's advice (p = 0·030), and 16% higher quality rating (p = 0·020). However, women who sought care in the 90th percentile facilities rated their waiting times as worse (22% lower, p = 0·039)., Interpretation: Higher management scores were associated with higher scores for some process and experiential outcomes. Large variations in management performance indicate the need to strengthen management practices to help realize the full potential of PHC in improving health outcomes., Competing Interests: Dr. Bitton reports grants from Bill and Melinda Gates Foundation, during the conduct of the study. Dr. Gawande reports grants from Bill and Melinda Gates Foundation, during the conduct of the study; and Dr. Gawande is the CEO of Haven, the health care venture founded by Amazon, Berkshire Hathaway, and JPMorgan Chase. This does not alter our adherence to PLOS ONE policies on sharing data and materials. Dr. Hirschhorn reports grants from Bill & Melinda Gates Foundation, during the conduct of the study. Dr. Lipsitz reports grants from Bill & Melinda Gates Foundation, during the conduct of the study. Dr. Macarayan reports grants from Bill & Melinda Gates Foundation, during the conduct of the study. Dr. Miller reports grants from Bill and Melinda Gates Foundation, during the conduct of the study. Dr. Otupiri has nothing to disclose. Ms. Ratcliffe reports grants from Bill and Melinda Gates Foundation, during the conduct of the study.

Objective To determine the health facility cost of cesarean section at a rural district hospital in Rwanda. Methods Using time-driven activity-based costing, this study calculated capacity cost rates (cost per minute) for personnel, infrastructure and hospital indirect costs, and estimated the costs of medical consumables and medicines based on purchase prices, all for the pre-, intra- and post-operative periods. We estimated copay (10% of total cost) for women with community-based health insurance and conducted sensitivity analysis to estimate total cost range. Results The total cost of a cesarean delivery was US$339 including US$118 (35%) for intra-operative costs and US$221 (65%) for pre- and post-operative costs. Costs per category included US$46 (14%) for personnel, US$37 (11%) for infrastructure, US$109 (32%) for medicines, US$122 (36%) for medical consumables, and US$25 (7%) for hospital indirect costs. The estimated copay for women with community-based health insurance was US$34 and the total cost ranged from US$320 to US$380. Duration of hospital stay was the main marginal cost variable increasing overall cost by US$27 (8%). Conclusions for Practice The cost of cesarean delivery and the cost drivers (medicines and medical consumables) in our setting were similar to previous estimates in sub-Saharan Africa but higher than earlier average estimate in Rwanda. The estimated copay is potentially catastrophic for poor rural women. Investigation on the impact of true out of pocket costs on women's health outcomes, and strategies for reducing duration of hospital stay while maintaining high quality care are recommended.

TOWARDS A NEW CERTIFICATION OF HEALTHCARE FACILITIES FOR 2020.: The accreditation process, now a certification process for healthcare facilities, has constantly evolved since 1999 in order to improve the quality and safety of care provided to patients. In order to meet demographic, epidemiological and social challenges, it needs to be revised again. The French National Health Authority board has fixed three main objectives for the 2020 version: to medicalise certification, simplify it and adapt it to hospital groups in the public and private sector., (Copyright © 2018. Published by Elsevier Masson SAS.)

This work discusses the dominant models and tensions within the health field regarding the conceptualization of the human body (as a machine), the process of health work (industrial and artisanal models), institutions (hospitals and health centers) and primary agents (the medical corporation and the medical industrial complex). The context of analysis is the United States from the end of the 19th century to the present. Economic-political, ideological-cultural, and scientific-technical dimensions are discussed, which permeate the historicity of the field. The purpose is to illustrate how the health field has transformed over time, as well as the role instrumental reason and financial capital has played in this process, to the detriment of relational aspects.

A health centre and its staff have undertaken a sustainable health approach which aims to reduce the impact of the environment on health. One of the initiatives focused on the improvement of indoor air quality. A change to practices was possible thanks to a participative approach, the support of the staff and constant communication., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Healthcare and medical-social facilities have a major responsibility within society, that of the quality of care, but also that of developing a system of sustainable and socially-responsible health. This system must meet the three pillars which constitute such an approach: economic, social and environmental sustainability. Innovation remains central to the sustainable evolution of practices and the first results are now visible., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Introduction: The purpose of this study is to reconcile public health workforce supply and demand data to understand whether the expected influx of public health graduates can meet turnover events., Methods: Four large public health workforce data sources were analyzed to establish measures of workforce demand, voluntary separations, and workforce employees likely to retire at state and local health departments. Data were collected in 2014-2016 and analyzed in 2016 and 2017. Potential workforce supply (i.e., candidates with formal public health training) was assessed by analyzing data on public health graduates. Supply and demand data were reconciled to identify potential gaps in the public health workforce., Results: At the state and local level, ≅197,000 staff are employed in health departments. This is down more than 50,000 from 2008. In total, ≥65,000 staff will leave their organizations during fiscal years 2016-2020, with ≤100,000 staff leaving if all planned retirements occur by 2020. During 2000-2015, more than 223,000 people received a formal public health degree at some level. More than 25,000 students will receive a public health degree at some level in each year through 2020., Conclusions: Demands for public health staff could possibly be met by the influx of graduates from schools and programs of public health. However, substantial implications exist for transferal of institutional knowledge and ability to recruit and retain the best staff to sufficiently meet demand., (Copyright © 2018 American Journal of Preventive Medicine. All rights reserved.)

Background: The structure of long-term care (LTC) for old people has changed: care has been shifted from institutions to the community, and death is being postponed to increasingly old age. The aim of the study was to analyze how the use and costs of LTC in the last two years of life among old people changed between 2002 and 2013., Methods: Data were derived from national registers. The study population contains all those who died at the age of 70 years or older in 2002-2013 in Finland (N = 427,078). The costs were calculated using national unit cost information. Binary logistic regression and Cox proportional hazard models were used to study the association of year of death with use and costs of LTC., Results: The proportion of those who used LTC and the sum of days in LTC in the last two years of life increased between 2002 and 2013. The mean number of days in institutional LTC decreased, while that for sheltered housing increased. The costs of LTC per user decreased., Conclusions: Use of LTC in the last two years of life increased, which was explained by the postponement of death to increasingly old age. Costs of LTC decreased as sheltered housing replaced institutional LTC. However, an accurate comparison of costs of different types of LTC is difficult, and the societal costs of sheltered housing are not well known.

The government of India has, over the past decade, implemented the "integration" of traditional, complementary and alternative medical (TCAM) practitioners, specifically practitioners of Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-rigpa, and Homoeopathy (collectively known by the acronym AYUSH), in government health services. A range of operational and ethical challenges has manifested during this process of large health system reform. We explored the practices and perceptions of health system actors, in relation to AYUSH providers' roles in government health services in three Indian states - Kerala, Meghalaya, and Delhi. Research methods included 196 in-depth interviews with a range of health policy and system actors and beneficiaries, between February and October 2012, and review of national, state, and district-level policy documents relating to AYUSH integration. The thematic 'framework' approach was applied to analyze data from the interviews, and systematic content analysis performed on policy documents. We found that the roles of AYUSH providers are frequently ambiguously stated and variably interpreted, in relation to various aspects of their practice, such as outpatient care, prescribing rights, emergency duties, obstetric services, night duties, and referrals across systems of medicine. Work sharing is variously interpreted by different health system actors as complementing allopathic practice with AYUSH practice, or allopathic practice, by AYUSH providers to supplement the work of allopathic practitioners. Interactions among AYUSH practitioners and their health system colleagues frequently take place in a context of partial information, preconceived notions, power imbalances, and mistrust. In some notable instances, collegial relationships and apt divisions of responsibilities are observed. Widespread normative ambivalence around the roles of AYUSH providers, complicated by the logistical constraints prevalent in poorly resourced systems, has the potential to undermine the therapeutic practices and motivation of AYUSH providers, as well as the overall efficiency and performance of integrated health services., (Copyright © 2016 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Whether facility-based implementation of Helping Babies Breathe (HBB) reduces neonatal mortality at a population level in low and middle income countries (LMIC) has not been studied. Therefore, we evaluated HBB implementation in this context where our study team has ongoing prospective outcome data on all pregnancies regardless of place of delivery., Methods: We compared outcomes of birth cohorts in three sites in India and Kenya pre-post implementation of a facility-based intervention, using a prospective, population-based registry in 52 geographic clusters. Our hypothesis was that HBB implementation would result in a 20 % decrease in the perinatal mortality rate (PMR) among births ≥1500 g., Results: We enrolled 70,704 births during two 12-month study periods. Births within each site did not differ pre-post intervention, except for an increased proportion of <2500 g newborns and deliveries by caesarean section in the post period. There were no significant differences in PMR among all registry births; however, a post-hoc analysis stratified by birthweight documented improvement in <2500 g mortality in Belgaum in both registry and in HBB-trained facility births. No improvement in <2500 g mortality measures was noted in Nagpur or Kenya and there was no improvement in normal birth weight survival., Conclusions: Rapid scale up of HBB training of facility birth attendants in three diverse sites in India and Kenya was not associated with consistent improvements in mortality among all neonates ≥1500 g; however, differential improvements in <2500 g survival in Belgaum suggest the need for careful implementation of HBB training with attention to the target population, data collection, and ongoing quality monitoring activities., Trial Registration: The study was registered at ClinicalTrials.gov: NCT01681017 .

Background: In 2004, Ghana began implementation of a National Health Insurance Scheme (NHIS) to minimize out-of-pocket expenditure at the point of use of service. The implementation of the scheme was accompanied by increased access and use of health care services. Evidence suggests most health facilities are faced with management challenges in the delivery of services. The study aimed to assess the effect of the introduction of the NHIS on health service delivery in mission health facilities in Ghana. We conceptualised the effect of NHIS on facilities using service delivery indicators such as outpatient and inpatient turn out, estimation of general service readiness, revenue and expenditure, claims processing and availability of essential medicines. We collected data from 38 mission facilities, grouped into the three ecological zones; southern, middle and northern. Structured questionnaires and exit interviews were used to collect data for the periods 2003 and 2010. The data was analysed in SPSS and MS Excel., Results: The facilities displayed high readiness to deliver services. There were significant increases in outpatient and inpatient attendance, revenue, expenditure and improved access to medicines. Generally, facilities reported increased readiness to deliver services. However, challenging issues around high rates of non-reimbursement of NHIS claims due to errors in claims processing, lack of feedback regarding errors, and lack of clarity on claims reporting procedures were reported., Conclusion: The implementation of the NHIS saw improvement and expansion of services resulting in benefits to the facilities as well as constraints. The constraints could be minimized if claims processing is improved at the facility level and delays in reimbursements also reduced.

Objective: To characterize the impact of widespread inventory management policies on stock-outs of essential drugs in Zambia's health clinics and develop related recommendations., Methods: Daily clinic storeroom stock levels of artemether-lumefantrine (AL) products in 2009-2010 were captured in 145 facilities through photography and manual transcription of paper forms, then used to determine historical stock-out levels and estimate demand patterns. Delivery lead-times and estimates of monthly facility accessibility were obtained through worker surveys. A simulation model was constructed and validated for predictive accuracy against historical stock-outs, then used to evaluate various changes potentially affecting product availability., Findings: While almost no stock-outs of AL products were observed during Q4 2009 consistent with primary analysis, up to 30% of surveyed facilities stocked out of some AL product during Q1 2010 despite ample inventory being simultaneously available at the national warehouse. Simulation experiments closely reproduced these results and linked them to the use of average past monthly issues and failure to capture lead-time variability in current inventory control policies. Several inventory policy enhancements currently recommended by USAID | DELIVER were found to have limited impact on product availability., Conclusions: Inventory control policies widely recommended and used for distributing medicines in sub-Saharan Africa directly account for a substantial fraction of stock-outs observed in common situations involving demand seasonality and facility access interruptions. Developing central capabilities in peripheral demand forecasting and inventory control is critical. More rigorous independent peer-reviewed research on pharmaceutical supply chain management in low-income countries is needed.

Background and Objective: Artemisinin combination therapies such as artemether-lumefantrine (AL) are effective for first-line treatment of uncomplicated acute Plasmodium falciparum malaria. However, the safety profile of AL in large populations has not been fully assessed. The objective of this study was to establish the safety of AL in public health facilities in Tanzania using the Cohort Event Monitoring (CEM) method., Methodology: Patients who presented to public health facilities in four regions of Tanzania who were prescribed AL were enrolled in a CEM study, a prospective, observational cohort study to establish a profile of adverse events (AEs) for the medicine when used in routine clinical practice. Pre- and post-treatment forms were used to record baseline information and new health events before and 7 days after treatment., Results: A total of 8040 patients were enrolled in the study, of whom 6147 were included in the analysis. Following treatment initiation, a total of 530 AEs were reported in 6% (383) of the patients. The most frequent post-treatment AEs were in alimentary system (42%), including vomiting, nausea, diarrhoea, abdominal pain and anorexia, followed by AEs in the neurological system (25%). Causality assessment of the events showed that 51.9% (275/530) were possibly related to AL. There was a significant difference in the frequency of AEs by age-group with an increase in the number of AEs as age increased (P < 0.001). There was no statistically significant difference in the frequency of the events between males and females (P = 0.504). The AE profile was consistent with the AEs reported in the product information and in other studies; no new adverse drug reactions were identified. The majority of the reported AEs were the same as the symptoms of malaria and therefore indistinguishable from the underlying disease., Conclusions: The safety profile of AL for treatment of malaria continues to be favourable. CEM as a pharmacovigilance tool has proven to provide reliable safety data in a short period.

Objectives: It has been suggested that since 1990, de-institutionalisation of mental healthcare in Western Europe has been reversed into re-institutionalisation with more forensic beds, places in protected housing services and people with mental disorders in prisons. This study aimed to identify changes in the numbers of places in built institutions providing mental healthcare in Western Europe from 1990 to 2012, and to explore the association between changes in psychiatric bed numbers and changes in other institutions., Settings and Data: Data were identified from 11 countries on psychiatric hospital beds, forensic beds, protected housing places and prison populations. Fixed effects regression models tested the associations between psychiatric hospital beds with other institutions., Results: The number of psychiatric hospital beds decreased, while forensic beds, places in protected housing and prison populations increased. Overall, the number of reduced beds exceeded additional places in other institutions. There was no evidence for an association of changes in bed numbers with changes in forensic beds and protected housing places. Panel data regression analysis showed that changes in psychiatric bed numbers were negatively associated with rising prison populations, but the significant association disappeared once adjusted for gross domestic product as a potential covariate., Conclusions: Institutional mental healthcare has substantially changed across Western Europe since 1990. There are ongoing overall trends of a decrease in the number of psychiatric hospital beds and an increase in the number of places in other institutions, including prisons. The exact association between these trends and their drivers remains unclear. More reliable data, information on the characteristics of patients in different institutions, long-term pathway analyses and effectiveness studies are required to arrive at evidence-based policies for the provision of institutional mental healthcare., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Carbapenem-resistant Enterobacteriaceae (CRE), a group of pathogens resistant to most antibiotics and associated with high mortality, are a rising emerging public health threat. Current approaches to infection control and prevention have not been adequate to prevent spread. An important but unproven approach is to have hospitals in a region coordinate surveillance and infection control measures. Using our Regional Healthcare Ecosystem Analyst (RHEA) simulation model and detailed Orange County, California, patient-level data on adult inpatient hospital and nursing home admissions (2011-2012), we simulated the spread of CRE throughout Orange County health-care facilities under 3 scenarios: no specific control measures, facility-level infection control efforts (uncoordinated control measures), and a coordinated regional effort. Aggressive uncoordinated and coordinated approaches were highly similar, averting 2,976 and 2,789 CRE transmission events, respectively (72.2% and 77.0% of transmission events), by year 5. With moderate control measures, coordinated regional control resulted in 21.3% more averted cases (n = 408) than did uncoordinated control at year 5. Our model suggests that without increased infection control approaches, CRE would become endemic in nearly all Orange County health-care facilities within 10 years. While implementing the interventions in the Centers for Disease Control and Prevention's CRE toolkit would not completely stop the spread of CRE, it would cut its spread substantially, by half., (© The Author 2016. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health.)