The acceptability and feasibility of task-sharing for mental healthcare in low and middle income countries: A systematic review

Task-sharing has frequently been proposed as a strategy to overcome human resource shortages in order to scale up mental health care. Although evidence suggests this approach is effective, to date no review has been conducted to assess its acceptability and feasibility among service users and health care practitioners. This review summarises current findings and provides evidence-based recommendations to improve the success and sustainability of task-sharing approaches. All study designs were included and both qualitative and quantitative data were extracted and reviewed using a comparative thematic analysis. In total, 21 studies were included, nine of which were of strong or adequate quality and twelve of unknown quality. The review highlighted that task-sharing is not an outright solution for overcoming human resource shortages in low and middle income countries. A number of factors need to be considered in order for task-sharing to be acceptable and feasible, for example the incidence of distress experienced by the task-sharing workforce, their self-perceived level of competence, the acceptance of the workforce by other health care professionals and the incentives provided to ensure workforce retention. As the main barrier to addressing these is a lack of resources, an increased investment in mental health care is essential in order to ensure that task-sharing interventions are successful and sustainable.     

Perspectives of physicians practicing in low and middle income countries towards generic medicines: A narrative review

Objectives

This review was conducted to document published literature related to physicians’ knowledge, attitudes, and perceptions of generic medicines in low- and middle-income countries (LMICs) and to compare the findings with high-income countries.

Methods

A systematic search of articles published in peer-reviewed journals from January 2001 to February 2013 was performed. The search comprised nine electronic databases. The search strategy involved using Boolean operators for combinations of the following terms: generic medicines, generic medications, generic drugs, generic, generic substitution, generic prescribing, international non-proprietary, prescribers, doctors, general practitioners, physicians, and specialists.

Results

Sixteen articles were included in this review. The majority (n = 11) were from high income countries and five from LMICs. The main difference between high income countries and LMICs is that physicians from high income countries generally have positive views whereas those from LMICs tend to have mixed views regarding generic medicines. Few similarities were identified among different country income groups namely low level of physicians’ knowledge of the basis of bioequivalence testing, cost of generic medicines as an encouraging factor for generic medicine prescribing, physicians’ concerns towards safety and quality of generic medicines and effect of pharmaceutical sales representative on generic medicine prescribing.

Conclusion

The present literature review revealed that physicians from LMICs tend to have mixed views regarding generic medicines. This may be due to differences in the health care system and pharmaceutical funding system, medicine policies, the level of educational interventions, and drug information sources in countries of different income levels.     

A systematic review of the social and economic burden of influenza in low- and middle-income countries

ObjectivesThe economic burden of seasonal influenza outbreaks as well as influenza pandemics in lower- and middle-income countries (LMIC) has yet to be specifically systematically reviewed. The aim of this systematic review is to assess the evidence of influenza economic burden assessment methods in LMIC and to quantify the economic consequences of influenza disease in these countries, including broader opportunity costs in terms of impaired social progress and economic development.MethodsWe conducted an all language literature search across 5 key databases using an extensive list of key words for the time period 1950–2013. We included studies which explored direct costs (medical and non-medical), indirect costs (productivity losses), and broader economic impact in LMIC associated with different influenza outcomes such as confirmed seasonal influenza infection, influenza-like illnesses, and pandemic influenza.ResultsWe included 62 full-text studies in English, Spanish, Russian, Chinese languages, mostly from the countries of Latin American and the Caribbean and East Asia and Pacific with pertinent cost data found in 39 papers. Estimates for direct and indirect costs were the highest in Latin American and the Caribbean. Compared to high-income economies, direct costs in LMIC were lower and productivity losses higher. Evidence on broader impact of influenza included impact on the wider national economy, security dimension, medical insurance policy, legal frameworks, distributional impact, and investment flows.ConclusionThe economic burden of influenza in LMIC encompasses multiple dimensions such as direct costs to the health service and households, indirect costs due to productivity losses as well as broader detriments to the wider economy. Evidence from sub-Saharan Africa and in pregnant women remains very limited. Heterogeneity of methods used to estimate cost components makes data synthesis challenging. There is a strong need for standardizing research, data collection and evaluation methods for both direct and indirect cost components.     

Reasons related to non-vaccination and under-vaccination of children in low and middle income countries: findings from a systematic review of the published literature, 1999-2009

Objective

Despite increases in routine vaccination coverage during the past three decades, the percent of children completing the recommended vaccination schedule remains below expected targets in many low and middle income countries. In 2008, the World Health Organization Strategic Advisory Group of Experts on Immunization requested more information on the reasons that children were under-vaccinated (receiving at least one but not all recommended vaccinations) or not vaccinated in order to develop effective strategies and interventions to reach these children.

Methods

A systematic review of the peer-reviewed literature published from 1999 to 2009 was conducted to aggregate information on reasons and factors related to the under-vaccination and non-vaccination of children. A standardized form was used to abstract information from relevant articles identified from eight different medical, behavioural and social science literature databases.

Findings

Among 202 relevant articles, we abstracted 838 reasons associated with under-vaccination; 379 (45%) were related to immunization systems, 220 (26%) to family characteristics, 181 (22%) to parental attitudes and knowledge, and 58 (7%) to limitations in immunization-related communication and information. Of the 19 reasons abstracted from 11 identified articles describing the non-vaccinated child, 6 (32%) were related to immunization systems, 8 (42%) to parental attitudes and knowledge, 4 (21%) to family characteristics, and 1 (5%) to communication and information.

Conclusions

Multiple reasons for under-vaccination and non-vaccination were identified, indicating that a multi-faceted approach is needed to reach under-vaccinated and unvaccinated children. Immunization system issues can be addressed through improving outreach services, vaccine supply, and health worker training; however, under-vaccination and non-vaccination linked to parental attitudes and knowledge are more difficult to address and likely require local interventions.     

A cost comparison of introducing and delivering pneumococcal,rotavirus and human papillomavirus vaccines in Rwanda

BackgroundDetailed cost evaluations of delivery of new vaccines such as pneumococcal conjugate, human papillomavirus (HPV), and rotavirus vaccines in low and middle-income countries are scarce. This paper differs from others by comparing the costs of introducing multiple vaccines in a single country and then assessing the financial and economic impact at the time and implications for the future. The objective of the analysis was to understand the introduction and delivery cost per dose or per child of the three new vaccines in Rwanda to inform domestic and external financial resource mobilization.MethodsStart-up, recurrent, and capital costs from a government perspective were collected in 2012. Since pneumococcal conjugate and HPV vaccines had already been introduced, cost data for those vaccines were collected retrospectively while prospective (projected) costing was done for rotavirus vaccine.ResultsThe financial unit cost per fully immunized child (or girl for HPV vaccine) of delivering 3 doses of each vaccine (without costs related to vaccine procurement) was $0.37 for rotavirus (RotaTeq^®) vaccine, $0.54 for pneumococcal (Prevnar^®) vaccine in pre-filled syringes, and $10.23 for HPV (Gardasil ^®) vaccine. The financial delivery costs of Prevnar^® and RotaTeq^® were similar since both were delivered using existing health system infrastructure to deliver infant vaccines at health centers. The total financial cost of delivering Gardasil^® was higher than those of the two infant vaccines due to greater resource requirements associated with creating a new vaccine delivery system in for a new target population of 12-year-old girls who have not previously been served by the existing routine infant immunization program.ConclusionThe analysis indicates that service delivery strategies have an important influence on costs of introducing new vaccines and costs per girl reached with HPV vaccine are higher than the other two vaccines because of its delivery strategy. Documented information on financial commitments for new vaccines, particularly from government sources, is a useful input into country policy dialogue on sustainable financing and co-financing of new vaccines, as well as for policy decisions by donors such as Gavi, the Vaccine Alliance.     

Trauma registry implementation and operation in low and middle income countries: A scoping review

ABSTRACT

Injury is a major public health crisis contributing to more than 4.48 million deaths annually. Trauma registries have proven highly effective in reducing injury morbidity and mortality rates in high income countries. They are a critical source of information for injury prevention, benchmarking care, quality improvement, and resource allocation. Historically, low and middle income countries (LMICs) have largely been excluded from trauma registry development due to limited resources. Recently, this has begun to change with low-resource hospitals adopting innovative strategies to implement trauma registries. Nonetheless, dissemination of these strategies remains fragmented. Hospitals looking to develop their own trauma registries have no current, comprehensive resource that summarises the implementation decisions of other registries in similar contexts. This scoping review aims to identify where trauma registries are located in LMICs, bringing up to date previous estimates, and to identify the most common approaches to registry implementation and operation in these settings.     

Intent to obtain pediatric influenza vaccine among mothers in four middle income countries

BackgroundDespite a large burden of influenza in middle income countries, pediatric vaccination coverage remains low. The aims of this study were to (1) describe mothers’ knowledge and attitudes about influenza illnesses and vaccination, and (2) identify characteristics associated with mothers’ intent to vaccinate their child.MethodsFrom 2015 to 2017, infants 0–11 months old in Nicaragua, Philippines, Jordan, and Albania were enrolled from community settings and hospitals. Interviewers administered a questionnaire to their mothers. Mothers of infants aged 6–11 months rated their intention (small-to-moderate vs. large chance) to accept pediatric vaccination if it was offered at no-cost. The importance of knowledge, attitudes, and sociodemographic characteristics in predicting influenza vaccination intention was measured as the mean decrease in Gini index when that factor was excluded from 1000 decision trees in a random forest analysis.ResultsIn total, 1,308 mothers were enrolled from the community setting and 3,286 from the hospital setting. Prevalence of at least some knowledge of influenza illness ranged from 34% in Philippines to 88% in Albania (in the community sample), and between 23% in Philippines to 88% in Jordan (in the hospital sample). In the community sample, most mothers in Albania (69%) and Philippines (58%) would accept the influenza vaccine, and these proportions were higher in the hospital sample for all countries except Albania (48%) (P < 0.0001). Perceived vaccine safety (mean decrease in Gini index = 61) and effectiveness (55), and perceived knowledge of influenza vaccine (45) were the most important predictors of influenza vaccination intention in models that also included country and community versus hospital sample.ConclusionIntent to vaccinate infants aged 6–11 months in four middle income countries was tied primarily to knowledge of the vaccine and perceptions of vaccine safety and effectiveness. These findings were noted among mothers interviewed in the community and mothers of recently hospitalized infants.     

Cost-effectiveness of human papillomavirus vaccination in low and middle income countries: A systematic review

The World Health Organization recommends establishing that human papillomavirus vaccination is cost-effective before vaccine introduction. We searched Pubmed, Embase and the Cochrane Library to 1 April 2012 for economic evaluations of human papillomavirus vaccination in low and middle income countries. We found 25 articles, but almost all low income countries and many middle income countries lacked country-specific studies. Methods, assumptions and consequently results varied widely, even for studies conducted for the same country. Despite the heterogeneity, most studies conclude that vaccination is likely to be cost-effective and possibly even cost saving, particularly in settings without organized cervical screening programmes. However, study uncertainty could be reduced by clarity about vaccine prices and vaccine delivery costs. The review supports extending vaccination to low income settings where vaccine prices are competitive, donor funding is available, cervical cancer burden is high and screening options are limited.     

Cost-effectiveness of influenza vaccination in prior pneumonia patients in Israel

Pneumonia is a common complication of influenza infection, and accounts for the majority of influenza mortality. Both the WHO and the Ministry of Health in Israel prioritize seasonal influenza vaccination primarily on the basis of age and specific co-morbidities. Here we consider whether the targeting of individuals previously infected with pneumonia for influenza vaccination would be a cost-effective addition to the current policy. We performed a retrospective cohort data analysis of 163,990 cases of pneumonia hospitalizations and 1,305,223 cases of outpatient pneumonia from 2004 to 2012, capturing more than 54% of the Israeli population. Our findings demonstrate that patients infected with pneumonia in the year prior had a substantially higher risk of becoming infected with pneumonia in subsequent years (relative risk >2.34, p < 0.01). Results indicated that the benefit of targeting for influenza vaccination patients hospitalized with pneumonia in prior year would be cost-saving regardless of age. Complementing the current policy with the targeting of prior pneumonia patients would require vaccination of only a further 2.3% of the Israeli population to save additional 204–407 quality-adjusted life years (QALYs) annually at a mean price of 58–1056 USD/QALY saved. Global uncertainty analysis demonstrates that the cost-effectiveness of adding this policy is robust over a vast range of conditions. As prior pneumonia patients are currently not prioritized for influenza vaccination in Israel, nor elsewhere, this study suggests a novel supplement of current policies to improve cost-effectiveness of influenza vaccination. Future studies should use case–control study to further evaluate the effectiveness of vaccination in prior pneumonia patients.     

The optimal number of routine vaccines to order at health clinics in low or middle income countries

In a low or middle income country, determining the correct number of routine vaccines to order at a health clinic can be difficult, especially given the variability in the number of patients arriving, minimal vaccination days and resource (e.g., information technology and refrigerator space) constraints. We developed a spreadsheet model to determine the potential impact of different ordering policies, basing orders on the arrival rates seen in the previous 1, 3, 6, or 12 sessions, or on long-term historical averages (where these might be available) along with various buffer stock levels (range: 5-50%). Experiments varied patient arrival rates (mean range: 1-30 per session), arrival rate distributions (Poisson, Normal, and Uniform) and vaccine vial sizes (range: 1-dose to 10-dose vials). It was found that when the number of doses per vial is small and the expected number of patients is low, the ordering policy has a more significant impact on the ability to meet demand. Using data from more prior sessions to determine arrival rates generally equates to a better ability to meet demand, although the marginal benefit is relatively small after more than 6 sessions are averaged. As expected, the addition of more buffer is helpful in obtaining better performance; however, this advantage also has notable diminishing returns. In general, the long-term demand rate, the vial sizes of the vaccines used and the method of determining the patient arrival rate all have an effect on the ability of a clinic to maximize the demand that is met.     

Social capital and mental health: a comparative analysis of four low income countries

Women and the poor are disproportionately affected by common mental disorders (CMD), and women in low income countries are particularly at risk. Social capital may explain some of the geographical variation in CMD, but the association between social capital and CMD in low income countries has rarely been studied. This paper aims to explore the relationship between individual and ecological measures of social capital and maternal CMD in four low income countries. Cross-sectional data from the Young Lives (YL) study with information across 234 communities in Peru, Ethiopia, Vietnam and Andhra Pradesh (India) were used. The mental health of mothers of one-year-old children (n=6909), and the individual cognitive and structural social capital of all respondents was assessed. Ecological social capital was calculated by aggregating individual responses to the community level. Multi-level modelling was used to explore the association between individual and ecological (community level) social capital and maternal CMD in each of the four countries, adjusting for a wide range of individual and community level confounders. The analysis shows that individual cognitive social capital is associated with reduced odds of CMD across all four countries. The results for structural social capital are more mixed and culturally specific, with some aspects associated with increased odds of CMD. This suggests that structural social capital has context-specific effects and cognitive social capital more universal effects on maternal CMD.     

Cold-adapted live attenuated influenza vaccines developed in Russia: Can they contribute to meeting the needs for influenza control in other countries?

It is now more than 30 years since the first cold-adapted influenza viruses were developed in Russia as potential live, attenuated vaccines. In the past 15–20 years considerable experience has been gained from Russian and joint Russian-US laboratory and clinical studies with type A monovalent and bivalent vaccines prepared with genetic reassortant viruses derived from one of these cold-adapted viruses in particular, A/Leningrad/134/57. More recent experiences include use of trivalent cold-adapted vaccines with a type B component. The overall high level of safety of individual and combined vaccines in pre-school and school-aged children, with illness reductions in open field trials equivalent to that seen with inactivated vaccines, is such as to suggest that practical measures might now be justified to facilitate expansion of the use of these vaccines to other countries. It is proposed that further experimentation with the Russian cold-adapted live attenuated vaccines should be focused on issues that will relate to the public health perspective, i.e. selection of the single best candidiate type A and B vaccines for intense study using as criteria their potential for meeting licensing requirements outside Russia, and documenting the clinical protective efficacy of a single vaccine dose compared to two doses as studied until now. Resolution of these issues is important to ensure that costs for future live vaccine production, control, and utilization will be kept at lowest levels so that expanded use of live vaccines will have maximum cost-benefit and affordability. To guide those interested in these issues, examples are given of populations for whom a licensed live cold-adapted vaccine might be considered, together with indications of extra data needed to fully validate each suggested use.     

Ancillary benefits of seasonal influenza vaccination in middle-income countries

While seasonal influenza vaccines (SIV) remain the best method to prevent influenza-associated illnesses, implementing SIV programs may benefit countries beyond disease reduction, strengthening health systems and national immunization programs, or conversely, introduce new challenges. Few studies have examined perceived impacts of SIV introduction beyond disease reduction on health systems; understanding such impacts will be particularly salient in the context of COVID-19 vaccine introduction. We collected qualitative data from key informants—Partnership for Influenza Vaccine Introduction (PIVI) contacts in six middle-income PIVI vaccine recipient countries—to understand perceptions of ancillary benefits and challenges from SIV implementation. Respondents reported benefits associated with SIV introduction, including improved attitudes to SIV among risk groups (characterized by increased demand) and perceptions that SIV introduction improved relationships with other ministries and collaboration with mass media. Challenges included sustaining investment in SIV programs, as vaccine supply did not always meet coverage goals, and managing SIV campaigns.     

Improving access to affordable vaccines for middle-income countries in the african region

Despite the remarkable power of immunization reducing morbidity and mortality due to vaccine preventable diseases, one in five African children still does not receive all the basic, necessary vaccines. This is particularly true of the 10 middle-income countries (MICs) in the WHO African Region, where data demonstrates that immunization coverage is decreasing. These countries are not eligible for Gavi support in accessing new vaccines because of their relatively high per capita income level and will gradually increase with the transitioning of countries out of Gavi support. Thus, WHO was requested to facilitate access to affordable vaccines in relation to middle-income countries and those transitioning out of Gavi support in the near future. With commitment to address the issue, WHO Regional Office for Africa convened a consultative meeting from 09 to 11 April 2018 in Brazzaville, Congo to explore ways of improving access to affordable vaccines for MICs in the Region. The meeting brought together 17 low, middle and upper middle income countries in the African Region. Immunization partners and other WHO Regions also participated in the consultation to share experiences and explore ways of increasing access to affordable vaccines in MICs in the African Region. At the end of the meeting a number of solutions and action points were proposed for implementation in the Region.     

Management of hypertension in low and middle income countries: Challenges and opportunities

Hypertension is one of the most important risk factors for cardiovascular morbidity and mortality. More than a quarter of the global adult population (972 million) is currently hypertensive and almost three quarters (639 million) live in developing countries. Hypertension management therefore is of great public health importance in the developing world. In this paper, we review screening, diagnosis and management using lifestyle measures and pharmacotherapy given the resources of developed nations. We then discuss the barriers and challenges to implementing this approach and what can be done regarding prevention, screening, lifestyle modification and pharmacotherapy in developing countries. By adopting a comprehensive population based approach including policy level interventions directed at promoting lifestyle changes; a healthy diet (appropriate calories, low in saturated fats and salt additives and rich in fruits and vegetables), increased physical activity, and a smoke free environment, properly balanced with a high risk approach of cost effective clinical care, developing countries can effectively control hypertension and improve public health. Existing scientific knowledge regarding prevention, treatment and management should be harnessed as a health priority to reduce the disease burden associated with uncontrolled hypertension.     

The partnership for influenza vaccine introduction (PIVI): Supporting influenza vaccine program development in low and middle-income countries through public-private partnerships

Influenza vaccination remains the most effective tool for reducing seasonal influenza disease burden. Few Low and Middle-Income Countries (LMICs) have robust, sustainable annual influenza national vaccination programs. The Partnership for Influenza Vaccine Introduction (PIVI) was developed as a public-private partnership to support LMICs to develop and sustain national vaccination programs through time-limited vaccine donations and technical support. We review the first 5 years of experience with PIVI, including the concept, country progress toward sustainability, and lesson learned. Between 2013 and 2018, PIVI worked with Ministries of Health in 17 countries. Eight countries have received donated vaccines and technical support; of these, two have transitioned to sustained national support of influenza vaccination and six are increasing national support of the vaccine programs towards full transition to local vaccine program support by 2023. Nine additional countries have received technical support for building the evidence base for national policy development and/or program evaluation. PIVI has resulted in increased use of vaccines in partner countries, and early countries have demonstrated progress towards sustainability, suggesting that a model of vaccine and technical support can work in LMICs. PIVI expects to add new country partners as current countries transition to self-reliance.     

Cost-effectiveness of HIV screening in high-income countries: A systematic review

IntroductionOver 2 million people in high-income countries live with HIV. Early diagnosis and treatment present benefits for infected subjects and reduce secondary transmissions. Cost-effectiveness analyses are important to effectively inform policy makers and consequently implement the most cost-effective programmes. Therefore, we conducted a systematic review regarding the cost-effectiveness of HIV screening in high-income countries.MethodsWe followed PRISMA statements and included all papers evaluating the cost-effectiveness of HIV screening in the general population or in specific subgroups.ResultsThirteen studies considered routine HIV testing in the general population. The most cost-effective option appeared to be associating one-time testing of the general population with annual screening of high-risk groups, such as injecting-drug users. Thirteen studies assessed the cost-effectiveness of HIV screening in specific settings, outlining the attractiveness of similar programmes in emergency departments, primary care, sexually transmitted disease clinics and substance abuse treatment programmes.DiscussionEvidence regarding the health benefits and cost-effectiveness of HIV screening is growing, even in low-prevalence countries. One-time screenings offered to the adult population appear to be a valuable choice, associated with repeated testing in high-risk populations. The evidence regarding the benefits of using a rapid test, even in terms of cost-effectiveness, is growing. Finally, HIV screening seems useful in specific settings, such as emergency departments and STD clinics.     

Cost-effectiveness analysis of typhoid conjugate vaccines in five endemic low- and middle-income settings

BackgroundTyphoid fever remains endemic in low- and middle-income countries. Programmatic use of existing vaccines is limited, but upcoming typhoid conjugate vaccines (TCVs) could warrant wider use. We evaluated the cost-effectiveness of five TCV delivery strategies in three urban areas (Delhi and Kolkata, India and Nairobi, Kenya) and two rural settings (Lwak, Kenya and Dong Thap, Vietnam) with varying incidence.Methods and findingsWe evaluated routine infant vaccination with and without catch-up campaigns among older individuals. We used a dynamic model of typhoid transmission to simulate cases, hospitalizations, deaths, disability-adjusted life-years (DALY) lost, treatment and intervention costs. We estimated cost-effectiveness (in terms of cost in international dollars (I$) per DALY averted) from the healthcare payer perspective, and assessed how it was influenced by uncertain model parameters. Compared to no vaccination, routine infant vaccination at I$1/dose was cost-saving in Delhi and Dong Thap, “very cost-effective” in Kolkata and Nairobi, and “cost-effective” in Lwak according to World Health Organization thresholds. However, routine vaccination was not the optimal strategy compared to strategies that included a catch-up campaign, which yielded the highest probability of being cost-saving in Delhi and Dong Thap and were most likely to provide a return on investment above a willingness-to-pay threshold of I$1440 in Kolkata, I$2300 in Nairobi, and I$5360 in Lwak. Vaccine price impacted the optimal strategy, and the number of doses required and rate of hospitalization were the primary sources of uncertainty.ConclusionRoutine vaccination with TCV would be cost-effective in most settings, and additional one-time catch-up campaigns would also be economically justified.