Aga Khan Development Network

for universal health coverage, say Fawzia Rasheed and colleagues

As the Sustainable Development Goals are adopted by United Nations member states, children with congenital disorders remain left behind in policies, programs, research, and funding. Although this finding was recognized by the creation and endorsement of the 63rd World Health Assembly Resolution in 2010 calling on United Nations member states to strengthen prevention of congenital disorders and the improvement of care of those affected, there has been little to no action since then. The Sustainable Development Goals call for the global health and development community to focus first and foremost on the most vulnerable and those left behind in the Millennium Development Goal era. To maximize the opportunity for every woman and couple to have a healthy child and to reduce the mortality and severe disability associated with potentially avoidable congenital disorders and their consequences for the children affected, their families and communities, and national health care systems, we propose priority measures that should be taken urgently to address this issue.

BACKGROUND AND OBJECTIVES: Vitamin D is essential for healthy development of bones, but little is known about the effects of supplementation in young stunted children. Our objective was to assess the effect of vitamin D supplementation on risk of rickets and linear growth among Afghan children. METHODS: In this double-blind, placebo-controlled trial, 3046 children ages 1 to 11 months from inner-city Kabul were randomly assigned to receive oral vitamin D3 (100 000 IU) or placebo every 3 months for 18 months. Rickets Severity Score was calculated by using wrist and knee radiographs for 631 randomly selected infants at 18 months, and rickets was defined as a score >1.5. Weight and length were measured at baseline and 18 months by using standard techniques, and z scores were calculated. RESULTS: Mean (95% confidence interval [CI]) serum 25-hydroxyvitamin D (seasonally corrected) and dietary calcium intake were insufficient at 37 (35–39) nmol/L and 372 (327–418) mg/day, respectively. Prevalence of rickets was 5.5% (placebo) and 5.3% (vitamin D): odds ratio 0.96 (95% CI: 0.48 to 1.92); P = .9. The mean difference in height-for-age z score was 0.05 (95% CI: −0.05 to 0.15), P = .3, although the effect of vitamin D was greater for those consuming >300 mg/day of dietary calcium (0.14 [95% CI: 0 to 0.29]; P = .05). There were no between-group differences in weight-for-age or weight-for-height z scores. CONCLUSIONS: Except in those with higher calcium intake, vitamin D supplementation had no effect on rickets or growth.

Objectives The aim of this study was to determine the prevalence and forms of gender discrimination and sexual harassment experienced by medical students and physicians in French-speaking part of Switzerland. Design and setting We conducted an online survey using a questionnaire of 9 multiple-choice and 2 open questions between 24 January 2019 and 24 February 2019. Our target population was medical students and physicians working at hospitals and general practitioners from the French-speaking part of Switzerland. The online survey was sent via social media platforms and direct emails. We compared answers between male-determined and female-determined respondents using either χ 2 or Fisher’s exact tests. Results Among 1071 responders, a total of 893 were included (625 females, 264 males, 4 non-binary and 1 non-binary and male). 178 were excluded because they did not mention their working place or were working only outside Switzerland. Because of the small number of non-binary participants, they were not contemplated in further statistical analysis. Of 889 participants left, 199 (31.8%) women and 18 (6.8%) men reported having personally experienced gender discrimination, in terms of sexism, difficulties in career development and psychological pressure. Among women, senior attendings were the most affected (55.2%), followed by residents (44.1%) and junior attendings (41.1%). Sexual harassment was equally observed among women (19.0%) and men (16.7%). Compared with men (47.0%), women (61.4%) expressed the need to promote equality and inclusivity in medicine more frequently (p<0.001), as well as the need for support in their professional development (38.7% women and 23.9% men; p<0.001). Conclusions Gender discrimination in medicine in French-speaking Switzerland affects one-third of women, in particular, those working in hospital settings and senior positions.

This article argues that plastics ought to be included under the category of ‘hazardous’ healthcare waste and suggests that health professionals should strive for alternatives as part of their mission to improve health. The focus of this paper is on replacing, rather than recycling, plastics. The rationale for this stance stems from the unbridled escalation of plastics use, the fact that few countries have significant recycling capacity, and because the process of recycling as well as the end products of recycled plastics remain hazardous to health and the environment. Issues related to incinerated plastic, plastics in single-use items, plastic blister packs and containers for medicines, as well as plastics which are unrelated to healthcare but which nevertheless make up a substantial part of general healthcare waste are discussed. Suggestions are put forward to dramatically reduce plastics in all such cases. To support needed reforms and to guide best practice for single-use plastics in particular, a call for a reliable reference source is made—similar to the Essential Medicines Lists, which would share updated information on the most problematic items in use and environmentally friendly alternatives in each case. It is argued that concerted action by health professionals to improve healthcare waste, beginning with plastics, would send much needed market signals to industry to produce environmentally-friendly products for healthcare and would likely lead to solutions for domestic waste, too.

OBJECTIVE: To explore the clinical and programmatic feasibility of using 800 μg of sublingual misoprostol to prevent and treat postpartum hemorrhage (PPH) during home delivery. METHODS: The present double-blind randomized controlled trial included women who underwent home deliveries in Chitral district, Khyber Pakhtunkhwa province, Pakistan, after presenting at healthcare facilities during the third trimester of pregnancy between May 28, 2012, and November 27, 2014. Participants were randomized in a 1:1 ratio to receive either 800 μg of misoprostol or placebo sublingually if PPH was diagnosed, having previously received a prophylactic oral dose of 600 μg misoprostol. The primary outcome, hemoglobin decrease of 20 g/L or greater from pre- to post-delivery assessment, was compared on a modified intention-to-treat basis. RESULTS: There were 49 patients allocated to receive misoprostol and 38 allocated to receive placebo; the incidence of a 20 g/L decrease in hemoglobin was similar between the groups (20/43 [47%] vs 19/33 [58%], respectively; P=0.335). CONCLUSION: There was no significant difference in clinical outcomes between the two trial arms. ClinicalTrials.gov:NCT01485562.

Very few examples of footprints exist for lower-middle-income countries and none for low-income countries. Where footprints do exist, they suggest that healthcare in LMICs is more carbon intensive per unit of expenditure than in high-income or upper-middle-income countries. At the same time, delivery of global commitments on Universal Health Coverage implies that healthcare provision in low and middle-income countries (LMICs) must grow more rapidly than anywhere else in the word. There has been little or no access to appropriate, comprehensive but affordable support to enable operations in LMICs to calculate full Scope 1,2 and 3 footprints. Without this it has been challenging for operations in LMICs to effectively target actions to reduce their emissions. With this in mind this paper sets out to demonstrate an approach to carbon foot printing healthcare in LMICs that is sufficiently robust to support targeted action, while using tools, resources and data that are freely accessible in all countries. This paper describes and discusses a 4-tiered ‘hybrid’ approach, developed using the international Greenhouse Gas Protocol. The approach was used successfully by staff to generate carbon footprints for healthcare organisations in 8 LMICs in South and Central Asia and East Africa. The organisations covered all fall within the Aga Khan Development Network (AKDN); specifically, the Aga Khan Health Services (AKHS) and the Aga Khan Universities (AKU) The principles discussed in this paper, have been used to build a comprehensive carbon management tool in Microsoft Excel. The use of the approach and the tool has enabled AKDN healthcare providers to effectively, baseline, target and structure their carbon reduction activity. This work has had to pragmatically balance accuracy with deliverability in an LMIC context. While footprinting for Scope 1 and 2 has followed standard protocols, proxy data has been used to generate high level supply chain footprints, this has then been refined with data from suppliers. The tool and its accompanying guide are published and available, free to use, from AKDN to support other healthcare organisations in footprinting and reducing their own carbon emissions.

BACKGROUND: The impact of the Choosing Wisely (CW) campaign is debated as recommendations alone may not modify physician behavior. OBJECTIVE: The aim of this study was to assess whether behavioral interventions with physician assessment and feedback during quality circles (QCs) could reduce low-value services. DESIGN AND PARTICIPANTS: Pre-post quality improvement intervention with a parallel comparison group involving outpatients followed in a Swiss-managed care network, including 700 general physicians (GPs) and 150,000 adult patients. INTERVENTIONS: Interventions included performance feedback about low-value activities and comparison with peers during QCs. We assessed individual physician behavior and healthcare use from laboratory and insurance claims files between August 1, 2016, and October 31, 2018. MAIN MEASURES: Main outcomes were the change in prescription of three low-value services 6 months before and 6 months after each intervention: measurement of prostate-specific antigen (PSA) and prescription rates of proton pump inhibitors (PPIs) and statins. KEY RESULTS: Among primary care practices, a QC intervention with physician feedback and peer comparison resulted in lower rates of PPI prescription (pre-post mean prescriptions per GP 25.5 ± 23.7 vs 22.9 ± 21.4, p value<0.01; coefficient of variation (Cov) 93.0% vs 91.0%, p=0.49), PSA measurement (6.5 ± 8.7 vs 5.3 ± 6.9 tests per GP, p<0.01; Cov 133.5% vs 130.7%, p=0.84), as well as statins (6.1 ± 6.8 vs 5.6 ± 5.4 prescriptions per GP, p<0.01; Cov 111.5% vs 96.4%, p=0.21). Changes in prescription of low-value services among GPs who did not attend QCs were not statistically significant over this time period. CONCLUSION: Our results demonstrate a modest but statistically significant effect of QCs with educative feedback in reducing low-value services in outpatients with low impact on coefficient of variation. Limiting overuse in medicine is very challenging and dedicated discussion and real-time review of actionable data may help.

Health sciences curricular planners are challenged to add new content to established education programs. There is increasing pressure for content in public health, health systems, global health, and planetary health. These important areas often compete for curricular time. What is needed is a convergence model that builds a common framework within which students can integrate areas and better align this knowledge to the individual client or patient who they have responsibility to support. A population health framework is proposed for health sciences education programs that supports a common conceptual understanding of population health. The framework links five thematic areas that have influence on health and wellbeing and a sixth element that defines the range of methodologies essential to understanding health and wellbeing, from the individual to the population. The five areas providing convergence are: (1) the biopsychosocial development of the individual, (2) the socioeconomic factors that influence health and wellbeing, (3) the physical natural and built environment including climate, (4) the continuum of public health and health care systems, and (5) the nation state and global relationships. Using this framework, students are encouraged to think and understand individual health and wellbeing in context to the population and to utilize the appropriate methodological tools to explore these relationships. Planning for a new undergraduate medicine program illustrates the curricular elements that will be used to support student learning with foundation knowledge applied and tracked throughout the program. The proposed framework has application across health sciences disciplines and serves to build a common understanding that supports cross professional communication and collaboration.

Though Switzerland has one of the highest life expectancies in the world, this global indicator may mask significant disparities at a local level. The present study used a spatial cluster detection approach based on individual death records to investigate the geographical footprint of life expectancy inequalities in the state of Geneva, Switzerland. Individual-level mortality data (n = 22,751) were obtained from Geneva's official death notices (2009-2016). We measured life expectancy inequalities using the years of potential life lost or gained (YPLLG) metric, defined as the difference between an individual's age at death and their life expectancy at birth. We assessed the spatial dependence of YPLLG across the state of Geneva using spatial autocorrelation statistics (Local Moran's I). To ensure the robustness of the patterns discovered, we ran the analyses for ten random subsets of 10,000 individuals taken from the 22,751 deceased. We also repeated the spatial analysis for YPLLG before and after controlling for individual-level and neighborhood-level covariates. The results showed that YPLLG was not randomly distributed across the state of Geneva. The ten random subsets revealed no significant difference with the geographic footprint of YPLLG and the population characteristics within Local Moran cluster types, suggesting robustness for the observed spatial structure. The proportion of women, the proportion of Swiss, the neighborhood median income, and the neighborhood median age were all significantly lower for populations in low YPLLG clusters when compared to populations in high YPLLG clusters. After controlling for individual-level and neighborhood-level covariates, we observed a reduction of 43% and 39% in the size of low and high YPLLG clusters, respectively. To our knowledge, this is the first study in Switzerland using spatial cluster detection methods to investigate inequalities in life expectancy at a local scale and based on individual data. We identified clear geographic footprints of YPLLG, which may support further investigations and guide future public health interventions at the local level.

The local department of health is using these data in plan-Community-driven data revolution is feasible in developing countries: experiences from an integrated health information...