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The use of rapid and inexpensive nonlaboratory-based screening tests for drug quality assessments is recommended as a component of a drug quality assurance program in poor resource settings. We have established routine Minilab test procedures to screen product quality and a proficiency testing program to determine the competency of the inspectors and reliability of results. Samples for the proficiency testing were prepared by pulverizing a standard reference tablet of the appropriate drug and making serial dilutions with starch to obtain concentrations of 0, 40, and 100%. The samples, which were labeled only with the drug name and an identifying letter, were given to inspectors for quality screening using Minilab procedures. In round 1 of the proficiency test, only 3 of 28 substandard samples were correctly identified. Round 2 of the proficiency test, which was administered after a performance qualification test for the analytical method, showed much improvement: 19 of 27 substandard drugs were correctly identified, while 5 out of 9 inspectors made the correct inference on the quality of 45 samples. However, in both rounds, 2 inspectors failed to identify substandard samples, indicating that their technical competencies need to be improved for the reliability of the results. Although the thin-layer chromatography screening methods provide a rapid means for drug quality assessment, they need to be put in the hands of competent users. The inclusion of a proficiency test in the screening program provides a measure of determining competency of the personnel and reliability of the results.

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Pharmacists' roles are evolving from that of compounders and dispensers of medicines to that of experts on medicines within multidisciplinary health care teams. In the developing country context, the pharmacy is often the most accessible or even the sole point of access to health care advice and services. Because of their knowledge of medicines and clinical therapeutics, pharmacists are suitably placed for task shifting in health care and could be further trained to undertake functions such as clinical management and laboratory diagnostics. Indeed, pharmacists have been shown to be willing, competent, and cost-effective providers of what the professional literature calls "pharmaceutical care interventions"; however, internationally, there is an underuse of pharmacists for patient care and public health efforts. A coordinated and multifaceted effort to advance workforce planning, training and education is needed in order to prepare an adequate number of well-trained pharmacists for such roles. Acknowledging that health care needs can vary across geography and culture, an international group of key stakeholders in pharmacy education and global health has reached unanimous agreement that pharmacy education must be quality-driven and directed towards societal health care needs, the services required to meet those needs, the competences necessary to provide these services and the education needed to ensure those competences. Using that framework, this commentary describes the Pharmacy Education Taskforce of the World Health Organization, United Nations Educational, Scientific and Cultural Organization and the International Pharmaceutical Federation Global Pharmacy and the Education Action Plan 2008–2010, including the foundation, domains, objectives and outcome measures, and includes several examples of current activities within this scope.

A cross-sectional survey was performed in 24 systems of care providing antiretroviral medications in Ethiopia, Kenya, Rwanda, Tanzania, and Uganda to examine current practices in monitoring rates of treatment adherence and defaulting. Only 20 of 48 facilities reported routinely measuring individual patient adherence levels; only 12 measured rates of adherence for the clinic population. The rules for determining which patients were included in the calculation of rates were unclear. Fourteen different definitions of treatment defaulting were in use. Facilities routinely gather potentially useful data, but the frequency of doing so varied widely. Individual and program treatment adherence and defaulting are not routinely monitored; when done, the operational definitions and methods varied widely, making comparisons across programs unreliable. There is a pressing need to determine which measures are the most feasible and reliable to collect, the most useful for clinical counseling, and most informative for program management.

When accountability is strengthened, the opportunity for corruption diminishes, and beneficial outcomes of the health system, such as responsiveness, equity, and efficiency surge.

PROGRES is a master organizational capacity assessment tool developed by Management Sciences for Health (MSH) staff in February 2014.

During 2014, the World Federation of Public Health Associations (WFPHA) conducted an on-line survey of its 82 PHA members, to identify the state of organizational governance of national public health associations, as well as the factors that influence optimal organizational governance. Responses were received from 62 PHAs. The two most important factors that support governance effectiveness were a high degree of integrity and ethical behavior of the PHA’s leaders (77%) and the competence of people serving on the PHA’s governing body (76%). Lack of financial resources was considered the most important factor that negatively affected organizational governance effectiveness (73%). Lack of mentoring for future PHA leaders; ineffective or incompetent leadership; lack of understanding about good governance practices; and lack of accurate information for strategic planning were identified as factors influencing PHA governance effectiveness. Critical elements for PHA sustainability included diversity, gender-responsiveness and inclusive governance practices, and strategies to build the future generation of public health leaders.

Ethiopia has achieved rapid expansion of TB microscopic centers for acid fast bacilli (AFB). However, external quality assurance (EQA) services were, until recently, limited to few regional and sub-regional laboratories. In this paper, we describe the decentralization experience and the result of EQA using random blinded rechecking. We decentralized sputum smear AFB EQA from 4 regional laboratories (RRLs) to 82 EQA centers and enrolled 956 health facilities (HFs) in EQA schemes. From 2012 to 2014 (Phase I), the false positivity rate declined from 0.6% to 0.2% and false negativity fell from as high as 7.6% to 1.6% in supported HFs. In HFs that joined in Phase II, FN rates ranged from 5.6% to 7.3%. The proportion of HFs without errors increased from 77.9% to 90.5% in Phase I HFs and from 82.9% to 86.9% in Phase II HFs. Overall sensitivity and specificity were 95.0% and 99.7%, respectively. Positive predictive and negative predictive values were 93.3% and 99.7%, respectively. Decentralizing blinded rechecking of sputum smear microscopy is feasible in low-income settings. While a comprehensive laboratory improvement strategy enhanced the quality of microscopy, laboratory professionals' capacity in slide reading and smear quality requires continued support.

Rwanda's Community-Based Health Insurance (CBHI) scheme has been recognized internationally for its success. From 2012 to 2015, MSH and the University of Rwanda-College of Medicine and Health Sciences-School of Public Health, studied the impact on access and equity of the scheme.

Community-Based Health Insurance (CBHI) is one of the key elements identified to achieve the goal of universal access to health care, which is central to the Rwandan government's strategy to become a middle-income country by 2020. Other key elements include performance-based financing to incentivize improved service delivery and quality improvement initiatives.

The study is one of a set of three pieces of work supported by The Rockefeller Foundation to help strengthen the Community Based Health Insurance (CBHI) program in Rwanda. 

Community-based health insurance (CBHI) is much debated as a way of tackling the challenge of providing access to health care for the poor in developing countries without worsening their economic situation.

Launched in 1999, Community-Based Health Insurance (CBHI) in Rwanda has reached extensive coverage for health care services. CBHI was developed by the Government of Rwanda in response to a drop in the use of health services after the reintroduction of user fees in 1996.

The communication and coaching skills program supports managers in the health care system to coach their teams and nurture their staff for improved organizational performance also supporting the implementation of other development interventions.

Providing maternal, newborn, and child health (MNCH) services in rural locations in developing countries can be a significant challenge due to community isolation, poor infrastructure, and rare or inadequate health worker training.To support the implementation of MNCH service delivery improvement projects, the USAID-funded, MSH-led Leadership, Management, and Governance (LMG) Project integrated a

Family Care International, the International Center for Research on Women (ICRW) and the KEMRI-CDC Research and Public Health Collaboration conducted a research study in Kenya to document the financial and social costs of maternal death to families in a poor, remote community and the ways that these costs affect newborn survival, child health and education, and family well-being.

This fact sheet provides information about misoprostol’s critical role in preventing and treating postpartum bleeding or hemorrhage (PPH), one of the leading causes of maternal death worldwide.

A Toolkit for Using Evidence from the State of the World’s Midwifery 2014 Report to Create Policy Change at the Country Level

Burkina Faso: Amid times of political crisis, civil society advocates call for increased invesment in women's and children's health Kenya: Women's and children's health in a devolved state: Advocates tackle crippling health worker shortages through budget advocacy

Half of the Ugandan population obtains medicines from the public sector. Yet, we found only 3/5 of 455 inspected public health facilities meet Good Pharmacy Practice (GPP) standards. Facilities using SPARS (the Supervision, Performance Assessment, and Recognition Strategy) tended to perform better than unsupervised facilities, substantiating the value of supporting supervision interventions in GPP areas that need strengthening. Non-compliant indicators can be improved through practices and behavioral changes; some require infrastructure investments. We conclude that regular National Drug Authority inspections of public sector pharmacies in conjunction with interventions to improve GPP adherence can revolutionize patient care in Uganda.

On the eve of the 69th World Health Assembly, MSH and The Rockefeller Foundation release this progress report on the work of many organizations to develop concrete measurements of UHC progress – for both access to basic care and its affordability to all.

Ethambutol (EMB) resistance can evolve through a multistep process, and mutations in the ubiA (Rv3806c) gene appear to be responsible for high-level EMB resistance in Mycobacterium tuberculosis. We evaluated the prevalence of ubiA and embB (Rv3795) mutations in EMB-resistant strains originating from Africa and South Korea. No differences in embB mutation frequencies were observed between strains from both origins. However, ubiA mutations were present in 45.5% 6.5% of the African EMB-resistant isolates but in only 9.5% 1.5% of the South Korean EMB-resistant isolates. The ubiA mutations associated with EMB resistance were localized to regions encoding the transmembrane domains of the protein, whereas the embB mutations were localized to regions encoding the extramembrane domains. Larger studies are needed to investigate the causes of increased ubiA mutations as a pathway to high-level EMB resistance in African countries, such as extended EMB usage during tuberculosis treatment.

In the past 30 years, debate has raged over maternal influence on infant death in Northeast Brazil. Scheper-Hughes, in two acclaimed articles and a book, sparked the controversy by alleging that nordestina mothers disinvest disfavored children of resources, thereby contributing to their deaths. We propose an interpretation of maternal investment through retrospective contextualization of a three-tiered series of factors. Between 2011 and 2013, we analyzed 316 ethnographic interviews about childhood death collected in the interior of Ceará. Our subsample comprises 58 death narratives from grieving mothers whose children died during the 12 months preceding the interview between 1979 and 1989; follow-up studies of 13 of those grieving mothers were conducted in 2011. Our sample closely resembles that of Scheper-Hughes, and from its stories we identify seven contexts—historical, political, economic, ecological, biological, social, and spiritual—that constrict how mothers grieve. Each context interrelates with the others, forming a cultural niche that regulates accepted emotionality, modes of suffering, roles of authority figures, and so on. We explore these contexts, offering alternatives to Scheper-Hughes’s theory, and conclude that a community-wide tendency to neglect never existed.

A child's risk of developing tuberculosis (TB) can be reduced by nearly 60% with administration of 6 months course of isoniazid preventive therapy (IPT). However, uptake of IPT by national TB programs is low, and IPT delivery is a challenge in many resource-limited high TB-burden settings. Routinely collected program data was analyzed to determine the coverage and outcome of implementation of IPT for eligible under-five year old children in 28 health facilities in two regions of Ethiopia. A total of 504 index smear-positive pulmonary TB (SS+) cases were reported between October 2013 and June 2014 in the 28 health facilities. There were 282 under-five children registered as household contacts of these SS+ TB index cases, accounting for 17.9% of all household contacts. Of these, 237 (84%) were screened for TB symptoms, and presumptive TB was identified in 16 (6.8%) children. TB was confirmed in 5 children, producing an overall yield of 2.11% (95% confidence interval, 0.76-4.08%). Of 221 children eligible for IPT, 64.3% (142) received IPT, 80.3% (114) of whom successfully completed six months of therapy. No child developed active TB while on IPT. Contact screening is a good entry point for delivery of IPT to at risk children and should be routine practice as recommended by the WHO despite the implementation challenges.

Moving the global response towards the universal test and treat model will pose huge challenges to public health systems in resource-limited settings, including global and local supply chain systems. These challenges are especially acute in Africa, which accounts for over 70% of the persons affected by HIV.To ensure that there are enough anti-retrovirals available to treat the nearly 25 million people that will require them by 2020 represents a near doubling of the ARV supplied to treat the 13 million currently on treatment. Similarly, to monitor those on treatment means an unprecedented scale-up of viral load testing throughout Africa. Larger issues include whether the capacity exists at the local level to handle these commodities when they arrive in the most severely affected countries, including considerations of the human resources and costs needed to make this strategy effective. We believe that such ‘‘real world’’ analysis of proposed strategies and policies is essential to ensure their most effective implementation.

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