Change in glycaemic control with structured diabetes self-management education in urban low-resource settings: multicentre randomised trial of effectiveness.

BACKGROUND: In high-resource settings, structured diabetes self-management education is associated with improved outcomes but the evidence from low-resource settings is limited and inconclusive. AIM: To compare, structured diabetes self-management education to usual care, in adults with type 2 diabetes, in low-resource settings. DESIGN: Single-blind randomised parallel comparator controlled multi-centre trial. Adults (> 18 years) with type 2 diabetes from two hospitals in urban Ghana were randomised 1:1 to usual care only, or usual care plus a structured diabetes self-management education program. Randomisation codes were computer-generated, and allotment concealed in opaque numbered envelopes. The intervention effect was assessed with linear mixed models. MAIN OUTCOME: Change in HbA1c after 3-month follow-up. Primary analysis involved all participants. CLINICALTRIAL: gov identifier:NCT04780425, retrospectively registered on 03/03/2021. RESULTS: Recruitment: 22nd until 29th January 2021. We randomised 206 participants (69% female, median age 58 years [IQR: 49-64], baseline HbA1c median 64 mmol/mol [IQR: 45-88 mmol/mol],7.9%[IQR: 6.4-10.2]). Primary outcome data was available for 79 and 80 participants in the intervention and control groups, respectively. Reasons for loss to follow-up were death (n = 1), stroke(n = 1) and unreachable or unavailable (n = 47). A reduction in HbA1c was found in both groups; -9 mmol/mol [95% CI: -13 to -5 mmol/mol], -0·9% [95% CI: -1·2% to -0·51%] in the intervention group and -3 mmol/mol [95% CI -6 to 1 mmol/mol], -0·3% [95% CI: -0·6% to 0.0%] in the control group. The intervention effect was 1 mmol/mol [95%CI:-5 TO 8 p = 0.726]; 0.1% [95% CI: -0.5, 0.7], p = 0·724], adjusted for site, age, and duration of diabetes. No significant harms were observed. CONCLUSION: In low-resource settings, diabetes self-management education might not be associated with glycaemic control. Clinician's expectations from diabetes self-management education must therefore be guarded.

Multilevel Governance and Control of the COVID-19 Pandemic in the Democratic Republic of Congo: Learning from the Four First Waves.

The COVID-19 pandemic continues to impose a heavy burden on people around the world. The Democratic Republic of the Congo (DRC) has also been affected. The objective of this study was to explore national policy responses to the COVID-19 pandemic in the DRC and drivers of the response, and to generate lessons for strengthening health systems' resilience and public health capacity to respond to health security threats. This was a case study with data collected through a literature review and in-depth interviews with key informants. Data analysis was carried out manually using thematic content analysis translated into a logical and descriptive summary of the results. The management of the response to the COVID-19 pandemic reflected multilevel governance. It implied a centralized command and a decentralized implementation. The centralized command at the national level mostly involved state actors organized into ad hoc structures. The decentralized implementation involved state actors at the provincial and peripheral level including two other ad hoc structures. Non-state actors were involved at both levels. These ad hoc structures had problems coordinating the transmission of information to the public as they were operating outside the normative framework of the health system. Conclusions: Lessons that can be learned from this study include the strategic organisation of the response inspired by previous experiences with epidemics; the need to decentralize decision-making power to anticipate or respond quickly and adequately to a threat such as the COVID-19 pandemic; and measures decided, taken, or adapted according to the epidemiological evolution (cases and deaths) of the epidemic and its effects on the socio-economic situation of the population. Other countries can benefit from the DRC experience by adapting it to their own context.

Learning from the COVID-19 pandemic for future epidemics and pandemics preparedness and response in Guinea: Findings from a scoping review

The outbreak of the novel coronavirus (SARS-CoV-2) in December 2019 prompted a response from health systems of countries across the globe. The first case of COVID-19 in Guinea was notified on 12 March 2020;however, from January 2020 preparations at policy and implementation preparedness levels had already begun. This study aimed to assess the response triggered in Guinea between 27th January 2020 and 1st November 2021 and lessons for future pandemic preparedness and response. We conducted a scoping review using three main data sources: policy documents, research papers and media content. For each of these data sources, a specific search strategy was applied, respectively national websites, PubMed and the Factiva media database. A content analysis was conducted to assess the information found. We found that between January 2020 and November 2021, the response to the COVID-19 pandemic can be divided into five phases: (1) anticipation of the response, (2) a sudden boost of political actions with the implementation of strict restrictive measures, (3) alleviation of restrictive measures, (4) multiple epidemics period and (5) the COVID-19 variants phase, including the strengthening of vaccination activities. This study provides several learning points for countries with similar contexts including: (1) the necessity of setting up, in the pre-epidemic period, an epidemic governance framework that is articulated with the country's health system and epidemiological contexts;(2) the importance of mobilizing, during pre-epidemic period, emergency funds for a rapid health system response whenever epidemics hit;(3) each epidemic is a new experience as previous exposure to similar ones does not necessarily guarantee population and health system resilience;(4) epidemics generate social distress because of the restrictive measures they require for their control, but their excessive securitization is counterproductive. Finally, from a political point of view, decision-making for epidemic control is not always disinterested;it is sometimes rooted in political computations, and health system actors should learn to cope with it while, at the same time, safeguarding trusted and efficient health system responses. We conclude that health system actors anticipated the response to the COVID-19 pandemic and (re-) adapted response strategies as the pandemic evolved in the country. There is a need to rethink epidemics governance and funding mechanisms in Guinea to improve the health system response to epidemics.

The Role of the Private Sector in the COVID-19 Pandemic: Experiences From Four Health Systems.

As societies urbanize, their populations have become increasingly dependent on the private sector for essential services. The way the private sector responds to health emergencies such as the COVID-19 pandemic can determine the health and economic wellbeing of urban populations, an effect amplified for poorer communities. Here we present a qualitative document analysis of media reports and policy documents in four low resource settings-Bangladesh, Ghana, Nepal, Nigeria-between January and September 2020. The review focuses on two questions: (i) Who are the private sector actors who have engaged in the COVID-19 first wave response and what was their role?; and (ii) How have national and sub-national governments engaged in, and with, the private sector response and what have been the effects of these engagements? Three main roles of the private sector were identified in the review. (1) Providing resources to support the public health response. (2) Mitigating the financial impact of the pandemic on individuals and businesses. (3) Adjustment of services delivered by the private sector, within and beyond the health sector, to respond to pandemic-related business challenges and opportunities. The findings suggest that a combination of public-private partnerships, contracting, and regulation have been used by governments to influence private sector involvement. Government strategies to engage the private sector developed quickly, reflecting the importance of private services to populations. However, implementation of regulatory responses, especially in the health sector, has often been weak reflecting the difficulty governments have in ensuring affordable, quality private services. Lessons for future pandemics and other health emergencies include the need to ensure that essential non-pandemic health services in the government and non-government sector can continue despite elevated risks, surge capacity to minimize shortages of vital public health supplies is available, and plans are in place to ensure private workplaces remain safe and livelihoods protected.

Adapting the Community-based Health Planning and Services (CHPS) to engage poor urban communities in Ghana: protocol for a participatory action research study.

INTRODUCTION: With rapid urbanisation in low-income and middle-income countries, health systems are struggling to meet the needs of their growing populations. Community-based Health Planning and Services (CHPS) in Ghana have been effective in improving maternal and child health in rural areas; however, implementation in urban areas has proven challenging. This study aims to engage key stakeholders in urban communities to understand how the CHPS model can be adapted to reach poor urban communities. METHODS AND ANALYSIS: A Participatory Action Research (PAR) will be used to develop an urban CHPS model with stakeholders in three selected CHPS zones: (a) Old Fadama (Yam and Onion Market community), (b) Adedenkpo and (c) Adotrom 2, representing three categories of poor urban neighbourhoods in Accra, Ghana. Two phases will be implemented: phase 1 ('reconnaissance phase) will engage and establish PAR research groups in the selected zones, conduct focus groups and individual interviews with urban residents, households vulnerable to ill-health and CHPS staff and key stakeholders. A desk review of preceding efforts to implement CHPS will be conducted to understand what worked (or not), how and why. Findings from phase 1 will be used to inform and co-create an urban CHPS model in phase 2, where PAR groups will be involved in multiple recurrent stages (cycles) of community-based planning, observation, action and reflection to develop and refine the urban CHPS model. Data will be managed using NVivo software and coded using the domains of community engagement as a framework to understand community assets and potential for engagement. ETHICS AND DISSEMINATION: This study has been approved by the University of York's Health Sciences Research Governance Committee and the Ghana Health Service Ethics Review Committee. The results of this study will guide the scale-up of CHPS across urban areas in Ghana, which will be disseminated through journal publications, community and government stakeholder workshops, policy briefs and social media content. This study is also funded by the Medical Research Council, UK.

'It's far too complicated': why fragmentation persists in global health.

BACKGROUND: Despite many efforts to achieve better coordination, fragmentation is an enduring feature of the global health landscape that undermines the effectiveness of health programmes and threatens the attainment of the health-related Sustainable Development Goals. In this paper we identify and describe the multiple causes of fragmentation in development assistant for health at the global level. The study is of particular relevance since the emergence of new global health problems such as COVID-19 heightens the need for global health actors to work in coordinated ways. Our study is part of the Lancet Commission on Synergies between Universal Health Coverage, Health Security and Health Promotion. METHODS: We used a mixed methods approach. This consisted of a non-systematic literature review of published papers in scientific journals, reports, books and websites. We also carried out twenty semi-structured expert interviews with individuals from bilateral and multilateral organisations, governments and academic and research institutions between April 2019 and December 2019. RESULTS: We identified five distinct yet interconnected sets of factors causing fragmentation: proliferation of global health actors; problems of global leadership; divergent interests; problems of accountability; problems of power relations. We explain why global health actors struggle to harmonise their approaches and priorities, fail to align their work with low- and middle-income countries' needs and why they continue to embrace funding instruments that create fragmentation. CONCLUSIONS: Many global actors are genuinely committed to addressing the problems of fragmentation, despite their complexity and interconnected nature. This paper aims to raise awareness and understanding of the causes of fragmentation and to help guide actors' efforts in addressing the problems and moving to more synergistic approaches.