The Lancet and colonialism: past, present, and future.

The historical and contemporary alignment of medical and health journals with colonial practices needs elucidation. Colonialism, which sought to exploit colonised people and places, was justified by the prejudice that colonised people's ways of knowing and being are inferior to those of the colonisers. Institutions for knowledge production and dissemination, including academic journals, were therefore central to sustaining colonialism and its legacies today. This invited Viewpoint focuses on The Lancet, following its 200th anniversary, and is especially important given the extent of The Lancet's global influence. We illuminate links between The Lancet and colonialism, with examples from the past and present, showing how the journal legitimised and continues to promote specific types of knowers, knowledge, perspectives, and interpretations in health and medicine. The Lancet's role in colonialism is not unique; other institutions and publications across the British empire cooperated with empire-building through colonisation. We therefore propose investigations and raise questions to encourage broader contestation on the practices, audience, positionality, and ownership of journals claiming leadership in global knowledge production.

Building better tuberculosis control systems in a post-COVID world: learning from Pakistan during the COVID-19 pandemic.

OBJECTIVES: All countries impacted by COVID-19 have had to change routine health service delivery. Although this has reversed some of the progress made in reducing the global burden of tuberculosis (TB) disease, there is an opportunity to incorporate lessons learned to improve TB programmes going forward. APPROACH: We use Pakistan as a case study to discuss three important adaptations in light of COVID-19: bringing care closer to patients; strengthening primary health care systems; and proactively addressing stigma and fear. FINDINGS: COVID-19 control in Pakistan has restricted people's ability to travel and this has forced the TB programme to reduce the need for in-person health facility visits and bring care closer to patients' homes. Strategies that may be useful for providing more convenient care to patients in the future include: : remote treatment support using telemedicine; collaborating with private healthcare providers; and establishing community medicine collection points. As part of the response to COVID-19 in Pakistan, the out-patient departments of major tertiary and secondary care hospitals were closed, and this highlighted the importance of strengthening primary healthcare for both better pandemic and TB control. Finally, stigma associated with COVID-19 and TB can be addressed using trusted community-based health workers, such as Lady Health Workers in Pakistan.

Mitigating the impact of COVID-19 on tuberculosis and HIV services: A cross-sectional survey of 669 health professionals in 64 low and middle-income countries.

OBJECTIVE: The experiences of frontline healthcare professionals are essential in identifying strategies to mitigate the disruption to healthcare services caused by the COVID-19 pandemic. METHODS: We conducted a cross-sectional study of TB and HIV professionals in low and middle-income countries (LMIC). Between May 12 and August 6, 2020, we collected qualitative and quantitative data using an online survey in 11 languages. We used descriptive statistics and thematic analysis to analyse responses. FINDINGS: 669 respondents from 64 countries completed the survey. Over 40% stated that it was either impossible or much harder for TB and HIV patients to reach healthcare facilities since COVID-19. The most common barriers reported to affect patients were: fear of getting infected with SARS-CoV-2, transport disruptions and movement restrictions. 37% and 28% of responses about TB and HIV stated that healthcare provider access to facilities was also severely impacted. Strategies to address reduced transport needs and costs-including proactive coordination between the health and transport sector and cards that facilitate lower cost or easier travel-were presented in qualitative responses. Access to non-medical support for patients, such as food supplementation or counselling, was severely disrupted according to 36% and 31% of HIV and TB respondents respectively; qualitative data suggested that the need for such services was exacerbated. CONCLUSION: Patients and healthcare providers across numerous LMIC faced substantial challenges in accessing healthcare facilities, and non-medical support for patients was particularly impacted. Synthesising recommendations of frontline professionals should be prioritised for informing policymakers and healthcare service delivery organisations.

Improving National Intelligence for Public Health Preparedness: a methodological approach to finding local multi-sector indicators for health security.

The COVID-19 epidemic is the latest evidence of critical gaps in our collective ability to monitor country-level preparedness for health emergencies. The global frameworks that exist to strengthen core public health capacities lack coverage of several preparedness domains and do not provide mechanisms to interface with local intelligence. We designed and piloted a process, in collaboration with three National Public Health Institutes (NPHIs) in Ethiopia, Nigeria and Pakistan, to identify potential preparedness indicators that exist in a myriad of frameworks and tools in varying local institutions. Following a desk-based systematic search and expert consultations, indicators were extracted from existing national and subnational health security-relevant frameworks and prioritised in a multi-stakeholder two-round Delphi process. Eighty-six indicators in Ethiopia, 87 indicators in Nigeria and 51 indicators in Pakistan were assessed to be valid, relevant and feasible. From these, 14-16 indicators were prioritised in each of the three countries for consideration in monitoring and evaluation tools. Priority indicators consistently included private sector metrics, subnational capacities, availability and capacity for electronic surveillance, measures of timeliness for routine reporting, data quality scores and data related to internally displaced persons and returnees. NPHIs play an increasingly central role in health security and must have access to data needed to identify and respond rapidly to public health threats. Collecting and collating local sources of information may prove essential to addressing gaps; it is a necessary step towards improving preparedness and strengthening international health regulations compliance.

Using critical information to strengthen pandemic preparedness: the role of national public health agencies.

COVID-19 has demonstrated that most countries' public health systems and capacities are insufficiently prepared to prevent a localised infectious disease outbreak from spreading. Strengthening national preparedness requires National Public Health Institutes (NPHIs), or their equivalent, to overcome practical challenges affecting timely access to, and use of, data that is critical to preparedness. Our situational analysis in collaboration with NPHIs in three countries-Ethiopia, Nigeria and Pakistan-characterises these challenges. Our findings indicate that NPHIs' role necessitates collection and analysis of data from multiple sources that do not routinely share data with public health authorities. Since initiating requests for access to new data sources can be a lengthy process, it is essential that NPHIs are routinely monitoring a broad set of priority indicators that are selected to reflect the country-specific context. NPHIs must also have the authority to be able to request rapid sharing of data from public and private sector organisations during health emergencies and to access additional human and financial resources during disease outbreaks. Finally, timely, transparent and informative communication of synthesised data from NPHIs will facilitate sustained data sharing with NPHIs from external organisations. These actions identified by our analysis will support the availability of robust information systems that allow relevant data to be collected, shared and analysed by NPHIs sufficiently rapidly to inform a timely local response to infectious disease outbreaks in the future.

What are the barriers to implementing national antimicrobial resistance action plans? A novel mixed-methods policy analysis in Pakistan.

Despite political commitment to address antimicrobial resistance (AMR), countries are facing challenges to implementing policies to reduce inappropriate use of antibiotics. Critical factors to the success of policy implementation in low- and middle-income countries (LMIC), such as capacity for enforcement, contestation by influential stakeholders and financial interests, have been insufficiently considered. Using Pakistan as a case study representing a populous country with extremely high antibiotic usage, we identified 195 actors who affect policies on antibiotic use in humans and animals through a snowballing process and interviewed 48 of these who were nominated as most influential. We used a novel card game-based methodology to investigate policy actors' support for implementation of different regulatory approaches addressing actions of frontline healthcare providers and antibiotic producers across the One Health spectrum. We found that there was only widespread support for implementing hard regulations (prohibiting certain actions) against antibiotic suppliers with little power-such as unqualified/informal healthcare providers and animal feed producers-but not to target more powerful groups such as doctors, farmers and pharmaceutical companies. Policy actors had limited knowledge to develop implementation plans to address inappropriate use of antibiotics in animals, even though this was recognized as a critical driver of AMR. Our results indicate that local political and economic dynamics may be more salient to policy actors influencing implementation of AMR national action plans than solutions presented in global guidelines that rely on implementation of hard regulations. This highlights a disconnect between AMR action plans and the local contexts where implementation takes place. Thus if the global strategies to tackle AMR are to become implementable policies in LMIC, they will need greater appreciation of the power dynamics and systemic constraints that relate to many of the strategies proposed.

Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries?

BACKGROUND: Healthcare providers' (HCPs) professionalism refers to their commitment and ability to respond to the health needs of the communities they serve and to act in the best interest of patients. Despite attention to increasing the number of HCPs in low- and middle-income countries (LMIC), the quality of professional education delivered to HCPs and their resulting professionalism has been neglected. The Global Action Plan on Antimicrobial Resistance (AMR) seeks to reduce inappropriate use of antibiotics by urging patients to access antibiotics only through qualified HCPs, on the premise that qualified HCPs will act as more responsible and competent gatekeepers of access to antibiotics than unqualified HCPs. METHODS: We investigate whether weaknesses in HCP professionalism result in boundaries between qualified HCPs and unqualified providers being blurred, and how these weaknesses impact inappropriate provision of antibiotics by HCPs in two LMIC with increasing AMR-Pakistan and Cambodia. We conducted 85 in-depth interviews with HCPs, policymakers, and pharmaceutical industry representatives. Our thematic analysis was based on a conceptual framework of four components of professionalism and focused on identifying recurring findings in both countries. RESULTS: Despite many cultural and sociodemographic differences between Cambodia and Pakistan, there was a consistent finding that the behaviour of many qualified HCPs did not reflect their professional education. Our analysis identified five areas in which strengthening HCP education could enhance professionalism and reduce the inappropriate use of antibiotics: updating curricula to better cover the need for appropriate use of antibiotics; imparting stronger communication skills to manage patient demand for medications; inculcating essential professional ethics; building skills required for effective collaboration between doctors, pharmacists, and lay HCPs; and ensuring access to (unbiased) continuing medical education. CONCLUSIONS: In light of the weaknesses in HCP professionalism identified, we conclude that global guidelines urging patients to only seek care at qualified HCPs should consider whether HCP professional education is equipping them to act in the best interest of the patient and society. Our findings suggest that improvements to HCP professional education are needed urgently and that these should focus not only on the curriculum content and learning methods, but also on the social purpose of graduates.

Methodological gaps and opportunities for studying multisectoral collaboration for health in low- and middle-income countries.

The current body of research into multisectoral collaborations (MSCs) for health raises more questions than it answers, both in terms of how to implement MSCs and how to study them. This article reflects on current methodological gaps and opportunities for advancing MSC research, based on a targeted review of existing literature and qualitative input from researchers and practitioners at the 2018 Health Systems Research (HSR) Symposium in Liverpool. Through framework analysis of 205 MSC research papers referenced in a separately published MSC 'overview of reviews' paper, this article identifies six broad MSC question domains ('meta questions') and applies content analysis to estimate the relative frequency with which these meta questions and the research method(s) used to answer them are present in the literature. Results highlight a preponderance of research exploring MSC implementation using case study methods, which, in aggregate, does not seem to adequately meet policymakers' and practitioners' needs for generalizable or transferable insights. The content analysis is complemented by qualitative insights from HSR Symposium participants and the authors' own experience to identify six key methodological gaps in research on MSC for health. For each of these gaps, we propose areas in which we believe there are opportunities for methodological development and innovation to help advance this field of study, including: better understanding the role of power dynamics in shaping MSCs; development of a classification framework (or frameworks) of governance arrangements; exploring divergence of perspective and experience among MSC partners; identifying or generating theoretical frameworks for MSC that work across sectors and disciplines; developing intermediate indicators of collaboration; and increasing transferability of insights to other contexts. Collaboration with researchers outside of the health sector will enhance efforts in each of these areas, as will the establishment and strengthening of pluralistic MSC evidence networks also involving policymakers and practitioners.

Invisible medicine sellers and their use of antibiotics: a qualitative study in Cambodia.

BACKGROUND: Global attention to antimicrobial resistance has increased interest in tackling the widespread inappropriate dispensing of antibiotics by informal, for-profit healthcare providers (HCPs). We provide new evidence on an understudied group of informal HCPs: invisible medicine sellers (IMS) who operate without any marked facility. We investigated factors that influence community decisions on which HCPs to purchase medicines from, focusing on reasons for using IMS, and compared different HCPs' knowledge of antibiotic use. METHODS: We conducted community focus group discussions (FGDs) in seven purposively selected villages representing high and low informal HCPs use in two peri-urban districts in Phnom Penh, Cambodia. Using information from the FGDs to identify HCPs that sell medicines, we interviewed 35 participants: 21 HCPs (including five IMS) and 14 key informants, including government HCPs and village leaders. We adopted an interpretative approach and conducted a thematic analysis. RESULTS: Community members typically knew of several formal and informal HCPs selling medicines nearby, and IMS were common, as were doctors that sell medicines covertly. Two factors were most salient in influencing the choice of HCP for medicine purchasing. The first was trust in the effectiveness of medicines provided, judged by the speed of symptomatic relief. This pushed HCPs to provide several medicines, including antibiotics, at the first consultation. The second was the convenience offered by IMS and other informal HCPs: supplying medicines when other facilities are closed, accepting delayed payments, providing incomplete courses of medication and selling human antibiotics for animal use. CONCLUSION: This first study focusing on IMS indicates that it is important, but challenging, for public health agencies to engage with them to reduce inappropriate use of antibiotics. Although public health facilities must fill some gaps that informal HCPs are currently addressing, such as access to medicines at night, reducing demand for unnecessary antibiotics is also critical.

What can motivate Lady Health Workers in Pakistan to engage more actively in tuberculosis case-finding?

BACKGROUND: Many interventions to motivate community health workers to perform better rely on financial incentives, even though it is not clear that monetary gain is the main motivational driver. In Pakistan, Lady Health Workers (LHW) are responsible for delivering community level primary healthcare, focusing on rural and urban slum populations. There is interest in introducing large-scale interventions to motivate LHW to be more actively involved in improving tuberculosis case-finding, which is low in Pakistan. METHODS: Our study investigated how to most effectively motivate LHW to engage more actively in tuberculosis case-finding. The study was embedded within a pilot intervention that provided financial and other incentives to LHW who refer the highest number of tuberculosis cases in three districts in Sindh province. We conducted semi-structured interviews with 20 LHW and 12 health programme managers and analysed these using a framework categorising internal and external sources of motivation. RESULTS: Internal drivers of motivation, such as religious rewards and social recognition, were salient in our study setting. While monetary gain was identified as a motivator by all interviewees, programme managers expressed concerns about financial sustainability, and LHW indicated that financial incentives were less important than other sources of motivation. LHW emphasised that they typically used financial incentives provided to cover patient transport costs to health facilities, and therefore financial incentives were usually not perceived as rewards for their performance. CONCLUSIONS: This study indicated that interventions in addition to, or instead of, financial incentives could be used to increase LHW engagement in tuberculosis case-finding. Our finding about the strong role of internal motivation (intrinsic, religious) in Pakistan suggests that developing context-specific strategies that tap into internal motivation could allow infectious disease control programmes to improve engagement of community health workers without being dependent on funding for financial incentives.

How can we improve priority-setting for investments in health research? A case study of tuberculosis.

BACKGROUND: Although enhanced priority-setting for investments in health research for development is essential to tackling inequalities in global health, there is a lack of consensus on an optimal priority-setting process. In light of the current surge in tuberculosis (TB) research investment, we use TB as a case study. METHODS: We investigated two critical aspects of a research prioritisation process, namely the criteria that should be used to rank alternative research options and which stakeholders should be involved in priority-setting. We conducted semi-structured interviews with 24 key informants purposively selected from four distinct groups - academia, funding bodies, international policy or technical agencies, and national disease control programmes. Interview transcripts were analysed verbatim using a framework approach. We also performed a systematic analysis of seven diverse TB research prioritisation processes. RESULTS: There was consensus that well-defined and transparent criteria for assessing research options need to be agreed at the outset of any prioritisation process. It was recommended that criteria should select for research that is likely to have the greatest public health impact in affected countries rather than research that mainly fills scientific knowledge gaps. Some interviewees expressed strong views about the need - and reluctance - to make politically challenging decisions that place some research areas at a lower priority for funding. The importance of taking input from stakeholders from countries with high disease burden was emphasised; such stakeholders were notably absent from the majority of prioritisation processes we analysed. CONCLUSIONS: This study indicated two critical areas for improvement of research prioritisation processes such that inequalities in health are better addressed - the need to deprioritise some research areas to generate a specific and meaningful list for investment, and greater involvement of experts working in high disease-burden countries.

'LMICs as reservoirs of AMR': a comparative analysis of policy discourse on antimicrobial resistance with reference to Pakistan.

Antimicrobial resistance (AMR) has recently emerged as a salient global issue, and policy formulation to address AMR has become a contested space, with various actors sharing competing-and sometimes contradictory-explanations of the problem and the range of possible solutions. To facilitate national policy setting and implementation around AMR, more needs to be done to effectively engage policymakers in low- and middle-income countries (LMICs). However, there is a dearth of research on differences in issue framing by external agencies and LMIC's national policymakers on the problem of AMR; such analyses are imperative to identify areas of conflict and/or potential convergence. We compared representations of AMR across nine policy documents produced by multilateral agencies, donor countries and an LMIC at the forefront of the global response to AMR-Pakistan. We analysed the texts in relation to five narratives that have been commonly used to frame health issues as requiring action: economic impact, stunting of human development, consequences for health equity, health security threats and relationship with food production. We found that AMR was most frequently framed as a threat to human health security and economic progress, with several US, UK and international documents depicting LMICs as 'hotspots' for AMR. Human development and equity dimensions of the problem were less frequently discussed as reasons to address the growing burden of AMR. It is clear that no single coherent narrative on AMR has emerged, with notable differences in framing in Pakistani and external agency led documents, as well as across stakeholders primarily working on human vs animal health. While framing AMR as a threat to economic growth and human security has achieved high-level political attention and catalysed action from governments in high-income countries, our analysis suggests that conflicting narratives relevant to policymakers in Pakistan may affect policy-making and impede the development and implementation of integrated initiatives needed to tackle AMR.

"For how long are we going to take the tablets?" Kenyan stakeholders' views on priority investments to sustainably tackle soil-transmitted helminths.

Recent global commitments to shift responsibility for Neglected Tropical Disease (NTD) control to affected countries reflect a renewed emphasis on sustainability, away from aid-dependency. This calls for a better understanding of how domestic stakeholders perceive investments in different strategies for NTD control. Soil transmitted helminths (STH) are among the NTDs targeted for elimination as a public health problem by international agencies through mass drug administration, provided periodically to at-risk population groups, often using drugs donated by pharmaceutical companies. This study was conducted in Kenya at a time when responsibilities for long running STH programmes were transitioning from external to national and sub-national agencies. Following an initial assessment in which we identified key domestic stakeholders and reviewed relevant scientific and government documents, the perspectives of stakeholders working in health, education, community engagement and sanitation were investigated through semi-structured interviews with national level policymakers, county level policymakers, and frontline implementers in one high-STH burden county, Kwale. Our conceptual framework on sustainability traced a progression in thinking, from ensuring financial stability through the technical ability to adapt to changing circumstances, and ultimately to a situation where a programme is prioritised by domestic policymakers because empowered communities demand it. It was clear from our interviews that most Kenyan stakeholders sought to be at the final stage in this progression. Interviewees criticised long-term investment in mass drug administration, the approach favoured predominantly by external agencies, for failing to address underlying causes of STH. Instead they identified three synergistic priority areas for investment: changes in institutional structures and culture to reduce working in silos; building community demand and ownership; and increased policymaker engagement on underlying socioeconomic and environmental causes of STH. Although challenging to implement, the shift in responsibility from external agencies to domestic stakeholders may lead to emergence of new strategic directions.