Blockchain for Universal Health Coverage

Mass migration has become one of the 21st century's greatest challenges. With an estimated 214 million people on the move internationally and forced displacement at a record high, population mobility is one of the leading policy issues of the 21st century. Women and children with no identity can be missed by national social programs in addition to the risks posed by being on the move. Developments in Blockchain can enable the tracking and delivery of in-kind aid and facilitate cash assistance programs in humanitarian settings and coordinate, collect, and analyse data in crisis to enable a timely and appropriate response. This chapter presents the ways in which Blockchain is being deployed in humanitarian and refugee settings and a series of case studies from Finland, Moldova, Kenya, and Iraq. While promising progress has been made, there remains a need for more research and evaluation as these technologies are implemented, increased user participation in design, and to ensure that privacy and security issues are addressed.

Studies suggest issues may arise when using childcare setting assessment tools designed for high-resource settings in low-resource settings to assess and improve the quality of care, including placing disproportionate weight on features of the childcare environment that may not be available or culturally appropriate within the low-resource context. This study compares a novel assessment tool developed in and for low-income and low-resource settings with a standardized "gold standard" tool developed for use in high-resource settings. The study included a randomized sample of 34 childcare centers in a low-resource context that provided care for approximately 918. Results suggest that the WCI-QCUALS assessment tool performed better at differentiating among childcare settings that were consolidated into the lowest rating on the ECERS-R. Further, the WCI-QCUALS was found to be a feasible, appropriate stand-alone tool for assessing the quality of childcare centers in low-resource settings. Additional refinement and validity testing in other countries and contexts will improve the understanding of how the quality of childcare across different contexts can be measured, and improved assessment of childcare quality in low-resource settings will enhance the ability to identify low-quality care that can be remedied to ensure appropriate care for vulnerable children.

Caregiver-infant interactions shape infants' early visual experience; however, there is limited work from low-and middle-income countries (LMIC) in characterizing the visual cognitive dynamics of these interactions. Here, we present an innovative dyadic visual cognition pipeline using machine learning methods which captures, processes, and analyses the visual dynamics of caregiver-infant interactions across cultures. We undertake two studies to examine its application in both low (rural India) and high (urban UK) resource settings. Study 1 develops and validates the pipeline to process caregiver-infant interaction data captured using head-mounted cameras and eye-trackers. We use face detection and object recognition networks and validate these tools using 12 caregiver-infant dyads (4 dyads from a 6-month-old UK cohort, 4 dyads from a 6-month-old India cohort, and 4 dyads from a 9-month-old India cohort). Results show robust and accurate face and toy detection, as well as a high percent agreement between processed and manually coded dyadic interactions. Study 2 applied the pipeline to a larger data set (25 6-month-olds from the UK, 31 6-month-olds from India, and 37 9-month-olds from India) with the aim of comparing the visual dynamics of caregiver-infant interaction across the two cultural settings. Results show remarkable correspondence between key measures of visual exploration across cultures, including longer mean look durations during infant-led joint attention episodes. In addition, we found several differences across cultures. Most notably, infants in the UK had a higher proportion of infant-led joint attention episodes consistent with a child-centered view of parenting common in western middle-class families. In summary, the pipeline we report provides an objective assessment tool to quantify the visual dynamics of caregiver-infant interaction across high- and low-resource settings.

Coronavirus disease (COVID-19) is an unprecedented pandemic. COVID-19 is a highly contagious and potentially fatal respiratory infection which has spread within three months of its outbreak to more than 173 countries, causing 3.7 million infections and 256,551 deaths at this writing. Unfortunately, no treatment or vaccine currently exists for COVID-19, although several clinical trials are on-going to find a definite solution to this pandemic. Prevention through public health measures remain the best strategy recommended till date. This prevention involves physical distancing and compulsory confinement at home in several European countries, in the UK and USA. Unfortunately, home confinement decreed in most high-income countries like France has been dangerous for women, victims of psychological, physical and sexual violence from their intimate partner. Violence between intimate partners has become an unintended consequence of the stay-at-home policy against COVID-19. Since the promulgation of a home confinement decreed in many high resource settings (USA, UK, Europe, Canada, Australia, etc), the rate of violence between intimate partners has increased tremendously resulting to the worst scenario, women’s death in some of these countries. The stay-at-home law is not yet a national decree in several low resource settings like Africa, where COVID-19 has not been declared an epidemic in several countries. However, intimate partner violence has been reportedly described as a real violation of women’s right before the advent of the COVID-19 pandemic in the African continent. This commentary highlights the effects of intimate partner violence due to COVID-19 confinement in France and extrapolates what may be the effect of an implementation of a COVID-19 confinement law in Cameroon. Also, the authors suggest recommendations to lessen the burden of intimate partner violence in countries with a stay-at-home policy.

Chapter 4 focuses on the ethical aspects of the EEPs concept to ask how and under what circumstances hosting undergraduate students from high resource settings can be of benefit to hosting locations in low resource settings. To the extent that there is a literature on this aspect – and there is little – there is some suggestion that electives may be of no direct benefit and, indeed, may have a negative impact on already resource-constrained contexts. Why should low resource settings subsidise the burden of training healthcare students in resource rich countries? There may be alternative ways of mitigating this potential imbalance through cash payments (income) or by restricting students to observational-only opportunities. The chapter reviews the EEP intervention from the perspective of hosts identifying approaches which may be of reciprocal benefit.

The available evidence for the prehospital use of tourniquets is largely based on the military experience of high-resource countries over the last 30years. Though the lifesaving benefits of an appropriately applied tourniquet to stop catastrophic bleeding are undeniable, the potential consequences of tourniquet application differ greatly within different environments. In many low resource settings, both the time until initial treatment and the evacuation time to a qualified medical care can range from hours to days. The global burden of trauma disproportionally affects low- and middle-income countries, however the guidelines and training regimes surrounding tourniquet use are based upon data collected from high resource settings may not be directly transferable to these settings. A scoping review was employed to assess the geographical and socioeconomic distribution of the currently available reports with clinical outcomes regarding prehospital tourniquet use. Multiple factors were analyzed including socioeconomic, civilian/military, and geographic variables. Following PRISMA-ScR guidelines, the search strategy was outlined, and a title/abstract screening followed by a full text screening was performed separately by two qualified physicians. Reports not presenting outcome measures were excluded. A total of 52 reports involving 27,429 patients were included in this scoping review. Most reports were conducted in the USA (48%) or Iraq/Afghanistan (31%), with all primary authors affiliated with high-income countries, such as the USA, Israel, and the UK. No reports meeting the inclusion criteria had primary authors based in low-income countries. The study population was predominantly young (mean age 31years) and male (89%). Penetrating trauma from ballistic injuries and blasts were the most common mechanisms of injury. The average pre-hospital tourniquet application time was 146min (median: 72min). Mortality was the most frequently reported outcome (85%), followed by limb salvage (63%) and neurological impairment (48%). This review highlights the limited data on pre-hospital tourniquet use in resource-limited settings, creating a gap that risks misinformed interventions in these contexts. The absence of research originating from authors in the low-income settings being studied is notable. Addressing this disparity is crucial to developing safe and effective guidelines applicable across diverse global healthcare environments.

Targeted pathways in breast cancer: molecular and protein markers guiding therapeutic decisions.

Background‘Tele-Mental Health (MH) services,’ are an increasingly important way to expand care to underserved groups in low-resource settings. In order to continue providing psychiatric, psychotherapeutic and counselling care during COVID-19-related movement restrictions, Médecins Sans Frontières (MSF), a humanitarian medical organization, abruptly transitioned part of its MH activities across humanitarian and resource-constrained settings to remote format.MethodsFrom June–July of 2020, investigators used a mixed method, sequential explanatory study design to assess MSF staff perceptions of tele-MH services. Preliminary quantitative results influenced qualitative question guide design. Eighty-one quantitative online questionnaires were collected and a subset of 13 qualitative follow-up in-depth interviews occurred.ResultsRespondents in 44 countries (6 geographic regions), mostly from Sub-Saharan Africa (39.5%), the Middle East and North Africa (18.5%) and Asia (13.6%) participated. Most tele-MH interventions depended on audio-only platforms (80%). 30% of respondents reported that more than half of their patients were unreachable using these interventions, usually because of poor network coverage (73.8%), a lack of communication devices (72.1%), or a lack of a private space at home (67.2%). Nearly half (47.5%) of respondents felt their staff had a decreased ability to provide comprehensive MH care using telecommunication platforms. Most respondents thought MH staff had a negative (46%) or mixed (42%) impression of remote care. Nevertheless, almost all respondents (96.7%) thought tele-MH services had some degree of usefulness, notably improved access to care (37.7%) and time efficiency (32.8%). Qualitative results outlined a myriad of challenges, notably in establishing therapeutic alliance, providing care for vulnerable populations and those inherent to the communications infrastructure.ConclusionTele-MH services were perceived to be a feasible alternative solution to in-person therapeutic interventions in humanitarian settings during the COVID-19 pandemic. However, they were not considered suitable for all patients in the contexts studied, especially survivors of sexual or interpersonal violence, pediatric and geriatric cases, and patients with severe MH conditions. Audio-only technologies that lacked non-verbal cues were particularly challenging and made risk assessment and emergency care more difficult. Prior to considering tele-MH services, communications infrastructure should be assessed, and comprehensive, context-specific protocols should be developed.

Considerations for service delivery for emergency care in low resource settings.

Not available.

Significant disparities remain in prenatal care utilization across countries, the specific socioeconomic and systemic factors contributing to these gaps have not been consistently synthesized. This review evaluates the gap by comparing barriers to timely and adequate prenatal care between high and low resource settings by focusing on the factors affecting prenatal service utilization through socioeconomic status and geography cultural barriers and system-related factors. The systematic review explored databases such as PubMed, Google Scholar, Scopus, Web of Science, and ScienceDirect. The recent studies from 2014 up to 2024 underwent evaluation based on Boolean operators combined with indexed keywords. Eligible studies included quantitative study designs examining barriers to prenatal care among women of reproductive age. Screening was conducted by two reviewers independently by following PRISMA guidelines. A total of 20 studies were included as per the eligibility criteria. Due to heterogeneity in study design, a structured narrative review synthesis was conducted. The main barriers identified were Socioeconomic limitations because of low income and insufficient insurance coverage and the challenges of distance to healthcare facilities and inadequate transportation combined with cultural barriers such as traditional gender roles and stigmatization and traditional beliefs. The barriers identified in high-income settings were that immigrant and refugee women faced challenges due to their status uncertainties, difficulties with language and unfamiliarity with healthcare systems. Depression along with abuse and multiple caregiving duties emerged as a major psychological factor that prevented women from accessing healthcare. System-related factors like Long waiting times and inadequate medical personnel along with insufficient respect from healthcare providers were the major identified factors. The utilization of prenatal care is influenced by a multifaceted interplay of the individual, cultural, socioeconomic, and systems factors. It is important to strengthen these community-based measures, including financial and structural assistance, to enhance equitable, timely, and sufficient prenatal care across diverse settings.

Introduction Burn injuries remain a significant global health burden, particularly in lower-resource settings. Understanding disparities in outcomes between low-resource and high-resource regions is needed to inform interventions. We hypothesize that burns managed in low-resource countries are an independent risk factor for mortality. Methods We queried the World Health Organization (WHO) Global Burn Registry (GBR) from inception to September 2024. Individuals were stratified based on care in low-resource (LRC) and high-resource countries (HRC). Descriptive statistics between cohorts (LRC vs. HRC) were leveraged to summarize demographics, burn characteristics, facility resources, and hospital care outcomes. Multivariable logistic regression analysis was performed for mortality while controlling for confounding factors. Results There were 9,274 cases with 4,169 (45%) managed in LRC and 5,105 (55%) in HRC. The median age at time of burn injury was 24 years (IQR: 4-40 years). The male population was 54% in LRC and 65% in HRC (P< 0.001). The median total body surface area (TBSA) burned was higher in LRC (20%, IQR: 10-40%) compared to HRC (15%, IQR: 5-25%, P< 0.001). Inhalation injury was also more prevalent in LRC (23%) than in HRC (9%, P< 0.001). Both the median Baux and modified Baux scores were higher for LRC, 50 and 52, respectively, compared to HRC, 41 and 42, respectively (P< 0.001). Flame injuries were significantly higher in LRC (56% vs. 43% HRC, P< 0.001). There was a significantly higher proportion of head and neck, trunk, and lower extremity burn injuries in LRC (P< 0.001). Critical care resources, computer and internet access, operating room availability, rehabilitation capabilities, and specialist capabilities were significantly lower in LRC (P< 0.001). A higher proportion of patients in HRC underwent surgery (61% vs. 40% LRC, P< 0.001). Discharge was significantly higher (82% vs. 59%) in HRC and mortality was significantly lower (11%) compared to LRC (29%, P< 0.001). After adjusting for demographics and burn-related factors, management in an LRC significantly increased the odds of mortality (OR 2.69, 95%CI 2.25-3.24, P< 0.001). Conclusions Individuals treated in LRC had higher mortality, even after adjusting for demographic and burn injury-related characteristics. These findings underscore the need for greater access to specialized care and targeted interventions in low-resource settings to improve burn care. Applicability of Research to Practice Significant disparities in burn care exist between low-resource and high-resource settings, emphasizing the urgent need for targeted interventions. The findings suggest that increasing access to specialized burn care, critical care resources, and surgical interventions in LRC can be potential avenues to reduce mortality rates. Funding for the Study N/A

Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page)Background and AimsThe present review provides a comprehensive...

The World Health Organization safe surgery checklist as a catalyst for system improvement.

Background Diabetes is a major global health challenge, impacting millions and disproportionately affecting low- and middle-income countries (LMICs), where approximately three-quarters of affected individuals reside. Despite abundant guidance on diabetes management, most evidence is derived from high-resource settings, potentially impeding effective application in low-resource settings. This study explored issues related to the application of the current clinical practice guidelines (CPG) for diabetes management in Ecuador, from the perspective of local health professionals. Methods We developed 5 focus groups in Quito, the capital of Ecuador, in a low-income district. The groups included doctors, nurses, and health promoters; they discussed four sections of the CPG concerning their daily practice. Qualitative results are contrasted with quantitative research based on patient records. Results The Ecuadorian health system considers patients with diabetes a priority group, yet a patient may wait up to 4 months to receive their first appointments and once they receive their diagnosis several criteria set out in the CPG are not followed due to lack of time and resources, particularly the delivery of multidisciplinary attention. Access to specialized consultations, such as an ophthalmological assessment is severely restricted, and it can take up to a year to get an appointment. Clinicians expressed difficulties in adapting the nonpharmacological recommendations to different socioeconomic backgrounds, while at times, prescription choices are determined by medicine stock regardless of the patient’s actual needs. Conclusions Healthcare professionals have developed a series of ad-hoc strategies to ensure healthcare for their patients, pointing out the difficulties of applying CPG within a health system that lacks basic resources. Healthcare is intertwined with social inequalities among the Ecuadorian population that have worsened since the covid19 pandemic. Key messages • We identified significant challenges in applying the CPG in low resource settings. Clinicians adapt by introducing novel ways to overcome limitations at times to the detriment of the patient’s health. • CPGs need to be tailored to the context considering socioeconomic realities of the population and limited resources in the health setting.