Anna Palagyi

Introduction: Trauma is a leading cause of paediatric morbidity and mortality, but is often managed at non-paediatric specialist centres, where limited familiarity with paediatric patient management impacts care quality and outcomes. Telemedicine presents a unique solution to these problems, having the potential to improve patient outcomes by influencing the immediate assessment, management and disposition of injured children. This scoping review aims to detail the use of telemedicine in acute paediatric trauma: when and where it is used, what outcomes have been evaluated and any evidence gaps. Methodology: We conducted a scoping review to identify primary studies that evaluated the use of telemedicine in paediatric trauma. Five databases were searched for relevant studies published prior to June 2024. Results: Nine studies were included. Most papers ( n = 8) reported on the effect of telehealth on patient treatment decisions and outcomes, including a decrease in mortality ( n = 1), impact on patient disposition ( n = 1) and change in patient care due to telehealth ( n = 1). Clinician satisfaction ( n = 3), parent satisfaction ( n = 3) and difficulties encountered with telemedicine usage (n = 2) were also explored. Conclusion: When employed to connect rural mixed emergency departments with paediatric trauma centres, telemedicine has the potential to influence initial management and improve appropriate disposition rates, with demonstrated improvement in care quality and survival rates, as well as improved stakeholder satisfaction. However, there is a need for higher-quality evidence generated through prospective studies to validate the use of telemedicine in paediatric trauma and demonstrate its impact on value-based care provided to children and their support networks.

Scaling up effective public health interventions is crucial for achieving universal health coverage, yet remains challenging. We report the use of the Plan-Do-Study-Act (PDSA) quality improvement model to support the iterative scale-up of a community-based cardiovascular disease risk management program in Malang District, East Java, Indonesia. A pragmatic implementation study comprising three PDSA cycles was conducted in 10 ‘test of scale-up’ villages between April 2021 and December 2022. Each cycle included: 1) the capture of quantitative outcomes, such as the number of new community members screened per month and diagnostic summaries with predicted risk status; and 2) semi-structured interviews and focus group discussions with health care workers, community members, and community health workers in each village to assess acceptability, adoption, adaptations and perceived effectiveness. Based on identified implementation barriers, local Technical Working Groups designed change strategies, which were implemented and evaluated in subsequent cycles. The COVID-19 pandemic disrupted program delivery in the first two PDSA cycles, reducing screening to an average of 112 and 7, respectively. In cycle 3, 463 community members were screened. Across the 10 participating villages, 42 interviews and 30 focus group discussions were conducted per PDSA cycle. Key barriers included difficulty reaching male community members, inadequate resourcing, limited essential medications and poor integration with existing health information systems. Change strategies included centralising screening activities, leveraging instant messaging platforms, additional activities to engage men and streamlined procurement processes. Each village demonstrated versatility in addressing implementation challenges. These findings highlight the utility of the PDSA model in supporting the iterative scale-up of a community-based cardiovascular disease risk management programs in real-world settings, even amid significant disruptions such as the COVID-19 pandemic.

In Indonesia, the world's fourth most populous country, cardiovascular diseases (CVDs) are a leading cause of death and disability. Government efforts to reduce the burden of CVD include a community-based prevention and early detection programme, and the provision of medicines to prevent cardiovascular events. Disruptions to medicine supply chains, service provision, and movement during the COVID-19 pandemic potentially threatened the continuity of these efforts. We investigated the distribution and dispensing of common CVD medicines in Malang district, East Java, before the pandemic and early in its course. From January to October 2020, we collected monthly data on stock levels, sales or dispensing volumes, and price for five common CVD medicines (amlodipine, captopril, furosemide, glibenclamide and simvastatin), from a public and a private distributor, and from public health facilities (n = 4) and private pharmacies (n = 2). We further complied monthly data on patient numbers in two primary health centres. We tracked changes in stocks held and volumes dispensed by medicine type and sector, comparing the three months before the local COVID-19 response was mobilised with the subsequent seven months. We conducted interviews with pharmacists (n = 12), community health workers (n = 2) and a supply chain logistics manager to investigate the reasons for observed changes, and to learn details of any impacts or mitigation measures. The pandemic affected demand more than supply, causing medicine stocks to rise. Restricted service provision, lock-down measures and fear of infection contributed to a sharp drop in patient numbers and dispensing volumes in the public sector. Meanwhile private sector sales, especially of lower-priced CVD medicines, rose. Community health workers attributed some poor health outcomes to interruption in regular patient check-ups; this interruption was aggravated by formal mitigation policies. Fears that COVID-19 would interrupt medicine availability were unfounded in East Java. Public sector patients may have compensated for reduced service access by switching to private pharmacies. Mitigation policies that ignored administrative procedures were not effective.

Lower-middle income Indonesia, the world’s fourth most populous country, has struggled to contain costs in its mandatory, single-payer public health insurance system since the system’s inception in 2014. Public procurement policies radically reduced prices of most medicines in public facilities and the wider market. However, professional associations and the press have questioned the quality of these low-cost, unbranded generic medicines. We collected 204 samples of four cardiovascular and one antidiabetic medicines from health facilities and retail outlets in East Java. We collected amlodipine, captopril, furosemide, simvastatin, and glibenclamide, sampling to reflect patients’ likelihood of exposure to specific brands and outlets. We recorded sales prices and maximum retail prices and tested medicines for dissolution and percentage of labeled content using high-performance liquid chromatography. We conducted in-depth interviews with supply chain actors. All samples, including those provided free in public facilities, met quality specifications. Most manufacturers make both branded and unbranded medicines. Retail prices varied widely. The median ratio of price to the lowest price for an equivalent product was 5.1, and a few brands sold for over 100 times the minimum price. Prices also varied between outlets for identical products because retail pharmacies set prices to maximize profit. Because very-low-cost medicines were universally available and of good quality, we believe richer patients who chose to buy branded products effectively protected medicine quality for poorer patients in Indonesia because manufacturers cross-subsidize between branded and unbranded versions of the same medicine.

This mixed-methods study aimed to: 1) characterise veterinary antimicrobial imports into Fiji over a 12 month period; and 2) evaluate the knowledge, perception and practice of antibiotic use and antimicrobial resistance (AMR) among livestock farmers in the Central Division of Fiji. Out of 15 antibiotic import shipments during November 2016−October 2017, just under half (40%) were initiated by non-government veterinarians, with the broad-spectrum antibiotics amoxicillin and cephalosporin being imported most frequently. 7% of antibiotic imports were initiated by individual (non-veterinary) users. Semi-structured interviews with 10 livestock farmers from Fiji’s Central Division found that, despite the widespread use of antibiotics with livestock, farmers were not aware of AMR or its risk to public and animal health. Educational barriers and social norms may discourage farmers from questioning veterinary personnel about antibiotic administering practices. Veterinarian-delivered education and awareness campaigns may be considered to help improve veterinary−farmer AMR communications and assist Fijian livestock farmers to optimise antibiotic usage.

Background Community health workers (CHWs) play a critical role in supporting health systems, and in improving accessibility to primary healthcare. In many settings CHW programmes do not have formalised employment models and face issues of high attrition and poor performance. This study aims to determine the employment preferences of CHWs in Malang district, Indonesia, to inform policy interventions. Methods A discrete choice experiment was conducted with 471 CHWs across 28 villages. Attributes relevant to CHW employment were identified through a multistage process including literature review, focus group discussions and expert consultation. Respondents’ choices were analysed with a mixed multinomial logit model and latent class analyses. Results Five attributes were identified: (1) supervision; (2) training; (3) monthly financial benefit; (4) recognition; and (5) employment structure. The most important influence on choice of job was a low monthly financial benefit (US$~2) (β=0.53, 95% CI=0.43 to 0.63), followed by recognition in the form of a performance feedback report (β=0.13, 95% CI=0.07 to 0.20). A large monthly financial benefit (US$~20) was most unappealing to respondents (β=−0.13, 95% CI=−0.23 to −0.03). Latent class analysis identified two groups of CHWs who differed in their willingness to accept either job presented and preferences over specific attributes. Preferences diverged based on respondent characteristics including experience, hours’ worked per week and income. Conclusion CHWs in Malang district, Indonesia, favour a small monthly financial benefit which likely reflects the unique cultural values underpinning the programme and a desire for remuneration that is commensurate with the limited number of hours worked. CHWs also desire enhanced methods of performance feedback and greater structure around training and their rights and responsibilities. Fulfilling these conditions may become increasingly important should CHWs work longer hours.