Healthcare research, planning, and delivery with minimal community engagement can result in financial wastage, failure to meet objectives, and frustration in the communities that programmes are des...

An increase in the number of older people experiencing disability and dependence is a critical aspect of the demographic change that will emerge within Europe due to the rise in life expectancy. In this scenario, prevention of these conditions is crucial for the well-being of older citizens and for the sustainability of our healthcare systems. Thus, the diagnosis and management of conditions like frailty, which identifies the people at the highest risk for developing those adverse outcomes, is of critical relevance. Currently, assessment of frailty relies primarily on measuring functional parameters, which have limited clinical utility. In this viewpoint article, we describe the FRAILOMIC Initiative, an international, large-scale, multi-endpoint, community- and clinic-based research study funded by the European Commission. The aim of the study is to develop validated measures, comprising both classic and ‘omics-based' laboratory biomarkers, which can predict the risk of frailty, improve the accuracy of its diagnosis in clinical practice and provide a prognostic forecast on the evolution from frailty to disability. The initiative includes eight established cohorts of older adults, encompassing >75,000 subjects, most of whom (∼70%) are aged >65 years. Data on function, nutritional status and exercise habits have been collected, and cardiovascular health has been evaluated at baseline. Subjects will be stratified as ‘non-frail' or ‘frail' using Fried's definition, all adverse outcomes of interest will be recorded and differentially expressed biomarkers associated with the risk of frailty will be identified. Genomic, proteomic and transcriptomic investigations will be carried out using array-based systems. As circulating microRNAs in plasma have been identified in the context of senescence, ageing and age-associated diseases, a miRNome-wide analysis will also be undertaken to identify a miRNA-based signature of frailty. Blood concentrations of secreted proteins known to be upregulated significantly in senescent endothelial cells and other hypothesis-driven biomarkers will be measured using ELISAs. The FRAILOMIC Initiative aims to issue a series of interim scientific reports as key results emerge. Ultimately, it is hoped that this study will contribute to the development of new clinical tools, which may help individuals to enjoy an old age that is healthier and free from disability.

Tanzania launched its first National Action Plan (NAP) on antimicrobial resistance (AMR) in 2017 to reduce the burden of AMR in the country and contribute to the global response. We aimed to analyze the implementation of the NAP on AMR in Tanzania using the governance framework. In-depth interviews were conducted with human and animal health practitioners and national-level policy actors. We adapted Chua’s AMR governance framework to analyze the development and implementation of the NAP in Tanzania. Implementation of the NAP has realized several achievements, including: (i) the establishment of a functioning Multi-Sectoral Coordinating Committee for coordinating the implementation of AMR activities; (ii) existence of governance structure; (iii) establishment of human and animal surveillance sites; (iv) creation of AMR awareness in the community and (v) availability of guidelines at the health facility level to ensure AMR stewardship. However, some dimensions of the governance areas, including reporting and feedback mechanisms, accountability, transparency and sustainability of AMR plans, are not effectively implemented. Addressing these challenges should involve strengthening the collaboration of the different sectors involved at different NAP implementation levels by careful planning and coordination, and provision of adequate resources to ensure sustainability.

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.

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.

Introduction: Strengthening health systems in conflict-affected settings has become increasingly professionalised. However, evaluation remains challenging and often insufficiently documented in the literature. Many, particularly small-scale health system evaluations, are conducted by government bodies or non-governmental organisations (NGO) with limited capacity to publish their experiences. It is essential to identify the existing literature and main findings as a baseline for future efforts to evaluate the capacity and resilience of conflict-affected health systems. We thus aimed to synthesise the scope of methodological approaches and methods used in the peer-reviewed literature on health system evaluation in conflict-affected settings. Methods: We conducted a scoping review using Arksey and O’Malley’s method and synthesised findings using the WHO health system ‘building blocks’ framework. Results: We included 58 eligible sources of 2,355 screened, which included examination of health systems or components in 26 conflict-affected countries, primarily South Sudan and Afghanistan (7 sources each), Democratic Republic of the Congo (6), and Palestine (5). Most sources (86%) were led by foreign academic institutes and international donors and focused on health services delivery (78%), with qualitative designs predominating (53%). Theoretical or conceptual grounding was extremely limited and study designs were not generally complex, as many sources (43%) were NGO project evaluations for international donors and relied on simple and lower-cost methods. Sources were also limited in terms of geography (e.g., limited coverage of the Americas region), by component (e.g., preferences for specific components such as service delivery), gendered (e.g., limited participation of women), and colonised (e.g., limited authorship and research leadership from affected countries). Conclusion: The evaluation literature in conflict-affected settings remains limited in scope and content, favouring simplified study designs and methods, and including those components and projects implemented or funded internationally. Many identified challenges and limitations (e.g., limited innovation/contextualisation, poor engagement with local actors, gender and language biases) could be mitigated with more rigorous and systematic evaluation approaches.