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It is January 2014, and the case protagonist, David Milestone (senior advisor at the Center for Accelerating Innovation and Impact at the U.S. Agency for International Development's Global Health Bureau), is preparing for a meeting of global stakeholders and pharmaceutical manufacturers who are interested in reducing mortality caused by childhood pneumonia and are prepared to donate $10 million to support this effort.

Milestone's goal is to propose a strategy to address childhood pneumonia in Uganda, toward which the $10 million donation would go. In addition to effectively and sustainably reducing childhood pneumonia deaths, the plan must align the interests of various stakeholders behind the problem. A successful strategy in Uganda could be a model for interventions elsewhere. The United Nations Commission on Lifesaving Commodities for Women and Children recently identified Uganda as a “pathfinder” country, meaning it could serve as the example for other countries wrestling with the same issues. This is a remarkable opportunity to change the lives of children in Uganda—and all around the world.

After reading and analyzing the case, students will be able to:

• Perform a stakeholder analysis

• Appreciate the challenges involved in improving public health, especially in developing countries

• Create a patient journey and use it to identify potential impact points

Perform a stakeholder analysis

Appreciate the challenges involved in improving public health, especially in developing countries

Create a patient journey and use it to identify potential impact points

Statelessness is the worst possible form of violation of fundamental human rights which can lead to improper health systems management and serious adverse health outcomes in children. To address this, the Thai Cabinet introduced the Health Insurance for People with Citizenship Problem (HIPCP) in 2010. The purpose of this study is to examine the association between insurance affiliations and the health status of stateless children insured with the HIPCP. The presence of pneumonia was selected as a proxy for health status. The comparison groups were Thai children insured with the Universal Coverage Scheme (UCS) which was launched in 2002 and the uninsured children of low-skilled migrants in Thailand.

A retrospective study was conducted at four selected district hospitals: Mae Ramat Hospital, Phop Phra Hospital, Tha Song Yang Hospital and Umphang Hospital in Tak Province, located in northwestern Thailand. The study used the medical records of children aged 0-15 years who were admitted to the aforementioned hospitals between January 1, 2013 and December 31, 2017. Multivariate logistic regression model was applied with a binary response variable (ever diagnosed with pneumonia: yes/no). Exposure was three types of insurance status (uninsured, HIPCP and UCS) while covariates were age, sex, domicile and year of hospitalization of children.

Of 7,098 hospitalized children between 2013 and 2017, 1,313 were identified with pneumonia. After controlling for key covariates, multivariate results depicted that the odds of pneumonia was 4 per cent higher in stateless children insured with the HIPCP as compared with uninsured children but non-significant (adjusted odds ratio [AOR] = 1.040, 95 per cent confidence interval [CI] = [0.526, 2.160], p = 0.916). Similarly, the odds of pneumonia was 10 per cent higher in Thai children insured with the UCS as compared with uninsured children but non-significant (AOR = 1.100, 95 per cent CI = [0.594, 2.180], p = 0.767). The children who were hospitalized in 2017 were 26 per cent more likely to have pneumonia as compared with those who were hospitalized in 2013 with statistical significance (AOR = 1.260, 95 per cent CI = [1.000, 1.580], p = 0.050). Results remained robust after performing sensitivity analyses.

This study suggests that health insurance is not associated with the health status of vulnerable children especially in the presence of multiple health interventions for uninsured and/or undocumented children living along the Thai–Myanmar border area. Further experimental studies are warranted to understand the causal relationship between insurance and health outcomes and to overcome the limitations of this observational study.

This study has discovered that age and domicile of children are independently associated with pneumonia. In comparison with the youngest age group (0-1 year), the older age groups presented a significantly lower odds for pneumonia. The children living in Phop Phra, Tha Song Yang and Umphang districts revealed a reduced risk for pneumonia as compared with children living in Mae Ramat district.

Staphylococcus aureus (S. aureus), Klebsiella pneumoniae (K. pneumoniae) and Streptococcus pneumoniae (S. pneumoniae) are among the pathogens detected during Hajj pilgrimage known to cause pneumonia. This study aims to evaluate the antibacterial activity of activated carbon cloth (ACC) with Ag⁺ impregnated with zinc oxide nanoparticles (ZnO NPs) against these pathogens.

ZnO NPs were impregnated into ACC-Ag⁺ via layer-by-layer (LbL) self-assembly. Scanning electron microscope (SEM) was used to observe the fine surface morphological details of the ACC-Ag⁺-ZnO sheets. Antibacterial activity of the ACC-Ag⁺-ZnO sheets was evaluated using the disk-diffusion susceptibility assay. Allergy patch test was done to evaluate allergic reactions of the ACC-Ag⁺-ZnO sheets on human skin.

SEM micrographs showed successful impregnation of ZnO NPs into the ACC-Ag⁺ sheets. Disk-diffusion susceptibility assay results of ACC-Ag⁺-ZnO sheets against S. aureus, K. pneumoniae and S. pneumoniae showed good antibacterial activity; with 1.82 ± 0.13 mm zone of inhibition for S. pneumoniae, at a ZnO concentration of 0.78 mg mL^-1. No signs of human skin irritation were observed throughout the allergy patch test.

Results indicate that ACC-Ag⁺-ZnO sheets could potentially be embedded within surgical face masks (pilgrims’ preferred) to reduce the risks involved with the transmission of respiratory tract infections during and after mass gatherings (e.g. Hajj/Umrah, Olympics).

Humanitarian crises increase vulnerability of children to pneumonia, so aid agencies store pharmaceuticals in advance of this demand. Decisions on how much to store are plagued by many diverse challenges as is common in humanitarian contexts, so this study considers storing more medications to improve the relatively poor (∼80) demand coverage at a representative aid agency.

The paper combines inventory theory with health economics to calculate the impact inventory increases would have on the final cost of pneumonia treatment. It can then assess to what extent inventory can be increased while pneumonia treatment remains cost effective.

The study finds that more drug investment has only a small effect on the final treatment cost. Substantial drug inventory increases remain well within established guidelines for highly cost-effective treatments, so the agency should consider large increases as an efficient use of funding.

The study focuses on pneumonia treatment only to allow sufficient depth of analysis. Further research could look at many other treatments using the same approach, although some problem scenarios will include complicating parameters like drug perishability.

The level of pharmaceutical inventory at humanitarian warehouses is a high-value decision for the aid sector. The method shows the potential for health economics to provide practical decision support for a wide range of humanitarian and ministry of health warehouse operations. While large increases in inventory investment are within guidelines, there is an asymptotically increasing cost as demand coverage approaches 100%. As a result, decision makers may want to set a target demand coverage (e.g. 99%) and allocate remaining aid funding to other projects.

Many humanitarian supply chain decisions lack analytical support due to issues with complexity, scale or a lack of reliable input data, and this study is the first to provide analytical insights which can greatly improve the current approach to inventory control policies for pneumonia medications and beyond.

Timely administration of antimicrobials in patients with community‐acquired pneumonia is now a standard of care. The purpose of this paper is to present a large observational study to understand the issues that result in a delay in the administration of antibiotics to patients with community‐acquired pneumonia

This prospective study involved all six hospitals in the Edmonton area: patients were enrolled at the time of hospitalization if they were adults aged ≥17 years with a clinical presentation consistent with community‐acquired pneumonia. A retrospective chart review was performed to determine the reasons why it took more than eight hours to administer the first dose of antibiotics.

The paper finds that of all 3,394 hospitalized patients, 646 (19.0 percent) received antibiotics over four hours after admission to the emergency department and in most instances the delay was more than 12 hours. A total of 30 percent of the delays were justifiable – 17 percent due to diagnostic indecision and 13 percent due to recent receipt of an antibiotic at home or at another institution prior to transfer. All the other delays were unnecessary and easily correctable. In this paper the data indicate that only 5.6 percent of 3,394 patients had an adequate reason for delay in antibiotic administration. Thus a reasonable target for timely administration of antibiotics is at least 90 percent of the patient population.

The strengths of this study lie in its large number of patients, inclusiveness and real world context.

This paper aims to explore the development trend of OA articles and their advantages and disadvantages in the process of fighting the pandemic, and conduct a multi-level and multi-angle analysis of the relationship between publishing costs and the influence of OA articles.

This study first compares the total number of articles in Web of Science with the number of OA articles, and the total number of COVID-19 related articles with the total number of OA articles. Subsequently, using the methods of institutional cooperation co-occurrence network, keyword co-occurrence and multidimensional scale analysis, and using the literature on the topic of COVID-19 in CNKI (Chinese National Knowledge Infrastructure) as the data set, we generate visualized maps of research results distribution and keyword co-occurrence network with the help of the Statistical Analysis Toolkit for Infometrics (SATI)

The research results show that the citation frequency and use frequency of OA articles related to COVID-19 are significantly higher than that of non-OA articles. OA articles dominate in the anti-pandemic process, with a series of advantages such as short review cycle, timeliness, high social benefit, high participation and fast dissemination playing an important role. Under the model of author's non-payment for OA article, the degree of institutional cooperation and author cooperation is enhanced, which improves the fluidity of knowledge, strengthens close links between keywords and enhances significant academic influence; OA articles will continue to promote research in the field of COVID-19, but the lack of quality of some OA articles may hinder their development. Then OA articles will further focus on clinical medicine, and related results will continue to promote the development and communication of OA articles in this field.

Corresponding measures are also proposed for the existing problems of OA articles, to provide a reference for the publication and dissemination of OA articles in public health emergencies in the future.

This study aims to evaluate the quality of a speech and language therapy (SLT) swallow service provided to adults with intellectual disability (ID) by exploring the process and outcome factors; to explore the process of what is done to and for the patient including identifying dysphagia, choking and pneumonia risk, typical interventions and management; examine clinical outcomes; and explore the relationship of outcomes with risk factors, satisfaction with the service and the impact of the service on the number of choking incidents and admissions to acute hospital with swallow concerns.

There were three specific work packages: (1) collecting and scrutinising patient data from the clinical record for adults with ID referred to the SLT swallow service over a six-month period. The researcher created aims, defined the limits to achieve the aims, designed a standardised data collection form, set out where data was in the clinical record, piloted, set limits for collection and trained reviewers; (2) gathering experience and satisfaction surveys from patients, caregivers and referrers over the six-month study period; and (3) monitoring choking adverse incident reports and hospital admission with swallow concerns for the whole ID population.

Choking and hospital admission were the main reasons for referral, and pneumonia risk significantly predicted dysphagia impairment. The research highlighted common dysphagia risk factors, interventions and recommendations for this population. The SLT swallow service is a quality service that is highly valued by patients, their caregivers and referrers. The service achieves significant clinical improvements, helps identify dysphagia and provides management to reduce associated risks.

This study found common dysphagia risk factors, interventions and recommendations; it also found that the therapy outcome measures/Royal College of Speech and Language Therapy online outcome tool was a meaningful outcome measure, and that pneumonia risk significantly predicted dysphagia impairment, all of which could inform the identified dysphagia research priorities for this population.

Naming usual care in treatment and recommendations could help ensure a fair service and could help form quality indicators. People with ID, their caregivers and staff generated valuable ideas for improvement, and further involvement work could create a logic model for the service. Other future work could explore the use of screening tools, increase multidisciplinary team working, improve access to instrumental assessments, raise awareness of swallowing and promote important oral health and medication reviews. By using this information to shape quality improvement work and policies, one can work toward addressing high health-related inequalities and preventable deaths associated with dysphagia in this vulnerable population.

It may be useful to raise awareness that adults with ID age earlier and that one should not exclude them from older people’s services because of an age threshold, often set higher than their life expectancy. This study highlighted a possible inequality of access issue for adults with ID who do not have direct care or day care staff. There is a need to increase access to awareness training so caregivers and general practitioners can recognise swallow difficulties and know how to make a referral for a swallow assessment.

Overall, the evaluation of the swallow service to adults with ID suggests that SLT have a quality service for adults with ID that is highly valued and provides significant clinical improvements. By building on these strengths, SLT could extend the reach, influence and impact of their services to help those adults with ID who have emerging swallow difficulties or who do not access the service.

The paper aims to study the relationship between hospital quality and hospital profits for a sample of 88 Alabama hospitals.

Quality is measured by three groups of procedures performed on newly admitted patients as suggested by the health quality alliance (HQA). Profit is measured for eight hospital services. Regression analyses tested the underlying relationships.

Quality of care for newly admitted cardiac and pneumonia patients are indicators of quality translatable into profits. Given a choice between the two, the pneumonia procedures were more effective in predicting profits.

As one of the early extensions of the HQA methodology, this paper does demonstrate linkages between quality and profits. Total number of employees was not significant, but governmental versus non‐governmental hospital analyses provide promise for future research.