During the COVID-19 pandemic, intellectual property licensing through bilateral agreements and the Medicines Patent Pool were used to facilitate access to new COVID-19 therapeutics in low- and middle-income countries (LMICs). The lessons learnt from the application of the model to COVID-19 could be relevant for preparedness and response to future pandemics and other health emergencies.The speed at which affordable versions of a new product are available in LMICs is key to the realization of the potential global impact of the product. When initiated early in the research and development life cycle, licensing could facilitate rapid development of generic versions of innovative products in LMICs during a pandemic. The pre-selection of qualified manufacturers, for instance building on the existing network of generic manufacturers engaged during the COVID-19 pandemic, the sharing of know-how and the quick provision of critical inputs such as reference listed drugs (RLDs) could also result in significant time saved. It is important to find a good balance between speed and quality. Necessary quality assurance terms need to be included in licensing agreements, and the potentials of the new World Health Organization Listed Authority mechanism could be explored to promote expedited regulatory reviews and timely access to safe and quality-assured products.The number, capacity, and geographical distribution of licensed companies and the transparency of licensing agreements have implications for the sufficiency of supply, affordability, and supply security. To foster competition and support supply security, licenses should be non-exclusive. There is also a need to put modalities in place to de-risk the development of critical pandemic therapeutics, particularly where generic product development is initiated before the innovator product is proven to be effective and approved. IP licensing and technology transfer can be effective tools to improve the diversification of manufacturing and need to be explored for regional manufacturing for accelerated access at scale in in LMICs and supply security in future pandemics.

Urban inequalities are exacerbated due to rapid urbanisation. This is also evident within slums in low- and middle-income countries, where high levels of heterogeneity amongst the slum population lead to differential experiences in Water, Sanitation, and Hygiene (WASH) and housing access. This scoping review provides evidence of the interconnection of WASH and housing and presents barriers to access and the consequences thereof for slum dwellers. It does so while considering the social stratification amongst urban slum dwellers and their lived experiences. A systematic search of journal articles was conducted in November 2022 in PubMed, Scopus, and Web of Science. A total of 33 papers were identified which were full text reviewed and data extracted. Infrastructure, social and cultural, socio-economic, governance and policy and environmental barriers emerged as general themes. Barriers to WASH and housing were more frequently described concerning women and girls due to gender norms within WASH and the home. Barriers to WASH lead to compromised health, socio-economic burdens, and adverse social impacts, thus causing residents of slums to navigate their WASH mobility spatially and over time. Insights from this review underscore the need for an intersectional approach to understanding access inequalities to WASH and housing.

Antimicrobial resistance (AMR) is a global public health crisis that impedes the therapeutic effectiveness of available antimicrobial agents. Due to the high burden of infectious diseases and limited resources, especially trained healthcare professionals, low- and middle-income countries (LMICs) are particularly susceptible to the detrimental effects of AMR. Sometimes, as the first and last point of contact for patients seeking treatment for infections, community pharmacists can play a pivotal role in the stewardship required for AMR. This review aims to highlight the contributions made by community pharmacists in LMICs as AMR stewards. The review considers the challenges from the perspectives of limited resources, inadequate training, a lack of policies and regulations, and issues related to patient behavior. Community pharmacists in LMICs could optimize their advocacy contributions by focusing on One Health AMR stewardship. Transformational and actionable patient and population-centric antimicrobial stewardship (AMS) is feasible with the synergy of policymakers and other healthcare providers in the implementation of AMS policies and programs that support community pharmacists in their efforts to promote rational antimicrobial use.

Among the multiple factors impeding equitable childhood immunization coverage in low- and middle-income countries (LMICs), gender barriers stand out as perhaps the most universal. Despite increasing recognition of the importance of gender considerations in immunization programming, there has not yet been a systematic assessment of the evidence on gender barriers to immunization. We conducted a scoping review to fill that gap, identifying 92 articles that described gender barriers to immunization. Studies documented a range of gender influencers across 43 countries in Africa and South Asia. The barrier to immunization coverage most frequently cited in the literature is women\'s lack of autonomous decision-making. Access to immunization is significantly impacted by women\'s time poverty; direct costs are also a barrier, particularly when female caregivers rely on family members to cover costs. Challenges with clinic readiness compound female caregiver\'s time constraints. Some of the most important gender barriers lie outside of the usual purview of immunization programming but other barriers can be addressed with adaptations to vaccination programming. We can only know how important these barriers are with more research that measures the impact of programming on gender barriers to immunization coverage.

Objectives: Fewer than one-fifth of all studies on gender-affirming care originate from low- and middle-income countries (LMICs). This is the first systematic review to examine surgical demographics and outcomes following gender-affirming surgery (GAS) in LMICs. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, five databases were systematically searched for original studies and case series on GAS within LMIC settings. Excluded reports included animal studies, non-English language studies, secondary studies including reviews, individual case reports and conference abstracts. Results: This review includes 34 studies involving n = 5064 TGNB individuals. Most studies (22, 64.7%) were from upper-middle-income countries, followed by lower-middle-income countries (12, 35.3%). A total of 31 studies (91.2%) reported on post-operative outcomes. Of n = 5013 patients who underwent GAS, 71.5% (n = 3584) underwent masculinizing and 29.5% (n = 1480) underwent feminizing procedures. The predominant procedures were metoidioplasty (n = 2270/3584, 63.3%) and vaginoplasty (n = 1103/1480, 74.5%). Mean follow-up was 47.7 months. In patients who underwent metoidioplasty, 6.8% (n = 155) of patients experienced a complication and 6.3% (n = 144) underwent revision surgery. In patients who underwent vaginoplasty, 11.5% (n = 127) of patients experienced a complication and 8.5% (n = 94) underwent revision surgery. Of the studies (25/34, 73.5%) that reported on quality of life and post-operative satisfaction, the majority showed marked improvements in psychosocial and functional outcomes. Notably, no post-surgical regret was reported among the surveyed patients. Conclusions: Existing literature on GAS in LMICs remains scarce and is concentrated in select institutions that drive specific procedures. Our review highlights the low reported volumes of GAS, variability in surgical outcomes and quality of life.

BACKGROUND: Brain tumors pose a significant threat to public health, with high rates of mortality and morbidity, affecting individuals of all ages and having a significant impact on healthcare systems. Limited neurosurgical workforces remain one of the critical problems experienced in low resource settings.
OBJECTIVE: To explore and summarize the key challenges to neurosurgical care of brain tumors in terms of workforce in LMICs METHODS: A comprehensive literature search was conducted using Scopus, PubMed, CINAHL, and Google Scholar from inception to October 20, 2022. All extracted data was screened independently by two reviewers and thematically analyzed.
RESULTS: We found and screened 3764 articles, of which 33 studies were included in our final analysis as per our inclusion criteria. Among the studies included, 33% highlighted the limited number of neurosurgeons, 39% emphasized the absence of specialized surgical teams, 7% pointed out a shortage of nursing staff, and 4% noted suboptimal anesthesia teams. The study uncovered the need for improved training programs in neuro-oncology (32%) and neuro-anesthesia (3%), as well as improved collaboration (32%) and multidisciplinary team structures (15%), are essential for tackling these workforce challenges and improving patient outcomes.
CONCLUSIONS: It is crucial to implement targeted interventions and policy changes to address the barriers to the workforce in providing effective neurosurgical care to patients with brain tumors in developing countries. This might entail capacity building and training programs for healthcare professionals. Policymakers should consider allocating resources and funding for workforce development and making neurosurgical care a priority in healthcare plans.

BACKGROUND: Exposure to ambient fine particulate matter (PM2.5) has been associated with reduced human fecundity. However, the attributable burden has not been estimated for low- and middle-income countries (LMICs), where the exposure-response function between PM2.5 and the infertility rate has been insufficiently studied.
OBJECTIVE: This study examined the associations between long-term exposure to PM2.5 and human fecundity indicators, namely the expected time to pregnancy (TTP) and 12-month infertility rate (IR), and then estimated PM2.5-attributable burden of infertility in LMICs.
METHODS: We analyzed 164,593 eligible women from 100 Demographic and Health Surveys conducted in 49 LMICs between 1999 and 2021. We assessed PM2.5 exposures during the 12 months before a pregnancy attempt using the global satellite-derived PM2.5 estimates produced by Atmospheric Composition Analysis Group (ACAG). First, we created a series of pseudo-populations with balanced covariates, given different levels of PM2.5 exposure, using a matching approach based on the generalized propensity score. For each pseudo-population, we used 2-stage generalized Gamma models to derive TTP or IR from the probability distribution of the questionnaire-based duration time for the pregnancy attempt before the interview. Second, we used spline regressions to generate nonlinear PM2.5 exposure-response functions for each of the two fecundity indicators. Finally, we applied the exposure-response functions to estimate number of infertile couples attributable to PM2.5 exposure in 118 LMICs.
RESULTS: Based on the Gamma models, each 10 µg/m3 increment in PM2.5 exposure was associated with a TTP increase by 1.7 % (95 % confidence interval [CI]: -2.3 %-6.0 %) and an IR increase by 2.3 % (95 %CI: 0.6 %-3.9 %). The nonlinear exposure-response function suggested a robust effect of an increased IR for high-concentration PM2.5 exposure (>75 µg/m3). Based on the PM2.5-IR function, across the 118 LMICs, the number of infertile couples attributable to PM2.5 exposure exceeding 35 µg/m3 (the first-stage interim target recommended by the World Health Organization global air quality guidelines) was 0.66 million (95 %CI: 0.061-1.43), accounting for 2.25 % (95 %CI: 0.20 %-4.84 %) of all couples affected by infertility. Among the 0.66 million, 66.5 % were within the top 10 % high-exposure infertile couples, mainly from South Asia, East Asia, and West Africa.
CONCLUSIONS: PM2.5 contributes significantly to human infertility in places with high levels of air pollution. PM2.5-pollution control is imperative to protect human fecundity in LMICs.

UNASSIGNED: Digital technology has the potential to support or infringe upon human rights. The ubiquity of mobile technology in low- and middle-income countries (LMICs) presents an opportunity to leverage mobile health (mHealth) interventions to reach remote populations and enable them to exercise human rights. Yet, simultaneously, the proliferation of mHealth results in expanding sensitive datasets and data processing, which risks endangering rights. The promotion of digital health often centers on its role in enhancing rights and health equity, particularly in LMICs. However, the interplay between mHealth in LMICs and digital rights is underexplored. The objective of this scoping review is to bridge this gap and identify digital rights topics in the 2022 literature on mHealth in Southeast Asian LMICs. Furthermore, it aims to highlight the importance of patient empowerment and data protection in mHealth and related policies in LMICs.
UNASSIGNED: This review follows Arksey and O\'Malley\'s framework for scoping reviews. Search results are reported using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist. Frequency and content analyses were applied to summarize and interpret the data.
UNASSIGNED: Three key findings emerge from this review. First, the digital rights topics covered in the literature are sparse, sporadic, and unsystematic. Second, despite significant concerns surrounding data privacy in Southeast Asian LMICs, no article in this review explores challenges to data privacy. Third, all included articles state or allude to the role of mHealth in advancing the right to health.
UNASSIGNED: Engagement in digital rights topics in the literature on mHealth in Southeast Asian mHealth is limited and irregular. Researchers and practitioners lack guidance, collective understanding, and shared language to proactively examine and communicate digital rights topics in mHealth in LMIC research. A systematic method for engaging with digital rights in this context is required going forward.

BACKGROUND: Decentralization of a health system is a complex and multidimensional phenomenon that demands thorough investigation of its process logistics, predisposing factors and implementation mechanisms, within the broader socio-political environment of each nation. Despite its wide adoption across both high-income countries (HICs) and low-and-middle-income countries (LMICs), empirical evidence of whether decentralization actually translates into improved health system performance remains inconclusive and controversial. This paper aims to provide a comprehensive description of the decentralization processes in three countries at different stages of their decentralization strategies - Pakistan, Brazil and Portugal.
METHODS: This study employed a systematic analysis of peer-reviewed academic journals, official government reports, policy documents and publications from international organizations related to health system decentralization. A comprehensive search was conducted using reputable databases such as PubMed, Google Scholar, the WHO repository and other relevant databases, covering the period up to the knowledge cutoff date in June 2023. Information was systematically extracted and organized into the determinants, process mechanics and challenges encountered during the planning, implementation and post-decentralization phases. Although decentralization reforms have achieved some success, challenges persist in their implementation. Comparing all three countries, it was evident that all three have prioritized health in their decentralization reforms and aimed to enhance local decision-making power. Brazil has made significant progress in implementing decentralization reforms, while Portugal and Pakistan are still in the process. Pakistan has faced significant implementation challenges, including capacity-building, resource allocation, resistance to change and inequity in access to care. Brazil and Portugal have also faced challenges, but to a lesser extent. The extent, progress and challenges in the decentralization processes vary among the three countries, each requiring ongoing evaluation and improvement to achieve the desired outcomes.
CONCLUSIONS: Notable differences exist in the extent of decentralization, the challenges faced during implementation and inequality in access to care between the three countries. It is important for Portugal, Brazil and Pakistan to address these through reinforcing implementation strategies, tackling inequalities in access to care and enhancing monitoring and evaluation mechanism. Additionally, fostering knowledge sharing among these different countries will be instrumental in facilitating mutual learning.

OBJECTIVE: To evaluate the current state of neurosurgical care in Central Asia, identify the challenges and advancements, and propose recommendations to improve neurosurgical capabilities and access in Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan.
METHODS: A comprehensive review of the neurosurgical infrastructure, availability of neurosurgeons, technological advancements, and healthcare policies in the five Central Asian countries. Analysis included published literature, healthcare reports, and expert opinions to assess the state of neurosurgical care and identify areas for improvement.
RESULTS: Significant variation in neurosurgical care was observed across the region. Kazakhstan showed notable advancements, including an increased number of neurosurgeons and progress in specialized fields such as vascular neurosurgery and brain tumor management. Other countries, like Uzbekistan, Tajikistan, and Kyrgyzstan, made strides in improving neurosurgical care but still faced substantial challenges. Common issues included a shortage of neurosurgeons, limited facilities, and inadequate access to modern technology. The lack of research data further highlighted the need for urgent intervention.
CONCLUSIONS: To enhance neurosurgical care in Central Asia, a multipronged approach involving targeted investments, policy reforms, international collaborations, and knowledge sharing is recommended. This includes establishing specialized neurosurgical training programs and fellowships, investing in infrastructure and technology, fostering international collaborations for training and research, introducing early neurosurgery education in medical schools, improving access to online education resources, and promoting telemedicine for consultations and follow-up care. These measures are necessary to expand access to essential neurosurgical care and improve outcomes in the regions.