The International classification of diseases and related health problems, 11th revision (ICD-11) includes an organized system of linked biomedical concepts and hierarchical coding tables called linearizations, of which the most important is the ICD-11 for Mortality and Morbidity Statistics. A publicly accessible web-based platform supports the dynamic maintenance of ICD-11 content, including proposals for modifications, based on scientific evidence and clinical relevance. This paper describes how proposals submitted through the platform are reviewed by the ICD-11 Medical and Scientific Advisory Committee. We analysed World Health Organization data on proposals to modify ICD-11 entities submitted between 2021 and 2025, according to proposal source, subject area, proposal type, time to decision and outcome. The advisory committee reviewed 256 proposals concerning 92% (24/26) of ICD-11 chapters. Proposals were submitted by international bodies, individual practitioners, patient advocacy groups and scholarly societies, with similar acceptance rates across groups. The most common proposal type was the addition of an entry, which had an acceptance rate 65% (81/125); followed by the deletion of an obsolete entity, which had an acceptance rate of 77% (44/57). The mean time to decision was 13.8 months. Overall, 69% (176/256) of proposals were recommended for adoption. These findings indicate that the advisory committee's review process is functioning adequately, with reasonable acceptance rates following scientific scrutiny. Outreach should be considered to encourage submissions in chapters with few updates between 2021 and 2025. Turnaround time may improve with the expansion of the advisory committee's membership and clearer guidance on proposal quality.
Objective:To assess the feasibility of fixed-dose, praziquantel preventive chemotherapy against schistosomiasis in young children in rural Madagascar, focusing on treatment uptake and sustainability. Methods:We used the Consolidated Framework for Implementation Research to guide the study. Between November 2022 and December 2023, children aged 9 to 24 months at various venues were offered 300 mg of praziquantel as a crushed half tablet mixed with water and sugar. We conducted a cross-sectional survey among caregivers to assess treatment uptake and acceptability, children's compliance with drug administration, anxiety about adverse events, and praziquantel's tolerability and safety. Factors associated with uptake and acceptability were identified using Poisson regression. Findings:The study analysis included 5142 child-caregiver pairs. The praziquantel uptake rate was 86.2% (95% confidence interval, CI: 85.3-87.1) and 80.2% (95% CI: 79.1-81.3) of caregivers regarded repeated preventive chemotherapy acceptable. Clear anxiety, and uncertainty, about adverse events were the most significant factors associated with refusal of both initial and repeated treatment. No children experienced serious adverse events or choking. Of the 4434 children who received praziquantel, 152 (3.4%) swallowed a partial dose, whereas 2467 (55.6%) cried and 1833 (41.3%) initially resisted treatment, but ultimately received it. Conclusion:Fixed-dose praziquantel preventive chemotherapy using a crushed half tablet with water and sugar was feasible in preschool-aged children and was potentially sustainable. This approach has a strong potential for scaling up in areas where schistosomiasis is highly endemic.
Objective:To estimate the volume and patterns of antimicrobial sale for food-producing animals in Bangladesh and to provide evidence to support national policy decisions. Methods:We used the World Organisation for Animal Health tool (animal antimicrobial use calculation module) for data collection and calculation of quantities of antimicrobials used in animals. We collected data on the overall amount of antimicrobials sold for use in food-producing animals, disaggregated by antimicrobial class, active molecule and route of administration. Findings:In 2023, 475 750 kg of antimicrobials were sold for use in animals across 301 products and 38 molecules. Oral administration accounted for 95.91% (456 301/475 750) of total antimicrobials sold. Tetracyclines were the most sold antimicrobial class, accounting for 32.22% (153 274/475 750) of antimicrobials sold for use in food-producing animals. The second most-sold class was aminoglycosides at 19.77% (94 044/475 750) of total sales. As regards to active molecules, chlortetracycline, neomycin, ceftriaxone, oxytetracycline, metronidazole, sulfamethoxazole, ciprofloxacin and enrofloxacin accounted for 79.34% (377 438/475 749) of the total national antimicrobial sale. Just over one fifth of the antimicrobials sold belong to classes considered to be highest priority critically important antimicrobials for humans (according to the World Health Organization's list). These classes were third- and fourth-generation cephalosporins, fluoroquinolones, other quinolones and polymyxins. Conclusion:Our findings highlight antimicrobial overuse and misuse in food-producing animals in Bangladesh and the need for policy interventions to combat antimicrobial resistance. Our report provides baseline data to support Bangladesh's National action plan on antimicrobial resistance and enable evidence-based policy development and strengthening of antimicrobial stewardship in the veterinary sector.
Objective:To assess the market landscape of penicillin formulations used for the treatment of syphilis and rheumatic heart disease in the World Health Organization South-East Asia Region. Methods:We analysed market data for five essential penicillin formulations across nine countries in the South-East Asia Region using a survey form to collect data on product registration, inclusion in national essential medicines lists, procurement, availability, pricing and demand forecasting. Findings:Substantial disparities exist in registration status, procurement and pricing across the region. The price of benzathine benzylpenicillin 1.2 million international units (IU) in Timor-Leste was over 23 times higher than in Bangladesh (3.45 United States dollars, US$, versus US$ 0.15), while the price for 2.4 million IU varied by up to 55-fold across the region. Several countries reported supply issues, including shortages of benzathine benzylpenicillin in India, Maldives, Myanmar, Thailand and Timor-Leste; aqueous benzylpenicillin in Sri Lanka during the 2022 economic crisis; and supply disruptions of phenoxymethylpenicillin 250 mg in Maldives and Sri Lanka. Morbidity-based estimates indicated annual regional demand of 171 966 061 vials of benzathine benzylpenicillin 2.4 million IU and 923 053 121 tablets of phenoxymethylpenicillin 250 mg, with corresponding costs of US$ 62 127 441 and US$ 48 005 181, respectively. India has the highest demand of these two formulations. Conclusion:Differences in registration, procurement, pricing and forecasting undermine reliable access to penicillin products in the South-East Asia Region. Stronger regional collaboration, improved forecasting, harmonized regulatory approaches and pooled procurement strategies are needed to secure equitable and sustainable access.
Problem:Current laboratory assessment tools aimed at improving bacteriology and testing for antimicrobial resistance focus on quality of laboratory services. No guidance exists for establishing bacteriology services necessary for diagnosis and surveillance of antimicrobial resistance in low- and middle-income countries. Approach:Comprehensive laboratory needs assessment tools and procurement catalogues were developed, piloted and used by the Fleming Fund programme. These tools were designed to support the strengthening of bacteriology testing capacity within national antimicrobial resistance surveillance systems receiving Fleming Fund support. Setting:The tools were used in reference laboratories and surveillance sites for antimicrobial resistance in 24 countries in the African, South-East Asia and Western Pacific regions, comprising 341 clinical, veterinary, aquaculture, food safety and environmental laboratories. Relevant changes:The needs assessment tool provides a structured framework for laboratory renovation and installation of bacteriology testing equipment. The procurement catalogues list reagents and consumables for antimicrobial resistance surveillance of priority pathogens in humans in the World Health Organization Global Antimicrobial Resistance and Use Surveillance System and selected bacteria in terrestrial and aquatic food-producing animals. Combined with training and capacity-building initiatives supported through other Fleming Fund investments, these efforts have substantially enhanced diagnostic capacity for bacterial infections and antimicrobial resistance surveillance in the laboratories. Lessons learnt:These tools were instrumental in identifying gaps to enhance bacteriology laboratory capacity and capabilities and became an essential resource for procurement, tracking supplies and asset management. The tools are adaptable and can strengthen laboratory capacity in settings and health programmes beyond bacteriology and antimicrobial resistance surveillance.
Maternal mortality, defined as the death of a woman during pregnancy or shortly after childbirth, is a key target of the sustainable development goals. Yet, in many low- and middle-income countries, accurate measurement of maternal mortality remains a major challenge. Reliable death registration systems are often incomplete or absent, making it difficult to calculate the maternal mortality ratio. However, opportunities exist to improve measurement. In about two thirds of low- and middle-income countries, more than 80% of births now occur in health facilities. This shift means that health facilities can serve as a valuable source of data not only for local quality improvement but also for informing population mortality estimates. However, this requires high-quality data. To improve the quality of facility-based data, we propose four simple quality metrics: (i) plausibility of reported national and subnational levels and patterns; (ii) the ratio of reported stillbirths to maternal deaths; (iii) the distribution of causes of death; and (iv) the share of deaths among women aged 35 years and older. Using data from the United Republic of Tanzania as an example, we show how these metrics can be applied to assess the completeness and internal consistency of routine health data systems. Our example aims to encourage quality assessment of facility-based data in other countries, alongside: (i) individual death reporting using standardized classification of causes of death; (ii) centralized data quality assessment based on the proposed metrics; and (iii) regular national on-site assessment of the completeness and accuracy of maternal and perinatal death reporting.
Umbrella protocols have recently come to be widely used in clinical trial designs. However, the value of this approach in public health is less well recognized. The coronavirus disease 2019 (COVID-19) pandemic highlighted the need for rapid, reliable and scalable evaluation of diagnostic technologies. In the United Kingdom of Great Britain and Northern Ireland, this need prompted the development of an umbrella research protocol enabling multiple clinical evaluation studies of similar designs to be undertaken under a single overarching preapproved ethics and governance framework. We describe the development, implementation and evolution of this protocol, which was designed to support timely assessment of the performance of in vitro diagnostic devices and associated testing approaches in various settings. The umbrella protocol allowed studies to be started quickly during the pandemic, reduced administrative burdens, supported regulatory submissions and enabled prospective collection of samples for surveillance. While the system described reflects British governance structures, the principles underpinning this approach, including proportionality (ensuring oversight requirements are appropriate to the risk level), standardization and preapproved flexibility, are applicable to many settings. The protocol now forms part of the United Kingdom's wider pandemic preparedness structure and illustrates how preapproved, adaptable research frameworks can accelerate evidence generation during outbreaks. The world is now assessing lessons from the COVID-19 pandemic and it is timely to consider how research systems can support innovative designs such as umbrella protocols. We therefore summarize lessons learnt and practical considerations to support other countries seeking to adopt similar approaches within their own ethical and regulatory systems.
Problem:The World Health Organization recommends a benchmark for uncorrected visual acuity of ≥ 6/12 in 80% of patients at 4 to 6 weeks following cataract surgery. In low-resource countries, reaching this benchmark is challenging and assessing progress is difficult. Approach:This intervention involved modest investments recommended by the Better Operative Outcome Software Tool (BOOST) application (app). The investments targeted specific causes of poor cataract surgery results at hospitals in Ethiopia to improve vision outcomes. Fifteen ophthalmic surgeons from 11 public secondary and tertiary eye care centres in five regional Ethiopian states collected pre-intervention data using the BOOST app. Based on 20 consecutive patients with vision < 6/60, BOOST identified case selection, intraoperative complications or postoperative refractive error as the leading causes of poor outcomes. Each facility then invested 2500 United States dollars (US$) to target its leading cause, recorded outcomes for 60 consecutive cataract patients, and then compared the proportion with uncorrected vision ≥ 6/12 before and after the intervention. Local setting:All 11 centres are Orbis International partners and services provided at the facilities are highly subsidized or free of charge. Relevant changes:After implementing targeted interventions at the facilities to address undetected ocular comorbidity, surgical complications or postoperative refractive errors, 501 (56.0%) of 894 patients had good results (≥ 6/12), compared to 289 (32.2%) of 897 patients before the intervention. Lessons learnt:Using the BOOST app as an approach for quality monitoring and improvement enables benchmarking across contexts and can enhance surgical outcomes when paired with recommended targeted investments.
Objective:To determine tuberculosis prevalence among health-care facility patients and to assess the effectiveness of chest radiography in facility-based tuberculosis screening. Methods:Our cross-sectional analysis used individual-level data collected during 2020-2023 from adults presenting at 796 health-care facilities participating in a public-private partnership in 15 provinces of Viet Nam. We constructed tuberculosis care cascades stratified by symptomatic presentation according to the World Health Organization (WHO) four-symptom screening and chest radiography. We reported diagnostic yield, number needed to screen and positivity. Findings:Among 1 423 818 participants, 22 598 had bacteriologically confirmed tuberculosis. Diagnostic yields were 2.2% (19 289/892 894) among symptomatic individuals with cough, 1.0% (1869/191 677) among symptomatic individuals without cough and 0.4% (1440/339 247) among asymptomatic individuals. Tuberculosis-suggestive chest radiograph results compared with normal results increased bacteriologically confirmed positivity by 9.4 percentage points in symptomatic individuals with cough (17.3%; 18 746/108 650 versus 7.9%; 543/6851), by 4.6 percentage points in symptomatic individuals without cough (12.6%; 1748/13 831 versus 8.0%; 121/1515) and by 7.6 percentage points in asymptomatic individuals (15.0%; 1328/8862 versus 7.4%; 112/1511). Without chest radiography, the number of individuals requiring testing to detect tuberculosis among symptomatic individuals with cough and without a cough would have been 6.5 (1 084 571/165 679) and 5.4 (892 894/165 679) times higher, respectively. Conclusion:Chest radiograph screening can reduce the number of expensive molecular tests used in symptomatic patients and enable tuberculosis diagnosis in asymptomatic patients. Future research should analyse cost and cost-effectiveness of using chest radiography in active and intensified case finding.
In 2024, the Lancet Commission on Investing in Health proposed targeting investment in 15 priority conditions through 19 modular interventions to improve global health by 2050. While pragmatic, this approach may not fully capture the complex-adaptive nature of health and health systems, nor their social, economic and political determinants. In an iterative, interpretive analysis, proposed global health investment frameworks were mapped against complexity, systems thinking and health epistemology frameworks; five thematic areas were identified for further development: (i) health as emergent from interdependent, social-biological systems; (ii) the non-biomedical determinants driving inequities; (iii) health systems' adaptive requirements; (iv) epistemic injustices that marginalize non-Western perspectives; and (v) the need for context-sensitive, community-led implementation of health measures. Recent major disruptions to international aid financing, while challenging, present a unique opportunity to redesign health investment on more sustainable and locally grounded foundations, where national governments deliberately invest in the social determinants of health as direct health improvement strategies rather than merely as adjacent social policy. To seize this opportunity, we propose five guiding principles for policy-makers: (i) community co-production of interventions; (ii) adaptive governance structures; (iii) complex systems literacy in workforce training to navigate interdependencies and uncertainty; (iv) cross-sectoral partnerships to address determinants of health; and (v) context-sensitive metrics that incorporate community engagement to support learning within health systems. These are not optional enhancements to existing approaches; they are the foundations without which any health investment strategy will continue to treat the symptoms of inequity rather than its causes.
Problem:A 6.4-magnitude earthquake struck Jajarkot district in Karnali province, Nepal, on 3 November 2023, disrupting electricity supply at essential birthing centres and health posts. The loss of power disabled baby warmers and heating systems, putting mothers and babies at risk. Approach:The World Health Organization (WHO) Country Office in Nepal conducted rapid facility assessments across eight municipalities and identified three priority birthing centres with critical power deficits. In partnership with the health ministry and local authorities, WHO identified local vendors to install hybrid 5.45 kW photovoltaic systems within 17 days of contract initiation to ensure continuous, off-grid power supply. Local setting:The three facilities, serving over 7500 people, are located in steep, mountainous terrain. One of the facilities had no grid connection and the two others relied on unreliable seasonal hydropower, which fails during the winter dry season. Relevant changes:By the end of December 2023, the hybrid photovoltaic systems were operational, providing 24-hour electricity supply. Baby warmers and room heaters were in continuous use, reducing newborn hypothermia risk. Institutional deliveries increased: Pajaru Kha Health Post recorded five deliveries in two weeks following installation compared with none during the preceding winter period (October-December 2023). Lessons learnt:The installation was facilitated by rapid assessment, early engagement of pre-identified local vendors, and use of existing supply chains and technical capacity. Strong coordination among WHO, the health ministry and local governments enabled timely decision-making. Prior health cluster coordination training, clear governance mechanisms, streamlined approvals and access to emergency funding helped maintain momentum and ensure on-schedule procurement and installation.
