The clinical course of noma explains why survival has historically dominated the care agenda. The disease, whose exact aetiology remains incompletely understood but is associated with severe malnutrition, poor oral hygiene, infectious diseases such as measles and profound poverty, advances through stages that can progress from gingival inflammation to extensive orofacial gangrene with alarming speed. Without prompt treatment with antibiotics, nutrition support and wound care, mortality is high. For those who survive, the consequences are lifelong: altered facial appearance, impaired ability to eat and speak, trismus that restricts jaw movement, and the need for multiple reconstructive operations spread over years. For decades, the measure of success in noma care has been survival, wound closure and surgical reconstruction. But as Fastenau emphasizes, survival is not recovery. A child who lives through noma may then face exclusion from school, ridicule and discrimination, restricted opportunities for employment and relationships, and a deeply internalized sense of shame that no operation can simply excise.

The quantitative evidence behind this argument has grown sharply in recent years, and it is difficult to dismiss. A 2026 cross-sectional study of 244 children aged 6 to 16 years with noma-related facial disfigurement, conducted at the Noma Children’s Hospital in Sokoto, Nigeria, found clinically significant depressive symptoms in 76.6 percent of participants, with girls particularly affected. The authors of that study were careful to note its limitations: it was a single specialist-centre population dealing with severe sequelae, and screening for depressive symptoms cannot be equated with a formal psychiatric diagnosis. Even so, the magnitude of the finding is striking. Research from Ethiopia has similarly documented substantial psychosocial and functional morbidity among people living with untreated noma sequelae, painting a consistent picture across endemic settings. When three out of four children screened at a specialist hospital show depressive symptoms of clinical significance, the argument that more evidence is needed before action becomes, as the PLOS Mental Health article puts it, increasingly difficult to defend.

Fastenau frames this situation as a second neglect, a concept that gives the article its analytical force. The first neglect is the familiar one: preventable and treatable disease allowed to progress because poverty, malnutrition, weak health systems and delayed access to care remain unaddressed across the regions where noma occurs. The second neglect begins after survival, when visible disfigurement, stigma, psychological distress and social exclusion are treated as secondary consequences rather than as part of the disease burden itself. This framing matters because it changes what health systems are obliged to count. If psychological suffering is an integral component of noma, then a programme that reconstructs faces while leaving depression, anxiety and internalized stigma untreated has addressed only part of the disease, and its reported outcomes systematically overstate the benefit delivered to patients.

The practical question is how mental health care could possibly be delivered in the settings where noma occurs, given that many endemic countries face severe shortages of specialized mental health professionals. Building stand-alone psychiatric services for a comparatively rare and geographically dispersed disease would be neither realistic nor sustainable, and fortunately, the article argues, it is also unnecessary. The World Health Organization’s essential care package to address mental health and stigma for persons affected by neglected tropical diseases, released in 2025 and elaborated through 2026, points in a different direction: integrate mental health care, psychosocial support and stigma reduction into existing neglected tropical disease programmes, community services and primary care. This approach is particularly relevant for diseases associated with visible differences and disability, including noma, leprosy, cutaneous leishmaniasis, Buruli ulcer and lymphatic filariasis. WHO’s integrated skin-NTD framework already provides a platform that combines case detection, disability prevention, stigma reduction, rehabilitation and person-centred care, and noma should enter these systems rather than sit beside them.

The mechanics of such integration are concrete rather than abstract. In endemic settings, frontline health workers trained to recognize early noma could also be trained to recognize psychological distress, using the same community contacts and referral chains that already exist for disease detection. Primary health care services could incorporate brief, validated mental health screening tools into routine assessment and follow-up of noma patients, creating a structured pathway from identification to support. Clear referral pathways could connect people requiring more intensive psychiatric care with whatever specialized services are available. Existing leprosy and skin-NTD programmes, which have accumulated decades of experience with peer-support groups, counselling, self-care groups and stigma-reduction interventions, could expand to include people affected by noma rather than reinventing these structures. Community health workers could extend their support to families as well as patients, because stigma, caregiving burdens and poverty rarely affect the individual alone, a lesson documented in detail in studies of Hansen’s disease-affected households in rural India.

Timing is another central element of the argument. Psychosocial support, the article contends, should begin before reconstructive surgery, continue throughout treatment and extend long afterwards. The reasoning is physiological and psychological at once: surgery can restore function and appearance, but it cannot automatically reverse years of rejection, interrupted schooling, social withdrawal or internalized shame that accumulated while the child was growing up with a visible difference. A reconstructed face does not by itself reopen a classroom or rebuild a social network. This is why the article proposes that mental health outcomes, social participation and quality of life should become legitimate indicators of successful noma rehabilitation, standing alongside surgical and clinical outcomes rather than beneath them. What gets measured, in global health as elsewhere, determines what gets funded, implemented and sustained.

Integration also demands a shift in who is seen as an expert. The article argues that people affected by noma must move beyond being recipients of services and become participants in designing programmes, training health workers, delivering community education, leading stigma reduction, providing peer support and shaping research. Experiences from Nigeria and Burkina Faso demonstrate that noma prevention, early detection and care can build on existing primary health care and community platforms rather than creating parallel disease-specific systems, and survivor involvement strengthens these efforts. The case is not merely ethical. People with lived experience understand dimensions of stigma, concealment, health-seeking behaviour and social reintegration that health professionals may never observe from the clinic. Their participation can make services more acceptable to the communities they are meant to reach, and it can expose outcomes that conventional clinical indicators systematically miss, such as whether a child has actually returned to school or resumed friendships after discharge.

Research priorities, the article argues, must change accordingly. What is needed are longitudinal studies that assess depression, anxiety, stigma, social participation, education and quality of life, as well as family wellbeing, before and after medical and surgical interventions, so that the psychological trajectory of recovery can be mapped and interventions evaluated against it. Yet Fastenau is explicit that the absence of perfect evidence must not become an excuse for inaction. The available data already establish that psychosocial morbidity is substantial, and WHO now provides an implementation framework for integrated neglected tropical disease mental health care that countries can adapt. The recognition of noma as a neglected tropical disease created a rare policy window to redefine what successful noma control means. Preventing disease and ensuring early treatment remain paramount, and reconstructive surgery will remain indispensable for many survivors. But the endpoint cannot simply be a closed wound or a reconstructed face. A health system, the article concludes, should not claim to have treated noma until it has also addressed the person’s opportunity to live, learn, participate and belong. Mental health and psychosocial support are not optional additions to noma care. They are noma care.

Subject of Research: Integration of mental health and psychosocial support into care for people affected by noma, a neglected tropical disease causing facial disfigurement

Article Title: Saving faces is not enough: Mental health must become core noma care

Article References: Fastenau, A. (2026). Saving faces is not enough: Mental health must become core noma care. PLOS Mental Health, 3(9), e0000723. https://doi.org/10.1371/journal.pmen.0000723

Image Credits: AI Generated

DOI: 10.1371/journal.pmen.0000723

Keywords: noma, neglected tropical diseases, mental health, depression, stigma, facial disfigurement, reconstructive surgery, WHO, Nigeria, psychosocial support, global health, child health

The stakes of this ambiguity are far from academic. When a patient interrupts tuberculosis treatment, the consequences cascade outward: treatment failure, relapse, continued transmission of the bacterium, and, most dangerously, the emergence of drug-resistant strains that are far costlier and harder to cure. Poor adherence worsens individual prognosis and undermines population-level control of the disease, imposing heavy burdens on health systems, particularly in low- and middle-income countries where tuberculosis remains the infectious disease at greatest risk of escalation. If researchers cannot agree on what adherence actually is, the evidence base for interventions designed to support it rests on shifting sand.

The terminology itself has a complicated history. Early research spoke of compliance, a word that carried a paternalistic undertone, framing patients as subjects who ought to obey medical orders and implicitly assigning blame when behaviour diverged from clinical instruction. The World Health Organization later championed adherence, a term intended to soften that blame and imply agreement between patient and provider. But, as the Porto team notes, this linguistic shift was never accompanied by a clearly articulated theoretical framework. The result is that compliance and adherence are now used interchangeably across much of the literature, without any genuine conceptual distinction between them.

Contemporary theory has moved well beyond this vocabulary problem. Adherence is now understood as a complex, multidimensional and dynamic phenomenon, shaped not only by individual behaviour but by socioeconomic conditions, health system factors, disease characteristics and the nature of the treatment itself. Modern taxonomies distinguish between initiation, the point at which a prescribed regimen is first taken; implementation, the extent to which actual dosing matches the prescription over time; and persistence, the length of time before premature discontinuation. In the tuberculosis field specifically, concept analyses describe adherence as a fluctuating spectrum, with patients moving between more and less adherent states as resources, relationships and circumstances change. The question the review posed was whether observational research actually measures that construct.

To find out, the researchers searched eight bibliographic databases from inception to February 2026, covering Web of Science, SCOPUS, PsycInfo, Sociology Source Ultimate, Medline, EMBASE, LILACS and CINAHL. From more than 60,000 records identified, deduplication and multi-stage screening, with inter-reviewer agreement formally assessed using Cohen’s Kappa, yielded 103 observational studies of drug-susceptible tuberculosis in adults, drawn from 32 countries. The African Region contributed the largest share of studies, followed by the Americas and the Western Pacific. The team then applied an inductive content analysis, mapping the labels authors used onto the constructs their measurement strategies implicitly presupposed, and generating alluvial plots to visualise the pathways from label to instrument to operational definition.

The findings reveal a field where definition is the exception rather than the rule. Sixty-eight percent of the included studies provided no explicit definition of adherence at all, allowing operational criteria to serve as de facto definitions. Another 15.5 percent cited external definitions, most often from the WHO or national tuberculosis programmes, but then failed to distinguish between the conceptual level and the operational one, describing adherence as concordance with treatment while analysing programmatic indicators. Only a small subset, 8.7 percent, acknowledged adherence as a multifactorial and complex phenomenon involving behavioural, cognitive or psychosocial processes such as effort, intention and commitment.

The construct mapping exposed just how far labels drift from what is actually measured. Among studies using the word adherence, the most frequent implied construct was behavioural execution, at 39.8 percent, but a substantial share instead operationalised it as dose ingestion, at 22.3 percent, treatment persistence, at 23.3 percent, or programmatic compliance. The label compliance mapped to a similarly scattered range of constructs. By contrast, terms such as default, abandonment and loss to follow-up clustered more tightly around treatment persistence, typically defined as treatment interruption exceeding one or two months. In other words, studies that appear statistically comparable may be measuring entirely different phenomena, a situation the authors describe as conceptually incommensurable even when the numbers look commensurable.

Measurement practices were equally heterogeneous. Nearly two-thirds of studies relied on clinician assessment or self-report, most commonly through validated questionnaires such as the Morisky Medication Adherence Scale, the Medication Adherence Report Scale, or study-specific instruments. Yet even multidimensional scales were routinely collapsed: 19.4 percent of studies dichotomised their outcomes using thresholds, 17.5 percent retained ordinal categories, and only two analysed adherence as a continuous variable. Pill counts and attendance at directly observed therapy visits featured in a further group of studies, with binary definitions classifying patients as non-adherent if a single dose was missed or if intake fell below cut-offs ranging from 75 to 95 percent. A substantial minority mined secondary data from tuberculosis registers and surveillance systems, where treatment outcome categories stood in for behaviour, and pharmacy dispensing records yielded proportion-of-days-covered indicators. Strikingly, only five studies employed direct measures, all using urine drug metabolite testing to detect recent ingestion, and even these provided snapshot assessments rather than longitudinal pictures.

The authors argue that these patterns reflect an unresolved ontological ambiguity rather than mere measurement variation. When WHO definitions were cited, their application frequently diverged from the conceptual breadth implied, and the conceptual ambitions articulated in study introductions were often diluted at the point of analysis. The shift from compliance to adherence, they suggest, has been largely rhetorical and linguistic rather than methodological. The problem is compounded by study design: more than 70 percent of the included studies were cross-sectional, reinforcing a static representation of what is in reality a dynamic, months-long process. Dichotomisation strips away the behavioural, relational and structural dimensions captured by the instruments, reconstituting adherence as a stable individual trait rather than a trajectory, and blurring the distinction between behaviour and programmatic outcome.

The review does carry limitations worth noting. As a scoping review, it characterised conceptual and measurement practices rather than the strength of empirical associations, and assigning implied constructs inevitably involved analytic judgement, though ambiguous cases were conservatively retained as unclear. The scope was restricted to observational studies of drug-susceptible tuberculosis in adults, so practices in drug-resistant or paediatric contexts, and in intervention trials or digital adherence technology research, may differ. Grey literature was excluded, and database indexing may have under-captured research from some regions. Still, the authors’ prescription is clear: studies should explicitly define the dimension of treatment-taking behaviour under investigation; analytic approaches should preserve the temporal and multidimensional nature of adherence rather than reducing it to binary scales; and the WHO and national programmes should standardise reporting by requiring explicit distinction between conceptual definitions, measurement strategies and analytic classifications. Without such changes, they warn, people may be labelled non-adherent on the basis of wildly heterogeneous processes, from an occasional missed dose to structural disruption of their lives, and interventions may be misdirected away from the social and structural mechanisms that truly shape whether tuberculosis treatment succeeds.

Subject of Research: Measurement and definition of tuberculosis treatment adherence in observational research

Article Title: Measurement of Tuberculosis treatment adherence: A methodological scoping review of observational studies

Article References: Measurement of Tuberculosis treatment adherence: A methodological scoping review of observational studies. (n.d.). https://doi.org/10.1371/journal.pgph.0007422

Image Credits: AI Generated

DOI: 10.1371/journal.pgph.0007422

Keywords: tuberculosis, treatment adherence, scoping review, measurement methods, construct validity, public health, drug-susceptible TB, self-report, treatment persistence, WHO, observational studies, PLOS Global Public Health

The research team, led by Tadesse Hailu of Bahir Dar University in Ethiopia together with collaborators in Spain, Thailand, and Malaysia, screened 651 published records drawn from PubMed, Google Scholar, Scopus, and ScienceDirect. After applying strict eligibility criteria under the PRISMA reporting framework, they retained 27 studies covering 16,358 children under the age of fourteen across eight African countries. Pooling the results with a random-effects model, the researchers calculated an overall prevalence of 14 percent, with a 95 percent confidence interval stretching from 12.2 to 15.9 percent. Given that an estimated 613.9 million people worldwide carry the parasite, with more than three-quarters of infections concentrated in Southeast Asia, the Western Pacific, and Africa, the pediatric share of that burden is clearly substantial.

What makes the figure alarming is not its size alone but the strong evidence that it represents a floor rather than a ceiling. The review found that prevalence estimates swung dramatically depending on how investigators looked for the parasite. When teams relied on direct smear microscopy or formol-ether concentration, the two techniques that dominate routine helminth testing across the continent, reported prevalence sometimes collapsed to fractions of a percent. When researchers deployed more sensitive tools, such as agar plate culture, the Baermann concentration technique, or quantitative polymerase chain reaction, detection rates climbed steeply. The single highest pooled estimate, 36 percent, emerged when PCR was combined with culture and microscopy, a finding the authors describe as a signal that conventional diagnostics systematically miss a large fraction of true infections.

The biology of S. stercoralis explains why it is such a diagnostic escape artist. Unlike hookworms and other soil-transmitted helminths that shed eggs in generous numbers, this parasite produces larvae that exit the body in small, intermittent bursts. A single stool sample examined under a microscope may simply contain too few larvae to spot, particularly when the larval load is low or excretion is sporadic. Direct smears and concentration techniques, which perform adequately for eggs of other worms, were never designed to catch this pattern. The result is a parasite that can persist undetected in a child’s intestine for decades, quietly reproducing through an autoinfection cycle in which larvae re-enter the bloodstream from the gut itself.

That autoinfection ability is what transforms strongyloidiasis from a usually mild nuisance into a potential killer. In most children the infection causes little more than skin irritation at the site of larval penetration, a dry cough as larvae migrate through the lungs, and vague gastrointestinal complaints. But in people whose immune systems are compromised, by disease, malnutrition, or immunosuppressive therapy, the parasite can multiply unchecked, producing hyperinfection syndrome or disseminated strongyloidiasis, conditions that are frequently fatal if unrecognized. Because chronic infections can last a lifetime, a child infected today carries that risk into adulthood, making accurate pediatric mapping a long-term safety issue rather than a short-term one.

The geographic pattern uncovered by the meta-analysis adds another layer of concern. Côte d’Ivoire recorded the highest pooled prevalence at 27 percent, followed closely by Ethiopia at 26 percent and Tanzania at 17 percent. At the other end of the scale, São Tomé and Príncipe reported just 2 percent and Ghana 3 percent. The authors caution that these contrasts almost certainly reflect diagnostic practice as much as genuine epidemiology. Every one of the nine Nigerian studies included in the review, for example, used formol-ether concentration, direct smear microscopy, or a combination of the two, methods with very low sensitivity for this particular worm. Ethiopia, by contrast, contributed several studies built on intensive diagnostic work-ups, which helps explain why individual Ethiopian surveys reported prevalence as high as 48.5 percent.

Heterogeneity across the pooled studies was extreme, with an I-squared statistic of 100 percent, meaning virtually all of the observed variation among studies reflects real differences in methods, settings, and populations rather than sampling noise alone. Cochran’s Q test confirmed statistically significant differences between countries, between diagnostic approaches, and between data collection sites. Children sampled in school and clinic settings showed a pooled prevalence of 21 percent, compared with 17 percent in community-based samples, a pattern the authors attribute in part to the inclusion of non-school-attending children with higher exposure, alongside the protective effect of school-based deworming and health education programs.

Beyond the laboratory, the review situates the parasite firmly in the landscape of poverty and sanitation. Transmission thrives where open defecation persists, where footwear use is inconsistent, and where children’s frequent contact with contaminated soil provides the larvae their route of entry. Malnutrition, widespread among African children, and impaired immunity may both amplify susceptibility. Older children tend to accumulate more exposure through outdoor play and soil contact, while younger children face household-level risks, and the authors argue that these behavioral and environmental variables must be weighed when designing surveillance and control strategies aligned with World Health Organization recommendations.

The study is not without limitations, and the authors are candid about them. The evidence base rests overwhelmingly on cross-sectional surveys, which capture a snapshot rather than the dynamics of infection. Methodological heterogeneity in study design, geography, and diagnostics was considerable, only English-language publications were included, grey literature may have been missed, and the 27 studies were distributed unevenly across a continent of 54 countries, leaving vast areas effectively unmapped. Publication bias, checked with a funnel plot, showed no clear signal, offering some reassurance that the pooled estimate is not inflated by selective reporting, but the certainty of the evidence remains limited by the observational nature of the underlying data.

Even with those caveats, the message for policymakers is difficult to ignore. Strongyloidiasis remains one of the most neglected of the neglected tropical diseases, absent from most routine deworming campaigns because it is invisible to the standard tests those campaigns rely on. The authors urge researchers to establish standardized diagnostic protocols for the parasite and call for implementation of the WHO guideline on preventive chemotherapy for strongyloidiasis, so that surveillance, diagnosis, and treatment in endemic African settings can finally catch up with the true scale of the problem. Until sensitive methods such as agar plate culture, Baermann concentration, and molecular testing move from research laboratories into routine practice, millions of infected children will continue to carry a treatable parasite that no one is counting, and no one is treating.

Subject of Research: Prevalence of Strongyloides stercoralis infection among African children assessed through systematic review and meta-analysis

Article Title: Prevalence of Strongyloides stercoralis infection among African children: A systematic review and meta-analysis

Article References: Hailu, T., Amor, A., Alemu, G., Tadesse, H., Nissapatorn, V., & Al-Mekhlafi, H. (2026). Prevalence of Strongyloides stercoralis infection among African children: A systematic review and meta-analysis. PLOS Neglected Tropical Diseases, 20(10), e0014759. https://doi.org/10.1371/journal.pntd.0014759

Image Credits: AI Generated

DOI: 10.1371/journal.pntd.0014759

Keywords: Strongyloides stercoralis, strongyloidiasis, neglected tropical diseases, soil-transmitted helminths, Africa, children, meta-analysis, diagnostics, PCR, public health, parasitology, WHO

The timing of the review is significant. The World Health Organization’s 2025 World Report on the Social Determinants of Health Equity acknowledged that while some progress has been made toward advancing health equity, that progress remains obstructed by inequitable economic, social, and political systems that reinforce existing power structures. In other words, the global health community has long understood that the roots of unequal health run deep into the architecture of society itself, yet the machinery for changing that architecture remains underdeveloped and, crucially, under-evaluated. The new review set out to answer a deceptively simple question: when public health collaborates across sectors to act on the determinants of health, what impacts are actually reported in the published literature?

Methodologically, the team conducted a rapid scoping review, a streamlined form of evidence synthesis designed to map the breadth of a research landscape rather than produce the exhaustive, quality-weighted estimates of a full systematic review. The researchers searched Ovid Medline and the Web of Science Social Sciences Citation Index for articles published between 2012 and 2024. To keep the evidence relevant to comparable high-income policy contexts, they restricted inclusion to studies from Norway, Finland, Denmark, Sweden, Australia, New Zealand, Canada, the United States, and the United Kingdom, written in English or French. The interventions of interest were specific: intersectoral initiatives undertaken by public health in collaboration with sectors outside of health, aimed at improving health equity through action on the structural or social determinants of health, and reporting related outcomes. The reporting followed the PRISMA-ScR extension, the recognized standard for transparent scoping reviews.

The yield was strikingly small. Eleven articles met the inclusion criteria: one systematic review and ten primary studies. For a field that has been championed in policy documents for decades, from the WHO Commission on Social Determinants of Health onward, the scarcity of published evaluations is itself a finding. The authors note that while there have been notable shifts since the 2013 review, there remain a limited number of published studies on this topic. That gap matters because intersectoral action is frequently promoted as a foundational public health practice; without documented outcomes, its promise risks resting on rhetoric rather than evidence.

What the eleven studies did report falls into several distinct categories, and the taxonomy the reviewers developed is one of the review’s most useful technical contributions. First, they identified reported actual and projected population health impacts, meaning changes in health outcomes or trajectories that studies attributed, at least in part, to intersectoral work. Second, they catalogued impacts on the structural determinants of health, a category that includes what the authors call policy and system wins, culture shift, and redistribution of power or an intent to redistribute it. This distinction is important: structural determinants are the governance, economic, and policy arrangements that generate social stratification in the first place, and changing them is a far more ambitious target than delivering services.

Third, the review documented reported impacts on the social determinants of health themselves, the everyday conditions in which people live, work, and age, such as housing quality, income security, and neighborhood environments. Fourth, and perhaps most practically, the reviewers identified tools that enable intersectoral action to succeed. Two enabling mechanisms stood out: authorizing environments and structured planning and implementation processes. An authorizing environment refers to the political and institutional space in which cross-sector collaboration is permitted, mandated, and resourced; without senior-level authorization, intersectoral initiatives tend to stall at the level of goodwill and informal networking. Structured planning and implementation, meanwhile, provides the operational scaffolding, shared goals, defined roles, and accountability mechanisms that convert collaboration into concrete policy change.

The review also situates its findings within a broader conceptual vocabulary that has become standard in health equity scholarship. The abbreviations that pepper the article’s methods reflect this infrastructure: HiAP, or Health in All Policies, describes the whole-of-government approach of systematically considering health in policy developed across all sectors; PSEI, or Policy, Systems, Environment and Infrastructure, frames the multiple levels at which public health interventions operate; and the Commission on Social Determinants of Health, whose landmark 2008 report galvanized the field, supplies the conceptual foundation for distinguishing structural from social determinants. The review was funded by the Public Health Agency of Canada through the National Collaborating Centre for Determinants of Health, with the funders participating as co-authors and advisory group members, an arrangement the authors disclose transparently.

For readers wondering why cross-sector work should be so consequential, the logic is worth spelling out. A public health agency cannot legislate affordable housing, set minimum wages, or design transit systems. Those levers sit with municipal planners, finance ministries, and transportation authorities. Yet each of those policy domains exerts measurable influence on morbidity and mortality. Intersectoral action is the practice of bringing public health’s evidence, equity lens, and population perspective into those decision-making arenas, so that policies affecting housing, income, or transport are designed with their health consequences in view. When such collaboration succeeds, the reported impacts can include new policies adopted, systems reorganized, and, at the deepest level, a shift in organizational culture and a redistribution of who holds power over the decisions that shape health.

The emphasis on power is one of the more candid aspects of the review. The authors report impacts described as culture shift and redistribution of power, or an intent to do so, language that acknowledges health inequity is not an accident of geography or individual behavior but a product of how societies organize resources and authority. The WHO’s 2025 report made the same point at the global scale, identifying inequitable economic, social, and political systems as the central obstacle to health equity. By documenting cases where intersectoral action has moved those systems, even incrementally, the review provides public health practitioners with concrete examples that such change is possible, alongside a framework for describing what success looks like beyond traditional health metrics.

Still, the review’s conclusions are appropriately measured. The authors characterize intersectoral action as a promising public health approach for advancing health equity, a deliberately cautious formulation that reflects both the encouraging signals and the thin evidence base. Eleven studies across nine countries and twelve years is a modest harvest, and the reviewers do not claim that the included studies establish effectiveness in the way a large body of randomized trials would. Instead, the review maps the terrain: it shows that reported impacts exist across population health outcomes, structural determinants, and social determinants, and it names the enabling conditions, authorizing environments and structured implementation, that appear to make those impacts attainable. For policymakers, the message is that cross-sector collaboration deserves investment not only as an aspiration but as an evaluated practice, with publication of outcomes treated as part of the work itself. For researchers, the scarcity of studies is an invitation: the field needs more rigorous, well-documented evaluations of intersectoral initiatives if the promise of acting on the determinants of health is ever to be matched by a commensurate body of evidence. The review, published open access with a comprehensive search strategy and study descriptions available as supplementary files, offers both a starting point and a challenge for the next decade of health equity research.

Subject of Research: Intersectoral action as a public health practice for advancing health equity through the structural and social determinants of health

Article Title: Reported policy impacts through intersectoral action as a public health practice for health equity: a rapid scoping review

Article References: Saxena, N., Mahar-Klassen, H., Warren, R., Abdalla, R., Lucyk, K., Kwan, A., Ndumbe-Eyoh, S., Botero, N. C., & Betker, C. (2026). Reported policy impacts through intersectoral action as a public health practice for health equity: a rapid scoping review. BMC Public Health. https://doi.org/10.1186/s12889-026-29449-9

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29449-9

Keywords: health equity, intersectoral action, social determinants of health, structural determinants, public health, scoping review, Health in All Policies, policy impact, WHO, cross-sector collaboration, Reported, policy

The starting point for the new index was deliberately simple and internationally recognizable: the four cornerstones of health articulated by the World Health Organization. These cornerstones, which cover balanced diet, appropriate physical activity, avoidance of tobacco and rational use of alcohol, served as the dimensional skeleton of the framework. Around that skeleton, the researchers fleshed out a full set of candidate indicators drawn from the contents of China’s own health-related policy documents. This dual anchoring matters. By rooting the index simultaneously in WHO doctrine and in national policy language, the team ensured that the resulting tool speaks both the universal language of global health promotion and the specific administrative vocabulary that Chinese health authorities use when designing campaigns, screening programs and evaluation schemes.

To decide which candidate items deserved a place in the final instrument, the researchers turned to the modified Delphi method, a technique long favored in health services research for distilling expert judgment into measurable consensus. Fifty experts were recruited to the panel and consulted across multiple iterative rounds, each round feeding anonymous feedback back to the group so that opinions could converge without the distortions of face-to-face hierarchy or dominant personalities. The response dynamics across the three consultation rounds tell their own story about engagement: the effective response rates were 60 percent in the first round, rising to 90 percent in the second, and settling at 66.67 percent in the third. That second-round surge suggests the panelists found the evolving framework increasingly worth their time, while the final-round taper reflects the natural completion of consensus once most disagreements have been resolved.

Expert engagement is only meaningful if the experts themselves are credible, and the study quantifies this through the authority coefficient, a composite of each panelist’s judgment basis and familiarity with the topic. The authority coefficients for the three rounds came in at 0.906, 0.899 and 0.904 respectively, figures that sit comfortably in the range conventionally interpreted as high expert authority. In practical terms, the people scoring the indicators were not casual observers but specialists whose self-assessed command of the subject matter remained consistently strong across the entire consultation. Equally important was whether the panel actually converged. The Kendall Harmony Coefficient, a rank-based measure of agreement among raters, reached 0.342 in the third round, indicating statistically meaningful coordination of expert opinion after two rounds of structured feedback.

With consensus achieved on the indicator set, the researchers faced the harder mathematical problem of weighting: not all lifestyle behaviors contribute equally to health outcomes, and an index that treats every item identically would misrepresent reality. Here the team employed the Analytic Hierarchy Process, a structured decision-making technique that decomposes complex judgments into pairwise comparisons and then checks whether those comparisons are internally coherent. The AHP calculations assigned weights to the four dimensions of 0.286, 0.286, 0.286 and 0.143 respectively, a strikingly egalitarian distribution in which three of the WHO cornerstones carry equal weight while the fourth carries half. Every comparison matrix passed the consistency test, meaning the experts’ pairwise judgments did not contradict one another in ways that would undermine the derived weights.

The resulting Chinese Adult Healthy Lifestyle Index System comprises 4 dimensions containing 22 individual items, a granularity fine enough to capture specific behaviors while remaining compact enough for practical deployment in surveys, clinics and community health screenings. But a consensus-built checklist is not automatically a valid measuring instrument, so the team subjected the scale to classical psychometric evaluation using questionnaire data. Exploratory factor analysis identified six robust factors that together accounted for 62.337 percent of the total variance in responses. Intriguingly, this statistical structure did not simply reproduce the four theoretical dimensions. Instead, the dietary and risk behavior domains naturally differentiated into subdomains during the analysis, refining the initial four-dimensional framework in a data-driven way that suggests the underlying behavioral architecture is more layered than the policy categories alone imply.

Reliability testing reinforced the case for the instrument. The Cronbach’s alpha coefficient for the full scale reached 0.819, a value indicating acceptable internal consistency, meaning the items within the scale tend to measure the same underlying construct rather than a grab bag of unrelated behaviors. For a tool intended to be administered across diverse adult populations, from urban office workers to rural residents, that coherence is essential. The study’s procedures were approved by the Medical Ethics Committee of Shanxi Medical University under ethical code 2024020, with informed consent obtained from all individual participants, and the authors declare no competing interests. The research received no specific grant from funding agencies in the public, commercial or not-for-profit sectors, making it an unusually lean affair for an instrument of this ambition.

Why does a Chinese-specific lifestyle index matter when international instruments already exist? The most widely used measure, the Health-Promoting Lifestyle Profile, was developed in a Western context, and its assumptions about diet, social norms and health behaviors do not always translate cleanly across cultures. Dietary patterns in China, the role of traditional foods, the epidemiology of tobacco use, and the policy infrastructure of health promotion all differ from the settings in which imported scales were validated. By grounding each of the 22 items in Chinese policy documents and vetting them through a domestic expert panel, the Shanxi Medical University team has produced a framework whose content validity is anchored in the lived and governed reality of the population it aims to assess. The authors conclude that the index system demonstrates scientific rigor and content validity in its constructed indicators, providing a culturally adapted framework for assessing healthy lifestyle behaviors among Chinese adults.

The potential applications extend well beyond academic measurement. A validated index with transparent weights gives health authorities a quantitative instrument for population surveillance, allowing them to track lifestyle scores over time, identify which behavioral domains lag in which regions, and evaluate whether interventions actually move the needle. Employers, insurers and community health centers could use the 22-item structure for rapid screening, while researchers gain a common metric that makes cross-study comparison feasible in a way that ad hoc lifestyle questionnaires never could. The equal weighting of three dimensions and the half-weighting of the fourth also encode an explicit value judgment that policymakers can debate and adjust, which is precisely what a transparent index is designed to enable.

There are, of course, the usual caveats that accompany any new instrument. The Delphi panel reflected expert consensus rather than direct predictive evidence, so longitudinal studies will be needed to confirm that higher scores on the index correspond to lower morbidity and mortality in Chinese cohorts. The exploratory factor structure, with its six emergent factors, hints that future revisions may reorganize the scale along more empirically natural lines. And the moderate third-round response rate reminds us that even well-designed consensus processes lose participants as they iterate. Still, the study represents a methodical fusion of global health doctrine, national policy content and rigorous psychometrics, and it arrives as China confronts the mounting burden of chronic disease driven by modifiable behaviors. If the index performs as its construction suggests, the humble act of scoring a lifestyle may become as routine in Chinese public health practice as measuring blood pressure.

Subject of Research: Construction and validation of a healthy lifestyle index system for Chinese adults using a modified Delphi method

Article Title: Construction of a healthy lifestyle index system for Chinese adults: a modified Delphi study

Article References: Guo, H., Shi, Y., Zhang, N., Wang, C., Tian, R., Luo, D., & Duan, Z. (2026). Construction of a healthy lifestyle index system for Chinese adults: a modified Delphi study. BMC Public Health. https://doi.org/10.1186/s12889-026-29736-5

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29736-5

Keywords: healthy lifestyle, Delphi method, index system, Chinese adults, public health, Analytic Hierarchy Process, psychometrics, WHO, health promotion, BMC Public Health, lifestyle modification, scale validation

Mental health disorders represent a substantial and growing share of the global burden of disease, yet in many low- and middle-income countries the health systems responsible for detecting and treating these conditions operate largely blind. Routine health information systems, the administrative machinery through which clinics report diagnoses, cases, and service delivery to district and national authorities, are the foundation of any evidence-based response. When those systems fail to capture mental health data, planners cannot estimate need, allocate medication, deploy specialists, or evaluate interventions. The quality of routine mental health reporting has long been recognized as particularly weak in resource-constrained settings, but the question of whether internationally supported training programs improve that quality has remained poorly understood. The new study set out to answer it directly.

The research team, led by Mithun Kumar Jha and Binita Kumari Paudel of Purbanchal University School of Health Sciences, conducted an explanatory mixed-methods study in twenty-eight primary health care facilities in Parsa District in the southern plains of Nepal. Fourteen of the facilities had staff trained under mhGAP, the WHO program designed to scale up services for mental, neurological, and substance use disorders by equipping non-specialist health workers with evidence-based protocols. The other fourteen had no mhGAP training. The quantitative arm of the study involved a retrospective analysis of twelve months of routine mental health reporting data drawn from Nepal’s Health Management Information System, which runs on the open-source District Health Information Software 2 platform, or DHIS2, used by dozens of countries worldwide. The qualitative arm consisted of in-depth interviews with eleven health workers, analyzed through the Consolidated Framework for Implementation Research, a widely used implementation science framework for identifying barriers and facilitators to putting evidence-based programs into practice.

The quantitative results were unambiguous and, in places, startling. Timeliness of reporting, meaning whether facilities submitted their monthly reports on schedule, was impressively high: every single mhGAP-trained facility achieved one hundred percent timeliness, and the untrained facilities were close behind at 96.4 percent. But completeness, the proportion of expected mental health data actually reported, was zero percent in both groups. Not a single facility in either arm of the study achieved complete mental health reporting over the twelve-month period, and most facilities reported no mental health cases at all across the entire year. Accuracy fared no better. The researchers found no consistency between the paper registers kept at the facilities and the data entered into DHIS2, meaning that in none of the twenty-eight facilities could the digital record be verified against the primary source documents. Because timeliness was analyzed as a continuous indicator rather than a categorical one, the authors note it was not subjected to formal statistical comparison, but the completeness and accuracy findings alone paint a bleak picture.

Perhaps the most telling contrast in the study was between structural readiness and functional performance. The mhGAP-trained facilities did show higher structural preparedness: they had trained personnel, and presumably the nominal capacity to identify and manage priority mental health conditions under the WHO protocols. Yet this structural advantage translated into no measurable improvement in the reporting domain. Whether a facility had received mhGAP training or not, its performance in routine mental health reporting was rated as poor. The authors conclude that the facilities lack functional routine reporting systems for mental health, and that training alone, however well designed, does not create the operational machinery needed to move data from a clinic register to a national database in a complete and accurate form.

The qualitative interviews, analyzed through the CFIR lens, help explain why this gap persists. Health workers described a system in which mental health remains peripheral to everyday primary care practice, with weak integration into the regular health information workflow. Without supportive supervision to reinforce training, without system-level coordination between the mental health program and the health management information system, and without mental health indicators being genuinely embedded in routine reporting expectations, the knowledge gained in mhGAP trainings had nowhere to go. A health worker may know how to diagnose depression or psychosis using a WHO protocol, but if no one checks whether those diagnoses are recorded, if the reporting forms and DHIS2 data elements are not aligned, and if supervisors never review the mental health column of the monthly report, the diagnosis simply never enters the record.

The implications reach far beyond Parsa District. The mhGAP program has been implemented in more than a hundred countries and is the centerpiece of global efforts to address the enormous treatment gap for mental, neurological, and substance use disorders, a gap that is widest precisely in the low- and middle-income countries where specialist psychiatrists are scarce. The program’s logic is elegant: train generalist health workers to deliver evidence-based care, and specialist-level treatment can be scaled without waiting for specialists. But the Nepal study exposes a critical dependency in that logic. Care that is delivered but not recorded is invisible to the health system. It cannot be counted, funded, resupplied, or improved. If routine reporting remains at zero completeness, then even successful mhGAP implementation at the clinical level would be undetectable in national statistics, and the program’s true coverage would be unknowable.

The study also carries a broader lesson for the rapidly digitizing world of global health data. Nepal’s adoption of DHIS2 represents a significant technical achievement, and the near-perfect timeliness scores show that facilities are capable of disciplined, punctual reporting when the system demands it. The failure is therefore not one of infrastructure or motivation but of functional integration: the mental health component of the information system has not been wired into the routines, supervision structures, and accountability mechanisms that make other reporting streams work. This distinction between structural readiness and functional performance is one that implementation scientists have emphasized for years, but it is rarely quantified so starkly. A trained workforce and a functioning software platform are necessary conditions for good data, and the Nepal results demonstrate they are nowhere near sufficient.

The authors call for comprehensive system-level interventions that go well beyond training. These would include regular supportive supervision that explicitly reviews mental health reporting, coordination between the mental health program and the health management information system so that indicators, registers, and digital data elements are aligned, and genuine integration of mental health into the routine reporting expectations placed on every primary health care facility. Such measures are less glamorous than international training workshops, but the evidence suggests they are where the real work lies. Without them, the study warns, reporting performance may not improve no matter how many workers are trained.

For a world preparing to confront a mental health crisis that the burden-of-disease data only partially captures, the message from Nepal is uncomfortable but valuable. The invisible fraction of the mental health burden, the cases that never appear in any register or dashboard, may be far larger than global statistics suggest, not because the cases do not exist but because the systems meant to see them are not looking. Fixing that will require treating mental health data not as an optional add-on to primary care but as a core, supervised, and audited function of every health facility, in Nepal and in every country that hopes to close the mental health gap.

Subject of Research: Routine mental health reporting performance in primary health care facilities in Nepal and the effect of WHO mhGAP training

Article Title: Mental health reporting performance in primary health care: a comparative mixed-methods study of mhGAP-trained and untrained health facilities in Nepal

Article References: Jha, M. K., & Paudel, B. K. (2026). Mental health reporting performance in primary health care: a comparative mixed-methods study of mhGAP-trained and untrained health facilities in Nepal. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15782-7

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15782-7

Keywords: mental health, mhGAP, Nepal, primary health care, DHIS2, health information systems, WHO, low- and middle-income countries, implementation science, CFIR, health services research, reporting completeness

The scale of the diagnostic delay is stark. Across high-burden countries, the median time from the first symptoms to a diagnosis stretches to 28 days in low-income settings, compared with just 10 days in upper-middle-income countries, and health system delays alone average 14 days versus 4. Every week of delay means more severe disease, more transmission in households and communities, and a higher risk of death, as well as possible long-term lung damage after treatment. The review highlights evidence that fewer than half of patients presenting with TB symptoms are ever offered a test, and standardized patient studies show that private providers frequently hand out empirical antibiotics instead of pursuing TB testing. Women often delay care because of caregiving burdens, power imbalances and limited financial autonomy, while men are held back by work pressures, costs and stigma. Distance to facilities compounds all of these factors.

Rapid molecular tests have already proven their worth. Since the World Health Organization recommended Xpert MTB/RIF in 2010 as the initial diagnostic test, replacing smear microscopy, and extended that endorsement to Xpert Ultra and India’s Truenat platform in 2020 and 2021, meta-analyses show these WHO-recommended diagnostics cut diagnostic delays by roughly two days and halve the time to diagnosis. Mortality benefits at the individual level are clearest among people living with HIV, but population-level studies consistently link the expansion of molecular testing with falling TB deaths. The economics are compelling: in South Africa, an investment of US$315 million in molecular diagnostics generated an estimated US$6.4 billion in societal benefits over a decade. Yet in 2024 only 54 percent of people newly diagnosed with TB were tested with a rapid molecular assay, and just 8 of 30 high-burden countries report such tests available at more than half of their diagnostic sites.

The bottleneck, the authors argue, is that current molecular platforms are too expensive, too infrastructure-hungry and too centralized. Xpert instruments cost between roughly US$17,000 and US$90,000, and Truenat systems between US$11,000 and US$18,000, which is prohibitive for low-volume rural clinics. A new generation of near-point-of-care molecular tests aims to change that by using isothermal amplification, a simpler and cheaper chemistry than real-time PCR, in compact, portable, battery-operable devices. The FIND pipeline directory now lists 73 technologies for TB diagnostic confirmation, comprising 51 near-point-of-care and 22 point-of-care platforms, although relatively few have been rigorously evaluated in the peer-reviewed literature.

The most advanced of these is MiniDock, made by PlusLife, a swab-based assay that the WHO recommended in early 2026. Using sputum, MiniDock achieves 85 percent sensitivity and 98 percent specificity in people with presumptive TB, falling to 79 percent sensitivity among people living with HIV. With tongue swabs, sensitivity is lower at 76 percent but specificity remains excellent at 99 percent. The EasyNAT MTC assay from Ustar Biotechnologies matched Xpert’s sensitivity in a single-site study in China, and a more portable, cheaper version called PortNAT is in development. Other systems, including FlashDetect, SARAGENE and UniAmp, are in the pipeline but lack published clinical performance data. None of the currently available near-point-of-care platforms detect drug resistance, which means patients with resistant infections would still need reflex testing on higher-complexity platforms.

Alongside these molecular advances, a parallel revolution is happening in sample types. Sputum, the traditional cornerstone of pulmonary TB diagnosis, is simply unavailable from many of the people who need testing most: the very ill, people living with HIV, children and those without obvious symptoms. Urine offers a striking practical advantage. A systematic review found that 98 percent of adults living with HIV could provide urine compared with 82 percent who could produce sputum, and among unselected individuals the gap widened to 99 percent versus 54 percent. Adding urine lateral flow lipoarabinomannan testing to sputum Xpert raised diagnostic yield from 71 to 78 percent, prompting the WHO to strongly recommend concurrent urine and sputum testing for adults with HIV. Urine-based Xpert Ultra, though less sensitive, offers the added advantage of rifampicin resistance detection.

For children, stool has emerged as a game-changing alternative to invasive gastric aspiration. Stool Xpert Ultra alone has moderate sensitivity, but combining stool with respiratory-specimen testing achieves 80 percent sensitivity in parallel, and testing two stool samples instead of one improves performance by 20 to 25 percent. A landmark Thai study showed that combinations of minimally invasive specimens matched the yield of two gastric aspirates. On this evidence, the WHO now recommends concurrent respiratory and stool molecular testing for all children with presumptive TB. Oral sampling is also maturing: tongue swabs consistently outperform cheek swabs and oral rinses, morning collection improves sensitivity, and among people unable to produce sputum, tongue swabs identified TB in 18 to 25 percent of cases, supporting a complementary rather than standalone role.

Lipoarabinomannan, or LAM, antigen tests occupy a different niche. These simple urine dipstick-style immunoassays detect a component of the TB bacterium’s cell wall and can be deployed anywhere, but their sensitivity is far lower than molecular tests. Determine TB-LAM, the only commercially available lateral flow LAM assay, detects just 42 percent of cases among people living with HIV with presumptive TB, though its benefit is greatest in hospitalized patients with advanced immunosuppression, where it has been shown to reduce mortality. Next-generation assays aim to close the gap: Silvamp TB LAM II reaches 56 percent sensitivity in people living with HIV, while BP-LAM, which incorporates urine concentration and novel monoclonal antibodies, achieved 63 percent sensitivity overall with consistent performance across HIV status, though its evidence remains limited to preprint data. Cross-reactivity with non-tuberculous mycobacteria remains a concern across the class.

Cost-effectiveness, the review stresses, is not determined by test price alone but by testing volume, instrument placement and linkage to care. In low-volume settings the cost per TB diagnosis can exceed seven times that of high-volume centers, so tiered strategies matter. Digital chest X-ray with computer-aided detection followed by confirmatory Xpert can halve screening costs with only modest yield loss, and CRP-based triage offers a similar advantage for symptomatic people. Here the new platforms change the arithmetic dramatically: PlusLife test cartridges cost US$3.60 and instruments roughly US$350, a fraction of the roughly US$10,000 price of conventional machines, potentially making decentralized molecular testing cost-effective even in quiet primary care clinics. Meanwhile, innovation is shifting south: nearly two-thirds of near-point-of-care and point-of-care technologies in the FIND pipeline are expected to originate from Africa, Southeast Asia and the Western Pacific, with China, India, Japan and South Korea already supplying WHO-endorsed products.

Translating these tools into practice still demands regulatory and health-system reform. Critical pathway analyses across nine high-burden countries found delays of two to eight years in national policy adoption, and dependence on imported diagnostics persists, though India’s regulatory framework has enabled rapid local deployment of Truenat and other homegrown assays. Regional harmonization through the Africa Medicines Agency and pooled procurement mechanisms could accelerate access, and at a workshop in Bangkok in July 2026, representatives from 13 countries outlined plans collectively targeting three million near-point-of-care tests. The review’s authors are clear about the remaining frontier: evidence on real-world impact, especially in children and community screening, is still thin, and the ultimate prize is a true point-of-care self-test that patients can use themselves. With shrinking donor budgets forcing countries to invest domestically, the convergence of cheap instruments, painless sampling and southern-led innovation may finally be the combination that brings TB diagnosis to everyone who needs it.

Subject of Research: Innovations in point-of-care diagnostic testing for pulmonary tuberculosis in low- and middle-income countries

Article Title: Diagnostic testing for pulmonary tuberculosis in low and middle-income countries: innovations to achieve universal access—a narrative review

Article References: Ismail, N. A., Berhanu, R. H., von Knorring, N., Loembe, M. M., Kohli, M., Hasan, R., Shanmugam, S. K., Sheokand, S., Katamba, A., Pai, M., & Omar, S. V. (2026). Diagnostic testing for pulmonary tuberculosis in low and middle-income countries: innovations to achieve universal access—a narrative review. eClinicalMedicine, 100, Article 104232. https://doi.org/10.1016/j.eclinm.2026.104232

Image Credits: AI Generated

DOI: 10.1016/j.eclinm.2026.104232

Keywords: tuberculosis, diagnostics, point-of-care testing, molecular assays, low- and middle-income countries, Xpert, Truenat, MiniDock, lipoarabinomannan, tongue swabs, stool testing, WHO

The research team, led by Santosh K. C. of Kathmandu University with Panna Thapa and Pramote Tragulpiankit of Mahidol University, set out to answer a question that health policy researchers in many low- and middle-income countries rarely ask with rigor: not whether a national medicines policy exists, but whether the individual actions written into it are actually operating. National Medicines Policies, as promoted by the World Health Organization, are meant to guarantee equitable access to medicines, assure their quality and safety, and promote their rational use. Yet systematic evidence on whether the specific actions embedded in such policies have moved beyond formal adoption into day-to-day operation has been strikingly limited. Nepal’s policy, guiding everything from domestic drug production to dispensing controls since the mid-1990s, had never been assessed at this granular level.

Methodologically, the study is a careful piece of policy forensics. The researchers extracted 44 discrete actions from the 1995 policy and its 2001 amendment, then mapped each one to the WHO’s canonical policy objectives: access, quality and safety, and rational use, plus a cross-cutting domain of enabling functions such as monitoring and coordination. Each action was coded against pre-specified, objectively defined criteria as fully operational, partially operational, or not operational, drawing on documentary and systems-level sources. The results were summarized through proportions and a descriptive operational status index, an unweighted summary of operational depth that the authors are careful to frame as a description rather than a performance score. In parallel, the team conducted 25 key informant interviews spanning policy makers, regulators, service delivery, industry, and civil society, analyzing them thematically with a hybrid deductive-inductive approach. The two strands were then integrated through a joint display and classified as convergence, complementarity, or divergence.

The headline numbers are sobering. Of the 44 policy actions, only 10, or 22.7 percent, were judged fully operational. Eighteen actions, 40.9 percent, were partially operational, and 16, or 36.4 percent, were not operational at all. In other words, more than a third of what Nepal’s medicines policy commits to has never functioned in any meaningful sense. The domain-level breakdown reveals a distinctive pattern: quality and safety, covering 16 actions, scored highest with an operational status index of 0.53, driven largely by product standards and import controls. Access, with 12 actions and an index of 0.50, showed moderate progress in production capacity and market availability. But rational use, covering 11 actions, collapsed to an index of 0.27, with not a single action fully operational, and enabling functions fared little better at 0.30 across five actions.

The quality and safety domain’s relative strength tells an important story about how Nepal’s policy has actually matured. Its gains rest on compliance-oriented instruments: product standards that manufacturers and importers must meet, and border controls that screen what enters the country. These are the kinds of discrete, enforceable measures that a resource-constrained regulator can implement without building elaborate institutions. Yet the interviews consistently qualified these documentary gains. Informants pointed to limited laboratory capacity, thin post-market surveillance, and incomplete regulatory maturity, suggesting that even the strongest domain of the policy operates with a shallow foundation. A country can demand quality standards on paper, the findings imply, but without laboratories to test products and surveillance systems to detect failures after products reach the market, the assurance is only as deep as the paperwork behind it.

Access presented a subtler picture, and one where the mixed-methods design proved its worth. The documentary strand recorded moderate progress in production capacity and market availability, and the interviews broadly converged with this. But the qualitative strand surfaced something the documents understated: persistent shortages of critical care medicines and weak pricing governance. This is complementarity in the methodological sense, where the interview data added dimensions that the formal record simply did not capture. Affordability governance emerged as an important complement that the paper trail missed entirely. For a policy whose first duty is equitable access, the gap between what documents show and what patients experience at the pharmacy counter is not a technical footnote; it is the difference between policy as text and policy as lived reality.

Rational use emerged as the study’s most alarming finding. Not one of the 11 actions in this domain was fully operational, and the interviews converged with the documentary evidence in describing prescription monitoring, antimicrobial stewardship, and dispensing controls as intermittent and non-institutionalized. The implications reach far beyond Nepal’s borders. Antimicrobial resistance is one of the defining global health threats of the coming decades, and stewardship systems, the mechanisms that keep antibiotics from being dispensed casually and prescribed without oversight, are its first line of defense. A medicines policy in which rational-use provisions exist only as aspiration means that the structural safeguards against resistance breeding in communities are effectively absent. The convergence between documents and informants here is particularly telling: this is not a case of paperwork overstating reality, but of both evidence streams independently confirming a systemic void.

The enabling functions domain, though small at five actions, may be the study’s most consequential diagnosis. Evidence converged on absent monitoring and evaluation systems, concentrated institutional ownership, and prolonged policy stasis. These are the machinery that keeps a policy alive between revisions: the feedback loops that tell a ministry whether its actions are working, the distributed ownership that prevents a policy from becoming the project of a single office, and the revision cycles that allow a policy to adapt to a pharmaceutical landscape transformed by globalization, new technologies, and emerging threats. A policy that has run for nearly thirty years without systematic monitoring and without revision is, in a precise sense, flying blind. The operational status index of 0.30 for this domain is low, but the qualitative finding of institutional concentration and stasis suggests the deeper problem is architectural rather than incremental.

What makes this study matter beyond Nepal is its template. The approach of decomposing a national medicines policy into discrete actions, coding each against objective operational criteria, and triangulating with frontline informants offers low- and middle-income countries a replicable method for auditing not just whether policies exist but whether they function. The study’s central conclusion is that Nepal’s policy has become operational primarily through discrete instruments and compliance-oriented controls, while the institutional and governance functions essential for reliable access, regulatory maturity, and rational use remain underdeveloped. As the country prepares to revise its policy for the first time in a generation, the authors argue that strengthening monitoring, accountability, workforce capacity, and rational-use systems is critical to translating policy intent into sustained public health impact. The lesson is universal: a medicines policy is not a document but a system, and systems fail quietly, action by unimplemented action, until someone finally counts.

Subject of Research: Operational status assessment of Nepal's national medicines policy using mixed methods

Article Title: Operational status of Nepal’s national medicines policy: a convergent mixed-methods assessment

Article References: Operational status of Nepal’s national medicines policy: a convergent mixed-methods assessment. (n.d.). https://doi.org/10.1186/s12913-026-15760-z

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15760-z

Keywords: National Medicines Policy, Nepal, medicines regulation, mixed methods, rational use of medicines, essential medicines, access to medicines, drug quality, antimicrobial stewardship, health policy implementation, pharmaceutical governance, WHO

The study, led by Shaolong Ren and colleagues working with the World Health Organization, is the first to quantify how the uneven introduction of nirsevimab, a long-acting monoclonal antibody licensed in 2022, and RSVpreF, a maternal vaccine licensed in 2023, could reshape global inequalities in infant RSV disease. The researchers built a static deterministic model that combined comprehensive epidemiological data on RSV burden, seasonality, and hospitalisation risk by birth month and age in months with country-level information on licensing and uptake as of June 2025. They then compared two futures: a world in which no country had introduced the products, and the world as it actually stood in mid-2025, with implementation frozen at that moment.

The baseline picture for 2019 revealed stark regional contrasts. The WHO African Region carried the highest incidence of RSV-associated acute lower respiratory infection, at 117.4 episodes per 1000 person-years, and the highest attributable mortality, yet paradoxically recorded the lowest hospital admission rate, just 12.6 per 1000 person-years. The Eastern Mediterranean Region, by contrast, had the highest admission rate at 29.9 per 1000. The African Region also showed the highest in-hospital case fatality ratio at 1.54 percent, closely followed by the South-East Asia Region at 1.49 percent. Crucially, in-hospital deaths accounted for only about 21 percent of RSV-attributable deaths in the African Region, meaning roughly four in five infants who died of RSV did so without ever reaching a hospital bed. Together, the African, South-East Asia and Eastern Mediterranean regions accounted for 88 percent of all infant RSV deaths.

The authors argue that the low hospitalisation rates in the highest-burden regions do not reflect milder disease. Instead, they point to barriers of affordability, distance and time to reach care. Severe RSV illness is treatable with supportive measures such as supplemental oxygen and intravenous hydration, but children in resource-limited settings often cannot access these in time. A recent study in Bangladesh underscored the point: 18.4 percent of children requiring hospitalisation were denied admission because of insufficient bed capacity, and those turned away faced a hazard ratio for death of 1.56 compared with children who were admitted. This pattern also implies, the researchers note, that preventive interventions could deliver even greater absolute benefit in poorly resourced settings, by averting the out-of-hospital deaths that currently dominate the mortality toll.

Against this backdrop, the implementation landscape as of June 2025 was strikingly skewed. Nirsevimab had been licensed in 54 countries and RSVpreF in 64, but only 16 and 12 countries respectively had incorporated them into their national immunisation programmes, and the overwhelming majority of those were high-income countries. The European Region accounted for 34 nirsevimab and 35 RSVpreF licences, and the Region of the Americas for 8 and 12, while the African Region had zero nirsevimab licences and just two for RSVpreF, and the South-East Asia Region only two of each. Of the countries that had licensed nirsevimab, 53 of 54 were high- or upper-middle-income; for RSVpreF the figure was 59 of 64. No low-income country had licensed either product.

The projections that followed were sobering. Under the June-2025 scenario, an estimated 4.64 million doses of nirsevimab and 1.96 million doses of RSVpreF would be administered annually, averting roughly 91,000 infant RSV hospital admissions and about 300 deaths worldwide. That translates to reductions of just 3.7 percent of global infant RSV admissions and 0.4 percent of deaths. The benefits were overwhelmingly concentrated in wealthy nations: high-income countries, which received about 90 percent of averted admissions and over 70 percent of averted deaths, saw reductions of 33.2 percent in hospitalisations and 29.1 percent in mortality. Middle-income countries saw relative reductions below 5 percent, and low-income countries, with no uptake at all, saw none.

The model’s assumptions were grounded in real-world evidence. Nirsevimab was assigned 83 percent effectiveness against RSV-associated hospital admission and 81 percent against attributable death, drawn from meta-analyses of real-world data; RSVpreF was assigned 71 and 77 percent respectively, informed by a test-negative study in Argentina. The model accounted for seasonal immunisation strategies with birth doses and catch-up doses for nirsevimab, year-round maternal vaccination in most countries, and mutual exclusivity between the two products to avoid double-counting protection. Uncertainty was propagated through 1000 simulation draws for each input parameter, and sensitivity analyses varying uptake, effectiveness, and alternative mortality data from the Global Burden of Disease Study 2023 all produced trends consistent with the main findings.

Most striking was what happened to measured inequality. The researchers ranked countries by RSV-attributable infant mortality and divided the global population into quintiles, then calculated the ratio of deaths between the highest- and lowest-risk fifths. Under no implementation, that ratio stood at 18.3, already a staggering expression of inequity. Under the June-2025 scenario it rose to 20.8, meaning the rollout of these lifesaving products is projected to make global RSV mortality inequality worse, not better. Within WHO regions, the increases were most pronounced where several countries had introduced the products: the ratio in the Region of the Americas climbed from 5.8 to 10.4, and in the European Region from 12.7 to 22.1. The authors warn that, drawing on the history of pneumococcal and rotavirus vaccines, coverage disparities between rich and poor countries can persist for years after initial introduction, so the true widening could exceed even these projections over the next five years.

There are signs that access may eventually improve. The WHO’s Strategic Advisory Group of Experts recommended infant RSV passive immunisation in late 2024, the WHO prequalified the maternal vaccine in March 2025, and Gavi’s board approved a funding window for RSV maternal immunisation programmes in July 2025. Yet the Gavi programme is not expected to introduce vaccines until 2028 and will initially reach only a handful of eligible countries. The study’s authors point to pooled procurement through UNICEF- and PAHO-led initiatives, the Gates Foundation-supported development of multi-dose vial formulations of the maternal vaccine, tiered pricing, technology transfer and stronger national immunisation advisory capacity as routes to accelerate adoption. At this juncture, they conclude, coordinated action by international agencies, governments, manufacturers and researchers is essential to ensure that the tools now transforming infant RSV outcomes in wealthy countries reach the infants who bear the greatest burden of the disease.

Subject of Research: Global regional inequality in infant RSV morbidity and mortality under expanded passive immunisation

Article Title: Regional inequality in infant RSV morbidity and mortality burden in the era of expanded RSV passive immunisation: a global projection modelling study

Article References: Ren, S., Cong, B., Zou, J., Guo, L., Nair, H., Sparrow, E., Feikin, D. R., & Li, Y. (2026). Regional inequality in infant RSV morbidity and mortality burden in the era of expanded RSV passive immunisation: a global projection modelling study. eClinicalMedicine, 100, Article 104219. https://doi.org/10.1016/j.eclinm.2026.104219

Image Credits: AI Generated

DOI: 10.1016/j.eclinm.2026.104219

Keywords: RSV, nirsevimab, RSVpreF, infant health, global health equity, modelling study, low- and middle-income countries, hospitalisation, maternal vaccination, monoclonal antibodies, WHO, vaccine access

The International Health Regulations, revised in 2005 after earlier versions proved inadequate, require all 196 signatory states to develop core capacities for detecting, reporting, and responding to public health events at their borders. Under the framework, countries must designate Points of Entry, including international airports, seaports, and major ground crossings, where routine health screening, emergency medical services, and communication systems must be available around the clock. When an event rises to the level of a Public Health Emergency of International Concern, as COVID-19 did in January 2020, these entry points become critical nodes in a worldwide surveillance and containment network. Yet the regulations have long been implemented unevenly, particularly in resource-constrained settings, and the new study set out to document precisely where those implementation gaps lie in Bangladesh.

The research team conducted an exploratory qualitative study between October 2022 and June 2023, in the aftermath of the pandemic’s acute phase. They selected four designated Points of Entry: Hazrat Shahjalal International Airport, the country’s busiest international air gateway; Shah Amanat International Airport in Chattogram; Chittagong Seaport, one of the largest maritime hubs in South Asia; and Benapole Ground Crossing, the principal land border crossing between Bangladesh and India. Data collection involved 30 interviews in total, comprising 20 in-depth interviews with frontline service providers and port users, and 10 key informant interviews with decision-makers and experienced service providers. All interviews were transcribed, coded, and subjected to thematic analysis using ATLAS.ti software, version 7.5.10, allowing the researchers to identify recurring patterns in how officials and travelers experience border health operations.

The central finding is stark: the study revealed more challenges than enablers on both the regulatory and public sides of IHR-2005 implementation. Among the most fundamental problems was a lack of understanding of the regulations themselves and their role in global infectious disease prevention and control. This is not a trivial administrative detail. If the officers stationed at an entry point do not grasp what the framework requires of them, or why it matters, the entire architecture of border health security weakens at its foundation. The researchers also identified inadequate training on IHR-2005 as a persistent barrier, compounding the knowledge deficit and leaving staff ill-prepared to execute the screening, reporting, and coordination duties the regulations demand.

Human resources emerged as another severe constraint. The study documented a critical shortage of personnel at the entry points, a problem familiar across many low- and middle-income countries where health workforces are stretched thin and border health posts compete with hospitals and clinics for scarce staff. Screening travelers for symptoms, managing health declarations, and responding to suspected cases all require trained people on the ground, and without them even well-designed protocols exist only on paper. The shortage interacts with the training gap in a damaging cycle: too few staff means those who are present cannot be spared for training, while untrained staff cannot build the institutional competence that would justify expanding the workforce.

Practical logistics added further friction. The researchers found limited availability of ambulances for transporting ill travelers, meaning that even when a potentially infectious passenger was identified, moving that person safely to a treatment facility could be difficult or delayed. Health offices were often inaccessible or not conveniently located at every Point of Entry, fragmenting the chain of command and slowing communication between border staff and the health authorities who must authorize and support public health actions. On the public side of the counter, the study recorded uncooperative behavior from travelers, a challenge that frontline screeners worldwide have encountered but which carries particular weight in crowded, high-throughput crossings where delays provoke frustration and evasion.

Not all entry points fared equally. The study found that Benapole Ground Crossing encountered the most significant obstacles in ensuring effective implementation of the regulations, and that the overall environment there was suboptimal. This finding matters because Benapole is one of the busiest land crossings in South Asia, handling enormous daily flows of passengers and goods between Bangladesh and India. Land crossings are inherently harder to manage than airports: passenger processing is less structured, infrastructure is often older, and the sheer volume of movement makes comprehensive screening difficult. By contrast, the other designated Points of Entry, including the two international airports and Chittagong Seaport, demonstrated good communication and coordination capacities, available medical and technical services, and a generally good environment, suggesting that implementation success in Bangladesh is less a uniform national failure than a uneven landscape in which some sites have achieved functional capacity while others lag far behind.

The methodological contribution of the study is also notable. According to the authors, no qualitative research on IHR-2005 implementation at designated Points of Entry in Bangladesh had been conducted before, making this the first in-depth account of how the framework operates, or fails to operate, at the country’s borders. Qualitative approaches of this kind capture dimensions that quantitative audits miss: the lived experience of officers who lack clear guidance, the frustrations of port users navigating health checks, and the informal workarounds that develop when formal systems fall short. The study received ethical approval from the Institutional Review Board of icddr,b under research protocol number PR-22149, with informed written consent obtained from all participants and transcripts anonymized and stored in password-protected databases. The work was funded by the Disease Control program of the Directorate General of Health Services, with core support from the governments of Bangladesh and Canada.

The findings carry implications well beyond Bangladesh’s borders. The COVID-19 pandemic demonstrated that a pathogen detected in one country can circle the globe within days, and that the strength of the weakest border health system can determine the speed of international spread. The World Health Organization has repeatedly emphasized that global health security depends on every country meeting the core capacity requirements of the regulations, and independent assessments have consistently shown that many low- and middle-income countries remain short of those benchmarks. Bangladesh’s experience illustrates the specific mechanisms by which the gap opens: knowledge deficits among staff, inadequate training pipelines, chronic understaffing, missing transport and infrastructure, and public non-cooperation. Each of these is addressable, but only with sustained investment and political attention rather than emergency-time improvisation.

The researchers conclude that the implementation of IHR-2005 at designated Points of Entry in Bangladesh faces significant challenges that hinder its effectiveness, and that addressing these barriers is essential to strengthen enforcement of the regulations and enhance the country’s ability to prevent and control the spread of infectious diseases at its key entry points. Their evidence suggests a clear agenda: systematic training on the regulations for all border health staff, recruitment to close the human resource gap, guaranteed ambulance and transport capacity for ill travelers, and health offices physically present and accessible at every designated entry point, with particular urgency at Benapole Ground Crossing. As the world prepares for future pandemics that experts consider inevitable rather than hypothetical, studies like this one provide the granular, ground-level evidence that turns abstract international commitments into workable practice. The borders of Bangladesh, like those of many countries, are only as secure against infectious disease as the people, training, and equipment stationed there, and this study shows exactly where those defenses need reinforcement.

Subject of Research: Implementation of the International Health Regulations 2005 for infectious disease control at designated Points of Entry in Bangladesh

Article Title: Critical gaps in infectious disease prevention and control: insights from IHR-2005 implementation enablers and challenges at key entry points in Bangladesh

Article References: Dutta, G. K., Hasan, M. K., Sanin, K. I., Roy, B. R., Ali, M. S., Islam, M. N., Islam, M. S., Khan, M. N. A., Mahmud, M., Nadia, N., Noushin, F., & Tofail, F. (2026). Critical gaps in infectious disease prevention and control: insights from IHR-2005 implementation enablers and challenges at key entry points in Bangladesh. BMC Public Health. https://doi.org/10.1186/s12889-026-29658-2

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29658-2

Keywords: IHR-2005, Points of Entry, Bangladesh, global health security, infectious disease control, border health, COVID-19, public health emergency, qualitative research, LMICs, Benapole Ground Crossing, WHO