This article describes similarities and differences in the response of governments and the international community to the current 2019 coronavirus disease (COVID-19) and the 2014 West African Ebola epidemic. It expresses the opinion that the speed and scale of the response to COVID-19 are affected by the important role that China plays in the global economy. By contrast, insufficient and less timely action was initially undertaken in West African countries during the 2014 Ebola epidemic. It concludes by stating why preparedness for and response to all disease outbreaks, also in countries of lower economic importance, should become a priority in the global health agenda.

BackgroundMore than half of artemisinin combination therapies (ACTs) consumed globally are dispensed in the retail sector, where diagnostic testing is uncommon, leading to overconsumption and poor targeting. In many malaria-endemic countries, ACTs sold over the counter are available at heavily subsidized prices, further contributing to their misuse. Inappropriate use of ACTs can have serious implications for the spread of drug resistance and leads to poor outcomes for nonmalaria patients treated with incorrect drugs. We evaluated the public health impact of an innovative strategy that targets ACT subsidies to confirmed malaria cases by coupling free diagnostic testing with a diagnosis-dependent ACT subsidy.Methods and findingsWe conducted a cluster-randomized controlled trial in 32 community clusters in western Kenya (population approximately 160,000). Eligible clusters had retail outlets selling ACTs and existing community health worker (CHW) programs and were randomly assigned 1:1 to control and intervention arms. In intervention areas, CHWs were available in their villages to perform malaria rapid diagnostic tests (RDTs) on demand for any individual >1 year of age experiencing a malaria-like illness. Malaria RDT-positive individuals received a voucher for a discount on a quality-assured ACT, redeemable at a participating retail medicine outlet. In control areas, CHWs offered a standard package of health education, prevention, and referral services. We conducted 4 population-based surveys—at baseline, 6 months, 12 months, and 18 months—of a random sample of households with fever in the last 4 weeks to evaluate predefined, individual-level outcomes. The primary outcome was uptake of malaria diagnostic testing at 12 months. The main secondary outcome was rational ACT use, defined as the proportion of ACTs used by test-positive individuals. Analyses followed the intention-to-treat principle using generalized estimating equations (GEEs) to account for clustering with prespecified adjustment for gender, age, education, and wealth. All descriptive statistics and regressions were weighted to account for sampling design. Between July 2015 and May 2017, 32,404 participants were tested for malaria, and 10,870 vouchers were issued. A total of 7,416 randomly selected participants with recent fever from all 32 clusters were surveyed. The majority of recent fevers were in children under 18 years (62.9%, n = 4,653). The gender of enrolled participants was balanced in children (49.8%, n = 2,318 boys versus 50.2%, n = 2,335 girls), but more adult women were enrolled than men (78.0%, n = 2,139 versus 22.0%, n = 604). At baseline, 67.6% (n = 1,362) of participants took an ACT for their illness, and 40.3% (n = 810) of all participants took an ACT purchased from a retail outlet. At 12 months, 50.5% (n = 454) in the intervention arm and 43.4% (n = 389) in the control arm had a malaria diagnostic test for their recent fever (adjusted risk difference [RD] = 9 percentage points [pp]; 95% CI 2–15 pp; p = 0.015; adjusted risk ratio [RR] ...

ObjectivesThere is an urgent need to understand how to improve targeting of artemisinin combination therapy (ACT) to patients with confirmed malaria infection, including subsidised ACTs sold over-the-counter. We hypothesised that offering an antimalarial subsidy conditional on a positive malaria rapid diagnostic test (RDT) would increase uptake of testing and improve rational use of ACTs.MethodsWe designed a 2×2 factorial randomised experiment evaluating 2 levels of subsidy for RDTs and ACTs. Between July 2014 and June 2015, 444 individuals with a malaria-like illness who had not sought treatment were recruited from their homes. We used scratch cards to allocate participants into 4 groups in a ratio of 1:1:1:1. Participants were eligible for an unsubsidised or fully subsidised RDT and 1 of 2 levels of ACT subsidy (current retail price or an additional subsidy conditional on a positive RDT). Treatment decisions were documented 1 week later. Our primary outcome was uptake of malaria testing. Secondary outcomes evaluated ACT consumption among those with a negative test, a positive test or no test.ResultsOffering a free RDT increased the probability of testing by 18.6 percentage points (adjusted probability difference (APD), 95% CI 5.9 to 31.3). An offer of a conditional ACT subsidy did not have an additional effect on the probability of malaria testing when the RDT was free (APD=2.7; 95% CI −8.6 to 14.1). However, receiving the conditional ACT subsidy increased the probability of taking an ACT following a positive RDT by 19.5 percentage points (APD, 95% CI 2.2 to 36.8). Overall, the proportion who took ACT following a negative test was lower than those who took ACT without being tested, indicated improved targeting among those who were tested.ConclusionsBoth subsidies improved appropriate fever management, demonstrating the impact of these costs on decision making. However, the conditional ACT subsidy did not increase testing. We conclude that each of the subsidies primarily impacts the most immediate decision.Trial registration numberNCT02199977.

BackgroundBrazil faces huge health inequality challenges since not all municipalities have access to primary care physicians. The More Doctors Programme (MDP), which started in 2013, was born out of this recognition, providing more than 18 000 doctors in the first few years. However, the programme faced a restructuring at the end of 2018.MethodsWe construct a panel municipality-level data between 2008 and 2017 for 5570 municipalities in Brazil. We employ a difference-in-differences empirical approach, combined with propensity score matching, to study the impacts of the programme on hospitalisations for ambulatory care sensitive conditions and its costs. We explore heterogeneous impacts by age of the patients, type of admissions, and municipalities that were given priority.FindingsThe MDP reduced ambulatory admissions by 2.9 per cent (p value <0.10) and the costs by 3.7 per cent (p value <0.01) over the mean. The reduction was driven by infectious gastroenteritis, bacterial pneumonias, asthma, kidney and urinary infections, and pelvic inflammatory disease. The results held on the subsample of municipalities targeted by the programme. By comparing the benefits of the programme from the reduction in the costs of ambulatory admissions to the total financial costs of the MDP, the impacts allowed the government to save at least BRL 27.88 (US$ 6.9 million) between 2014 and 2017.ConclusionAddressing inequalities in the distribution of the medical workforce remains a global challenge. Our results inform the discussion on the current strategy adopted in Brazil to increase access to primary healthcare in underserved areas.

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In many developing countries, male circumcision has been promoted as an effective HIV prevention strategy, and medical randomized controlled trials have indeed shown a causal link. However, there is limited empirical evidence to support this conclusion in countries where individuals can voluntary opt for different types of circumcision. The present study considers male circumcision in Lesotho, where HIV prevalence is among the highest in the world (23%). Here, men can opt for one of two types of circumcision: traditional male circumcision in initiation schools, or the medical option in health clinics. This paper investigates whether the former has medical effects on individual HIV status that are as beneficial as those shown for the latter. Controlling for the potential individual behavioral response after the operation, it was found that circumcision performed in initiation schools wholly offset the medical benefits of the surgical procedure. This supports anecdotal evidence that the operation performed by traditional circumcisers does not have the same protective effect against HIV transmission as the medical operation. No evidence of “disinhibition” behavior among circumcised men was found, nor differential risky sexual behavior among men circumcised, traditionally or medically. Considering that, in Lesotho, traditional male circumcision is undertaken by more than 90% of circumcised men, the findings highlight the need for further research into how the operation in initiation schools is performed and its medical benefits.

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