Marco Liverani - Academia.edu (original) (raw)

Papers by Marco Liverani

Natural Hazards

In the aftermath of natural disasters, emergency medical teams (EMTs) are dispatched to help loca... more In the aftermath of natural disasters, emergency medical teams (EMTs) are dispatched to help local rescue efforts. While some impact evaluations of EMTs are available, few comprehensive evaluations of the implementation of EMTs in natural disasters, have been published to date. As a result, the evidence base to inform global guidelines and best practices, is remarkably thin. This paper aims to provide a better understanding of the role of EMTs, by summarizing recent reports and case studies. Specifically, this summary aims to identify key improvement areas, as well as obstacles and opportunities for improvement. After a search of the literature, 40 publications met the inclusion criteria, and were included in this summary of the literature. The effective functioning of EMTs is codependent on interactions between different actors, including national governments, international organizations, NGOs, local government agencies, community stakeholders and the private sector. Five key impro...

Global Health Research and Policy

Background In many low- and middle-income countries (LMICs), health system capacities to address ... more Background In many low- and middle-income countries (LMICs), health system capacities to address the burden of non-communicable diseases (NCDs) are often inadequate. In these countries, wearable health technologies such as smartbands and smartwatches could be used as part of public health programmes to improve the monitoring, prevention, and control of NCDs. Considering this potential, the purpose of this study was to explore user experiences and perceptions of a health wearable in Cambodia. Methods Data collection involved a survey, conducted between November 2019 and January 2020, among different categories of participants (including hypertensive participants, non-hypertensive participants, postgraduate students, and civil servants). All participants were given a sample of a watch-type wearable and advised to use it day and night. One month after product delivery, we conducted a survey to explore their views and experiences. Results were analysed by using descriptive statistics an...

The American Journal of Tropical Medicine and Hygiene

Evidence on the effectiveness of low-cost, sustainable biological vector control tools for Aedes ... more Evidence on the effectiveness of low-cost, sustainable biological vector control tools for Aedes mosquitoes is limited. Therefore, the purpose of this trial was to estimate the impact of guppy fish in combination with the larvicide pyriproxyfen (PPF) (Sumilarv® 2MR) and communication for behavioral impact (COMBI) activities to reduce entomological indices in Cambodia. In this cluster randomized, controlled superiority trial, 30 clusters comprised of one or more villages each was allocated in a 1:1:1 ratio to receive either 1) all three interventions (guppies, PPF, and COMBI), 2) two interventions (guppies and COMBI), or 3) control (standard vector control). Entomological surveys among 40 randomly selected households per cluster were carried out quarterly. The primary outcome was the population abundance of adult female Aedes mosquitoes trapped using adult resting collections. In the primary analysis, adult female Aedes abundance and mosquito infection rates was aggregated over follo...

Health Policy and Planning

In low- and middle-income countries, patients may travel abroad to seek better health services or... more In low- and middle-income countries, patients may travel abroad to seek better health services or treatments that are not available at home, especially in regions where great disparities exist between the standard of care in neighbouring countries. While awareness of South–South medical travels has increased, only a few studies investigated this phenomenon in depth from the perspective of sending countries. This article aims to contribute to these studies by reporting findings from a qualitative study of medical travels from Cambodia and associated costs. Data collection primarily involved interviews with Cambodian patients returning from Thailand and Vietnam, conducted in 2017 in the capital Phnom Penh and two provinces, and interviews with key informants in the local health sector. The research findings show that medical travels from Cambodia are driven and shaped by an interplay of socio-economic, cultural and health system factors at different levels, from the effects of regiona...

Evidence on the effectiveness of low-cost, sustainable biological vector control tools for Aedes ... more Evidence on the effectiveness of low-cost, sustainable biological vector control tools for Aedes mosquitoes is limited. Therefore, the purpose of this trial is to estimate the impact of guppy fish, in combination with the use of the larvicide Pyriproxyfen (Sumilarv® 2MR), and Communication for Behavioral Impact (COMBI) activities to reduce entomological indices in Cambodia.In this cluster randomized, controlled superiority trial, 30 clusters comprising of one or more villages each (with approximately 170 households) will be allocated, in a 1:1:1 ratio, to receive either a) three interventions (guppies, Sumilarv® 2MR, and COMBI activities), b) two interventions (guppies and COMBI activities), or c) control (standard vector control).Households were invited to participate, and entomology surveys among 40 randomly selected households per cluster were carried out quarterly. The primary outcome was the population density of adult female Aedes mosquitoes (i.e. number per house) trapped usi...

The American Journal of Tropical Medicine and Hygiene

PLOS Neglected Tropical Diseases

Background In Cambodia dengue vector control activities are focused on larviciding with temephos ... more Background In Cambodia dengue vector control activities are focused on larviciding with temephos and pyrethroid based adulticide sprays to which Aedes have been shown to be increasingly resistant. A cluster randomized trial assessed the impact of using biological control tools (guppy fish, pyriproxyfen (PPF), and Communication for Behavioral Impact (COMBI) activities in combination), which would be used in a value comparison to traditional chemical control tools. Given these new intervention methods, a qualitative assessment was designed in order to represent the quality of understanding, acceptance, and implementation by participants. Methodology/Principal findings A total of 103 participants in 12 Focus Group Discussions (FGDs) and nine In-Depth Interviews (IDIs) were included in the study. The majority of participants in intervention villages (50 out of 80) preferred guppy fish over other vector control methods due to ease of use and rearing, quick reproduction and propensity to eat larvae. A substantial number of participants (11 out of 40) in intervention villages with PPF favored it due to long-lasting effectiveness, lack of smell and easy maintenance. Participants showed high demand for both interventions and were willing to pay between 100-500 riel (0.03-0.13 USD). Nearly all participants perceived that the interventions resulted in a reduction in Aedes mosquitos (both PLOS Neglected Tropical Diseases |

BMJ Global Health

et al. Using unannounced standardised patients to obtain data on quality of care in lowincome and... more et al. Using unannounced standardised patients to obtain data on quality of care in lowincome and middle-income countries: key challenges and opportunities.

Malaria Journal

Background: Large-scale use of insecticide-treated nets and indoor residual spraying have contrib... more Background: Large-scale use of insecticide-treated nets and indoor residual spraying have contributed to a significant decrease in malaria transmission worldwide. Further reduction and progress towards elimination, however, require complementary control measures which can address the remaining gaps in protection from mosquito bites. Following the development of novel pyrethroids with high knockdown effects on malaria vectors, programmatic use of spatial repellents has been suggested as one potential strategy to fill the gaps. This report explores social and contextual factors that may influence the relevance, uptake and sustainable use of a spatial repellent in two remote villages in Mondulkiri province, Cambodia, with endemic malaria transmission. The repellent consisted of polyethylene emanators, held in an open plastic frame and impregnated with 10% metofluthrin. Results: In a baseline survey, 90.9% of households in Ou Chra (n = 30/33) and 96.6% in Pu Cha (n = 57/59) were interviewed. Behavioural data were collected for all household occupants (n = 448). In both villages, there were times and places in which people remained exposed to mosquito bites. Prior to the installation of the repellent, 50.6 and 59.5% of respondents noted that bites occurred "very often" inside the house and in the outdoor area surrounding the house, respectively. Indoor biting was reported to occur more frequently in the evening, followed by at night, while outdoor biting occurred more frequently in the early morning. In a follow-up survey, spatial repellents were well received in both villages, although 63.2% of respondents would not replace bed nets with repellents. Most participants (96.6%) were willing to use the product again; the mean willingness to pay was US$ 0.3 per unit. A preference for local procurement methods emerged. Conclusion: Widespread use of spatial repellents would not fill all protective gaps, but, if their entomological efficacy can be ascertained, outdoor application has the potential to enhance vector control strategies in Cambodia. Successful implementation would require subsidisation and integration with the existing national malaria control strategy. It is hoped that this study, while contributing to a better understanding of the social contexts of residual malaria transmission, will generate further interest in the evaluation of spatial repellents for malaria control.

Health Research Policy and Systems

Background: Discussions within the health community routinely emphasise the importance of evidenc... more Background: Discussions within the health community routinely emphasise the importance of evidence in informing policy formulation and implementation. Much of the support for the evidence-based policy movement draws from concern that policy decisions are often based on inadequate engagement with high-quality evidence. In many such discussions, evidence is treated as differing only in quality, and assumed to improve decisions if it can only be used more. In contrast, political science scholars have described this as an overly simplistic view of the policy-making process, noting that research 'use' can mean a variety of things and relies on nuanced aspects of political systems. An approach more in recognition of how policy-making systems operate in practice can be to consider how institutions and ideas influence which pieces of evidence appear to be relevant for, and are used within, different policy processes. Methods: Drawing on in-depth interviews undertaken in 2015-2016 with key health sector stakeholders in Cambodia, we investigate the evidence perceived to be relevant to policy decisions for three contrasting health policy examples, namely tobacco control, HIV/AIDS and performance-based salary incentives. These cases allow us to examine the ways that policy-relevant evidence may differ given the framing of the issue and the broader institutional context in which evidence is considered. Results: The three health issues show few similarities in how pieces of evidence were used in various aspects of policy-making, despite all being discussed within a broad policy environment in which evidence-based policy-making is rhetorically championed. Instead, we find that evidence use can be better understood by mapping how these health policy issues differ in terms of the issue characteristics, and also in terms of the stakeholders structurally established as having a dominant influence for each issue. Both of these have important implications for evidence use. Contrasting concerns of key stakeholders meant that evidence related to differing issues could be understood in terms of how it was relevant to policy. The stakeholders involved, however, could further be seen to possess differing logics about how to go about achieving their various outcomeslogics that could further help explain the differences seen in evidence utilisation. Conclusion: A comparative approach reiterates that evidence is not a uniform concept for which more is obviously better, but rather illustrates how different constructions and pieces of evidence become relevant in relation to the features of specific health policy decisions. An institutional approach that considers the structural position of stakeholders with differing core goals or objectives, as well as their logics related to evidence utilisation, can further help to understand some of the complexities of evidence use in health policy-making.

Health Economics, Policy and Law

This study qualitatively investigates what factors apart from or in addition to financial incenti... more This study qualitatively investigates what factors apart from or in addition to financial incentives can encourage better performance of frontline health care providers. We interviewed health sector managers in Pakistan, Cambodia and China, and they highlighted many potential limitations in the applicability of financial incentives in their contexts. There was a consistent view that providers are not always primarily driven by monetary rewards and that non-monetary rewards – such as recognition from direct supervisors and career development – could have a greater influence on performance. Managers also highlighted several challenges related to the design and implementation of performance management schemes: supervisors may not have performance information necessary to determine which agents to reward; when performance information is available, organisational culture may value other attributes such as social ties or years of experience; finally, concentration of power at higher level...

BMJ Global Health

IntroductionIn global health discussions, there have been widespread calls for health policy and ... more IntroductionIn global health discussions, there have been widespread calls for health policy and programme implementation to be informed by the best available evidence. However, recommendations in the literature on knowledge translation are often decontextualised, with little attention to the local systems of institutions, structures and practices which can direct the production of evidence and shape whether or how it informs health decisions. This article explores these issues in the country setting of Cambodia, where the Ministry of Health has explicitly championed the language of evidence-based approaches to policy and planning.MethodsResearch for this paper combined multiple sources and material, including in-depth interviews with key informants in Phnom Penh and the analysis of documentary material and publications. Data collection and analysis focused on two key domains in evidence advisory systems: domestic capacities to generate health policy-relevant evidence and institutio...

PLoS neglected tropical diseases, Feb 16, 2018

Globally there are an estimated 390 million dengue infections per year, of which 96 million are c... more Globally there are an estimated 390 million dengue infections per year, of which 96 million are clinically apparent. In Cambodia, estimates suggest as many as 185,850 cases annually. The World Health Organization global strategy for dengue prevention aims to reduce mortality rates by 50% and morbidity by 25% by 2020. The adoption of integrated vector management approach using community-based methods tailored to the local context is one of the recommended strategies to achieve these objectives. Understanding local knowledge, attitudes and practices is therefore essential to designing suitable strategies to fit each local context. A Knowledge, Attitudes and Practices survey in 600 randomly chosen households was administered in 30 villages in Kampong Cham which is one of the most populated provinces of Cambodia. KAP surveys were administered to a sub-sample of households where an entomology survey was conducted (1200 households), during which Aedes larval/pupae and adult female Aedes m...

Health policy and planning, Jan 9, 2018

The recent outbreak of Ebola Virus Disease (EVD) in West Africa has drawn attention to the role a... more The recent outbreak of Ebola Virus Disease (EVD) in West Africa has drawn attention to the role and responsiveness of health systems in the face of shock. It brought into sharp focus the idea that health systems need not only to be stronger but also more 'resilient'. In this article, we argue that responding to shocks is an important aspect of resilience, examining the health system behaviour in the face of four types of contemporary shocks: the financial crisis in Europe from 2008 onwards; climate change disasters; the EVD outbreak in West Africa 2013-16; and the recent refugee and migration crisis in Europe. Based on this analysis, we identify '3 plus 2' critical dimensions of particular relevance to health systems' ability to adapt and respond to shocks; actions in all of these will determine the extent to which a response is successful. These are three core dimensions corresponding to three health systems functions: 'health information systems' (havin...

BMC Health Services Research

Background: There is growing interest in the expansion of community health workers programmes in ... more Background: There is growing interest in the expansion of community health workers programmes in low-and middle-income countries as a cost-effective approach to address shortages of health professionals. However, our understanding of the reception of large-scale programmes and how to improve them remains limited, with knowledge gaps about factors that may promote or discourage equitable access to services. This paper examines the case of the Village Malaria Workers (VMW) programme in Cambodia, an extensive community-based intervention for the management of malaria cases in remote rural areas. Method: Fieldwork was conducted in Kampot province, in six case villages characterised by different programme configuration, population size, and distance to the nearest public health facility. In these locations, in-depth interviews (n = 71) with VMWs, village authorities, and residents were conducted to identify facilitators and challenges to service utilisation. Data analysis was informed by a conceptual framework based on five domains of access to services: awareness, accessibility, accommodation, availability, and acceptability. Results: Factors that influenced the utilisation of VMW services in our research sites include: the nature of dissemination activities and their ability to reach different population groups; the village topography and the changing road infrastructure; the involvement of VMWs in other community roles and activities; perceptions about the type of disease after the onset of symptoms; the need for comprehensive diagnosis and care; perceptions about the status of VMWs as medical providers; length of VMW appointment. Conclusions: This study highlights the complexity and diversity of contextual factors that may influence the uptake of a community health programme. As in other countries, continued use of lay health workers in Cambodia to deliver diagnostic and curative services has the potential for great health and economic impact. However, further consideration should be given to the problem of access in different categories of residents and different contexts of implementation. In addition, a comprehensive mapping of changes in disease epidemiology, road infrastructure and the geography of access to services is crucial to inform policy development in this area.

BMJ global health, 2017

To assess progress towards universal health coverage, countries like Cambodia require evidence on... more To assess progress towards universal health coverage, countries like Cambodia require evidence on equity in the financing and distribution of healthcare benefits. This evidence must be based on a system-wide perspective that recognises the complex roles played by the public and private sectors in many contemporary healthcare systems. To undertake a system-wide assessment of who pays and who benefits from healthcare in Cambodia and to understand the factors influencing this. Financing and benefit incidence analysis will be used to calculate the financing burden and distribution of healthcare benefits across socioeconomic groups. Data on healthcare usage, living standards and self-assessed health status will be derived from a cross-sectional household survey designed for this study involving a random sample of 5000 households. This will be supplemented by secondary data from the Cambodian National Health Accounts 2014 and the Cambodian Socioeconomic Survey (CSES) 2014. We will also co...

BMJ open, Mar 8, 2017

The overuse of antimalarial drugs is widespread. Effective methods to improve prescribing practic... more The overuse of antimalarial drugs is widespread. Effective methods to improve prescribing practice remain unclear. We evaluated the impact of 10 interventions that introduced rapid diagnostic tests for malaria (mRDTs) on the use of tests and adherence to results in different contexts. A comparative case study approach, analysing variation in outcomes across different settings. Studies from the ACT Consortium evaluating mRDTs with a range of supporting interventions in 6 malaria endemic countries. Providers were governmental or non-governmental healthcare workers, private retail sector workers or community volunteers. Each study arm in a distinct setting was considered a case. 28 cases from 10 studies were included, representing 148 461 patients seeking care for suspected malaria. The interventions included different mRDT training packages, supervision, supplies and community sensitisation. Analysis explored variation in: (1) uptake of mRDTs (% febrile patients tested); (2) provider ...

Modern Italy, 2006

... DAL LAGO EMILIO QUADRELLI La città e le ombre Crimini, criminali, cittadini ... DAL LAGO EMIL... more ... DAL LAGO EMILIO QUADRELLI La città e le ombre Crimini, criminali, cittadini ... DAL LAGO EMILIO QUADRELLI La città e le ombre Crimini, criminali, cittadini ...

Asia & the Pacific Policy Studies, 2015

The wide circulation of substandard medicines in Southeast Asia is a serious public health concer... more The wide circulation of substandard medicines in Southeast Asia is a serious public health concern. Substandard medicines may contain none, or inadequate quantities of the active ingredient, or may contain harmful ingredients. This poses a considerable threat to human lives and an obstacle to infectious disease control at the national, regional and global level, also due to the associated risk of antimicrobial resistance. As trade liberalisation in the region intensifies, moreover, there are concerns that reduced custom controls and higher mobility of people and goods may increase the illicit trade in falsified medicines. In this context, crucial is the ability of governments to develop adequate regulations and capacities as well as enforcement measures to tackle these issues. Given the transnational nature of the problem, the establishment of effective mechanisms for crosscountry surveillance, information exchange and coordinated action is also necessary. In this article, we provide an overview of national responses, reflecting on strengths and limitations of past interventions. We then examine existing institutional frameworks for regional health cooperation, particularly the Association of Southeast Asian Nations, and their potential to support enhanced capacities and cooperation to address this challenge.

Natural Hazards

In the aftermath of natural disasters, emergency medical teams (EMTs) are dispatched to help loca... more In the aftermath of natural disasters, emergency medical teams (EMTs) are dispatched to help local rescue efforts. While some impact evaluations of EMTs are available, few comprehensive evaluations of the implementation of EMTs in natural disasters, have been published to date. As a result, the evidence base to inform global guidelines and best practices, is remarkably thin. This paper aims to provide a better understanding of the role of EMTs, by summarizing recent reports and case studies. Specifically, this summary aims to identify key improvement areas, as well as obstacles and opportunities for improvement. After a search of the literature, 40 publications met the inclusion criteria, and were included in this summary of the literature. The effective functioning of EMTs is codependent on interactions between different actors, including national governments, international organizations, NGOs, local government agencies, community stakeholders and the private sector. Five key impro...

Global Health Research and Policy

Background In many low- and middle-income countries (LMICs), health system capacities to address ... more Background In many low- and middle-income countries (LMICs), health system capacities to address the burden of non-communicable diseases (NCDs) are often inadequate. In these countries, wearable health technologies such as smartbands and smartwatches could be used as part of public health programmes to improve the monitoring, prevention, and control of NCDs. Considering this potential, the purpose of this study was to explore user experiences and perceptions of a health wearable in Cambodia. Methods Data collection involved a survey, conducted between November 2019 and January 2020, among different categories of participants (including hypertensive participants, non-hypertensive participants, postgraduate students, and civil servants). All participants were given a sample of a watch-type wearable and advised to use it day and night. One month after product delivery, we conducted a survey to explore their views and experiences. Results were analysed by using descriptive statistics an...

The American Journal of Tropical Medicine and Hygiene

Evidence on the effectiveness of low-cost, sustainable biological vector control tools for Aedes ... more Evidence on the effectiveness of low-cost, sustainable biological vector control tools for Aedes mosquitoes is limited. Therefore, the purpose of this trial was to estimate the impact of guppy fish in combination with the larvicide pyriproxyfen (PPF) (Sumilarv® 2MR) and communication for behavioral impact (COMBI) activities to reduce entomological indices in Cambodia. In this cluster randomized, controlled superiority trial, 30 clusters comprised of one or more villages each was allocated in a 1:1:1 ratio to receive either 1) all three interventions (guppies, PPF, and COMBI), 2) two interventions (guppies and COMBI), or 3) control (standard vector control). Entomological surveys among 40 randomly selected households per cluster were carried out quarterly. The primary outcome was the population abundance of adult female Aedes mosquitoes trapped using adult resting collections. In the primary analysis, adult female Aedes abundance and mosquito infection rates was aggregated over follo...

Health Policy and Planning

In low- and middle-income countries, patients may travel abroad to seek better health services or... more In low- and middle-income countries, patients may travel abroad to seek better health services or treatments that are not available at home, especially in regions where great disparities exist between the standard of care in neighbouring countries. While awareness of South–South medical travels has increased, only a few studies investigated this phenomenon in depth from the perspective of sending countries. This article aims to contribute to these studies by reporting findings from a qualitative study of medical travels from Cambodia and associated costs. Data collection primarily involved interviews with Cambodian patients returning from Thailand and Vietnam, conducted in 2017 in the capital Phnom Penh and two provinces, and interviews with key informants in the local health sector. The research findings show that medical travels from Cambodia are driven and shaped by an interplay of socio-economic, cultural and health system factors at different levels, from the effects of regiona...

Evidence on the effectiveness of low-cost, sustainable biological vector control tools for Aedes ... more Evidence on the effectiveness of low-cost, sustainable biological vector control tools for Aedes mosquitoes is limited. Therefore, the purpose of this trial is to estimate the impact of guppy fish, in combination with the use of the larvicide Pyriproxyfen (Sumilarv® 2MR), and Communication for Behavioral Impact (COMBI) activities to reduce entomological indices in Cambodia.In this cluster randomized, controlled superiority trial, 30 clusters comprising of one or more villages each (with approximately 170 households) will be allocated, in a 1:1:1 ratio, to receive either a) three interventions (guppies, Sumilarv® 2MR, and COMBI activities), b) two interventions (guppies and COMBI activities), or c) control (standard vector control).Households were invited to participate, and entomology surveys among 40 randomly selected households per cluster were carried out quarterly. The primary outcome was the population density of adult female Aedes mosquitoes (i.e. number per house) trapped usi...

The American Journal of Tropical Medicine and Hygiene

PLOS Neglected Tropical Diseases

Background In Cambodia dengue vector control activities are focused on larviciding with temephos ... more Background In Cambodia dengue vector control activities are focused on larviciding with temephos and pyrethroid based adulticide sprays to which Aedes have been shown to be increasingly resistant. A cluster randomized trial assessed the impact of using biological control tools (guppy fish, pyriproxyfen (PPF), and Communication for Behavioral Impact (COMBI) activities in combination), which would be used in a value comparison to traditional chemical control tools. Given these new intervention methods, a qualitative assessment was designed in order to represent the quality of understanding, acceptance, and implementation by participants. Methodology/Principal findings A total of 103 participants in 12 Focus Group Discussions (FGDs) and nine In-Depth Interviews (IDIs) were included in the study. The majority of participants in intervention villages (50 out of 80) preferred guppy fish over other vector control methods due to ease of use and rearing, quick reproduction and propensity to eat larvae. A substantial number of participants (11 out of 40) in intervention villages with PPF favored it due to long-lasting effectiveness, lack of smell and easy maintenance. Participants showed high demand for both interventions and were willing to pay between 100-500 riel (0.03-0.13 USD). Nearly all participants perceived that the interventions resulted in a reduction in Aedes mosquitos (both PLOS Neglected Tropical Diseases |

BMJ Global Health

et al. Using unannounced standardised patients to obtain data on quality of care in lowincome and... more et al. Using unannounced standardised patients to obtain data on quality of care in lowincome and middle-income countries: key challenges and opportunities.

Malaria Journal

Background: Large-scale use of insecticide-treated nets and indoor residual spraying have contrib... more Background: Large-scale use of insecticide-treated nets and indoor residual spraying have contributed to a significant decrease in malaria transmission worldwide. Further reduction and progress towards elimination, however, require complementary control measures which can address the remaining gaps in protection from mosquito bites. Following the development of novel pyrethroids with high knockdown effects on malaria vectors, programmatic use of spatial repellents has been suggested as one potential strategy to fill the gaps. This report explores social and contextual factors that may influence the relevance, uptake and sustainable use of a spatial repellent in two remote villages in Mondulkiri province, Cambodia, with endemic malaria transmission. The repellent consisted of polyethylene emanators, held in an open plastic frame and impregnated with 10% metofluthrin. Results: In a baseline survey, 90.9% of households in Ou Chra (n = 30/33) and 96.6% in Pu Cha (n = 57/59) were interviewed. Behavioural data were collected for all household occupants (n = 448). In both villages, there were times and places in which people remained exposed to mosquito bites. Prior to the installation of the repellent, 50.6 and 59.5% of respondents noted that bites occurred "very often" inside the house and in the outdoor area surrounding the house, respectively. Indoor biting was reported to occur more frequently in the evening, followed by at night, while outdoor biting occurred more frequently in the early morning. In a follow-up survey, spatial repellents were well received in both villages, although 63.2% of respondents would not replace bed nets with repellents. Most participants (96.6%) were willing to use the product again; the mean willingness to pay was US$ 0.3 per unit. A preference for local procurement methods emerged. Conclusion: Widespread use of spatial repellents would not fill all protective gaps, but, if their entomological efficacy can be ascertained, outdoor application has the potential to enhance vector control strategies in Cambodia. Successful implementation would require subsidisation and integration with the existing national malaria control strategy. It is hoped that this study, while contributing to a better understanding of the social contexts of residual malaria transmission, will generate further interest in the evaluation of spatial repellents for malaria control.

Health Research Policy and Systems

Background: Discussions within the health community routinely emphasise the importance of evidenc... more Background: Discussions within the health community routinely emphasise the importance of evidence in informing policy formulation and implementation. Much of the support for the evidence-based policy movement draws from concern that policy decisions are often based on inadequate engagement with high-quality evidence. In many such discussions, evidence is treated as differing only in quality, and assumed to improve decisions if it can only be used more. In contrast, political science scholars have described this as an overly simplistic view of the policy-making process, noting that research 'use' can mean a variety of things and relies on nuanced aspects of political systems. An approach more in recognition of how policy-making systems operate in practice can be to consider how institutions and ideas influence which pieces of evidence appear to be relevant for, and are used within, different policy processes. Methods: Drawing on in-depth interviews undertaken in 2015-2016 with key health sector stakeholders in Cambodia, we investigate the evidence perceived to be relevant to policy decisions for three contrasting health policy examples, namely tobacco control, HIV/AIDS and performance-based salary incentives. These cases allow us to examine the ways that policy-relevant evidence may differ given the framing of the issue and the broader institutional context in which evidence is considered. Results: The three health issues show few similarities in how pieces of evidence were used in various aspects of policy-making, despite all being discussed within a broad policy environment in which evidence-based policy-making is rhetorically championed. Instead, we find that evidence use can be better understood by mapping how these health policy issues differ in terms of the issue characteristics, and also in terms of the stakeholders structurally established as having a dominant influence for each issue. Both of these have important implications for evidence use. Contrasting concerns of key stakeholders meant that evidence related to differing issues could be understood in terms of how it was relevant to policy. The stakeholders involved, however, could further be seen to possess differing logics about how to go about achieving their various outcomeslogics that could further help explain the differences seen in evidence utilisation. Conclusion: A comparative approach reiterates that evidence is not a uniform concept for which more is obviously better, but rather illustrates how different constructions and pieces of evidence become relevant in relation to the features of specific health policy decisions. An institutional approach that considers the structural position of stakeholders with differing core goals or objectives, as well as their logics related to evidence utilisation, can further help to understand some of the complexities of evidence use in health policy-making.

Health Economics, Policy and Law

This study qualitatively investigates what factors apart from or in addition to financial incenti... more This study qualitatively investigates what factors apart from or in addition to financial incentives can encourage better performance of frontline health care providers. We interviewed health sector managers in Pakistan, Cambodia and China, and they highlighted many potential limitations in the applicability of financial incentives in their contexts. There was a consistent view that providers are not always primarily driven by monetary rewards and that non-monetary rewards – such as recognition from direct supervisors and career development – could have a greater influence on performance. Managers also highlighted several challenges related to the design and implementation of performance management schemes: supervisors may not have performance information necessary to determine which agents to reward; when performance information is available, organisational culture may value other attributes such as social ties or years of experience; finally, concentration of power at higher level...

BMJ Global Health

IntroductionIn global health discussions, there have been widespread calls for health policy and ... more IntroductionIn global health discussions, there have been widespread calls for health policy and programme implementation to be informed by the best available evidence. However, recommendations in the literature on knowledge translation are often decontextualised, with little attention to the local systems of institutions, structures and practices which can direct the production of evidence and shape whether or how it informs health decisions. This article explores these issues in the country setting of Cambodia, where the Ministry of Health has explicitly championed the language of evidence-based approaches to policy and planning.MethodsResearch for this paper combined multiple sources and material, including in-depth interviews with key informants in Phnom Penh and the analysis of documentary material and publications. Data collection and analysis focused on two key domains in evidence advisory systems: domestic capacities to generate health policy-relevant evidence and institutio...

PLoS neglected tropical diseases, Feb 16, 2018

Globally there are an estimated 390 million dengue infections per year, of which 96 million are c... more Globally there are an estimated 390 million dengue infections per year, of which 96 million are clinically apparent. In Cambodia, estimates suggest as many as 185,850 cases annually. The World Health Organization global strategy for dengue prevention aims to reduce mortality rates by 50% and morbidity by 25% by 2020. The adoption of integrated vector management approach using community-based methods tailored to the local context is one of the recommended strategies to achieve these objectives. Understanding local knowledge, attitudes and practices is therefore essential to designing suitable strategies to fit each local context. A Knowledge, Attitudes and Practices survey in 600 randomly chosen households was administered in 30 villages in Kampong Cham which is one of the most populated provinces of Cambodia. KAP surveys were administered to a sub-sample of households where an entomology survey was conducted (1200 households), during which Aedes larval/pupae and adult female Aedes m...

Health policy and planning, Jan 9, 2018

The recent outbreak of Ebola Virus Disease (EVD) in West Africa has drawn attention to the role a... more The recent outbreak of Ebola Virus Disease (EVD) in West Africa has drawn attention to the role and responsiveness of health systems in the face of shock. It brought into sharp focus the idea that health systems need not only to be stronger but also more 'resilient'. In this article, we argue that responding to shocks is an important aspect of resilience, examining the health system behaviour in the face of four types of contemporary shocks: the financial crisis in Europe from 2008 onwards; climate change disasters; the EVD outbreak in West Africa 2013-16; and the recent refugee and migration crisis in Europe. Based on this analysis, we identify '3 plus 2' critical dimensions of particular relevance to health systems' ability to adapt and respond to shocks; actions in all of these will determine the extent to which a response is successful. These are three core dimensions corresponding to three health systems functions: 'health information systems' (havin...

BMC Health Services Research

Background: There is growing interest in the expansion of community health workers programmes in ... more Background: There is growing interest in the expansion of community health workers programmes in low-and middle-income countries as a cost-effective approach to address shortages of health professionals. However, our understanding of the reception of large-scale programmes and how to improve them remains limited, with knowledge gaps about factors that may promote or discourage equitable access to services. This paper examines the case of the Village Malaria Workers (VMW) programme in Cambodia, an extensive community-based intervention for the management of malaria cases in remote rural areas. Method: Fieldwork was conducted in Kampot province, in six case villages characterised by different programme configuration, population size, and distance to the nearest public health facility. In these locations, in-depth interviews (n = 71) with VMWs, village authorities, and residents were conducted to identify facilitators and challenges to service utilisation. Data analysis was informed by a conceptual framework based on five domains of access to services: awareness, accessibility, accommodation, availability, and acceptability. Results: Factors that influenced the utilisation of VMW services in our research sites include: the nature of dissemination activities and their ability to reach different population groups; the village topography and the changing road infrastructure; the involvement of VMWs in other community roles and activities; perceptions about the type of disease after the onset of symptoms; the need for comprehensive diagnosis and care; perceptions about the status of VMWs as medical providers; length of VMW appointment. Conclusions: This study highlights the complexity and diversity of contextual factors that may influence the uptake of a community health programme. As in other countries, continued use of lay health workers in Cambodia to deliver diagnostic and curative services has the potential for great health and economic impact. However, further consideration should be given to the problem of access in different categories of residents and different contexts of implementation. In addition, a comprehensive mapping of changes in disease epidemiology, road infrastructure and the geography of access to services is crucial to inform policy development in this area.

BMJ global health, 2017

To assess progress towards universal health coverage, countries like Cambodia require evidence on... more To assess progress towards universal health coverage, countries like Cambodia require evidence on equity in the financing and distribution of healthcare benefits. This evidence must be based on a system-wide perspective that recognises the complex roles played by the public and private sectors in many contemporary healthcare systems. To undertake a system-wide assessment of who pays and who benefits from healthcare in Cambodia and to understand the factors influencing this. Financing and benefit incidence analysis will be used to calculate the financing burden and distribution of healthcare benefits across socioeconomic groups. Data on healthcare usage, living standards and self-assessed health status will be derived from a cross-sectional household survey designed for this study involving a random sample of 5000 households. This will be supplemented by secondary data from the Cambodian National Health Accounts 2014 and the Cambodian Socioeconomic Survey (CSES) 2014. We will also co...

BMJ open, Mar 8, 2017

The overuse of antimalarial drugs is widespread. Effective methods to improve prescribing practic... more The overuse of antimalarial drugs is widespread. Effective methods to improve prescribing practice remain unclear. We evaluated the impact of 10 interventions that introduced rapid diagnostic tests for malaria (mRDTs) on the use of tests and adherence to results in different contexts. A comparative case study approach, analysing variation in outcomes across different settings. Studies from the ACT Consortium evaluating mRDTs with a range of supporting interventions in 6 malaria endemic countries. Providers were governmental or non-governmental healthcare workers, private retail sector workers or community volunteers. Each study arm in a distinct setting was considered a case. 28 cases from 10 studies were included, representing 148 461 patients seeking care for suspected malaria. The interventions included different mRDT training packages, supervision, supplies and community sensitisation. Analysis explored variation in: (1) uptake of mRDTs (% febrile patients tested); (2) provider ...

Modern Italy, 2006

... DAL LAGO EMILIO QUADRELLI La città e le ombre Crimini, criminali, cittadini ... DAL LAGO EMIL... more ... DAL LAGO EMILIO QUADRELLI La città e le ombre Crimini, criminali, cittadini ... DAL LAGO EMILIO QUADRELLI La città e le ombre Crimini, criminali, cittadini ...

Asia & the Pacific Policy Studies, 2015

The wide circulation of substandard medicines in Southeast Asia is a serious public health concer... more The wide circulation of substandard medicines in Southeast Asia is a serious public health concern. Substandard medicines may contain none, or inadequate quantities of the active ingredient, or may contain harmful ingredients. This poses a considerable threat to human lives and an obstacle to infectious disease control at the national, regional and global level, also due to the associated risk of antimicrobial resistance. As trade liberalisation in the region intensifies, moreover, there are concerns that reduced custom controls and higher mobility of people and goods may increase the illicit trade in falsified medicines. In this context, crucial is the ability of governments to develop adequate regulations and capacities as well as enforcement measures to tackle these issues. Given the transnational nature of the problem, the establishment of effective mechanisms for crosscountry surveillance, information exchange and coordinated action is also necessary. In this article, we provide an overview of national responses, reflecting on strengths and limitations of past interventions. We then examine existing institutional frameworks for regional health cooperation, particularly the Association of Southeast Asian Nations, and their potential to support enhanced capacities and cooperation to address this challenge.