Category Archives: Director’s Choice – From the Journals

Vertical Health Care Programmes or Health System Strengthening: A False Dichotomy

Health care development is sometimes classified as vertical or horizontal. Vertical programmes target specific diseases or disease clusters. For example tuberculosis, HIV and malaria, are targeted by the Global Fund. Horizontal programmes, by contrast, seek to strengthen the system within which health care is embedded. Such programmes are concerned with human resources, financing, education, and supply chains, among many other functions.

There has been a strong push to move from vertical to horizontal programmes from many corners, including from this News Blog. Supporters of such a change in emphasis cannot but acknowledge the massive successes that vertical programmes have notched up, especially in the fields of infant health, maternal health, and infectious diseases.

However, the limitations of a purely diseased-based approach have become increasingly evident. Logically, it is not even possible to instigate a vertical approach in a complete system vacuum. For example, it would be difficult, if not impossible, to instigate a programme to improve HIV care, if the supply chain could not make drugs available and if the health system could not support basic diagnostic services. That said, vertical surfaces should not be able to siphon off more than their fair share of the health services infrastructure.

A recent Lancet paper on health services in Ethiopia made a further important point,[1] that vertical systems can make a very good platform to extend and deepen generic health systems. In fact, that is precisely what has happened in that country, with full support from the Global Fund and GAVI, the Vaccine Alliance. They refer to this combination of vertical and generic development as a “diagonal” investment approach. We would prefer to describe the relationship as one of symbiosis in which vertical and horizontal programmes are designed to reinforce each other.

The Ethiopian initiative involved strengthening the system at multiple levels, from health service financing, human resources policies, education, investment in primary care, and community outreach activities, along with support for community action and self-help (including the “IKEA model” previously described in this news blog).[2] Certainly, Ethiopia, along with other countries such as Bangladesh, Thailand and Rwanda, stand out for having achieved remarkable improvements over many dimensions of health. In Ethiopia the reduction in mortality for children under the age of five years was 67% from the 1990 baseline, while there was a 71% decline in the maternal mortality ratio and deaths from malaria, tuberculosis and HIV were halved. This took place against a financial backdrop of declining international aid but increasing domestic expenditure. The combination of vertical programmes and health system strengthening seems to have ensured that the money was not wasted.

— Richard Lilford, CLAHRC WM Director


  1. Assefa Y, Tesfaye D, Van Damme W, Hill PS. Effectiveness and sustainability of a diagonal investment approach to strengthen the primary health-care system in Ethiopia. Lancet. 2018; 392: 1473-81.
  2. Lilford RJ. Pre-payment Systems for Access to Healthcare. NIHR CLAHRC West Midlands News Blog. 18 May 2018.

Childhood IQ and Mortality

Many studies have shown an association between childhood intelligence and mortality. However, most studies have been conducted with male participants, and potential mechanisms for the putative association are poorly understood. A recent paper looked at a large sample of Swedish people in an attempt to clarify these issues.[1]

The authors looked at IQ data from 19,919 Swedes who were 13 years old at the time (9,817 women), along with socioeconomic data from their childhood and middle age over the following 53 years. The analysis found an association between lower IQ and increased all-cause mortality. A one standard deviation decrease in IQ was associated with increased risk of all-cause mortality in both men (hazard ratio 1.31, 95% CI 1.23-1.39) and women (HR 1.16, 95% CI 1.08-1.25). Most causes of death were associated with lower IQ in men, while in women a lower IQ was associated with an increased risk of death from cancer and cardiovascular disease. When the authors adjusted for childhood socioeconomic factors the associations were slightly attenuated; but were further attenuated when adjusting for adulthood factors – considerably in men (overall mortality HR=1.17, 95% CI 1.08-1.26), and almost completely in women (HR 1.02, 95% CI 0.93-1.12). These results suggest that it is the social and socioeconomic circumstances in adulthood that contribute to the association between IQ and mortality, particularly in women, though the authors state that more research is needed to clarify the pathways linking childhood IQ and mortality across genders.

— Peter Chilton, Research Fellow


  1. Wallin AS, Allebeck P, Gustafsson J-E, Hemmingsson T. Childhood IQ and mortality during 53 years’ follow-up of Swedish men and women. J Epidemiol Community Health. 2018; 72(10): 926-32.

Can Diet Help Maintain Brain Health?

A recent study in the journal of Neurology looked at the long-term effects high fruit and vegetable intake had on a person’s cognitive function.[1] The authors were able to research and follow-up 27,842 US men over a 26 year period. These men were middle-aged (mean age of 51 years) and were or had been health professionals.

Every four years, from 1986 to 2002, they completed questionnaires looking at their eating habits, and then completed subjective cognitive function questionnaires in 2008 and 2012. Logistic regression of the data found significant individual associations between higher intakes of vegetables (around six servings a day compared to two), fruits (around three servings a day compared to half) and fruit juice (once a day compared to less than once a month) and lower odds of moderate or poor subjective cognitive function. These associations remained significant after adjusting for non-dietary factors and total energy intake, though adjusting for dietary factors weakened the association with fruit intake. Daily consumption of orange juice (compared to less than one serving per month) was associated with much lower odds of poor subjective cognitive function, with an adjusted odds ratio of 0.53 (95% CI 0.43-0.67). Meanwhile the adjusted odds ratios for vegetables were 0.83 (05% CI 0.76-0.92) for moderate, and 0.66 (0.55-0.80) for poor subjective cognitive function. The authors also found that high intake of fruit and vegetables at the start of the study period was associated with a lower risk of poor subjective cognitive function at the end of the study. Although the study does not prove a causal link, the fact that the association lasted the length of the study support the idea that vegetable and fruit consumption may help avert memory loss.

— Peter Chilton, Research Fellow


  1. Yuan C, Fondell E, Bhushan A, Ascherio A, Okereke OI, Grodstein F, Willett WC. Long-term intake of vegetables and fruits and subjective cognitive function in US men. Neurology. 2018.

Senior Doctors and In-hospital Care

Readers of this News Blog may be aware that we are involved in the HiSLAC (high-intensity, specialist-led acute care) project that examines the impact of increasing consultant presence on acute in-hospital care at weekends.[1-4] Professor Julian Bion, the Principal Investigator for the project, recently drew our attention to two studies from the US that have shown some interesting results in relation to the potential impact of senior doctors on the quality of care. One of the studies was a cross-over randomised controlled trial (RCT) conducted in general medical wards in which increased supervision by attending physicians (senior doctors) was compared with standard supervision [5]; the other was a retrospective cohort study in which the association between physician’s age and patient outcomes was explored.[6]

In the RCT, the attending physicians joined residents and interns (doctors who are still in training) on their ward rounds to see previously admitted (i.e. not newly admitted) patients in the increased supervision group, while the attending physicians were available but did not join the ward rounds in the standard supervision group. Medical error rates did not differ significantly between increased vs standard supervision (91 [95% CI 77 to 104] vs 108 [95% CI 86 to 134] events per 1000 patient-days), but interns (the most junior doctors) spoke significantly less, and both residents and interns felt that they were lessefficient and less autonomous in the ward rounds with increased supervision.[5]

The retrospective cohort study was undertaken using a 20% random sample of Medicare (an US federal health insurance program primarily for elderly people) beneficiaries admitted to hospital with a medical condition and treated by hospitalists (senior doctors specialised in the general care of patients in hospitals). The association between the hospitalists’ age and 30-day mortality, 30-day re-admission and cost of care was explored with statistical adjustment covering patient characteristics, physician characteristics and hospital fixed effects (which essentially allows comparisons be made within hospitals). Adjusted 30-day mortality was found to increase with doctors’ age: 10.8%, 11.1%, 11.3% and 12.1% for ages <40, 40-49, 50-59 and ≥60 respectively. The association appears robust under various sensitivity and subgroup analyses, with an exception that no such association was found among doctors with a high volume of patients. Re-admission rates were similar between doctors’ age groups and costs of care were slightly higher among older doctors.[6]

What should we make out of these findings? For the RCT, the observed effect (reduction in medical errors) was in the expected direction but the study was under-powered (the sample size was powered to detect a 40% relative reduction in error rates vs. 15% actually observed). However, the junior doctors clearly felt qualified to ‘fly solo’. For the observational study, while the association between doctors’ age and care quality and outcomes may require further scrutiny, it is highly speculative. Since an experimental study is not on the cards, cause and effect reasoning must await triangulation of multiple observations across the chain from cause to effect.[7] Such a study is currently under way with respect to the cause of the “weekend effect”.[8]

— Yen-Fu Chen, Principal Research Fellow


  1. Watson SI, Chen YF, Bion JF, Aldridge CP, Girling A, Lilford RJ. Protocol for the health economic evaluation of increasing the weekend specialist to patient ratio in hospitals in England. BMJ Open. 2018; 8: e015561.
  2. Bion J, Aldridge CP, Girling A, et al. Two-epoch cross-sectional case record review protocol comparing quality of care of hospital emergency admissions at weekends versus weekdays. BMJ Open. 2017; 7: e018747.
  3. Chen Y-F, Boyal A, Sutton E, et al. The magnitude and mechanisms of the weekend effect in hospital admissions: A protocol for a mixed methods review incorporating a systematic review and framework synthesis. Syst Rev. 2016; 5(1): 84.
  4. Tarrant C, Sutton E, Angell E, Aldridge CP, Boyal A, Bion J. The ‘weekend effect’ in acute medicine: a protocol for a team-based ethnography of weekend care for medical patients in acute hospital settings. BMJ Open.2017; 7(4): e016755.
  5. Finn KM, Metlay JP, Chang Y, et al. Effect of increased inpatient attending physician supervision on medical errors, patient safety, and resident education: a randomized clinical trial. JAMA Intern Med. 2018; 178(7): 952-59.
  6. Tsugawa Y, Newhouse JP, Zaslavsky AM, Blumenthal DM, Jena AB. Physician age and outcomes in elderly patients in hospital in the US: observational study. BMJ. 2017; 357: j1797.
  7. Lilford RJ, Chilton PJ, Hemming K, Girling AJ, Taylor CA, Barach P. Evaluating policy and service interventions: framework to guide selection and interpretation of study end pointsBMJ. 2010; 341: c4413.
  8. Lilford RJ, Chen YF. The ubiquitous weekend effect: moving past proving it exists to clarifying what causes it. BMJ Qual Saf. 2015; 24(8): 480-2.


Impact of Childcare on Children

Leaving your child crying at the nursery door is a difficult experience that can leave a working parent questioning whether they have the right priorities. When I first experienced this a few years ago, a good friend working at Cancer Research sent me a summary of research showing an inverse association between institutional childcare and childhood cancer (probably mediated by early childhood infections). “Don’t worry, going to nursery is doing at least some good for your child!” she said.

A new study using data from the EDEN mother-child cohort (based in France) gives additional reasons to alleviate working parent guilt.[1] This study examined childcare arrangements in the first three years of life for 1,428 children, categorising this as: with a childminder, centre-based (i.e. nursery or crèche staffed with professionals), or informal (primarily parents, complemented with grandparents or other non-professionals). Emotional and behavioural development of the child were assessed at age 3, 5.5 and 8 years. Confounders, including child factors (such as birthweight, duration of breastfeeding), parental sociodemographic factors (such as marital status, mother’s perception of partner support), and parents’ mental health, were considered in analyses through propensity scores and inverse probability weights.

Formal childcare was found to predict lower levels of emotional symptoms and peer-relationship problems, and promote high levels of prosocial behaviour even at age 8. Children who were in centre-based childcare had the lowest levels of emotional symptoms and peer relationship problems.

Surprisingly (to me), subgroup analyses showed that girls, children whose mother had high education, and those whose mother was not depressed may benefit the most from formal childcare. The authors state that the result for girls is likely to be because childcare mainly reduces internalising problems which are more prevalent in girls. The fact that the other ‘low-risk’ children fare better when exposed to formal childcare is suggested to be because the universal curriculum is most appropriate for those who do not have more severe emotional and social development issues.

Clearly there are many things to consider when deciding whether to work while also a parent to a small child, even if a rule generally applies, only the person making the decision knows the context of their own family and what suits them best. Also worth noting that this observational study cannot prove a causal relationship. But for those of us who do choose to leave a child in centre-based care- this paper offers some solace in those moments of ambivalence.

— Oyinlola Oyebode, Associate Professor


  1. Gomajee R, El-Khoury F, Côté S, van der Waerden J, Pryor L, Melchior M; EDEN mother-child Cohorts Study Group. Early childcare type predicts children’s emotional and behavioural trajectories into middle childhood. Data from the EDEN mother-child cohort study. Journal of epidemiology and community health. J Epidemiol Community Health. 2018;72(11):1033-1043.

Examining Quality of TB Care with Standardised Patients

Kwan and colleagues have recently published another study to add to their growing portfolio of research on the use of standardised patients (SP) (i.e., actors trained to act as a real patient and portray a case) to examine the quality of tuberculosis (TB) care in India.[1] This interesting paper builds on their prior work, some of which we have discussed in earlier editions of this blog.[2]

TB is a significant problem in India. It accounts for a quarter of the world’s estimated 10.4 million new cases of TB annually, and nearly a third of the 1.7 million yearly TB deaths. The quality of healthcare provision in India’s private sector – the first point of contact for the bulk of symptomatic TB patients – is generally accepted to be suboptimal and highly variable.

This impressive study involved 2,652 SP-provider interactions across 1,203 health facilities and 1,288 provider practices in two economically disparate Indian cities (Mumbai and Patna) with a high prevalence of cases of TB. It focused on healthcare providers both with and without formal medical training, and was covertly nested within a Government of India initiated TB management improvement programme. The authors trained 24 local actors (seven female and 17 male) to portray four scenarios representing various stages of diagnostic and disease progression of TB. Over a nine month period, SPs undertook incognito visits to providers – with measures in place to protect against detection. Within two-hours of each visit a field researcher administered exit questionnaires to SPs to record details of the interaction. The main outcome of interest in this study was case-specific correct management based on local clinical guidelines for the management of TB.

The key findings were that:

  • Only 25% of SP-provider interactions resulted in standards-compliant care.
  • Only 35% of cases were correctly managed and of these, 53% of providers ordered a chest X-ray, 36% referred the SP for further care (roughly equal split of referrals to private and public sector providers), and 31% ordered a microbiological test for diagnosis – a relatively infrequent occurrence across all case scenarios.
  • Medicines (mostly antibiotics) were very frequently prescribed or dispensed – the average rate was three per interaction.
  • Rather unsurprisingly, yet reassuringly, medically trained providers were almost three times more likely than non-medically trained providers to correctly manage cases, ask for chest X-ray and/or sputum tests, and initiate anti-TB treatment.
  • Differences in case management for medically and non-medically trained providers between Mumbai and Patna were minimal.

However, the important take-home message is that, in spite of providing relatively higher-quality care, medically trained providers still only correctly managed 54% of interactions, and were more likely than others to prescribe unnecessary or harmful antibiotics, which in a global epidemic of antibiotic resistance, is a particularly worrying result.

A key strength of this study is that it provided representative data on actual provider behaviour, thus addressing the widely acknowledged ‘know-do’ gap, though it also reiterates two important and recurrent considerations for the use of SPs in research studies:

  1. SPs are most useful for first-visits and have not yet been used in repeat visits. But is it reasonable to assume that quality of care may be better at a follow-up visit? This is an issue worthy of investigation in future work.
  2. Should we be asking for prior consent from participating providers? A continuing issue of contention, particularly relevant to the use of SPs in real-life (not educational) settings.

— Navneet Aujla, Research Fellow


  1. Kwan A, Daniels B, Saria V, et al.Variations in the quality of tuberculosis care in urban India: A cross-sectional, standardized patient study in two cities. PLoS Med. 2018; 15(9): e1002653.
  2. Lilford RJ. Private Consultations More Effective Than Public Provision in Rural India. NIHR CLAHRC West Midlands News Blog. 23 June 2017.

Mortality Rate Convergence between High- and Low-Income Countries

A recent Lancet commission led by Watkins and others examined the rate of convergence between high- and low-income countries for a number of conditions.[1] Huge progress has been made in mortality of under-fives and from HIV/AIDS. Progress is less impressive for maternal mortality, and less impressive still for tuberculosis mortality. The authors argued for greater investment in the latter two topics. Other topics singled out for good reason include cervical cancer, hepatitis B and rheumatic heart disease, all on the grounds of great disparities between rich and poor populations. They also argue that more attention must be paid to preparing for pandemics, a topic covered by CLAHRC West Midlands.[2]

The authors argue for greater domestic spending and point out that the economic returns on investment arise from both increased productivity andthe improvement in human welfare, such as that captured in DALYs. But they are very keen to see better targeting of expenditure, which will require careful economic analysis, such as that we are carrying out into ambulance services. The authors argue for more savvy procurement to shape markets using Gavi, the vaccine alliance, as an excellent example. Following this model, rich countries could incentivise industry to develop new treatments for tuberculosis, for example. The authors make the excellent point that huge improvements could come from closing the delivery practice gap through population, policy and implementation research. The spread of unhealthy products needs to be curtailed following the model of the WHO convention in tobacco control.

A recurring theme is that many of the above objectives require international action: shaping markets, preparing for pandemics, and preventing diffusion if unhealthy products, for example. I am writing this report from Kigali at the close of the NIHR Global Surgery Unit conference. This has been precisely the kind of international collaboration that the authors are arguing for.

— Richard Lilford, CLAHRC WM Director


  1. Watkins DA, Yamey G, Schäferhoff M, et al. Alma-Ata at 40 years: reflections from the LancetCommission on Investing in Health. Lancet. 2018; 392: 1434-60.
  2. Watson SI, Chen Y-F, Nguyen-Van-Tam JS, Myles PR, Venkatesan S, Zambon M, Uthman O, Chilton PJ, Lilford RJ. Evidence synthesis and decision modelling to support complex decisions: stockpiling neuraminidase inhibitors for pandemic influenza usage. F1000Res. 2016; 5: 2293.

Multiple Indication Review: Liberal vs Conservative Oxygen Therapy in Acutely Ill Patients

Readers of the News Blog may know that we advocate the examination of evidence in its totality beyond the silos of individual diagnoses and conditions – if the underlying mechanism of a phenomenon or the hypothesis to be tested is common across these conditions. This can be achieved by a multiple indication review, a systematic review that examines the effects of an intervention or variable across different conditions.[1] Earlier this year Chu and colleagues published an excellent example of a multiple indication review, in which they examined evidence from randomised controlled trials (RCTs) that have compared liberal versus conservative use of oxygen in adults with acute illness.[2] They identified 25 RCTs including a total of 16,037 patients across neurological conditions (stroke and traumatic brain injury), sepsis, emergency surgery, critical care and cardiac conditions (myocardial infarction and cardiac arrest). A meta-analysis of this evidence across all conditions showed that liberal use of oxygen increased the risk of in-hospital death by 21% (relative risk 1.21, 95% CI 1.03 to 1.41) compared with a more conservative use. A similar, although slightly smaller increase in risk was also found for 30-day mortality and mortality at the longest follow-up of individual trials.

The findings were homogeneous within and across different conditions, and were supported by a meta-regression showing positive correlation between relative risk of in-hospital mortality and percentage point increase in SpO2(peripheral oxygen saturation). Liberal use of oxygen did not offer any benefits for reducing disability for patients suffering from stroke and traumatic brain injuries, nor did it reduce hospital length of stay and hospital-acquired infections for acute medical admissions. The only notable difference is that a liberal strategy of oxygen therapy was associated with reduced hospital-acquired infections for acute surgical admissions (RR 0.50, 95% CI 0.36 to 0.69). This finding was based on data from two RCTs that were terminated early and the authors urged further investigation in this patient population. Taken together, it appears too much of oxygen is not good for acutely ill patients. This conclusion, while contradicting some conventional wisdom, is also supported by several plausible mechanisms through which very high level of oxygen could damage our body such as causing acute lung injury and triggering inflammatory responses.[3]Establishing the optimum range of oxygen saturation that minimises the competing risks of hypoxaemia and hyperoxaemia”, as the authors suggested, seems to be the way forward.

— Yen-Fu Chen, Principle Research Fellow


  1. Chen YF, Hemming K, Chilton PJ, Gupta KK, Altman DG, Lilford RJ. Scientific hypotheses can be tested by comparing the effects of one treatment over many diseases in a systematic review. J Clin Epidemiol. 2014; 67(12): 1309-19.
  2. Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. 2018; 391: 1693-705.
  3. Hafner S, Beloncle F, Koch A, Radermacher P, Asfar P. Hyperoxia in intensive care, emergency, and peri-operative medicine: Dr. Jekyll or Mr. Hyde? A 2015 update. Ann Intensive Care.2015; 5(1): 42.

United Nations Declaration on Primary Healthcare: Is it Correct?

On October 20, the Lancet published an editorial on the Astana Declaration and the future of primary health care.[1] Primary health care can be characterised according to four delivery platforms: community based care; health centers; first-level hospitals; and population-based interventions.

We strongly support all four of these platforms in rural areas. We also think that population-based interventions and first-level hospitals are essential in urban areas, including slums. However, we think that it is premature to insist on community-based care and health centres for reactive care in densely crowded urban areas. This is for two reasons. First, the quality of care for patients presenting in the community is universally poor, as we have found in an ongoing systematic review. Second, such potential patients have access to good facilities in local hospitals and frequently attend outpatients departments of such hospitals.

We are examining the quality of care In the outpatients departments of urban hospitals and also the frequency with which people who live in slums choose hospital over community care. It is plausible that we will find that patients prefer such care when they have serious symptoms and that it is of higher quality than that provided in the community. If this hypothesis is confirmed, then a much more gradual approach should be adopted, and an immediate prescription for community strengthening of primary care may be premature.

— Richard Lilford, CLAHRC WM Director


  1. The Lancet .The Astana Declaration: the future of primary health care? 2018; 392: 1369.

Ethical Dilemmas for Cars

Imagine a scenario in the not-too distant future where self-driving cars have become commonplace. You and your family are being driven along by such a car, splitting your attention between checking your emails, talking to your passengers, and occasionally looking at the road ahead of you. As you are passing a lorry parked on the other side of the road, a person runs out into the road in front of you. What would you expect the artificial intelligence controlling your car to do? The obvious choice is to try to avoid hitting the person – immediately applying the brakes and swerving to the side. But what if the brakes fail? What is the likely risk of harm to yourself and your passengers if you hit the lorry? If avoiding a collision is impossible what should the AI choose to do?

A large team of psychologists, anthropologists and economists from various countries created an online quiz posing various ethical dilemmas to the public.[1] The respondents were given 13 scenarios involving an unavoidable fatal collision, and asked to decide whether to swerve or do nothing, and thus who to spare – for example, humans (vs. pets), young people (vs. old), people of higher status (vs. lower), females (vs. males), healthier people (vs. unhealthier), pedestrians (vs. passengers), etc. After 18 months they had received responses from 233 countries/territories, amounting to more than 40 million decisions. Overall, the researchers found the biggest difference in options were for sparing a human over a pet, a group of people over an individual, and a younger person over an older person. The most ‘spared characters’ were baby, girl, boy and pregnant woman; while the least were cat, criminal, and dog.

However, analysis of further questions revealed three distinct groups of countries, aligned by shared morals – predominantly Western countries (e.g. North America, Europe, Australia); predominantly Eastern countries (e.g. Japan, Indonesia, Pakistan); and predominantly Southern countries (e.g. Central and South America), along with France. Group differences included that the first group were more likely than the other two to choose inaction over swerving; the second group were more likely to choose to spare pedestrians or the lawful; while the third group were more likely to choose to spare females, the fit, the young, and those of higher status.

Of course, in real-life situations an artificial intelligence would need to be able to identify different people with certainty, and would need to factor in the probability of death, harm, etc. but this is an important first step. Before self-driving cars can even start to be allowed on real-life roads there needs to be in-depth global discussions about the ethical dilemmas artificial intelligences will face, and ensure that all car manufacturers take heed of such principles.

— Peter Chilton, Research Fellow


  1. Awad E, Dsouza S, Kim R, et al. The Moral Machine experiment. Nature. 2018.