Health policy in low- and middle-income countries

Resumen Según la Organización Mundial de la Salud (OMS), el tabaquismo es una de las principales causas de enfermedad crónica y la principal causa de muerte prevenible a nivel mundial. De no abordarse de manera urgente, para el año 2030 podría llegar a matar a 8 millones de personas anualmente, 80% de estas muertes ocurriendo en países de mediano/bajo ingreso. Los datos sobre la prevalencia de tabaquismo en Guatemala son escasos. Según la " Encuesta Global del Tabaco " en el 2008, en los primeros grados de secundaria hay una prevalencia de tabaquismo de 19.7% para hombres y 13.3% para mujeres. (Rev Guatem Cardiol Vol.24, sup 1, 2014, pag:s09-s12) Palabras Clave: Tabaco. Fumar. Tabaquismo. Abstract According to the World Health Organization (WHO), smoking is a major cause of chronic disease and the leading cause of preventable death globally. If not addressed urgently, 2030 might get to kill 8 million people annually, 80% of these deaths occurring in middle / low income countries. Data on smoking prevalence are scarce in Guatemala. According to "Global Survey of Tobacco" in 2008, in the early grades of school is a smoking prevalence of 19.7% for men and 13.3% for women. (Rev Guatem Cardiol Vol.24, sup 1, 2014, pag:s09-s12)

Background: Mental, neurological, and substance (MNS) use disorders are a leading cause of disability worldwide; specifically in Peru, MNS affect 1 in 5 persons. However, the great majority of people suffering from these disorders do not access care, thereby making necessary the improvement of existing conditions including a major rearranging of current health system structures beyond care delivery strategies. This paper reviews and examines recent developments in mental health policies in Peru, presenting an overview of the initiatives currently being introduced and the main implementation challenges they face. Methods: Key documents issued by Peruvian governmental entities regarding mental health were reviewed to identify and describe the path that led to the beginning of the reform; how the ongoing reform is taking place; and, the plan and scope for scale-up. Results: Since 2004, mental health has gained importance in policies and regulations, resulting in the promotion of a mental health reform within the national healthcare system. These efforts crystallized in 2012 with the passing of Law 29889 which introduced several changes to the delivery of mental healthcare, including a restructuring of mental health service delivery to occur at the primary and secondary care levels and the introduction of supporting services to aid in patient recovery and reintegration into society. In addition, a performance-based budget was approved to guarantee the implementation of these changes. Some of the main challenges faced by this reform are related to the diversity of the implementation settings, eg, isolated rural areas, and the limitations of the existing specialized mental health institutes to substantially grow in parallel to the scaling-up efforts in order to be able to provide training and clinical support to every region of Peru. Conclusion: Although the true success of the mental healthcare reform will be determined in the coming years, thus far, Peru has achieved a number of legal, policy and fiscal milestones, thereby presenting a unique and fertile environment for the expansion of mental health services. Implications for policy makers • The achievement of important legal and fiscal policy milestones provides a framework in which the mental health reform in Peru is taking place. Additionally, a specific budget allocation for the implementation of this reform guarantees a setting in which the changes are fostered and activities are implemented. • Despite this, it is important to identify the implementation challenges to overcome, for example, obstacles to the medication supply chain or the limited capacity for mental health training for primary healthcare providers. • These challenges have to be addressed at the macro, meso, and micro levels, and include policy-makers, infrastructure and organization of services, as well as the micro point-of-care level of users and providers. Implications for the public The implementation of a mental health reform process creates fertile ground on which to grow and improve mental healthcare delivery. In doing so, governmental institutions will need to collaborate with community-based, non-profit organizations as well as academic organizations in order to develop innovative and efficient implementation approaches to tackle the challenges that arise from implementing the reform activities within the public health system.

Objective
Access to healthcare is mostly contingent on out-of-pocket spending (OOPS) by health seekers, particularly in low- and middle-income countries (LMICs). This would require many LMICs to raise enough funds to achieve universal health insurance coverage. But, are  individuals or households willing to pay for health insurance, and how much? What factors positively affect WTP for health insurance?We wanted to examine the evidence for this, through a review of the literature.
Methods
We systematically searched databases up to February 2016 and included studies of individual or household WTP for health insurance. Two authors appraised the identified studies. We estimated the WTP as a percentage of GDP per capita, and adjusted net national income per
capita of each country. We used meta-analysis to calculate WTP means and confidence intervals, and vote-counting to identify the variables that more often affected WTP.
Result
16 studies (21 articles) from ten countries met the inclusion criteria. The mean WTP of individuals was 1.18% of GDP per capita and 1.39% of adjusted net national income per capita. The corresponding figures for households were 1.82% and 2.16%, respectively. Increases in family size, education level and income were consistently correlated with higher WTP for insurance, and increases in age were correlated with reduced WTP.
Conclusions
The WTP for healthcare insurance among rural households in LMICs was just below 2% of the GPD per capita. The findings demonstrate that in moving towards universal health coverage in LMICs, governments should not rely on households' premiums as a major financing source and should increase their fiscal capacity for an equitable health care system using other sources

Background Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high-and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle and nd high-Human Development Index (HDI) countries worldwide. Methods This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. Results 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). Conclusion A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. Trial registration: NCT02179112.

This study assessed perceptions and support among the Indian populace about plain packaging for all tobacco products. Twelve focus group discussions (n = 124), stakeholder analysis with 24 officials and an opinion poll with 346 participants were conducted between December 2011 and May 2012, Delhi. Plain packages for tobacco products were favored by majority of participants (69%) and key stakeholders (92%). The majority of participants perceived that plain packaging would reduce the appeal and promotional value of the tobacco pack (>80%), prevent initiation of tobacco use among children and youth (>60%), motivate tobacco users to quit (>80%), increase notice ability, and effectiveness of pictorial health warnings on tobacco packs (>90%), reduce tobacco usage (75% of key stakeholders). Majority of participants favored light gray color for plain packaging. This study provides key evidence to advocate with Indian Government and other countries in South Asia region to introduce plain packaging legislation for all tobacco products.

Background: Health-related organisations disseminate an abundance of clinical and implementation evidence that has potential to improve health outcomes in low-and middle-income countries (LMICs), but little is known about what influences a user decision to select particular evidence for action. Knowledge brokers (KBs) play a part as intermediaries supporting evidence-informed health policy and practice by selecting and synthesising evidence for research users, and therefore understanding the basis for KB decisions, can help inform knowledge translation strategies. The Theoretical Domains Framework (TDF), a synthesis of psychological theories, was selected as a promising analysis approach because of its widespread use in identifying influences on decisions to act on evidence-based healthcare guidelines. This study explored its application in the context of KB decisions regarding evidence for use in LMICs. Methods: The study analysed data collected from participants of a 2015 global maternal and newborn health conference in Mexico. A total of 324 conference participants from 56 countries completed an online survey and 20 from 15 countries were interviewed about evidence use and sharing after the conference. TDF domains and constructs were retrospectively applied and adapted during coding of qualitative data to enhance understanding of the KB decision process in selecting evidence for action.

Background: Delays in getting medical help are important factors in the deaths of many pregnant women and unborn children in the low-and middle-income countries (LMIC). Studies have suggested that the use of cell phones and radio communication systems might reduce such delays. Objectives: We review the literature regarding the impact of cell phones and radio communication systems on delays in getting medical help by pregnant women in the LMIC. Design: Cochrane Library, PubMed, Maternity and Infant care (Ovid), Web of Science (ISI), and Google Scholar were searched for studies relating to the use of cell phones for maternal and child health services, supplemented with hand searches. We included studies in LMIC and in English involving the simple use of cell phones (or radio communication) to either make calls or send text messages. Results: Fifteen studies met the inclusion criteria. All the studies, while of various designs, demonstrated positive contributory effects of cell phones or radio communication systems in reducing delays experienced by pregnant women in getting medical help. Conclusions: While the results suggested that cell phones could contribute in reducing delays, more studies of a longer duration are needed to strengthen the finding.

of trust in government to keep using the MCH services. Understanding the intended and unintended outcomes of CCT will help to build sustainable structures in policy designs to mitigate sudden programme withdrawal and its subsequent effects on target beneficiaries and the health system at large.

Since the outbreak of the novel coronavirus or SARS-CoV-2 (COVID-19), the word has witnessed multi-dimensional problems and challenges. The global social, economic and public health sectors are more vulnerable and going through an unprecedented crisis. During this overwhelm pandemic, maternal mortality could be exacerbated due to the redirection of health care services towards COVID-19. The continuous lockdown, fear of getting infected with COVID-19 and massive disruption in the provision of maternal health services (such as antenatal and postnatal care) has resulted in a significant decline in the institutional delivery rate in Bangladesh [1]. These disruptions could push back many low-and-middle-income countries (LMICs) endeavour on ensuring safe institutional deliveries. Globally, approximately 810 maternal deaths occur every day, most of which are preventable by using institutional and safe delivery [2]. In 2019, about 80 million deliveries occurred at health institutions globally [3], but this number may be reduced in a post-pandemic scenario. Pregnant women who deliver at home have an increased risk of maternal mortality due to factors such as haemorrhages, eclampsia, sepsis, and obstructed labour, etc. [4,5]. Evidence shows that 35% of all causes of antepartum, intrapartum and postpartum haemorrhage is due to unsafe home delivery practices [4-6]. Between 2010 and 2017, the maternal mortality ratio (MMR) in Bangladesh decreased substantially to 173 per 100 000 live births. Using institutional delivery with skilled health care professionals could reduce 16 to 33% of maternal deaths, globally [7,8]. Still, during this pandemic, the rate of institutional deliveries has been declining overwhelmingly. A study published in The Lancet [3] pointed out that institutional childbirth reduced by more than half in Nepal. A similar picture was presented for India [9] due to the lack of transport, fear among people and doctors, resulting in thousands in need of health care services being denied by hospitals. Before COVID-19 outbreak, half of the pregnant women in Bangladesh preferred to give birth at home, but the rate raised to 73% following the announcement of the lockdown on 26 March 2020. The pre-post lock-down differences are equally stark in the case of caesarian section [10]. District-wide data from Bangladesh confirms the worrying dip for institutional delivery [10]. Almost 20% of declines were found in most districts for both normal delivery (43 districts) and caesarian section (40 districts). In comparison, about one-third of the districts observed higher drops up to 40% for normal delivery in 19 districts and caesarian section in 18 districts. Major disruptions in institutional delivery occurred in the capital city Dhaka for both normal delivery at 42% and c-section at 41% [10].

Introduction: One way to slow the spread of resistant bacteria is by improved stewardship of antibiotics: using them more carefully and reducing the number of prescriptions. With an estimated 7%–10% of antibiotic prescriptions globally originating from dental practices and up to 80% prescribed unnecessarily, dentistry has an important role to play. To support the design of new stewardship interventions through knowledge transfer between contexts, this study aimed to identify factors associated with the decision to prescribe antibiotics to adults
presenting with acute conditions across primary care (including
dentistry).
Methods: Two reviews were undertaken: an umbrella review across primary healthcare and a systematic review in dentistry. Two authors independently selected and quality assessed the included studies. Factors were identified using an inductive thematic approach and mapped to the Theoretical Domains Framework (TDF). Comparisons between dental and other settings were explored. Registration number: PROSPERO_CRD42016037174.
Results: Searches identified 689 publications across primary care and 432 across dental care. Included studies (nine and seven, respectively) were assessed as of variable quality. They covered 46 countries, of which 12 were low and middle-income countries (LMICs). Across the two reviews, 30 factors were identified, with ‘patient/condition
characteristics’, ‘patient influence’ and ‘guidelines & information’ the most frequent. Two factors were unique to dental studies: ‘procedure possible’ and ‘treatment skills’. No factor related only to LMICs.
Conclusions: A comprehensive list of factors associated with antibiotic prescribing to adults with acute conditions in primary care settings around the world has been collated and should assist theory-informed design of new context-specific stewardship interventions.

BACKGROUND:
Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.

METHODS:
This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.

FINDINGS:
Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05-2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001).

INTERPRETATION:
Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.

In recent decades, there has been growing attention to the overuse of caesarean section (CS) globally. In light of a high CS rate at a university hospital in Tanzania, we aimed to explore obstetric caregivers' rationales for their hospital's CS rate to identify factors that might cause CS overuse. After participant observations, we performed 22 semi-structured individual in-depth interviews and 2 focus group discussions with 5-6 caregivers in each. Respondents were consultants, specialists, residents, and midwives. The study relied on a framework of naturalistic inquiry and we analyzed data using thematic analysis. As a conceptual framework, we situated our findings in the discussion of how transparency and auditing can induce behavioral change and have unintended effects. Caregivers had divergent opinions on whether the hospital's CS rate was a problem or not, but most thought that there was an overuse of CS. All caregivers rationalized the high CS rate by referring to circumstances outside their control. In private practice, some stated they were affected by the economic compensation for CS, while others argued that unnecessary CSs were due to maternal demand. Residents often missed support from their senior colleagues when making decisions, and felt that midwives pushed them to perform CSs. Many caregivers stated that their fear of blame from colleagues and management in case of poor outcomes made them advocate for, or perform, CSs on doubtful indications. In order to lower CS rates, caregivers must acknowledge their roles as decision-makers, and strive to minimize unnecessary CSs. Although auditing and transparency are important to improve patient safety, they must be used with sensitivity regarding any unintended or counterproductive effects they might have.

Objective: in light of the rising caesarean section rates in many developing countries, we sought to explore women's and caregivers' experiences, perceptions, attitudes, and beliefs in relation to caesarean section.
Design: qualitative study using semi-structured individual in-depth interviews, focus group discussions, and participant observations. The study relied on a framework of naturalistic inquiry and data were analysed using thematic analysis.
Setting: a public university hospital in Dar es Salaam, Tanzania.
Participants: we conducted a total of 29 individual interviews, 13 with women and 16 with caregivers, and two focus group discussions comprising five to six caregivers each. Women had undergone a caesarean section within two months preceding the interview and were interviewed in their homes. Caregivers were consultants, specialists, residents, and midwives.
Findings: both women and caregivers preferred vaginal birth, but caregivers also had a favourable attitude towards caesarean section. While caregivers emphasised their efforts to counsel women on caesarean section, women had often reacted with fear and shock to the caesarean section decision and perceived that there was a lack of indications. Although caesarean section was perceived as involving higher maternal risks than vaginal birth, both women and caregivers justified these risks by the need to ‘secure’ a healthy baby. Religious beliefs and community members seemed to influence women's caesarean section attitudes, which often made caregivers frustrated as it diminished their role as decision-makers. Undergoing caesarean section had negative socio-economic consequences for women and their families; however, caregivers seldom took these factors into account when making decisions.
Key conclusions and implications for practice: we raise a concern that women and caregivers might overlook maternal risks with caesarean section for the benefit of the baby, a shift in focus that can have serious consequences on women's health in low-resource settings. Caregivers need to reflect on how they counsel women on caesarean section, as many women perceived a lack of indication for their operations. Supportive attendance by a relative during birth and more comprehensive antenatal care counselling about caesarean section indications and complications might enhance women's autonomy and birth preparedness.

Background: Since the advent of health user fees in low-and middle-income countries in the 1980s, the discourse of global health actors (GHAs) has changed to the disadvantage of this type of healthcare financing mechanism. The aim of the study was to identify and analyze the stance of GHAs in the debate on user fees.

Climate change adaptation responses are being developed and delivered in many parts of the world in the absence of detailed knowledge of their effects on public health. Here we present the results of a systematic review of peer-reviewed literature reporting the effects on health of climate change adaptation responses in low-and middle-income countries (LMICs). The review used the 'Global Adaptation Mapping Initiative' database (comprising 1682 publications related to climate change adaptation responses) that was constructed through systematic literature searches in Scopus, Web of Science and Google Scholar (2013-2020). For this study, further screening was performed to identify studies from LMICs reporting the effects on human health of climate change adaptation responses. Studies were categorised by study design and data were extracted on geographic region,

Background: Peoples-uni (People’s Open Access Education Initiative) was established to help build Public Health
capacity in low- and middle-income countries (LMICs) through postgraduate level online courses. Graduates are
invited to join a virtual alumni group. We report the results of efforts to meet the need for health research capacity
building by exploring how the course alumni could be mobilised to perform collaborative research into the health
problems of their populations.
Methods: Two online surveys of Peoples-uni graduates were conducted with graduates from the first two and first
four cohorts in 2013 and 2014, respectively, to explore the formation of an alumni group that would collaborate to
further the research and development agenda in LMICs. This was followed by feedback on research-related activity
and outcomes via the online alumni and tutors’ forum to estimate early indicators of alumni success in relation to
capacity building in both the conduct and utilisation of research.
Results: Responses were received from 26 (87% response rate) graduates of the first survey and 42 (60% response
rate) of the second survey. Overall, 92% of the respondents to the first survey supported the creation of an alumni
group, especially if it helped to develop their own research skills and improve the health of their populations.
Findings from the second survey showed that study with Peoples-uni was felt to have had a major or potential
impact on the careers of the respondents, with 19% of graduates having progressed to a PhD programme to
further their research skills, and a further 48% being in the process of applying or intending to apply for doctoral
studies. Further feedback shows that at least one collaborative study has been completed and published by alumni
members with other collaborative studies planned. Ongoing support has been provided to graduates to help them
publish their work and apply for individual or collaborative research grants.
Conclusions: Harnessing the alumni of a Masters level course to perform collaborative research has considerable
potential to build research capacity in LMICs.
Keywords: Alumni, Low- and middle-income countries, Public health, Research capacity

To explore conceptions of obstetric emergency care among traditional birth attendants in rural Guatemala, elucidating social and cultural factors. design Qualitative in-depth interview study. Rural Guatemala. Thirteen traditional birth attendants from 11 villages around San Miguel Ixtahuacán, Guatemala. Interviews with semi-structured, thematic, open-ended questions. Interview topics were: traditional birth attendants' experiences and conceptions as to the causes of complications, attitudes towards hospital care and referral of obstetric complications. Conceptions of obstetric complications, hospital referrals and maternal mortality among traditional birth attendants. Pregnant women rather than traditional birth attendants appear to make the decision on how to handle a complication, based on moralistically and fatalistically influenced thoughts about the nature of complications, in combination with a fear of caesarean section, maltreatment and discrimination at a hospital level. There is a discrepancy between what traditional birth attendants consider appropriate in cases of complications, and the actions they implement to handle them. Parameters in the referral system, such as logistics and socio-economic factors, are sometimes subordinated to cultural values by the target group. To have an impact on maternal mortality, bilateral culture-sensitive education should be included in maternal health programs.

Mexico is undergoing rapid population ageing as a result of its epidemiological transition. This study explores the interface between this rapid population ageing and the burden of cancer. The number of new cancer cases is expected to increase by nearly 75% by 2030 (107,000 additional cases per annum), with 60% of cases in the elderly (aged ≥ 65). A review of the literature was supplemented by a bibliometric analysis of Mexico’s cancer research output. Cancer incidence projections for selected sites were estimated with Globocan software. Data were obtained from recent national census, surveys, and cancer death registrations. The elderly, especially women and those living in rural areas, face high levels of poverty, have low rates of educational attainment, and many are not covered by health insurance schemes. Out of pocket payments and private health care usage remain high, despite the implementation of Seguro Popular that was designed to achieve financial protection for the lowest income groups. A number of cancers that predominate in elderly persons are not covered by the scheme and individuals face catastrophic expenditure in seeking treatment. There is limited research output in those cancer sites that have a high burden in the elderly Mexican population, especially research that focuses on outcomes. The elderly population in Mexico is vulnerable to the effects of the rising cancer burden and faces challenges in accessing high quality cancer care. Based on our evidence, we recommend that geriatric oncology should be an urgent public policy priority for Mexico.

Background Safe surgery requires high-quality, reliable lighting of the surgical field. Little is reported on the quality or potential safety impact of surgical lighting in low-resource settings, where power failures are common and equipment and resources are limited. Methods Members of the Lifebox Foundation created a novel, non-mandatory, 18-item survey tool using an iterative process. This was distributed to surgical providers practicing in low-resource settings through surgical societies and mailing lists. Results We received 100 complete responses, representing a range of surgical centres from 39 countries. Poor-quality surgical field lighting was reported by 40% of respondents, with 32% reporting delayed or cancelled operations due to poor lighting and 48% reporting electrical power failures at least once per week. Eighty per cent reported the quality of their surgical lighting presents a patient safety risk with 18% having direct experience of poor-quality lighting leading to negative patient outcomes. When power outages occur, 58% of surgeons rely on a backup generator and 29% operate by mobile phone light. Only 9% of respondents regularly use a surgical headlight, with the most common barriers reported as unaffordability and poor in-country suppliers. Conclusions In our survey of surgeons working in low-resource settings, a majority report poor surgical lighting as a major risk to patient safety and nearly one-third report delayed or cancelled operations due to poor lighting. Developing and distributing robust, affordable, high-quality surgical headlights could provide an ideal solution to this significant surgical safety issue.