Over the last decade, international donors, technical specialists, and governments have come to recognize the potential of community-based organizations (CBOs) in the fight against HIV/AIDS. Recent empirical studies suggest that community engagement, including the involvement of CBOs, adds value to the national response to HIV/AIDS. With the emerging evidence of the effectiveness of engaging communities in the fight against AIDS, it is crucial to understand the economic dimension of community engagement. This article provides an analysis of funding and expenditure data collected from CBOs in three African countries: Kenya, Nigeria, and Zimbabwe. It presents descriptive information regarding CBO funding and expenditure and examines the factors associated with the total amount of funds received and with the proportions of the funds allocated to programmatic activities and program management and administration. An average CBO in the sample received US$29,800 annually or about US$2480 per month. The highest percentage of CBO funding (37%) came from multilateral organizations. CBOs in the sample spent most of their funds (71%) on programmatic activities including provision of treatment, support, care, impact mitigation, and treatment services. Over the last decade, international donors, technical specialists, and governments have come to recognize the potential of community-based organizations (CBOs) in the fight against HIV/AIDS. Recent pronouncements from key stakeholders in the global response to the epidemic emphasize the key role of community engagement . The UNARecent empirical evidence supports these pronouncements and suggests that community engagement, including the involvement of CBOs, adds value to the national response to HIV/AIDS. A review of evidence from 14 studies in eight countries in Africa and Asia found that community engagement was associated with increased mobilization of resources, improved knowledge, changes in sex behaviors, increased use of health services, and reduced HIV incidence and sexually transmitted infection (STI) prevalence in high-prevalence settings . An evalWith the emerging evidence of the effectiveness of engaging communities in the fight against AIDS, it is crucial to understand the economic dimension of community engagement. Assessing this dimension of CBO activity can improve our understanding of the amounts of domestic and international funding that reach local communities, of the types of sources from which CBOs receive their funding, of their vulnerabilities and resistance to fluctuations in the funding streams, and of the prospects for sustainability of the CBO response at the local level. A better understanding of the economic dimension of CBO engagement in the community response to HIV/AIDS is also necessary to assess whether the funds the CBOs receive are spent efficiently, what proportion of the funding is allocated to the activities that have the potential to benefit the community members, and what proportion is spent to benefit the CBOs themselves .Some research addressing funding and expenditure of civil society organizations  have been conducted. However, it tends to be concerned with the flow of funds on the macro-scale  and examines funding rather than expenditure e.g., . MoreoveThis study is part of a World Bank, Department of International Development (DFID), and UK Consortium on AIDS and International Development evaluation exercise to assess results achieved by community responses to HIV/AIDS.CBOs were defined as service organizations with involvement from community members that provide social services to local clients and included CSOs, nongovernmental organizations (NGOs), and faith-based organizations that target people infected with and affected by HIV and AIDS.Information, regarding amounts and sources of funding and amounts and categories of expenditure, was collected from 126 CBOs: 26 in Kenya (in two provinces – Nyanza and Western), 67 in Nigeria , and 33 in Zimbabwe  . Data weIn Kenya and Nigeria, in each community, data were collected from up to six (Kenya) or eight (Nigeria) CBOs providing services related to HIV/AIDS. If the number of CBOs in a given community was less than or equal to six (in Kenya) or eight (in Nigeria), data were collected from all CBOs in that community. If the number of CBOs in the community was larger, the largest and the smallest CBO were included in the sample and additional CBOs were randomly selected from among the remaining CBOs providing HIV/AIDS-related services in that community. In Nigeria, on average, about 59% of the CBOs registered with the National and State Agencies for the Control of AIDS were interviewed in each community. In Kenya, on average, about 54% of the CBOs registered with the National AIDS Control Council and/ or local HIV/AIDS agencies in each community were interviewed.In Zimbabwe, data were collected from organizations participating in the Manicaland M&E Facility Survey conducted as part of the Manicaland Project. Data were collected from all organizations that matched the operational definition of a CBO (see above). In Matabeleland, a list of organizations was provided by the District AIDS Coordinator. Data were collected from a convenience sample of organizations which matched our CBO definition.Reported amounts were annualized for all CBOs in the sample. All currencies reported were converted to US dollars. As data were collected in the three countries in different years , all US dollar amounts were deflated to 2011 values.Data on volunteers and persons reached by the CBOs were collected using the same instrument as the funding and expenditure data. The interviewed CBOs staff reported how many volunteers their organization had and how many people it had reached in the past 12 months. Regression models were used to examine the association between organizational factor for which data were collected as part of the study and the amount of funding and expenditure. To correct for heteroscedasticity and autocorrelation resulting from the CBOs clustered within the same countries and communities, we estimated regression models with robust standard errors . In the All analyses were conducted using STATA 11 .Data on volunteers were available for 84 CBOs and an average CBO had 86 volunteers. Data on persons reached were available for 84 CBOs and average CBO had reached 9686 individuals. Note that the arithmetic means reported here are inflated due to the presence of outliers.An average CBO in the sample received US$29,800 annually (standard deviation (SD): US$53,471). An average CBO in Zimbabwe received about US$72,000 , compared to US$10,000 (SD: US$7783) in Kenya and US$16,000 in Nigeria . The difference may be due to differences in the types of organizations included in the sample in Zimbabwe and the other two countries (see Discussion section). High SDs of the mean levels of funding, both in the overall sample and in the individual countries, demonstrate substantial variation in the funding reported by individual CBOs. Median levels of funding, which are less susceptible to the influence of outliers, were: US$ 9732  in the overall sample; US$ 9486  in Kenya; US$2851  in Nigeria; and US$ 53,847  in Zimbabwe.The funds came from public sources ; bilateral sources ; multilateral sources ; charities, foundations, and larger NGOs; and member contributions and income-generating activities (IGAs) .About 69% of total funds reported by CBOs came from international sources. The highest percentage of funding for CBOs in the sample came from multilateral organizations (35%). Only 5% came from member contributions and IGAs, even though 29.7% of CBOs reported receiving financial support from that source. Distribution of funding sources in each of the three countries is presented in There was little diversification in the types of funding sources. More than half of the CBOs (50.9%) reported receiving support from only one type of funding source .Regression analysis showed that CBOs funded by multilateral organizations received on average about US$27,535 more annually than organizations that did not receive funding from that source. Receiving funding from other types of sources  was not associated with the amount of funding received. In addition, sample CBOs located in Zimbabwe received significantly more funds that those located in Nigeria (reference group) and Kenya. The difference in funding between Nigerian and Kenyan CBOs included in the sample was not statistically significant see .CBOs in the evaluation sample spent about 71% of their funds on programmatic activities aimed at providing services to local populations affected by and infected with HIV . Within Funding allocation in each of the three countries in presented in 1 Each additional volunteer was associated with 0.04 percentage point of additional spending on program management. Every additional 100 clients served in a given year was associated with a 0.02 percentage point increase in spending on program management. CBOs that received funding from member contributions and IGAs spent about 14.1% less on program management than CBOs that did not receive funding from that source. Each additional US$1000 of total funding a CBO received regardless of the sources, was associated with a decrease of about 0.5 percentage point in the percentage of funds allocated to program management. Finally, CBOs that reported receiving funding from charities, foundations, and NGOs spent on average 18.7% more on program management than CBOs that did not receive funding from that source. Receiving funding from other types of funding sources was not associated with the percentage of funds spent on program management. The differences among the three countries were not statistically significant  .1 Each anificant .None of the factors included in the model were associated with the percentage of spending allocated to programmatic activities .An average CBO in the sample received US$29,800 annually. The data showed a significant difference in the level of annualized funding between CBOs in Zimbabwe  and Nigeria and Kenya . It is possible that Zimbabwean CBOs included in the sample were larger and better able to mobilize resources. However, regression model that examined the factors associated with the amount of funding showed no significant association between CBO size, measured as the number of volunteers, and the amount of funding received. Therefore, other organizational factors, such as prevailing types of CBO structures  and contextual factors  not captured by the data collected, are behind the difference in the CBO funding between Zimbabwe and the other two countries.The lowest percentage of total CBO funding (5%) came from member contributions and IGAs. Our findings corroborate the extant literature, which shows that CSOs providing services related to HIV/ AIDS rely primarily on international support e.g., . This isWe found little diversification in the types of sources from which CBOs receive financial support. It is possible that CBOs tend to specialize and target only specific types of funding agencies. It is also possible that funding from some sources is available only to some CBOs in some communities. Regardless of its causes, the lack of diversification can make CBOs vulnerable to fluctuations in international funding which can be very significant, especially given the recent global economic climate. For example, in 2007, Zimbabwe received US$62.7 million from bilateral sources to support its response to HIV/AIDS. In 2008, this funding dropped by more than 90% to US$5.5 million .The highest percentage of CBO funding (37%) came from multilateral organizations. However, only one-third of CBOs received support from that source. Our findings showed that those that did reported about US$27,500 more in annual funding than CBOs that did not receive support from that source. It is possible that multilateral organizations distribute their funding selectively to specific types of CBOs . Another possibility is that while multilateral funding is available to all CBOs, only some chose to or can tap into that source of funding. Further inquiry is needed to determine why some CBOs receive funding from multilateral donors while others do not.CBOs in the sample spent most of their funds (71%) on programmatic activities. This is encouraging and suggests the bulk of CBO funding ultimately reaches community members in the form of services provided. However, program management and administration expenditures accounted for 13% of total spending – substantially more than those reported in the National AIDS Spending Assessments for Kenya and Zimbabwe . Those fWe found that CBOs receiving support from foundations, charities, and larger NGOs tended to spent more on program management than CBOs that did not receive funding from these sources. It is possible that funding from these sources comes with fewer restrictions on how funds can be spent, and CBOs can direct more of this funding to support program management. It is also possible that this type of funding requires higher administrative costs. This is particularly likely if one CBO receives funding from several charities, foundations, and NGOs and is required to submit different reports with different information and indicators to different funding organizations.This study did not assess whether and to what extent CBO expenditure priorities matched the true community needs. Limited discussion of the way in which a sample of CBO interviewed in Nigeria selected the activities in which they engaged and whether those activities corresponded with the epidemic profiles of the communities can be found in It is possible that the factors affecting funding and expenditure were different in Kenya, Nigeria, and Zimbabwe. Unfortunately, the small sample size  did not allow us to estimate three separate country-specific regression models to assess whether and to what extent different factors influenced funding and expenditure in each country.Information on funding and expenditure was provided by the CBOs on a voluntary basis. We do not believe that a formal audit of the CBO accounts to assess the validity of the reported data was possible. We did assess the consistency of the information provided  as part of the data cleaning and entry process and followed up with the CBOs to clarify any discrepancies we found.One limitation of this study is that it uses a convenience sample of CBOs and therefore it cannot be considered representative of all CBOs in Zimbabwe, Nigeria, and Kenya. To our knowledge, no systematic data exist on the number of CBOs engaging in HIV/AIDS-related activities in any of the three countries. Therefore, it is impossible to estimate the proportion of the CBOs in each country that was included in our sample. The total number of CBOs and the percentages of CBOs interviewed  were comR2 values of the regression models). However, our intention was to examine the associations between funding, expenditure, and other selected characteristics of the CBOs  rather than to build a comprehensive predictive model of CBO funding and expenditure patterns.Another limitation is that our analysis does not capture potentially important contextual and organizational factors that may affect how much funds CBOs receive and how they spend them (this may be reflected in the relatively low adjusted Finally, our sample covers a limited geographic area in each of the three countries. Nevertheless, to our knowledge, this is the most comprehensive crosscountry data-set on CBO funding and expenditure collected at the community level using a consistent methodology. As such, it provides a stepping stone for a more systematic assessment of sources from which CBOs receive financial resources and how they allocate them.


The Dual Visuomotor Channel Theory proposes that visually guided reaching is a composite of two movements, a Reach that advances the hand to contact the target and a Grasp that shapes the digits for target purchase. The theory is supported by biometric analyses of adult reaching, evolutionary contrasts, and differential developmental patterns for the Reach and the Grasp in visually guided reaching in human infants. The present ethological study asked whether there is evidence for a dissociated development for the Reach and the Grasp in nonvisual hand use in very early infancy. The study documents a rich array of spontaneous self-touching behavior in infants during the first 6 months of life and subjected the Reach movements to an analysis in relation to body target, contact type, and Grasp. Video recordings were made of resting alert infants biweekly from birth to 6 months. In younger infants, self-touching targets included the head and trunk. As infants aged, targets became more caudal and included the hips, then legs, and eventually the feet. In younger infants hand contact was mainly made with the dorsum of the hand, but as infants aged, contacts included palmar contacts and eventually grasp and manipulation contacts with the body and clothes. The relative incidence of caudal contacts and palmar contacts increased concurrently and were significantly correlated throughout the period of study. Developmental increases in self-grasping contacts occurred a few weeks after the increase in caudal and palmar contacts. The behavioral and temporal pattern of these spontaneous self-touching movements suggest that the Reach, in which the hand extends to make a palmar self-contact, and the Grasp, in which the digits close and make manipulatory movements, have partially independent developmental profiles. The results additionally suggest that self-touching behavior is an important developmental phase that allows the coordination of the Reach and the Grasp prior to and concurrent with their use under visual guidance. The Dual Visuomotor Channel theory proposes that visually guided reaching consists of two movements, the Reach and the Grasp, each mediated by separate visuomotor pathways from occipital to parietofrontal neocortex Arbib, . The ReaAt the present time, little is known about how the Reach and the Grasp become integrated as a seamless visually guided act but it is reasonable to suppose that development in infancy plays a formative role. A number of prereach and pregrasp movements displayed by infants at different stages of development can be viewed as supporting the idea that the Reach and the Grasp have independent developmental origins. Prior to the onset of visually guided reaching, prereach movements include first orienting the eyes and head to a visual target  and the location on the body at which the contact was made . In addition, any self-grasping movement with a digit or number of digits on the body or clothes was also documented. Video recordings of the infants were made across the first 6 months of life because this time period includes the age at which self-grasping movements have been documented and precedes the age at which visually guided reaching becomes a frequent infant activity.Forty-two normal, full term infants (21 boys and 21 girls) participated in the study. None of the infants had sensory or motor impairments. The initial observations were made within a few days of birth and filming sessions ended when the infants were approximately 24 weeks old . The seating arrangement was in part determined by parental transport preference. Nevertheless, because Savelsbergh and van der Kamp , whereas others were filmed at only a few time points. There were no obvious differences in the data obtained from infants that were repeatedly filmed and those that were filmed only once. The samples were taken as close as possible to the 2 week interval markers  as long as the infants were alert during these recordings.At least 10 min duration of spontaneous activity was filmed for an infant on each filming session. At each sampling age, between 8 and 10 infants comprise the final data set. Some of the infants were available for repeated filming  and hand posture .Rostral vs. Caudal Body Contacts. Rostral contacts  scored all of the behavior while two other investigators  scored samples of behavior in order to establish rater reliability. Inter-rater reliability for whether the hand contacted the body, whether contact was Rostral or Caudal, and whether contact was Dorsum, Palmar, or Grasp exceeded 95% agreement between the raters.p-value of 0.05 was considered significant.The frequency of body contacts and hand posture contacts, as a function of infant age, were subject to statistical analyses using the computer program SPSS (v. 21.0.0.0). To accommodate uneven data points across infants, results were evaluated using repeated-measures mixed linear models  = 5.633, p < 0.01]. Post-hoc comparisons revealed that, compared to 0 weeks of age, the percentage of Caudal contacts was significantly increased at 14 (p < 0.05), 16 (p < 0.05), 18 (p < 0.01), and 20+ (p < 0.001) weeks of age.In sum, Caudal contacts began to occur with increasing frequency at approximately 14 weeks of age, progressing from contacts with the head and trunk to contacts with the hips, legs, and feet. Thus, as a proportion of all body contacts, Caudal contacts increased as a function of age as indicated by a repeated measures MLM for Caudal contacts that gave a significant effect of Age . Post-hoc comparisons revealed that, compared to 0 weeks of age, the percentage of Palmar contacts was significantly increased at 12 (p < 0.05), 14 (p < 0.05), 16 (p < 0.001), 18 (p < 0.001), and 20+ (p < 0.001) weeks of age.In sum, Palmar contacts began to occur with increasing frequency at approximately 12 weeks of age, progressing from contacts with the pads of the fingertips, to dynamic contacts with the open palm. As a proportion of all body contacts, Palmar contacts increased as a function of age as indicated by a repeated MLM for Palmar contacts that gave a significant effect of Age . Post-hoc comparisons revealed that, compared to 0 weeks of age, the percentage of Grasp contacts was significantly increased at 16 (p < 0.05), 18 (p < 0.05), and 20+ (p < 0.05) weeks of age.Figure p = 0.005), a significant Palmar vs. Grasp Rho = 0.770 (p = 0.009), but no Caudal vs. Grasp Rho = 0.503 (p = 0.138). The regression curves suggest that increases in Caudal and Palmar contacts are of a comparable magnitude and follow a similar developmental time course. By contrast, the regression curve for Grasps is reduced and shifted to the right, indicating that the incidence of Grasps did not become prominent until somewhat later. These relations are also reflected by follow-up tests described in the Dorsum-Palmer, Rostral-Caudal, and Grasp sections above. The significant relationship between Grasp and Palmar is likely due to the fact that a Grasp is dependent upon a Palmar contact.Normalized regression curves for Caudal, Palmar, and Grasp contacts are shown in Figure There are two novel contributions of this study. First, it was found that otherwise resting infants in the first 6 months of life made many, almost continuous, forelimb movements that resulted in hand contacts with the body. These contacts eventually included grasping and manipulating the body and clothes in all regions of the body. Thus, self-touching behavior in infants is revealed to be a behavior in which infants can practice reaching, and perhaps additionally acquire body awareness in relation to a hand-related schema. Second, the analysis of self-touching movements suggests that advancing the hand to different body targets and contacting the body with the digit tips and palm represent an early developmental phase of the Reach whereas grasping the body and clothes and performing manipulatory movements represent an early phase of the Grasp. Because Reach activities developmentally preceded Grasp activities, the results suggest some independence of the two movements. Taken together with previous work showing that infants do not need to view their own hand in order to transport it to a target .”It is important to note that the present study was primarily directed toward describing self-touching hand movements and secondarily at assessing the idea that during development there is some independence in the display of reaching and grasping movements as has been suggested in studies largely directed toward visually guided reaching (Von Hofsten and Lindhagen, Specifically, three aspects of hand-to-body contact were documented in relation to infant age: an increasing incidence of caudal body relative to rostral body contacts, an increasing incidence of palmar relative to dorsum hand contacts, and an increasing incidence of contacts that resulted in Grasps of the body and clothes. An increase in the incidence of palmar and caudal contacts occurred at a somewhat earlier age than did the increase in the incidence of Grasps. Because the Reach in adults is associated with forelimb movement and a more open hand to make palmar contact with a target, we suggest that the forelimb movement and palmar contact in infants is a manifestation of an infant Reach. Because the Grasp in adults includes digit flexion and closing to purchase and manipulate an object, we suggest that self-grasping in infants is an early manifestation of an infant Grasp. Thus, we suggest that the developmental pattern of these Reach and Grasp movements in infants supports the Dual Visuomotor Channel Theory, which proposes that the reaching act is enabled by separate Reach and Grasp neural systems. Of course, morphological development including increases in the length of the arms, the size of the hands, and body strength in all likelihood are also necessary for some part of the maturation of the movements. Nevertheless, the hand to body self-touching movements seen in the infants likely continue throughout life and likely continue to serve some of the same purposes in adults that they serve in infancy.The design of the present experiment is similar to that of a number of our previous studies in that it is ethological, focuses on infant spontaneity, and searches for structural organization within this activity. It also featured a number of procedures to ensure accurate measurement of spontaneous hand-to-body contacts in infants (Wallace and Whishaw, In many respects, this work differs from the more formal studies of visually guided reaching in which both the task and the outcome are constrained. For example, in the Wimmers studies (Wimmers et al., A number of caveats in relation to the present methods must be noted. First, infants were filmed in a variety of settings including the home and laboratory, the time of day during which filming occurred was variable, and the postures of the infants did vary somewhat depending upon their age, and all infants could not be filmed at every age. It might be considered, however, that such variation strengthens the ethological relevance of the sampling method. Second, infants were usually clothed and so it was not possible to confirm that similar hand-to-body behavior would be demonstrated in the absence of clothing. For example, the presence of clothing might serve to encourage grasping behavior. It was noted, however, that there were no obvious differences in the behavior of infants for whom clothes were tight fitting versus loose fitting. Third, the sampling periods were limited to resting behavior and did not include other activities, including breast or bottle feeding or interpersonal play, which could provide additional information concerning the development of hand contacts to the self and proximal objects. In addition, the infants' spontaneous activity included many other activities such as movements of the head, trunk, and legs and these activities were not documented. Nevertheless, the high number of hand-to-body contacts that occurred in each infant and the systematic changes in the location and way that the hand contacted the body across the developmental period examined suggests that this data sample is sufficiently robust to provide insights into an activity that must occur in infants many hundreds of times each day.There are a number of features of the present results that we feel justify concluding that they reveal a novel insight into the developmental progression of reaching behavior and its relation to the distinctive Reach and Grasp movements of adults as characterized by the Dual Visuomotor Channel Theory. First, studies that have manipulated the visual contribution to reaching show that without vision the Reach consists of a movement of extending the arm and hand with open digits in order to make palmar contact with a target (Karl et al., It is interesting that Pellijeff et al.  show thaWe were, of course, unable to determine the extent to which reaches to various body parts were vacuous versus goal directed but we propose that the scope and frequency of the movements provides ample room for arm movements to mature both in their configuration (von Hofsten, According to the Dual Visuomotor Channel Theory, the Grasp preshapes the digits relative to target size and adjusts the digits for appropriate target purchase Arbib, . In the Evidence that grasping movements have a partially different developmental onset than reaching movements was supported by our finding that the developmental profile of grasping frequency was statistically unrelated to the Rostrocaudal profile of body contact and was only somewhat weakly related to the Dorsopalmar profile of hand contact, which were themselves tightly coupled. That is, the onset of frequent self-grasping occurred at a somewhat later age than the onset of frequent caudal body contacts and palmar contacts. We suggest that this difference provides further support for the idea that the Reach and the Grasp have different developmental onset. That is, our results suggest that the Reach, consisting of an ability to move the hand to a body target with the digits open to make a Palmar contact with the target, is achieved before the hand begins to engage in substantial object purchase, which characterizes the Grasp. Of course, the movements are not completely unrelated because a Reach with Palmar contact necessarily precedes a Grasp. Nevertheless, it is interesting that an examination of the early development of visually guided reaching similarly suggests that Reach maturation precedes Grasp maturation (Karl and Whishaw, In previous work, we have suggested that the Reach and the Grasp have different evolutionary origins, the Reach derived from stepping and the Grasp derived from food handling movements (Karl and Whishaw, Speculatively, the present results could be related to the Dual Visuomotor Channel Theory in other ways, including the establishment of body spatial schema and hand action schema related to objects (Granmo et al., In summary, developmental research presupposes that developing actions are the foundation for more complex adult behavior (Lobo and Galloway, The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The expansion rate of the separation system showed a significant negative partial correlation with the daily costs of total, internal, and injection medicines as well as medical devices. Moreover, the rate of replacing brand name medicines with generic medicines showed a significant negative partial correlation with the daily costs of total and internal medicines. However, external and injection medicines and medical devices did not because only a few or no generic products of these types were sold in the Japanese market. Otherwise, expansion of the separation system was effective in reducing medicine costs, except in the case of external medicines. This suggests that the cost efficiency effect of the separation system does not function all the time.This study used publicly available data to examine the effect of the separation of dispensing and prescribing medicines between pharmacists in pharmacies and doctors in medical institutions (the separation system) and the generic medicine replacement ratio on the cost of various medicines in Japanese prefectures. For Japanese medical institutions, participation in the separation system is optional. Consequently, the expansion rate of the separation system for each administrative district is highly variable. In our multiple regression analysis, the dependent variables were the costs of  There are several studies that examine the effectiveness of interventions in clinical care by pharmacists. For example, th century, while in China, the government is still hesitating to introduce the system.With regard to pharmacists’ cost-effective activities, several studies have examined the influence of the separation of dispensing and prescribing medicines on medicine costs between pharmacists in pharmacies and doctors in medical institutions. This system  has been introduced and become familiar over several hundred years in European, North American, and Middle Eastern countries. On the other hand, Asian countries, for example the Republic of Korea and Japan, only began the widespread introduction of the separation system in the latter half of 20th century because the government expected it would reduce medicine costs, especially medicine costs, by decreasing the number of duplicate prescriptions and reducing the economic motive for prescriptions. However, little evidence has been reported to support these expectations. It has been pointed out that most economic evaluations of clinical pharmacy intervention suffer from several methodological limitations relating to the absence of a control group without clinical pharmacy interventions , we calculated daily costs of internal, external, and injection medicines as well as medical devices, like injection needles for patients’ own usage as well as those for total costs. The results were expected to provide a clear understanding of the cost efficiency of the separation system for various medicines and medical devices. We performed multiple linear regression analysis as follows: the dependent variables were daily medicine costs for internal medicines, external medicines, injection medicines, and medical devices per prescription. The independent variables were the expansion rate (%) of the separation system and the base ratio (%) of brand-name medicines replaced with generic medicines.We obtained 2013 fiscal data on average medicine cost and dosage days per prescription for each prefecture . We thenNationwide data on prescriptions are available from insurance applications for medicine expenses received from pharmacies, 99.9% of which are covered currently by medical insurance in Japan. In The independent variables were the expansion rate (%) of the separation system and the base ratio (%) of brand-name medicines replaced with generic medicines. We expected these variables to have a considerable influence on daily medicine costs . In addiWe obtained 2013 fiscal data of the expansion rate (%) of the separation system among administrative divisions in Japan . The expThese data were taken from the MHLW website—specifically, they were based on trends in the composition of medical expenses for computation processing in 2013 . From these data, we calculated the rate of brand name medicines replaced with generic medicines  for each prefecture. These data are precise because they are based on data for universal health care and medical insurance, which covers 99.9% of Japanese medical care.Multiple regression analysis was conducted using the various daily medicine costs per prescription as the dependent variable and the spreading rate and generic medicine replacement ratio as independent variables. All statistical analyses were performed using Excel Statistics 2012 .The results show Tables total, internal, external, and injection medicine costs as well as medical device costs.As for partial correlations, Tables total and internal medicines. In addition, for the cost of injection medicines and medical devices, a significant partial correlation was observed only in the expansion rate and not in the generic medicine replacement ratio. For the cost of external medicines, we observed no significant partial correlation for either the expansion rate or the generic medicine replacement ratio.The results reveal a significant partial correlation for the expansion rate and the generic medicine replacement ratio for the items included in the analysis of the costs of the eternal medicines and medical devices. Therefore, the costs of total, internal, and injection medicines are considered to be influenced by the expansion rate of the separation system and the generic medicine replacement ratio.We found significant multiple correlation, except for the costs of total and internal medicines had significant partial correlations with two factors—the expansion rate and the generic medicine replacement ratio. The marketing share of the costs of internal medicines is 84% of total medicine costs in Japan. Therefore, total costs were influenced easily by the costs of internal medicines. In addition, the costs of injection medicines and medical devices had significant partial correlations with the separation system. First, this study revealed that the separation system had a strong influence on reducing costs for total, internal, and injection medicines as well as medical devices  that the Japanese government has begun to consider whether to remove injection medicines had a significant partial correlation with the separation system, which is the same result as that for internal and total medicines. The economic efficiency of the separation system is considered to work in the field of injection medicines. Injection medicines are considered to be strong medicines and require doctors’ decisions, pharmacists’ review, and explanation for use by outpatients. Therefore, the economic efficiency effect for the separation of dispensing and prescribing could function normally.The costs of injection medicine costs. The reason is considered to be the low sales in Japan of injection medicines for outpatients’ use of injections at home, such as those for insulin, growth hormones, and pain-killers for cancer. Few pharmaceutical companies sell and manufacture these medicines. However, if many pharmaceutical companies were to sell injection medicines for outpatients in the future, the generic medicine replacement ratio would have a significant partial correlation with injection medicines.The generic medicine replacement ratio has no significant partial correlation with Medical device costs had a significant partial correlation with the separation system. This is the same as the result for injection medicine costs. Most medical devices adopted in Japanese public insurance are used with injection medicines, like injection needles and catheters, or are considered to require doctors’ decisions, pharmacists’ review, and explanation to outpatients, because these medical devices need expert knowledge for usage. Therefore, the economic efficiency of the separation system is considered to function in this field as it does for injection medicines.medical device costs, it does not influence daily medical device costs.In Japanese regulation, generic medicine can be substituted for brand-name medicine by community pharmacists when doctors have not forbidden substitution and patients have agreed to substitution. Although there is no regulation of generic medical devices in Japan, when considering the need for patients’ agreement, patients in prefectures where the generic medicine replacement ratio is high are considered to have significant interest in the price of medical devices. As the generic medicine replacement ratio is considered to have no significant correlation with total, internal, and injection medicines had significant multiple correlations with the expansion rate and the generic medicine replacement ratio, the particular relationships denoting causes and effects remain obscure. While there are some possible reasons, they are only hypotheses and this study was unable to establish them. For a clear explanation, we have to analyze the actions of patients, doctors, and pharmacists. This remains for further research.Although we found that the daily costs of total, internal, and injection medicines as well as medical devices. However, external medicines had no observable effect in reducing costs. It was notable that in most cases, the economic efficiency of the separation system functioned normally, although this was not the case for external medicines. This suggests that the cost-efficiency effect of the separation system does not function all the time.The results suggest that the separation system is effective in reducing medicine costs for


Dedicated logisticians restocked contraceptives monthly at facilities to maintain defined minimum stock levels, freeing up clinic staff. High stockout rates were virtually eliminated. Also, quality and timely data on contraceptives distributed allowed for better program management. Dedicated logisticians restocked contraceptives monthly at facilities to maintain defined minimum stock levels, freeing up clinic staff. High stockout rates were virtually eliminated. Also, quality and timely data on contraceptives distributed allowed for better program management. Contraceptive use in Senegal is among the lowest in the world and has barely increased over the past 5 years, from 10% of married women in 2005 to 12% in 2011. Contraceptive stockouts in public facilities, where 85% of women access family planning services, are common. In 2011, we conducted a supply chain study of 33 public-sector facilities in Pikine and Guediawaye districts of the Dakar region to understand the magnitude and root causes of stockouts. The study included stock audits, surveys with 156 consumers, and interviews with facility staff, managers, and other stakeholders. At the facility level, stockouts of injectables and implants occurred, on average, 43% and 83% of the year, respectively. At least 60% of stockouts occurred despite stock availability at the national level. Data from interviews revealed that the current “pull-based” distribution system was complex and inefficient. In order to reduce stockout rates to the commercial-sector standard of 2% or less, the Government of Senegal and the Senegal Urban Reproductive Health Initiative developed the informed push distribution model (IPM) and pilot-tested it in Pikine district between February 2012 and July 2012. IPM brings the source of supply (a delivery truck loaded with supplies) closer to the source of demand  and streamlines the steps in between. With a professional logistician managing stock and deliveries, the health facilities no longer need to place and pick up orders. Stockouts of contraceptive pills, injectables, implants, and intrauterine devices (IUDs) were completely eliminated at the 14 public health facilities in Pikine over the 6-month pilot phase. The government expanded IPM to all 140 public facilities in the Dakar region, and 6 months later stockout rates throughout the region dropped to less than 2%. National coverage of the IPM is expected by July 2015. Family planning use in Senegal is among the lowest in the world and has barely increased over the past 5 years, from 10% among married women in 2005 to 12% in 2011.Unmet need for family planning is high, estimated at 29%.In support of this goal, the Bill and Melinda Gates Foundation is providing funding to IntraHealth International to implement the Urban Reproductive Health Initiative (URHI) in Senegal, a collaboration with government and nongovernmental partners to demonstrate that improving the quality of integrated maternal and reproductive health services and expanding the role of the private sector in providing family planning can significantly increase contraceptive use. URHI is testing innovative approaches to improve quality of and expand access to family planning information, supplies, and services, with a goal of achieving a 20 percentage point increase in modern contraceptive uptake in urban areas of Senegal.Early on in the project, it became apparent that contraceptive stockouts in public facilities , and 45% either discontinued use or went to the private sector and paid 3 to 9 times the price they would have paid at the public-sector facility.Based on the warehouse and facility audits, we estimated that at least 60% of stockouts occurred despite stock availability at the national level, indicating that the in-country distribution system was not designed well or functioning effectively. Interviews and field observations revealed the following key issues:The public-sector distribution system is a highly complex “pull-based” system, involving an excessive number of steps and relying on about 900 midwives at service delivery points (SDPs) to accurately forecast, track, and order contraceptives. There are several problems with relying on midwives to manage stocks: the midwives lacked training on and ownership of the process, and more importantly, they lacked time because they were busy providing reproductive, maternal, and child health services.The pull-based system requires health facilities to replenish supplies using their own cash on hand, that is, working capital. In practice, most facilities have limited working capital, and so they are compelled to prioritize commodities that generate higher margins for the facility. Contraceptives generate relatively low margins, and so they are not a high priority, resulting in either limited or no replenishment of the facility's contraceptive stock.Facilities are responsible for picking up supplies from warehouses at their own expense, and frequently health care providers must take time away from providing services to perform this task.Many facilities maintain poor inventory records, thus providing little visibility into contraceptive method preference and consumption. The lack of accurate and timely data limits the country's ability to monitor and manage the performance of the family planning program.At least 60% of stockouts occurred despite stock availability at the national level.The standard “pull-based” system required health facilities to replenish supplies using limited cash on hand.With clear evidence and data on the magnitude of stockouts and the associated impact on individual and population health indicators, the government became highly motivated to reduce stockout rates to the commercial-sector standard of 2% or less. In addition, reliable data on product consumption across methods and facilities were critical to monitor the performance of the supply chain and to understand service delivery patterns.To achieve our goal of an aggressive reduction in stockouts, we analyzed commercial-sector solutions and applications of those solutions in public health systems. The “Delivery Team Topping Up” system in Zimbabwe,URHI and the Government of Senegal developed the “informed push distribution model” (IPM) and tested it in Pikine district over a 6-month pilot phase from February 2012 to July 2012. IPM brings the source of supply (a delivery truck loaded with supplies) closer to the source of demand  and streamlines the steps in between. With a professional logistician managing stock and deliveries, the health facilities no longer need to place orders and spend time picking up products .The informed push model brings the source of supply closer to the source of demand.Key features of the IPM include:Initial stock of contraceptives is provided at no cost to each facility.Dedicated logisticians restock facilities on a monthly basis to maintain a minimum level of stock that is defined by the logistician—around 2 months of estimated supply needs.Facilities pay only for the quantity of products that were sold and keep the margin.Logisticians collect data on product consumption at the time of delivery and report that data to the district medical chief within 72 hours.Logisticians are paid according to fixed-fee contracts that clearly define requirements and penalties based on stockout rates and data availability. During the pilot study, logistician contracts were funded and managed by the URHI program.Contraceptive sales revenue covers the cost of the logistician contracts.The effects of IPM implementation in Pikine were immediate and sustained. Stockouts of contraceptive pills, injectables, implants, and intrauterine devices (IUDs) were completely eliminated at all 14 public health facilities in the district over the course of the 6-month pilot phase. In the month before IPM was implemented, injectables and pills were stocked out in 57% of facilities, implants were stocked out in 86% of facilities, and IUDs in 14% . During During the informed push pilot phase, contraceptive stockouts were completely eliminated.Based on this dramatic impact on stockouts, the government decided to expand IPM to all 140 public facilities in the Dakar region; 6 months later, stockout rates throughout the region dropped to less than 2% according to facility and delivery records.Importantly, district and regional health managers now have access to timely and accurate monthly contraceptive consumption data from each participating SDP, as required by the logistician contracts, which enables the managers to quickly identify and address performance issues. For example, the Pikine district health management team identified a clinic that consistently consumed fewer implants than neighboring clinics. During a follow-up visit, the team learned that the midwife responsible for providing implants was uncomfortable with the procedure and unmotivated to learn it since she was nearing retirement. The management team responded by prioritizing this site to receive a newly graduated midwife; once placed, implant consumption increased to a level similar to that recorded in neighboring clinics.Better data from the informed push model have helped managers address performance issues.In another example of performance management enabled by the IPM data, the district noticed a significant decline in implant consumption across facilities in a single month. The management team quickly learned that there was a shortage of the local anesthetic used for the implant procedure, which triggered an emergency order at the national level.In Pikine, after 1 full year of implementing the informed push model (the 6-month pilot plus the following 6 months during expansion to the entire Dakar region) and maintaining stock of the full range of contraceptive methods, coupled with demand creation interventions and service delivery improvement measures, the average monthly consumption of pills increased by 127%, injectables by 121%, implants by 2,081%, and IUDs by 68%. These increases translate to an estimated growth in MCPR of approximately 11 percentage points in 1 year in Pikine, an unprecedented rate of growth in Senegal .When all methods are available at a facility, health care providers are more comfortable counseling women on the full range of options, and the woman has the opportunity to select the method she prefers without the influence of stockouts. In fact, since stockouts have been eliminated in Pikine, the method mix has evolved with a greater proportion of women selecting long-acting methods .In addition, other positive changes resulted from IPM implementation. First, health care workers have more time to provide care to patients because they do not have to manage stocks and logistics. Second, the regional and district health managers who experienced the impact of IPM for contraceptive products are advocating to use this distribution system for additional products. One example of where this has worked is in the region of Saint Louis, where 2 mobile warehouses were in place to deliver vaccines. The IPM was adapted to use the mobile warehouses for contraceptive distribution and data collection, and subsequently the regional managers insisted that HIV, malaria, tuberculosis, and essential medicines were also delivered via the mobile warehouses. This adapted version of IPM requires additional study to determine its cost-effectiveness relative to the contraceptive-only model implemented in Pikine.The informed push model has freed up health care workers to spend more time providing care to patients.In 2012, the Ministry of Health developed and launched a national family planning plan. Given the positive IPM results from Pikine, one of the key pillars of the plan is national expansion of the IPM. By July 2014, the plan calls for scaling up IPM throughout the 6 regions that comprise more than 65% of the population, and to national coverage by July 2015 .Senegal plans to scale up the informed push model nationally by 2015.To support rapid national expansion, the Bill and Melinda Gates Foundation and Merck for Mothers are providing funding to IntraHealth International to support the Government of Senegal to establish standard operating procedures; issue and manage contracts with private logisticians; provide training to those engaged in the system; and support data use and performance management. The IPM is currently designed to maintain preexisting financial flows to the extent possible while introducing payment of contracts with private logisticians. As the model expands into regions that are less densely populated, and with more difficult road conditions, modifications to the model are expected to enable delivery optimization. According to an agreed-upon schedule through mid-2016, these functions will be funded and overseen by the government in a phased manner.To ensure financial sustainability of the IPM, the government is evaluating different scenarios, and IPM design will remain flexible to respond to the most cost-effective and politically viable option. At present, the government is committed to advancing implementation of the IPM for family planning products, and there is interest in conducting an in-depth product segmentation analysis to guide the potential inclusion of other health products. Preliminary analysis suggests that the annual sales revenue from contraceptives when volumes reach the level required to support a national MCPR of 25% to 30% will be about US$1,050,000. At a national scale in the contraceptive-only scenario, the operating cost of the IPM was estimated at about $500,000, approximately 11% of national annual spending on contraceptives.Today, the public health system in Senegal is served by 7 unique supply chains, one for each of the 7 different product groups. Each vertical supply chain is funded through a unique agreement between a donor, the Ministry of Health, and the National Pharmacy, resulting in a wide range of operating procedures, personnel trainings, supervisory structures, data collection tools, and reporting requirements. The net effect is a distribution system that is uncoordinated and inefficient, resulting in stockouts across all product groups. With the political will and donor flexibility to better coordinate and manage this multiplicity as a segmented system, cost savings across Ministry of Health programs could be significant. Further analysis of costs associated with the current public-sector distribution channels across product categories is recommended, along with a comparative analysis of the cost per unit of product delivered through alternative distribution models.This pilot study of the informed push distribution model demonstrated feasibility as an appropriate and effective solution to contraceptive stockouts in Senegal, generating timely and accurate data on contraceptive consumption by facility. Access to and use of this data is transforming public health management practices in general, fostering a culture of data-driven performance improvement throughout the system. Achievement of Senegal's goals for family planning depend on the successful implementation of all priority interventions in the national plan, including demand generation, improved provider capacity, and an expanded network of SDPs; the IPM ensures availability of the products and data that underlie such success.


Swarm robotics is a promising approach for the coordination of large numbers of robots. While previous studies have shown that evolutionary robotics techniques can be applied to obtain robust and efficient self-organized behaviors for robot swarms, most studies have been conducted in simulation, and the few that have been conducted on real robots have been confined to laboratory environments. In this paper, we demonstrate for the first time a swarm robotics system with evolved control successfully operating in a real and uncontrolled environment. We evolve neural network-based controllers in simulation for canonical swarm robotics tasks, namely homing, dispersion, clustering, and monitoring. We then assess the performance of the controllers on a real swarm of up to ten aquatic surface robots. Our results show that the evolved controllers transfer successfully to real robots and achieve a performance similar to the performance obtained in simulation. We validate that the evolved controllers display key properties of swarm intelligence-based control, namely scalability, flexibility, and robustness on the real swarm. We conclude with a proof-of-concept experiment in which the swarm performs a complete environmental monitoring task by combining multiple evolved controllers. The safety coefficient is defined according to the following equation:Collisions between robots are undesirable in any task, as they can damage the real robots. To avoid collisions, we introduced a target distance) from its nearest neighbor. Robots should cover a large area without risking losing contact with the rest of the swarm, which can be an issue in unbounded environments. Examples in the literature include solutions that rely on preprogrammed behaviors [In a dispersion task, each individual robot in the swarm has to maintain a predefined distance . During evolution, controllers were rewarded for minimizing the difference between the current distance to the nearest neighbor and the target distance, according to the following equation:aggregation, is a canonical task in swarm robotics [Clustering, also known as robotics . Clusterrobotics , includirobotics .T is the total number of time steps in each trial, R is the number of robots, and ct is the number of clusters formed by the robots at step t.In our instance of the clustering task, the robots started randomly spread in a square-shaped area with a side-length of 100 m, and had the objective of finding one another so as to form a single cluster. However, since the communication range was limited and the environment was unbounded, certain initial conditions could lead to the formation of more than one cluster. During evolution, controllers were scored based on the number of clusters that they formed. Two robots belonged to the same cluster if the distance between them was inferior to 7 m. The fitness function was defined based on a weighted sum of the number of clusters throughout time:Swarms of robots are ideal for tasks where large areas need to be covered for monitoring or surveillance purposes. This task category has been explored in the past with several different control techniques, such as pheromone traces , odor soV) around it. The challenge in this task is to find a general movement pattern that takes into account many different shapes of the monitoring area and varying number of robots.In our area monitoring task, a geo-fence is defined to delimit an area of interest, and the robots should coordinate to continuously cover as much of the area as possible. During evolution, we tested the controllers in a variety of randomly generated geo-fences with different shapes, in order to obtain general behaviors. For the purpose of this task, we considered that each robot covers a circular area with a radius of 5 m .In order to assess the performance of the controllers, we divided the monitoring area into a grid with a fixed cell size of 1 mThe results of the evolutionary algorithm for all tasks can be found in In this section, we assess the evolved controllers on real robots and compare their performance on real robots to their performance in simulation. The experiments reported in this section were conducted over the course of four days, at Parque das Nações, Lisbon, Portugal, in a semi-enclosed waterbody with an area of 300 m × 190 m which is connected to the Tagus river, see We setup a scenario where the swarm had to navigate sequentially to four waypoints to assess the performance of the evolved homing controllers. Each waypoint was placed at a distance of 40 m from the previous one, and the active waypoint was changed periodically every 60 s. Each controller was tested once in this scenario, for a total of 4 minutes. All three controllers tested in the real robots were able to navigate successfully to the waypoint while avoiding collisions with the neighboring robots. In the real-robot dispersion tests, eight robots started in a cluster, and had to disperse to a distance of 20 m from their nearest neighbor. The robots were initially placed randomly in a square-shaped area with a side-length of 28 m, at a minimum distance of 5 m from the nearest neighbor. Each experiment lasted for 90 seconds.The results in The clustering controllers were tested by randomly placing the real robots in an area of 100x100 m, up to a maximum of 40 m from the nearest robot. Each experiment lasted for 180 seconds. Results for the clustering experiments greatly varied depending on the initial conditions, but this variation was also observed in the simulation environment see , top. If2. It should be noted that the evolutionary process did not optimize the controllers for areas with these specific shapes, but rather for randomly generated shapes in order to promote the evolution of general behaviors (see Section 4.2). Only the highest-performing controller was tested on real robots, since we did not observe any significant behavioral or performance differences in the other best controllers. Each experiment lasted for a total of five minutes.We assessed each of the three highest-performing area monitoring controllers in real robots in three areas: square, L-shaped, and rectangular. Each of the areas covered a total of 10,000 mThe controllers successfully monitored the three different areas, performing significantly better on the real robots than in simulation see , top. ThDesirable characteristics of swarm behaviors include scalability and robustness . PerformThe dispersion and clustering controllers were tested with four and six robots (in addition to the first experiments with eight robots) to determine if the evolved controllers were able to perform well independently of the number of robots in the swarm. In the dispersion experiments, while the controllers were able to perform the task successfully with swarms of different sizes, the results show a slight performance decrease in the experiments with six robots. It must be noted, however, that the error obtained is still relatively low, when compared to the target distance of 20 m. In the clustering experiments, the swarm was able to aggregate into a single cluster in all three samples with four robots, and in two out of three samples with six and eight robots. Since the communication range is limited, subsets of robots may initially be outside communication range or lose contact during an experiment, which can result in two or more isolated clusters.Ga). In the beginning of the experiment, Ga start dispersing. After 60 s, a group of four additional robots (Gb) starts moving towards the center of the swarm. When all robots of Gb are at the center (t = 130 s), their presence disturbs the dispersion of Ga, forcing Ga to separate even further. After the robots in Gb have been in the center for 60 s, they start the dispersion behavior along with the robots in Ga (at t = 180 s).We setup a dispersion task that starts with a group of four robots  collectively navigate from the base station to the center of the area of interest (homing); (ii) disperse; (iii) monitor the area of interest; (iv) aggregate, using the clustering behavior; and finally (v) return to the base station (homing). The robots start collecting temperature data after reaching the center of the monitoring area, before sub-task (ii). The different behaviors were triggered sequentially to produce a complete mission, with each behavior lasting for a predefined amount of time.t = 360 s), the estimated standard deviation of the error was < 0.14 for the whole area except in the corners where it was slightly higher (< 0.24). A video of the experiment is available in The trajectories of the real robots executing the multi-controller mission and the temperature data collected can be seen in Our experiments showed that evolutionary computation is a viable approach for the synthesis of control for swarms of robots operating outside of controlled laboratory environments. Below, we discuss the main challenges we faced in evolving control for the SRS, and the properties observed in the SRS with evolved control.For the most part, the definition and configuration of the evolutionary process was straightforward. The main challenge in configuring the evolutionary algorithm was the definition of the fitness functions. The fact that we used common swarm robotics tasks facilitated the definition of the fitness functions, however, once we started considering more complex tasks (as the temperature monitoring task in Section 7), it became hard to design effective fitness function that could express the task objectives. Moreover, previous works have shown that using standard evolutionary techniques for such complex and sequential tasks can be inadequate due to bootstrapping and deception issues , 72–74.building blocks a-priori, and then combine them in order to solve complex tasks [One solution is to synthesize the various ex tasks . We haveex tasks , 49, 75.ex tasks , we haveOne of the challenges of synthesizing control for aquatic surface robots is dealing with the unpredictable environmental conditions and unexpected circumstances associated with this environment. Many of the environmental variables affecting the robots can be extremely difficult, or even impossible, to model accurately. The simulation model was therefore a substantial simplification of reality. To compensate for the differences between the motion model and the real dynamics of the robots, as well as for other potential sources of stochasticity, we introduced a conservative amount of noise in the sensors, actuators, and environment, during evolution (Section 3). The introduction of noise is a computationally-effective way of promoting the evolution of robust controllers . In addiOur experimental results showed that the evolved controllers were generally able to cross the reality gap. In a number of experiments, a speed difference between some of the real robots and the simulated robots  contributed to differences in terms of performance. While the behaviors of the real robots were generally similar to those observed in simulation, some motion patterns did not transfer well. With the dispersion controllers, for instance, in simulation the robots started moving in small circles to maintain their current position. In reality, however, these circles were larger, which resulted in a lower performance. This difference highlights the limitations of the simplified physics model we adopted in the simulation environment. We are considering two different approaches to address these issues in future work: (i) further improve the simulated movement dynamics, thereby decreasing the mismatch between simulation and reality, and (ii) select for controllers that rely on motion patterns that transfer well from simulation to reality, as proposed in previous works , 40, 77.In this paper, we relied on four canonical swarm tasks  to validate the basic properties of swarm robotics in real conditions. All the collective tasks presented in this paper can be classified as swarm robotics tasks, according to the classification proposed by Brambilla et al. : (i) robRobustness: We demonstrated robustness explicitly with the monitoring task, by removing robots during task execution (see Section 6.2). In all tasks, there were also sporadic hardware failures, which resulted in individual failures that did not impact the behavior of the group (Section 6.2).Flexibility: The flexibility of the swarm could be observed in the different coordination strategies that were adopted by the swarm, when using controllers for different tasks. Furthermore, we showed the behavioral modularity of the system by assembling a high-level controller that relied on the combination of multiple previously evolved controllers (see Section 7).Scalability: We studied scalability explicitly using the clustering and dispersion behaviors (Section 6.1). We tested the same controller with different swarm sizes (from four to eight robots), and the performance and behavior of the swarm was similar regardless of the swarm size. In the monitoring task, we showed that the performance of the swarm (amount of space covered) was proportional to the number of robots (Section 6.2).The use of robots in real-world conditions will often imply hardware malfunctions, caused by prolonged use and environmental factors. In our experiments, the main source of faults were the robots’ motors, which sporadically and temporarily stopped, causing the robot to stop completely or start moving in circles. Other problems included the decrease of motor power with lower battery levels, and often erroneous GPS readings. These faults occurred often during the execution of all experiments reported in this paper. Even though these faults were not contemplated in simulation, and therefore were not taken into account during the evolutionary process, they did not compromise the overall performance of the swarm, highlighting the inherent robustness of swarm behaviors. In future work, we will study the fault-tolerance properties of the system more systematically by injecting different types of faults , and by An additional source of uncertainty, related to the hardware, was the heterogeneity among the robots of the swarm. Robots within the swarm often had different battery levels and motors with slight performance differences. We measured this heterogeneity in the monitoring task, where all robots display similar behaviors. In the real swarm, the difference between the slowest and the fastest robot was up to 0.6 m/s at certain times, while for the same task, in simulation, the difference between the slowest and the fastest robot was just 0.1 m/s. This suggests that the real swarm had to deal with a much higher degree of heterogeneity than what was contemplated during the evolutionary process.In this study, we have demonstrated that swarm robotics systems can effectively operate in real-world conditions. There are, however, a number of control-related issues to be addressed before the practical use of swarms of robots in real-world applications. Prominent challenges include:Integration of mission-specific sensors: In the experiments presented in this paper, the robot controllers relied mostly on their position and on the position of the neighboring robots for the behavioral decision process. The integration of data gathered from onboard sensors such as cameras or sonars, may however be an essential input for the controllers in other tasks. The challenge of evolving controllers capable of dealing with such data is twofold: (i) the data might not be trivial to decompose into meaningful information that can be fed to neural controllers; and (ii) the sensors would have to be accurately modeled in simulation.Robustness to faults: Another significant challenge is endowing controllers with the capability to cope with faults within the swarm. Although our experiments confirmed that swarm behaviors inherently have some degree of tolerance for individual faults, in real-world applications it may be necessary to guarantee that faulty individuals will not compromise the whole swarm. Approaches for fault detection [etection , fault tetection , and onletection  must theSafety: The robots should have the capability of dealing with external factors, such as nearby vessels, in a way that guarantees the safety of all parties and conforms with the existing regulations. Combining such fail-safe behaviors with the mission controllers may require the combination of evolved and manually programmed behaviors [ehaviors .Behavior flexibility and modularity: One concern when using evolutionary robotics is the difficulty in rapidly producing new behaviors or modify existing ones. One possible solution for this problem is to compose behaviors for new tasks based on existing building blocks [g blocks . In thisg blocks , 76.In this paper, we present for the first time a swarm robotics system with evolved control operating in a real-world uncontrolled environment. Our experiments relied on a swarm of small and inexpensive aquatic surface robots that used distributed self-organized control and local communication. In a simulation environment, we evolved controllers for four common collective tasks: homing, clustering, dispersion, and area monitoring.The evolved controllers were then systematically evaluated in the real robots in a large and uncontrolled aquatic environment. Our results showed that the controllers displayed similar behaviors and levels of performance in the real swarm as those observed in simulation. Moreover, we verified key desirable properties of swarm robotics systems, namely robustness, flexibility, and scalability. We finally showed how simple evolved behaviors can be combined to produce a complete mission, by carrying out a complete environmental monitoring task.Past studies in the field of swarm robotics and evolutionary robotics have been confined either to simulation (the vast majority), or to highly-controlled laboratory conditions. Our study contrasts with the previous work in these fields, as it relies on an evolved swarm of robots operating in a realistic and uncontrolled environment. Overall, our research demonstrates the potential of both swarm robotics systems and evolutionary robotics techniques as viable approaches for controlling multirobot systems in real-world scenarios.S1 TextDocument detailing the aquatic robotic platform and the experimental parameters of both the simulated and real experiments, in some cases repeating and extending the information given in the main manuscript.(PDF)Click here for additional data file.S1 VideoTraces of the robots’ positions when performing the experiment where the robustness of the swarm is assessed using the area monitoring task, as described in Section 6.2.(MP4)Click here for additional data file.S2 VideoVideo of the experiment detailed in Section 7, where the different swarm behaviors are composed sequentially in order to produce control for a temperature-sampling mission.(MP4)Click here for additional data file.


Reduced gravity offers unique opportunities to study motor behavior. This paper aims at providing a review on current issues of the known tools and techniques used for hypogravity simulation and their effects on human locomotion. Walking and running rely on the limb oscillatory mechanics, and one way to change its dynamic properties is to modify the level of gravity. Gravity has a strong effect on the optimal rate of limb oscillations, optimal walking speed, and muscle activity patterns, and gait transitions occur smoothly and at slower speeds at lower gravity levels. Altered center of mass movements and interplay between stance and swing leg dynamics may challenge new forms of locomotion in a heterogravity environment. Furthermore, observations in the lack of gravity effects help to reveal the intrinsic properties of locomotor pattern generators and make evident facilitation of nonvoluntary limb stepping. In view of that, space neurosciences research has participated in the development of new technologies that can be used as an effective tool for gait rehabilitation. Life evolved in the presence of gravity, which has two major impacts on motor functions: specific body orientation in space and antigravity muscle tone and specific rules of motion in the gravity field. Gravity plays an essential role in terrestrial locomotion. The dominant hypothesis regarding templates for bipedal walking in the gravity field is the pendular mechanism of walking, up to intermediate speeds, and the bouncing mechanism of running, up to the highest speeds attainable . The invUnderstanding locomotion characteristics is critical for those working in the area of gait biomechanics and neurophysiology of pattern generation networks and of exercise countermeasures for astronauts. Many researchers have investigated the effects of reducing and eliminating gravity on locomotive kinematics and kinetics –8. OtherSpaceflights are the more direct way to assess the effect of gravity on locomotion, but studying locomotion in actual hypogravity is demanding and expensive . The draThere are several apparatuses that have been used in the past to simulate reduced gravity locomotion. One of the more used systems is the vertical body weight support (BWS) Figures . These kThe tilted BWS systems Figures  are consAnother class of gravity-related manipulations is “subject load device” (SLD) that applies a gravity replacement force in the direction down to the surface. This type of SLD can be used in the vertical systems to increase the gravity  or in thBased on the passive gravity balancing technology, Ma et al. , 23 propIn the following section we discuss the basic principles of adaptation of locomotion to different gravity values using the technologies described here.V is the speed of locomotion, g is the acceleration of gravity, and L is a characteristic leg length. That is, all lengths, times, and forces scale by the same factors. In order to optimize the recovery of mechanical energy, the kinetic energy and the potential energy curves must be equal in amplitude and opposite in phase, as in a pendulum. Assuming that the change in kinetic energy within each step is an increasing function of the walking speed , the hypothesis was proposed that the inverted pendulum-like mechanism of energy exchange during walking would be optimized at slower speeds in reduced gravity [Despite some differences, all reduced gravity simulation approaches show a reasonable approximation of the reduction in the gravitational force acting on the center of body mass (COM) and similar results concerning the speed of gait transitions. An important consequence of the pendulum-like behavior of the limbs in the gravity field is the principle of dynamic similarity , which s gravity , 10. An  gravity , animal On Earth, walking and running gaits are usually adopted for different speeds of locomotion, with a preferred transition occurring at ~2 m/s for human adults and at slow speeds for children (Fr ~ 0.5), in accordance with the dynamic similarity theory . DiffereDespite similarities in approximating reduced gravity, there are nevertheless essential differences between different simulation approaches. The variables that showed the greatest differences between vertical and tilted reduced gravity systems  were maxIt is known that load plays a crucial role in shaping patterned motor output during stepping –36, and A key feature of adaptation to hypogravity is a remarkable nonlinear scaling of muscle activity patterns contrary to monotonic changes in foot loading. The simplest kind of change with simulated reduced gravity  was seenThere might be various factors accounting for the nonlinear reorganization of muscle activity patterns with gravity. To start with, nonlinear scaling also occurs during walking at different speeds at 1 g. For instance, VL and RF activity is quite small at low speeds (less than ~3 km/h) but becomes prominent at higher speeds (>4 km/h) , a speedConsidering complex, high-dimensional, dynamically coupled interactions between an organism and gravitational environment, in principle, one challenging solution is to adopt different coordination patterns and not only an optimal speed of locomotion. Are different gaits possible on other planets?One approach to study locomotor adaptations is to look at the effect of gravity on gait transitions. A gait has been defined as “a pattern of locomotion characteristic of a limited range of speeds described by quantities of which one or more change discontinuously at transitions to other gaits” . An impoInterestingly, the smoothness of gait transitions is accompanied by a gradual shift from inverted-pendulum gait to bouncing gait, resulting in a “paradoxical” inverted-pendulum running in the vicinity of run-walk and walk-run transitions . The swiOther significant influences of gravity on short-term and long-term gait adaptations may be related to its effects on the body reference configuration , 49 and Finally, the repertoire of known gaits can be expanded to a variety of animals. For instance, on Earth only a few legged species, such as water strider insects and some aquatic birds and lizards, can run on water. For most other species, including humans, this is precluded by body size and proportions, lack of appropriate appendages, and limited muscle power. However, if gravity is reduced to less than Earth's gravity, running on water should require less muscle power. Recently, Minetti et al.  used thiReduced gravity also offers unique opportunities for adjusting the basic patterns to altered locomotor conditions for gait rehabilitation. Body weight support systems coupled with robotic devices or pharmacologic treatments are now often used in the rehabilitation practice to assist physical therapy of individuals with neurological disorders. We will not review any detailed analysis of clinical outcomes for ambulation when using locomotor training with body weight support systems and refer to other reviews . NeverthNovel pharmacological strategies  and elecThis perspective outlines an interdisciplinary approach to extend our knowledge on adaptation of human locomotion to a hypogravity environment, including biomechanical, neurophysiological, and comparative aspects, effective exercise countermeasures for astronauts, and even exobiology of new forms of locomotion on different planets. The tools and techniques used for hypogravity simulation and their effects on human locomotion provide new insights into our understanding of the physiological effects of gravity. The beneficial effect of weightlessness on rhythmogenesis would further enhance the utility of this approach and developments of innovative technologies for gait rehabilitation.


The aryl hydrocarbon receptor (AHR) has long been studied by toxicologists as a ligand-activated transcription factor that is activated by dioxin and other environmental pollutants such as polycyclic aromatic hydrocarbons (PAHs). The hallmark of AHR activation is the upregulation of the cytochrome P450 enzymes that metabolize many of these toxic compounds. However, recent findings demonstrate that both exogenous and endogenous AHR ligands can alter innate and adaptive immune responses including effects on T-cell differentiation. Kynurenine, a tryptophan breakdown product, is one such endogenous ligand of the AHR. Expression of indoleamine 2,3-dioxygenase by dendritic cells causes accumulation of kynurenine and results in subsequent tolerogenic effects including increased regulatory T-cell activity. At the same time, PAHs found in pollution enhance Th17 differentiation in the lungs of exposed mice via the AHR. In this perspective, we will discuss the importance of the AHR in the immune system and the role this might play in normal physiology and response to disease. Study of this receptor traditionally was in the domain of toxicologists, as it was originally defined as a receptor to 2,3,7,8-tetrachlorodibenzo-n (TCDD) . It was n (TCDD) . As the n (TCDD) . A connen (TCDD) , and gen in vivo . Since t in vivo –12.The role of the AHR in responding to toxins is thought to have evolved, as invertebrate forms of the AHR do not bind TCDD , and the1), initially recognized as the rate-limiting enzyme in tryptophan metabolism. In 1998, it was reported that tryptophan catabolism by IDO1 and other enzymes was responsible for prevention of allogeneic fetal rejection in mice, and it was further revealed that this enzyme was generated by DCs, and in some way increased the differentiation of Tregs  model in mice. However, it has recently been shown that when this same ligand is administered intraperitoneally, Treg differentiation is favored and there is a reduction in EAE disease severity  or “effector” (meaning they favored differentiation of effector Th17 cells) , more reseverity , 22. Ourseverity –25. IL-2severity –28. We hin vitro . The in The AHR serves as a sensor that responds to signals, both from the outside environment or internal milieu, to modulate an immune response. In the setting of an endogenous immune response, the AHR helps contain the inflammation and decreases collateral damage, so the response does not cascade in strength and lead to autoimmune destruction. In responding to exogenous ligands, the AHR functions as a sensor to “danger” signals, such as dioxins, PAHs, and other components of pollution. This is of evolutionary benefit for individuals exposed to man-made pollution or other toxins, as illustrated by the following scenario. When someone is exposed to inhaled atmospheric pollution, damage to bacterial clearance mechanisms and the epithelial lining of the airway puts the individual at risk for endogenous bacterial invasion and activation of a reactive airway response. The AHR present in immune cells residing in the lung binds to fractions of PM (PAHs and others), leading to an enhancement of Th17 differentiation that can serve as an immune barrier to the endogenous bacteria found in the lining of the lung. Simultaneously, AHR activation leads to generation of IL-22 that helps with epithelial cell repair and maintenance of tight junctions. Finally, activation of the AHR causes an upregulation of cytochrome P450 enzymes that metabolize the harmful toxicants. Taken together, the AHR aids in tissue protection, repair, and toxin clearance  leads to high levels of kynurenine production. The TDO-2-derived kynurenine then acts through the AHR in tumor cells in an autocrine manner and promotes tumor survival as well as altering the regional immune response by favoring Treg development. These Tregs hamper the ability of the immune system to clear the tumor. This is particularly effective as the interaction between kynurenine and T-cells in the vicinity of the tumor leads to local regulation in the very location and milieu that the tumor resides in Ref. . In addiThe immune system is in a constant balance of regulation and inflammation, and loss of this equilibrium can lead to pathology. We hypothesize that exogenous ligands of the AHR found in pollution can aggravate autoimmune conditions in an AHR-dependent mechanism. For many years, there has been speculation that environmental exposures can aggravate or even cause autoimmune disease, and a recent analysis of epidemiologic data has supported this hypothesis. The specific exposures that lead to disease and the mechanisms through which they impart pathology remain unclear. Recent data suggest that modulation of the Treg/Th17 balance may be at the center of environmentally induced autoimmunity. An NIEHS workshop concluded that “dysregulated Th17 activity can lead to pathology” in various autoimmune diseases, and that both smoking and “AHR binding by aromatic hydrocarbons favors differentiation of Th17 cells and can exacerbate autoimmunity” . We receOne of the novel theories we have been studying in our lab is the possibility that exposure to pollution is altering the Treg/Th17 balance and leading to chronic rejection after solid organ transplant. This may be most relevant to lung transplantation, where the transplanted organ is at the interface with the outside environment . There iSome of the highest impact papers regarding the AHR in the last couple of years have described the relationship between gut immunity and the AHR. The presence of this receptor is necessary for the establishment of certain populations of immune cells in the gut. Furthermore, both dietary ligands of the AHR as well as ligands produced by gut bacteria interact with and alter the gastrointestinal immune system , 41. TheThe AHR is highly expressed in multiple cell types found in skin. As skin is one of the organs at the interface with the outside environment, it is likely that inflammatory disorders are altered by interaction with toxins and other environmental factors. A recent publication did document the protective role of various AHR ligands in reducing inflammation in a model for psoriasis . At the So does the relationship between the AHR and the immune system make us healthier and more able to withstand interactions with the environment, or leave us at risk for pathologic manipulation of the immune system in response to external and internal signals? We assert that the AHR does make us healthier, and allows us to survive in the environment that currently exists. The relationship of the endogenous ligand kynurenine and the AHR allows a feedback loop that dampens an immune response to prevent too much inflammation and autoimmunity, allowing a response to be self-limited. Exogenous ligands serve as “danger” signals that alert the immune system to toxic insults from the environment, allowing immune cells to play an early role in containing damage done by these exposures, helping repair local barriers, and containing local endogenous infectious exposures. At the same time, there are examples where disease processes have taken advantage of this connection to increase pathology. This scenario, where normal physiology or “protective” responses become overwhelmed and lead to increased severity of illness, is well documented in immune responses to pathology, including systemic inflammatory response syndrome in response to infection, multiple forms of autoimmunity, and resistance of cancer to its own destruction. As we better understand the mechanisms and signals behind the role of the AHR in the immune system, we will be able to manipulate this receptor to treat or prevent diseases as diverse as cancer, autoimmunity, and transplant rejection.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.