Purpose: While emergency department nurses in Indonesia are critical to quality care, the role lacks recognition and standard practices and regulation of scope of practice are absent. This research explored the role of nurses in Indonesian EDs.Method: The conceptual lens applied in the research was grounded theory. The main data source was 51 semi- structured interviews with 43 ED nurses, three directors of nursing, three nurse leaders and two nurse educators. Data were also generated through observations and memos.Results: Two key categories were constructed; shifting work boundaries and lack of authority. Shifting work boundaries was symbolic of a lack of professional authority and legitimized knowledge. Lack of authority reflected the dimension of professional autonomy through the nexus of power and knowledge. The interrelationship of these two concepts constructed a core category, securing legitimate power, which underpinned the positioning of nursing in Indonesia.Conclusions: The interconnection between political gains, tertiary knowledge, professional regulation and implementation of gender-sensitive policies was critical to the development of the ED role, the positioning of nursing within the health care system and improvement in quality of care. Increasing demand for emergency care services in Indonesia is linked to social economic change and demographic factors. The demographic factors are indicative of the pressure on the Indonesian health care system, with a population of close to 264 million in 2017  nurse. Indeed, the high numbers and high complexity of patients presenting to Indonesian EDs is linked to the rapid growth of the urban population and increased intercity traffic and shifting lifestyle. The five leading causes of death in adults in Indonesia, recorded in 2014, were cardiovascular diseases (37%), cancer (13%), injury (7%), diabetes (6%), and chronic respiratory diseases (5%) ; willing to share their experiences and to participate in audio recorded interviews; willing to be observed in their own environment. In phase one, 35 participants were recruited from the selected EDs. In the theoretical sampling phase, 16 further participants were recruited and the total sample constituted 51 nurses who contributed to a full exploration of the phenomenon under research.Participants in the data collection phase, The processes of data collection and analysis were undertaken simultaneously and were conducted as follows: contextual observations; participant interviews; and theoretical sampling interviews.The researcher invited participation through a display of posters in the EDs. Verbal and written information regarding the study was provided. All participants provided their written informed consent prior to the commencement of data collection.The data collection phase was conducted through contextual observations and a series of face to face participant interviews.Contextual observation was undertaken in each ED for around 6 hours as an initial step in the data collection process and was conducted prior to participant interview. The intention was to gain a global understanding of the ED environment or the context of this research. Observational data were recorded in field notes and researcher memos. Conceptual insights generated from the observational data, or what Glaser  terms thParticipant interviews were the main data source for this study. The interviews involved 35 ED nurses and were organized in two phases: initial interviews and a second round of interviews.How do you work as a nurse in emergency care services; describe and define your role?The initial interviews involved individual semi-structured interviews with 10 ED nurses . The interviews were performed in the Indonesian language and audio-recorded. Each interview commenced with open-ended questions:Further questions were posed for the purposes of clarifying participant responses, or based on what had been viewed during observation. Furthermore, focused questions sought to explore more deeply and in greater detail the significant issues expressed by participants. This interview process allowed for the expression of feelings, views, thoughts, and actions Charmaz, , to reflThe first interview was transcribed in Indonesian and initial coding commenced in that language. Significant analytical concepts produced from the first interview were further explored in a second participant interview. Thus in the initial interviews simultaneous processes of interview and analysis were carried out sequentially. The duration of the interviews was on average 50–70 minutes. Focused coding was conducted following initial coding. Significant issues generated at this stage were further explored in the second interviews.The second round of interviews encompassed 25 ED nurse participants and it were conducted sequentially in the EDs of hospital A with 11, hospital B with eight, and hospital C six participants. In this phase, the interview questions were shaped by significant issues produced through the focused coding process of initial interviews.Thus the first phase involved 18 hours of observations and 35 participant interviews consisting of initial interviews with 10 ED nurses and following some analysis further interviews with 25 participants.theoretical sampling, which involved interviews with 16 participants. These interviews involved five ED nurses, three ED nurse managers, three Directors of Nursing, three nurse leaders at the national level, and two nurse educators. The purpose of these interviews was to fill analytical gaps found in the previous analysis phase, and to illuminate and refine emergent concepts. Following this, all other data sources, including documents obtained in the theoretical sampling phase, were subjected to analysis using a combination of the constant comparative process, coding procedures, and interpretation.The second phase data collection was Data collection continued until sufficient data was generated to allow for a comprehensive exploration of the research area.Initial or open coding in this research involved analysis of the interview transcription incident by incident or line by line, where each segment of meaningful data was named or coded. Initial coding was the first step in the analysis process, which was conducted by naming these segments of data or unit of meaning, using significant words in the data Charmaz, .During open coding, the researcher was engaged in the process of interpretation and sought to interpret the meaning of each segment of data. This process is important in attending to participant voices, participant points of view, and interpretation .Professional regulation bestows authority through a process of exclusionary closure where legal boundaries separate one occupation from another Saks, . The lacIt has been argued above that authority is reflected in the level of control nurses exercise over nursing work that is grounded in the legitimacy or legal status that originates from regulations around to nursing practice. This data converges with the work of Haug , who argThe concept of authority in the current research reflected the degree to which the ED nurses controlled (or did not control) their practice by virtue of the positioning of nurses within the Indonesian health care structure. The level of nurses’ authority was shaped, in turn, by historical, political, and social processes.diploma 3 nursing education and it was not until 73 years later university-based nursing education was initiated at that University of Indonesia, in 1985. This social-cultural and historical legacy means that the majority of clinical nurses have not had access to university education. This situation can also be observed in the ED setting, where most of the nurses had a formal level education at diploma 3.The transition of Indonesian nursing from the vocational to professional level has thus been prolonged. The nursing work undertaken by trained personnel has existed since 1912. However, it was 49 years later, in 1961 that Indonesian nurses gained access to a “Of the 39 nurses who work in this ED, around 70% have experience in performing life-saving…. However, none are prepared formally  to work in the emergency setting. Also, only five nurses have nursing educational backgrounds on BSN degree” .In this research, the participants were of the view that they required formal education to support their role and to ensure consistency of practice in the ED setting, as can be seen below:In this context, delayed professionalization of nursing had resulted in inequalities in formal education levels, and sustained medical doctors in positions synonymous with power and as authority holders. For ED nurses, inequality in formal knowledge means inequitable levels of authority.Formal knowledge at an advanced level, as indicated by Freidson , is a so“Nursing work varies from providing information to patient families … to basic nursing interventions and to advanced interventions. The nurses (senior nurses) in the ED are also required to perform tasks such as life-saving interventions…. This is so even though, in reality, such practices are seen as a medical responsibility and are informally delegated to ED nurses” (OMN).Authority, in the research context, was thus a condition linked social- historically to the position of nursing as women’s work, which was further sustained by the altruistic values that prevailed within the Indonesian nursing community. Ultimately, prevailing social values ensured the continued subordination of nursing within the Indonesia health care structure.At the clinical practice level, nursing roles had been extended and yet without attracting the associated authority and the result was the entrenchment of inequality in the workplace and a lack of recognition for nursing work.“My first priority is to help the patient, and I will do what I can do and even with only verbal approval from the doctors, I (will do) life-saving intervention. Our first priority is to provide health services as soon as possible, to help the patient who needs the service. After all, if nurses don’t do this, who will?” .Furthermore, the notion of nursing as altruistic has sustained the subordination of nursing. The notion of altruism lends legitimacy to the context of “lacking authority” and inadequate formal education experienced by nurses. This can be seen in a research participant’s statement below:ED nurses self-define their role as taking action to save the lives of other people as a priority at the front line in emergency care services. The image of nursing as an altruistic profession has also resulted in a disconnect of nursing from a higher level of knowledge. The complex skills, expertise, and experience that require formal education at an advanced level for nurses have been inadequately recognized by society .The extension of nursing work beyond traditional boundaries was unavoidable, as ED nurses were positioned at the forefront of the emergency care services. Because of their experience, senior nurses were capable of dealing with the full range of cases and interventions in EDs. The condition, “We do external fixation and cleansing of wounds and manage critical patient conditions caused by trauma.… We do an artery ligature first before sending them to the operating room … this requires special skill. Special skills are needed to manage patients with an open abdominal trauma. Also, if a patient’s condition is getting worse, turning into pre-shock, we report to the ED doctor…” (EC).A further participant noted:The invisibility of emergency nursing knowledge served to reinforce the dominance of medical knowledge. Indeed, the extended work undertaken by nurses was socially and politically constructed as knowledge belonging to the medical sector.“The life-saving procedures we have responsibility for are less recognized. This is because all advanced life-saving interventions are recognized as medical interventions, so the allocation of financial rewards is mostly for authority holder….” (MO).An associated lack of authority also meant an absence of formal recognition for any expansion of the nursing role in the clinical setting, as can be seen in the research participant comment below:Advanced life-saving interventions are recognized as the work of the authority holder, as formally advanced practice nursing is still not recognized. For ED nursing at the micro level, formal knowledge at the advanced level is one source of authority and also formal and social recognition in the workplace. For a profession, specialized knowledge and self-regulation are the primary sources of authority.Weber , argued Delays in achieving professional status for advanced practice in Indonesian nursing is reflected in inequities in access to higher education and in a scarcity of authority. For Indonesian nursing, the social perception of nursing as women’s work has also created less political power at the health policy level. Wherever nursing has been perceived as women’s work, the voice of the nursing community has been granted little legitimacy or respect in policy debates Davies, .Inequalities in formal education have created inequitable authority and lack of formal recognition for the extended ED nursing work. The lack of legitimacy afforded nursing knowledge underpinned the social and political positioning of the ED nurses. The structural and interactional features of ED nursing work, as a consequence, meant that nurses had little capacity to negotiate work boundaries.Work on occupational boundaries tends to infer the stability of professions. The concept of boundary work relates to professional autonomy, authority and expertise Gieryn, , to the “Interventions in the ED … are mostly conducted by nurses, either independent nursing interventions or delegated interventions including life-saving. Mostly, ED doctors focus on providing medical therapy to other patients in this ED” (MN).The conceptualization of shifting work boundaries was perceived in terms of the extension of the ED nurses’ clinical activities. As noted below, where nursing work was extended, nurses redefined their work boundaries and consequently the boundaries of medical practice in general:The participants perceived that where the nursing work in the ED was extended, the boundaries of their daily practice are blurred.A blurring of work boundaries between health professionals is considered inevitable  the advanced interventions to senior nurses …” (TN).Integral to the phenomenon of shifting boundaries is the process of role substitution. For the ED nurses, role substitution signified “an extension of work activity” without legal definition, as the following research participant explains:The process of vertical role substitution is relevant to the ED nursing role in Indonesia, where informal delegation of work occurs regardless of qualifications. Thus, flexible work boundaries exist along with role substitution, where a lack of equivalency of education, power, and authority facilitates the delegation of tasks across professional boundaries , knowledge, culture and gender that gave rise to conflict. Yet, conflict was an essential part of the process of change in Indonesian nursing. Conflict provokes innovation and creativity and also new institutions that might lead to the improvement of a social system Coser, . While sThe contextual conditions that shaped the ED nursing role cannot be argued in isolation from gender and culture. Indonesia, in general, is characterized by a strongly patriarchal society Clark,  that hasThe delay in professionalization of Indonesian nursing is linked to gender and cultural issues. Professionalization is understood as a mechanism for occupational advancement to be achieved through internal methods of self-regulation Evetts, , 2013. advanced practice nursing this interaction means the importance of links between advanced practice nursing with advanced knowledge and skills at higher education and political power including professional autonomy.The interaction of gender and the health care system in Indonesia reflects what Meerabeau  refers tState and the nursing profession. The recognition of a profession starts with the achievement of professional self-regulation or professional autonomy which indicates that a government has granted a body the status of a fully-fledged profession (Saks, As in many countries, in Indonesia, the institution of professional self-regulation was associated with a sharing of power, in the governance of nursing between the on Saks, . Led by on Saks,  was appron Saks, .In Indonesia context, growing political support for nursing self-governance coincided with a rise in the number of nurses with higher degrees and the growth of higher degree nursing institutions in Indonesia. For nursing, in Indonesia and many countries, both political processes and the existence of a body of professional knowledge are central to the achievement of professional self-regulation and professional autonomy.The securing of legitimate knowledge for ED nurses in Indonesia can be explained as a struggle to shift what is largely invisible nursing knowledge from the margins in health care to a position where that knowledge is recognized by the Indonesian health care system and the broader society. Legitimate knowledge is a dimension of a process that engenders within nursing the authority, formal recognition, and legitimate power that is critical for positioning nursing in the health care system. Legitimate knowledge is that which is communicated in an academic setting, is known as official knowledge and is generated and protected through professional or institutional research Apple, . HoweverAs is the case globally, in Indonesia the construction of nursing knowledge as legitimate also requires broader structural change since the production of such knowledge is related to a gendered struggle for equality. The gendered exclusion of nursing in the production of legitimate knowledge has manifested as a disconnect between nursing and the nexus of knowledge at the higher degree level, and thus power or professional autonomy.Kuhlmann  indicateAs is the case in many countries, the interconnection between political gains, tertiary knowledge, and professional regulation has been the focus of Indonesian nursing in gaining professional authority and positioning nursing more strongly within the health care system. Professional regulation is critical to professional power, as it engenders in nursing the right to self-governance. Self-governance, in turn, is just as much a condition for, rather than a product of, control over an area of knowledge. Similarly, the expansion of nursing education at the post graduate level, of itself, is more an endpoint to a long struggle for political strength to establish professional autonomy for Indonesian nursing.The repositioning of nursing in the health care system in Indonesia and many countries also requires the political will of the government to develop gender-mainstreaming policies that reflect equal access and participation for nursing. Nursing cannot sit outside the dominant social structure that gives rise to a hierarchy of occupations and thus, legitimate knowledge is critical in claiming an area of expertise for nursing within the existing health care system.This GT study stresses the importance of reviewing literature in the Indonesian context. However, there were no prior studies related to the nursing role in the Indonesian context. Prior understanding of the research problem, therefore, was obtained largely through related literature from the international setting. The issues have been mediated by comparing and linking the research area to the conditions in Indonesian context.


Undocumented migrants in Israel, mostly originating from HIV endemic countries, are not covered by Israel’s universal healthcare coverage. We initiated a Public-Private Partnership (PPP) to handle this public health and humanitarian challenge. The PPP venture included the Ministry of Health (MoH), pharmaceutical companies, pharmacies, and specialized HIV clinics, the Israeli HIV Medical Society , and non-governmental organizations. This study describes the national policy process in conceptualizing and implementing access to HIV services for undocumented migrants through a PPP, and analyzes the preliminary results.This case study describes the process of creating a temporary Public-Private Partnership to provide HIV care for undocumented migrants based on institutional records of the Department of Tuberculosis and AIDS (DTA) and memories and reflections from partners.This case was analyzed according to the OECD-DAC criteria for development assistance . Demographic and serological data of patients referred between 2014 to 2018 were collected to monitor progress. and analyze preliminary medical and biological outcomes. Ethical approval was obtained from the Ministry of Health.Creating a policy to extend HIV care to undocumented migrants was a 15 year process that confronted several challenges within Israeli and international discourse, particularly concerning governmental response to the migration crisis. The use of a PPP model involving numerous stakeholders provided a solid, local feasibility demonstration that extending HIV care as a matter of policy would have positive implications for public health in Israel. During the first 2 years of the program (2014–2015), the MoH funded medical follow-up and the pharmaceutical companies provided antiretroviral treatment (ART) free of charge for only 100 patients at any given time, in addition to ART provided by the MoH for pregnant women. Since 2016, the MoH has fully covered this service and integrated it within the Israeli health system; this constitutes the major success of the PPP program. As of December 2018, the national program has monitored 350 patients and treated 316 (90.3%). The most prevalent disease present upon referral was Tuberculosis.To our knowledge, this study documents the first example of a successful PPP with government partnership in a high-income country to address undocumented migrants’ lack of access to health services in general and HIV care in particular. In light of the intensification of North-South migration, this Israeli case study could be useful for other countries facing similar challenges. It also has lessons within Israel, as the country grapples with other health problems among uninsured communities. Globally, migration remains a controversial topic, and health issues of migrants are often used as a pretext for discrimination . This isIn 2000, the United Nations declared HIV/AIDS (Human immunodeficiency virus/acquired immune deficiency syndrome) ‘a global threat’ . HoweverRecent decades have witnessed vast waves of migration from high HIV endemic/low income countries to low HIV endemic /high income countries, primarily in Europe . In 2015The international response to providing healthcare to non-citizens, particularly the undocumented, varies greatly from country to country. While countries such as Belgium, France, and the United Kingdom extend HIV care to undocumented migrants, many more do not provide any services and even restrict healthcare access . Of 48 rIsrael’s relationship with immigration is complex; since the establishment of the State of Israel, the government has encouraged Jewish immigration, especially in light of anti-Semitism elsewhere . When noIsrael is a country of low HIV/AIDS endemicity, as categorized by the WHO, with a HIV incidence remarkably lower than in most Western European countries , 11. YetAt the end of 2013, there were an estimated 160,000 non-Israeli residents living in Israel without health insurance, equivalent to 2% of the population , 15. AmoSeveral international organizations have emphasized the importance of Public-Private Partnership (PPP) in low-income countries in overcoming challenges to provide affordable healthcare access, particularly in fields of HIV, TB, and Malaria , 19. WhiIn 1997, Israel became one of the first countries to extend Tuberculosis (TB) care to all persons, regardless of citizenship status. This program allowed a full and free of charge diagnosis, prevention and treatment of TB, both ambulatory and hospitalized based, for non-Israeli citizens. While novel at the time, the concept of extending care to non-citizens was based on fundamental human rights and infectious disease prevention and treatment principles . Using tThis case study describes the process of creating a temporary public-private partnership to provide HIV care for undocumented migrants based on institutional records of the DTA and the memories and reflections of partners.p-value of < 0.05 was considered statistically significant.In addition, demographic and serological data (i.e. CD4) of all HIV patients referred to the program were collected for monitoring. The data covered for the period of the creation of the PPP in January 2014 until 2018 - 3 years following its integration into the Israeli health system (in 2016). Continuous variables were analyzed according to the mean, median, standard deviation and range. Categorical variables were analyzed according to frequencies and percentages. Student’s t-test was used to compare continuous variables while the Chi-square test was used to compare categorical variables. A In order to systematically analyze the strengths and weaknesses of our program, the OECD-DAC criteria for evaluating development assistance were used .Ethical approval was obtained from the Ministry of Health.During the period of 1990–2006, only 2766 undocumented migrants from SSA were reported in Israel . NumbersThe DTA next tried to collaborate with pharmaceutical companies, requesting that they provide ART free of charge, while the MoH would fund diagnosis and medical surveillance. Despite months of discussions, this endeavor was unsuccessful at that time.In parallel, the DTA attempted to acquire ART drugs from international suppliers at the cost quoted to low-income countries, but this was rejected due to legal concerns: namely, that pharmaceutical companies that hold the drug patents would file a lawsuit.As a result of these failed attempts, the majority of the undocumented PLWHIV were left untreated, with the exception of urgent care provided upon hospitalization, pregnant women  , and a sBy 2010, 36,616 undocumented migrants from SSA entered Israel . The arrThe DTA mapped the community actors who could potentially serve as partners in this venture, among both migrants and non-government organizations (NGOs). The IATF was commissioned by the DTA to perform an anthropological assessment, including mapping all formal/informal groups within the undocumented migrant population, including individuals with unofficial leadership roles and influence. Some of the HIV positive informants in the anthropological assessment subsequently became community promoters for the program. The DTA also recruited stakeholders from Israeli NGOs, which lead to partnerships with IATF and Physicians for Human Rights Israel.The DTA asked the United Nations High Commissioner for Refugees (UNHCR) to assist in brokering an agreement to allow Israel to purchase ART at a price similar to that in the migrants’ countries of origin. The UNHCR responded that it wasn’t possible, as Israel isn’t financially eligible for subsidized prices. Concurrently, the DTA initiated discussions with senior representatives from the four Israeli Health Maintenance Organizations, and with the managerial staff of each of the 8 pharmaceutical companies which produce/import ART in Israel. Convincing the pharmaceutical company representatives was ultimately successful by holding separate meetings with each company’s representative to address individual company concerns. After the individual meetings, the MoH Director General hosted a meeting with all eight representatives, who are generally in competitive roles, to reach a final agreement. The DTA also organized two national conferences to present the program to relevant professionals and simultaneously mitigate sociopolitical concerns.The PPP partners included the DTA, who led and coordinated the program, the MoH Division of Pharmaceuticals, all regional HIV clinics, a majority of the Tuberculosis clinics, all pharmaceutical companies marketing ART drugs in Israel, one pharmaceutical chain supplier, the Israeli HIV Medical Society, and two NGOs (the IATF and Physicians for Human Rights Israel). Stakeholders met biannually to discuss the progress and obstacles of the program.The first 40 patients accepted by the new program transferred from the IATF program, a majority of who were from SSA and arrived in Israel during the 1990s and early 2000s.New patients were referred to the DTA by HIV clinics, hospitals, and sexually transmitted infections clinics. To be eligible for the program, patients had to have arrived in Israel at least 6 months before referral , have an official form of identification , be ineligible for national insurance, and lack private health insurance.A medical committee composed of HIV/AIDS experts was formed to determine candidates’ inclusion in the program. Patients fell under one of four categories: 1) Approved for medical follow-up and ART; 2) Approved for medical follow-up and put on a waiting list to receive ART; 3) Approved for medical follow-up only and 4) Not accepted into the program. The committee prioritized the patient’s treatment according to ART availability, and determined the course of treatment according to clinical compatibility and medication availability.1Upon acceptance into the program, participants were assigned to one of Israel’s eight HIV clinics where he/she was provided care.ART prescriptions were filled at one pharmacy at the Tel Aviv Central Bus Station. The pharmacy was chosen due to its location at a national transportation hub and proximity to a neighborhood densely-populated by migrants. Patients were only allowed to receive medication in person with proper identifying documents. ART was provided monthly in order to monitor adherence.Pneumocystis carinii and Toxoplasmosis, and all active TB cases were treated [All HIV patients were tested for Latent TB Infection, received a prophylactic treatment for  treated , 25.Following a DTA-funded anthropological assessment of key informants in the undocumented community, a health education program was jointly created and implemented by IATF. This project was implemented by community health workers, and included health education gatherings and distribution of condoms and pamphlets in areas where undocumented migrants live. This was a means both to inform undocumented migrants about the new program and engage the population.The major success of this PPP was its full adoption by the MoH and integration into the Israeli health system at its conclusion in 2016.The national program was largely based on the original joint venture, with three major improvements: 1) the MoH assumed all financial costs of the program including purchase of the ART medications; 2) the budget was significantly increased which allowed more patients into the program and obliterated waiting lists; 3) Patients in the program received the ART in pharmacies operated by the hospitals in which the HIV clinics were located .Table Table During the first period of implementation, the pharmaceutical companies donated ART for only 100 patients at a time. As a result, there was a waiting list, which shrank progressively as the PPP expanded into a national governmental program. Since 2017, there hasn’t been a waiting list for ART in the program.In order to systematically analyze the strengths and weaknesses of our program and allow for global comparison with other health development projects, the OECD-DAC criteria for evaluating development assistance were used . This frThe OECD-DAC defines relevance as “the extent to which the aid activity is suited to the priorities and policies of the target group, recipient, and donor.” Using this definition, the program was found relevant for both undocumented migrants and the partners of the PPP. Considering many undocumented migrants who were referred to the program had extremely low CD4 levels Table , HIV carEffectiveness is defined as the extent to which an aid project attains its objectives. The PPP was very effective in its objective to provide HIV care services as an intermediary step towards inclusion of undocumented migrants in the healthcare system. Before the PPP, access to ART among undocumented PLWHIV was inconsistent and very limited in scope. The PPP’s objective was to increase the number of migrants who could access ART through organized professional channels, which was achieved.The parameters for efficiency involve three parts: 1) cost-efficiency 2) timely achievement of objectives and 3) efficiency compared to alternatives. A cost-utility analysis for the program has yet to be performed. However, the achievements of the PPP were achieved within the 2 year period agreed upon by all parties. In light of alternatives that severely limit or eliminate testing and treatment, including the prior system of only occasional provision of ART by NGOs or complete lack of treatment, the PPP and current national program are considered efficient.Sustainability is defined by OECD-DAC as the whether the benefits of an activity are likely to continue after donor funding has been withdrawn. The PPP program was made sustainable by its absorption into the MoH as a government program, where it was not only sustained, but expanded. The PPP allowed the MoH to progressively increase the budget of government program and to ultimately sustain the entire program without the donation of ART by pharmaceutical companies.Impact is defined as the intentional and unintentional changes produced by a development intervention. The PPP allowed a systematic path to HIV care for more undocumented migrants than prior to the program. However, the stakeholders were surprised by the relatively few undocumented PLWHIV who partook in the program compared to estimates of the number of undocumented migrants with HIV. While requiring further study, some of the reasons for the perceived low yield of the program may include poor access to health systems, fear from formal institutions, and continued migration beyond Israel. Considering both issues of HIV epidemiology and sociological aspects of migrant communities, the low yield did not lessen the impact of the program, which gives institutional footing to providing health services to undocumented migrants in Israel. However, this point requires consideration in building future strategies to maximize the impact in undocumented communities. In addition to more undocumented migrants accessing HIV care, the professional events surrounding the program created a framework for the importance of including undocumented migrants in care. Ultimately, the measure of impact in the HIV field is the UNAIDS 90–90-90 Care Cascade, which recommends that 90% of PLWHIV know they are HIV positive, 90% of those who know they are HIV positive are receiving ART, and 90% of those are virally-suppressed in each country . In ordeIn Israel, the MoH and other stakeholders recognized the public health imperative to treat PLWHIV regardless of citizenship status. Raising the importance of the health issues in the undocumented migrant community and their socio-political ramifications was a process that took several years, numerous meetings, and multiple national conferences. The role of the government in the PPP and its transition to a government program addressed Israel’s human rights responsibilities .The multi-sector partnership unified the abilities and talents of each stakeholder. The partnership with pharmaceutical companies to provide ART for a predetermined period of time without charge to the government or the recipients was a unique success of this process. In this case, IATF’s unique access and experience with this marginalized population provided the initial patient base of the PPP and an acceptable path to procuring donated medication. Additionally, the partnership with IATF contributed to trust with migrants that they would not be deported for seeking treatment.The use of the PPP model was an essential step towards the integration of this service in the Israeli health system. While the issue of extending HIV care required a solution that addressed the financial aspects of providing care, the PPP was a successful means of garnering political support and mitigating potential concerns about the ability of the Israeli system to provide care. As a result of this process, Israel is now one of few high-income countries which provides HIV care, including ART, to undocumented PLWHIV without charge.While the PPP reached a successful conclusion by its transfer to a government program, the capped number of drugs the pharmaceutical companies were willing to contribute to the program limited the amount of people who were immediately accepted for ART. While this limitation was removed after transfer to a government program, limiting patients receiving ART meant composing strict inclusion criteria for the first 2 years.The OECD-DAC criteria were an important tool for analyzing the program. However, further study is needed to quantify several aspects of the program, both in its PPP and government program iterations. Specifically, real-life service accessibility among a politically and economically vulnerable population needs to be assessed, in addition to analysis of serological data to determine changes in transmission and adherence to treatment.Moreover, the DTA estimates a higher number of undocumented migrants living with HIV in Israel than who were referred to the program. Analyzing potential barriers is an important next step. Researchers elsewhere have noted a lack of proof of the effectiveness of government-funded initiatives, mostly due to legal, social, administrative and economic barriers , 29, 30.This article details the process of creating a PPP to manage care for undocumented PLWHIV. To our knowledge, this is the first example of a PPP with state partnership in a high-income country to address an extreme need among the undocumented community. The PPP’s success demonstrated the feasibility of the program, and subsequently resulted in the galvanization of the program into the Israeli health system. While a PPP may not have achieved the same sustainability long-term, its use was an essential interim tool to address ideological and financial hurdles on a practical basis.


Cancer, chronic heart failure (CHF), and chronic obstructive pulmonary disease (COPD) in the advanced stages have similar symptom burdens and survival rates. Despite these similarities, the majority of the attention directed to improving the quality of end-of-life (EOL) care has focused on cancer.To assess the extent to which the quality of EOL care received by cancer, CHF, and COPD patients in the last month of life is diagnosis-sensitive.This is a retrospective observational study based on administrative data. The study population includes all Tuscany region residents aged 18 years or older who died with a clinical history of cancer, CHF, or COPD. Decedents were categorized into two mutually exclusive diagnosis categories: cancer (CA) and cardiopulmonary failure (CPF). Several EOL care quality outcome measures were adopted. Multivariable generalized linear model for each outcome were performed.The sample included 30,217 decedents. CPF patients were about 1.5 times more likely than cancer patients to die in an acute care hospital . CPF patients were more likely to be hospitalized or admitted to the emergency department  and less likely to use hospice services  than cancer patients in the last month of life. CPF patients had a four- and two-fold higher risk of intensive care unit admission or of undergoing life-sustaining treatments, respectively, than cancer patients .The study has highlighted the presence of significant differences in the quality of EOL care received in the last month of life by COPD and CHF compared with cancer patients. Further studies are needed to better elucidate the extent and the avoidability of these diagnosis-related differences in the quality of EOL care. The majority of people in high-income countries die of chronic conditions other than cancer . ChronicCancer, CHF, and COPD at the advanced stages have similar symptom burdens and illness experience –19. TheyAs far as the quality of EOL care is concerned, a few studies have compared patient outcomes across several malignant and non-malignant chronic conditions, with some showing a certain degree of consistency in the patterns of EOL care and treatment intensity provided across conditions  and otheIn order to assess the quality of EOL care, major indicators from administrative data were initially developed and adopted in the context of cancer care , 36, andThe aim of the present study is to compare the pattern and intensity of EOL care received by cancer, CHF, and COPD patients in the last month of life in order to assess the extent to which the quality of EOL care is diagnosis-sensitive.This is a retrospective observational study of residents in Tuscany based on data extracted from the regional healthcare administrative data system (RHCADS). The RHCADS comprises several healthcare data sources and the following databases were used for the study: enrolment registry, regional census, inpatient hospitalizations, death registry, emergency department (ED), and hospice. In the RHCADS, each resident is represented by a unique encrypted identifier that enables complete record linkage at the level of the individual across databases and over time.This study was conducted in accordance with the Helsinki Declaration. According to the Italian legislation (law 211/2003) and the regional procedures, the study does not need ethic approval as it is a purely observational study on routine collected anonymous data. Furthermore, because this was an observational retrospective study, patients had already been treated when the study protocol was written; therefore, it could not have modified their life-trajectories or care pathways in any way. Data were extracted from routinely collected administrative databases and there was no need to obtain additional data from individual residents. Data linkage to the patients was performed by using numerical codes, and researchers had access only to an anonymous dataset, which ensured residents’ privacy. For these reasons, no personal informed consent to the present analysis was requested for the study. The Tuscan Regional Health Agency is the authorized public entity  entitled to perform research and analysis on the RHCADS data.The study population includes all Tuscany region residents aged 18 years or older who died with a clinical history of cancer, CHF, or COPD in the years 2015 and 2016. More specifically, decedents who had at least one inpatient admission for cancer, CHF, or COPD in the last 36 months of life were included in the study. Because the inclusion criteria was based on inpatient admissions, the last 36-months of life time-frame was chosen in order to minimize the possibility of not including non-hospitalized decedents with cancer, CHF or COPD in the study population. Only decedents who have resided continuously in Tuscany for their last 36 months of life were included in the study as for this population it is possible to ensure complete information for the last 36 months of life. Both primary and secondary diagnosis codes associated with the hospital admissions were used. Decedents who had hospital admissions associated with cancer and cardiopulmonary failure diagnosis codes in the same or in distinct hospitalization episodes were excluded from the study. ED deaths occurring as a consequence of a trauma or injury were excluded from the study; these criteria aimed at excluding people who could not be recognized as being near the end of life until the time of death.According to the diagnosis codes of the hospitalizations occurred in the last 36 months of life see , decedenAll the covariates were captured at time of death. The following covariates were considered: age, sex, nationality, education level, comorbidity, and geographic region of residence. Comorbidity was measured using the Charlson comorbidity index (CCI) (Time Frame: last 36 months of life) .The outcome measures adopted in the study were derived from indicators reported to be associated with poor quality of EOL care , 37. SpeA descriptive analysis with an χ2 test for categorical and ordinal data and an unpaired t-test for continuous data were performed in order to evaluate significant associations between outcome measures and all the variables considered. A multivariable generalized linear model for binomial distribution for each outcome was performed, including the statistically significant variables resulting from the univariate analyses. Margins for CA and CPF have been computed to estimate adjusted probabilities. For each analysis, an α level of 0.05 is considered as significant. The statistical software Stata 14 SE was used for the data analyses.A total of 30,217 decedents with cancer, CHF, and COPD met the eligibility criteria. The patients’ characteristics are presented in The mean age of the sample is 80.47 years (standard deviation of 11.50 years) and males represent 49.98% of the sample. The CPF cohort represents the 59.76% of the study sample. Upon comparing the characteristics of patients of the two cohorts, patients with CPF were found to be older than the CA patients. The CPF cohort had a higher percentage of patients with a CCI≥3 compared to the CA cohort.Approximately a third of the CA patients died in acute care hospitals (36.45%), compared with 52.31% of those registered as CPF patients. Among the patients hospitalized in the last month of life, the proportion of patients with one or more ICU admissions or who underwent one or more LSTs was significantly higher in the CPF cohorts  than in the CA cohort . CPF cohort showed a significantly higher proportion of patients with one or more hospital admissions (76.25%) and ED admissions (64.9%) and a lower proportion of patients resorting to hospice services (1.04%) in the last month of life than the CA cohort .The variables significantly associated with each outcome of the univariate analyses were included in the multivariable generalized linear model . Furthermore, in the last month of life, CPF patients were more likely to be hospitalized or admitted to the ED  and less likely accessed to hospice services  than CA patients. Among the patients hospitalized in the last month of life, CPF patients have a risk of ICU admission or of undergoing LSTs that is about four- and two-fold higher than for CA patients, respectively .The aim of this study was to evaluate whether the quality and treatment intensity of EOL care—measured by several established outcome measures –38—diffeSpecifically, the study shows that patients with CPF had a higher risk of dying in acute care hospitals and considerably less access to hospice services in the last month of life than patients with CA, which is in line with the literature , 34, 40.In the last month of life, patients with CPF had a higher risk of hospitalization than patients with CA. In the literature, only a few studies have compared the hospitalization rates among cancer and non-cancer patients. In a large retrospective study conducted by Teno et al., a higher hospitalization rate in the last 90 days of life is reported among COPD patients . ConversAs far as ED admissions are concerned, the study revealed that CPF groups have a higher risk of ED admission in the last month of life compared to the CA group. A similar result was reported previously , althougAs for EOL treatment intensity, patients with CPF were at a higher risk of receiving LST or being admitted to the ICU than CA patients. In the literature, differences in EOL treatment intensity between cancer and non-cancer patients have been reported, although there is no general consensus on the extent and magnitude of these differences. A study by Barnato et al. comparing the CA and CHF/COPD cohorts did not find a universally higher EOL treatment intensity in the CHF/COPD cohort . ConversSeveral factors may explain these differences in EOL care across conditions. First, patients with CHF or COPD may be less frequently involved in patient–physician discussions on EOL matters, in the decision-making process, and in advance care planning. Although the prognosis of COPD and CHF at the advanced stages is poor, physicians may be reluctant to pursue advance care planning with CHF or COPD patients as their illness trajectories are characterized by prognostic uncertainty , 48, 49.Nevertheless, several prognostic models, care pathways, clinical guidelines, and recommendations of medical associations have been formulated to assist clinicians to overcome these barriers in patients with end organ failure , 47, 54.Considering that the study population is representative of the deaths occurring in the Tuscany region for CA, CHF, and COPD and that the CPF group represents the majority of the sample, the diagnosis differences in EOL care emerging from this study highlight a relevant issue as well as the need to strengthen EOL care pathways and future research for non-cancer chronic disease and multimorbidity patients. Furthermore, as the prevalence and burden of non-cancer chronic diseases and multimorbidity are expected to grow across many developed countries –5, the pThe sample analysed represents virtually the whole population of an administrative region with around 3.7 million inhabitants and a wide and varied geographical area . FurtherNevertheless, the study has several limitations. Firstly, as the study is a retrospective analysis based on administrative data, it may suffer the recognized limitations of using this approach, such as the lack of control on data quality (i.e. underreporting or incorrect reporting of data). However, the quality of administrative data in terms of accuracy and reliability is very high as the data are audited each year. Second, it was not possible to identify and include in the study decedents with cancer or with CHF/COPD who were not hospitalized during the study time-frame; this may have introduced a selection bias. However, it is possible to argue that the extent of this bias was limited as only a very small proportion of decedents with cancer or CHF/COPD was not hospitalized in the their last 36 months of life. Third, a retrospective analysis of administrative data does not allow consideration of important clinical data (e.g. disease severity) or patients’ preferences for care; this could have introduced a bias in the exposure-outcome relationship. Finally, it should be noted that the study relied on inpatients’ diagnosis codes to classify patients in the considered cohorts. This approach is widely adopted in research on EOL matters , 33, 34,Cancer, CHF, and COPD in the advanced stages have similar symptom burdens and survival rates. Despite these similarities, the majority of the attention directed to improving the quality of end-of-life (EOL) care has focused on cancer. Although awareness of the quality and aggressiveness of EOL care in CHF and COPD patients has increased recently, research on these issues is still limited. The study has highlighted the presence of significant differences in the quality of EOL care received in the last month of life by COPD and CHF compared with cancer patients. These findings suggest the presence of potential diagnosis-sensitive determinants of the quality of EOL care. Further studies that take into account patients’ preferences of care and disease severity are needed to better elucidate the extent and the avoidability of these differences in the quality of EOL care provided to different diagnosis groups.S1 File(DOC)Click here for additional data file.S2 File(DOC)Click here for additional data file.S1 Dataset(XLS)Click here for additional data file.


Lung cancer is the most commonly diagnosed cancer with 11.6% of the total cases attributable to lung cancer. It is currently the leading cause of death among cancer-related deaths worldwide. This is a major public health concern. Death due to lung cancer is preventable with interventions encouraging early presentation, diagnosis, smoking cessation and prompt and proper treatment. Literature shows that people are willing to screen for lung cancer if they understand the related risk, because of their behaviour, thus, highlighting the need for tailored interventions to address the associated risks. The aim of the review is to map the available literature on interventions raising community awareness about lung cancer  and effectiveness thereof among adults in resource-poor settings.A methodological framework of Arksey and O’Malley will be used to guide this scoping review of published data. This process will start by searching several databases, including the Cochrane Library, PubMed, Scopus, MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, Web of Science, Google Scholar and the Educational Resources Information Centre (ERIC). A two-stage process will be done, where, firstly, two reviewers will independently screen the titles and abstracts for eligibility to be included in the final selection of studies. Secondly, a full-text screening of the articles from selected titles and abstracts will then be conducted. A tool developed through an iterative process by the researchers will be used to analyse all bibliographic data and study characteristics of selected studies.The results will be used to inform policy and practice in terms of developing interventions on lung cancer awareness. The results of this scoping review will be disseminated through scientific publication, conferences and future workshops with health care professionals involved in lung cancer awareness campaigns.The online version of this article (10.1186/s13643-019-1138-x) contains supplementary material, which is available to authorized users. Cancer morbidity and mortality is increasingly becoming a major public health problem, and it is the second leading cause of death worldwide . GloballA study conducted in Malaysia among smokers and non-smokers showed that people were willing to go for screening, if they were informed that they were particularly at high risk of lung cancer, especially if they were smokers . Whilst Williams et al.  propose This article outlines the protocol for a scoping review of published literature focusing on interventions that have been proposed and/or implemented to raise community awareness about lung cancer  among adults in resource-poor settings.The scoping review is informed by the framework proposed by Arksey and O’Malley  which haThese stages and how they will be applied in the proposed scoping review are discussed below.The design of this protocol has been informed by the scanning of the existing literature. This exercise assisted in the development of the research question to guide the scope of the review. The broad research question this scoping review will attempt to answer: “What is the effect of community awareness interventions on lung cancer in resource-poor settings?” The review will give an overview of the various interventions available, appraise their effectiveness and identify barriers and facilitators to their effectiveness.Identification of studies relevant to this review will be achieved by searching electronic databases of the published literature (including published systematic reviews). These electronic databases include Cochrane Library, PubMed, Scopus, MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, Web of Science, Google Scholar, EMBASE and the Educational Resources Information Centre (ERIC). All reference lists of included studies will be searched to identify additional relevant studies. A variety of grey literature sources will also be searched to ensure that all relevant information is captured. Relevant grey literature databases  will be searched to identify studies, reports and conference abstracts applicable to this review  language of publication: English, (ii) timeframe: no time frame, (iii) study setting: resource-poor setting, and (iv) types of articles: randomised controlled trials, intervention studies , reports, literature reviews and evidence maps. Studies will be excluded if they do not meet any of the listed criteria.Search terms will be determined with input from the research team and in consultation with and academic librarian. However, the following are some of the keywords that are likely to be used to search for articles: lung cancer, awareness, community, interventions, and effective. Terms will be searched as both keywords in the title, abstract and/or subject headings (i.e. MeSH terms). The review articles retrieved were then screened for their titles, abstracts and index terms. The articles retrieved from each database will be imported into a reference management software, namely EndNote. Endnote will be used for managing records, keeping track of articles and producing a list of references included in the final review report.The review of articles will have two levels of screening. The first level will be title and abstract review, where two team members will independently screen the title and abstract of all retrieved citations for inclusion against a set of minimum inclusion criteria; the second, full-text review. Initially, a sample of the retrieved articles will be independently screened by two team members to ensure consistent application of the eligibility criteria for inclusion in the review. Any articles deemed relevant by one or both of the reviewers will be included in the full-text review. Inter-rater reliability will be assessed using percentage agreement. Once the percentage agreement reaches 80% or above, advancement to the next stage can be done. For lower agreement, the inclusion and exclusion criteria will be clarified. The team will ensure that the duplicates from the different search databases are eliminated. A member of the team will then screen titles and abstracts of the articles to exclude those that do not meet the eligibility criteria identified in the second stage of the protocol. The full-text articles will be retrieved for the titles and/or abstracts meeting the inclusion criteria.Disagreements about study eligibility of the sampled articles will be discussed between the two reviewers until a consensus is reached or by arbitration of a third reviewer, if required. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart –26 will Key pieces of information from the abstracts of the selected articles will be collected and sorted. Standard data items will be extracted from the published research literature that will include author, year of publication, study objectives and additional information  and will be reported. Based on the preliminary scoping phase, a data extraction framework was developed which will guide the full review articles retrieved from the literature fulfilling the eligibility criteria for inclusion Table . For eacThe framework will be pilot tested by two team members on a sample (30%) of the included studies in order to ensure that the coding framework is consistently applied. Additional categories may emerge during the pilot testing process. If necessary, the categories will be modified and the data extraction framework revised accordingly. Questions arising when piloting the framework will be discussed by the team and possible disagreement will be resolved through team consultations. Missing data may be found on some eligible abstracts, and this will be resolved and documented in consultation with the team members. The authors of those articles will be contacted in an attempt to obtain the required details. If there is no response from the authors in 2 to 3 weeks, this will be considered as no information available. However, the study will be included in the narrative with a mention that an attempt was made to contact the authors for the missing data.The team members that were piloting the framework will be responsible for independently charting the data from each included review study. Similarly, disagreements in extracted data between the two members will be discussed by these members until a consensus is reached or by arbitration of a third reviewer, if required.This review seeks to compile a summary of findings and then propose a “best” model/intervention in a resource-poor setting broadly present an overview of a particular area of interest. The study will present a narrative account of existing literature using thematic construction based on the different identified intervention types from the selected studies. The analysis of the data collected using the data extraction framework, in this scoping review, will provide information on the body of research that has been conducted on interventions to raise awareness on lung cancer in resource-poor settings. It will be able to provide information on the types of evidence available, the aggregated findings, and offer an outline of the published research rather than an assessment of the quality of individual studies. It would also highlight the effectiveness of the interventions reviewed and their material impact on the target populations. It is also beneficial in identifying gaps in the existing body of knowledge and future research topics.The results from this scoping review will inform the development of a tailored community lung cancer awareness intervention targeted at selected communities in KwaZulu-Natal, South Africa. This study does not require ethical approval, since the scoping review methodology comprises of reviewing and collecting data from publicly available publications and materials. The results of this scoping review will be disseminated through submitting an article for publication to a scientific journal, conferences, presentations and reports to policymakers and future workshops with professionals involved in lung cancer awareness campaigns. The results will provide a complete synopsis of the interventions on lung cancer awareness and highlight areas where evidence is controversial or missing.Additional file 1:Proposed PRISMA flowchart. (DOCX 29 kb)Additional file 2:Draft search strategy and results from three databases. (DOCX 15 kb)


Nikolai Ivanovich Pirogov is considered one of the most important anatomists and surgeons in the history of medicine. The Russian physician conducted more than 11,000 dissections and meticulously studied human anatomy, discovering important anatomical regions such as Pirogov's triangle. Pirogov developed surgical methods and techniques used by physicians for many decades such as Pirogov's amputation. Pirogov is also known for his contribution to war medicine, given his experience practicing medicine in the Crimean War as a surgeon, where he introduced innovative methods for the treatment of injured soldiers. Pirogov’s most important contribution to the scientific community is his humanistic and democratic mentality—which he maintained until the end of his life—elements necessary for the evolution of every modern physician and scientist. Nikolai Ivanovich Pirogov 1810–1881) is considered an outstanding anatomist and surgeon originating from Russia, with a significant body of scientific work . Pirogov succeeded in passing the entry exams and gained a scholarship from the Russian government to begin his training in the Baltic-German University of Dorpat in July that same year. Only 20 Russian students were accepted to Dorpat every year . Dorpat In 1829, Pirogov was released from some compulsory lectures to complete his doctoral thesis, “The feasibility of treating aneurysms at the inguinal artery by ligation of the abnormal aorta.” Pirogov applied his method to animals and proved the feasibility of his technique, which achieved a gradual obliteration at the aorta, avoiding paralysis of the hind limbs and pelvis. He then carried out the operation on patients with aneurysms of the inguinal artery, an operation in which Cooper had previously failed . PirogovIn May 1833, Pirogov visited Berlin to expand his knowledge of anatomy and surgery. At the Charite University Hospital, he met F. Schlemm, Professor of Anatomy, and Friedrich Dieffenbach, Professor of Surgery . The famIn May 1845, Pirogov left Berlin to visit St. Petersburg, but during his journey, he got sick with typhus and stayed in Riga until that September . After PPirogov had the strong belief that every physician should disclose every error made during his medical practice. He held that disclosing mistakes is important for preventing further errors and limiting consequences for a patient ,9.From 1836–1840, there were a large number of ophthalmologic cases in the Baltics. At that time, Pirogov and 15 medical students founded the first ophthalmologic clinic in the Baltics with 10 beds ,5. MoreoIn 1341, Pirogov left Dorpat University for the position of chairman of the department of surgery at the Medical–Surgical Imperial Academy in St. Petersburg . PirogovRazanowski summarized Pirogov’s time in St. Petersburg: “While he disserts a large hospital, he brings an anatomical institute into being and becomes its chief” while concurrently lecturing on topographical anatomy and pathology and consulting at several hospitals . During Pirogov lost his first wife to meningitis after the birth of his second son. After this tragedy, he visited Italy, France, and Germany, and in 1847, he visited the Caucasus where he practiced advanced surgery and became the first surgeon to use etherization in Europe ,16. He wPirogov, in his early 50s, decided to resign from his position at St. Petersburg Hospital. He could not tolerate the ignorance of most of the professors at the hospital and their lack of sincere interest in patient health. Anesthesia, surgical instruments, and an evidence-based medical approach were considered luxury assets, given the hospital’s finances .During the Crimean War campaign at Sevastopol in 1854, Pirogov accepted the position of surgeon general from the grand duchess Elena Pavlovna. Pirogov and the duchess had conceived of the idea of sending female nurses to treat wounded and sick soldiers (a first in Europe), building the foundation for the later establishment of the Russian Red Cross ,20. The In the battlefields of the Crimean War, Pirogov encountered dramatic situations. He and his assistants performed several hundred operations daily. Pirogov and his female nurses and physicians fell ill with typhus. Patients were positioned on boards, one next to the other, with no differentiation of their wounds—clean and unclean wounds were treated in the same way. The transportation of the patients was completely inadequate, and the supplies of linen and medical instruments were grossly insufficient .Moreover, Pirogov encountered administrative corruption in the military hospitals, and he quickly realized that the patients primarily suffered from factors due to insufficient administration. The epidemics and medical mistakes were only secondary causes of suffering for the patient soldiers. Pirogov’s priority was to uncover bad management and corruption in the military medical administration ,21.During the Crimean War, Pirogov conceived of the first “triage” system for the wounded soldiers. The battle casualties were distributed and isolated as quickly as possible. The seriously injured were moved into hospitals, away from the battlefront. Surgical operations were never carried out during battles; rather, patients were evacuated to military hospitals. The injured patients were classified into four categories: the hopeless who were relegated to the priest and nurses, those who needed operations urgently, those whose operations could be postponed for one or two days and, therefore, were evacuated to a nearby hospital, and the slightly wounded who were able to walk and were, therefore, sent to the nearest hospital to be treated and then returned to their units ,22-23.Pirogov introduced an amputation method known as Pirogov’s amputation in 1854, which consists of the amputation of the foot through the distal part of the tibia and fibula with a retention of part of the calcaneus. This leaves an excellent weight-bearing condition without prosthesis . DespitePirogov was ultimately disappointed in the military hierarchy system and resigned from military medicine. The Minister of Education offered him the position of the Curator of Education for the Odessa District. For five years, he oversaw the selection of professors in Russians Universities -27. As tIn 1881, Pirogov was diagnosed with a space-occupying lesion in his mouth. Moscow’s professors concluded the lesion was malignant. An operation was deemed essential and urgently, but when he was examined by the famous Billroth, Pirogov was told his disease was not serious, and it would pass without any surgical intervention. Pirogov remained at his estate and died later that year, on November 25, 1881. Billroth later stated that Pirogov would not have been able to withstand the operation, and the lesion would recur anyhow .Although Pirogov lived 200 years ago, his life and work are still worth mentioning. His scientific means of thinking, his humanistic mentality, and his democratic beliefs are an example for modern physicians and an inspiration for researchers. Pirogov’s penetrating point of view will always rank him among the greatest in the history of medicine.


Poultry meat production is now based on fast-growing strains, with consequences for animal health and welfare. There is also an increasing demand for products from extensive rearing systems; there are, however, several criticisms including the difficulty of slaughtering chickens from a logistic, legislative and economic point of view. A possible solution could be represented by the use a Mobile Poultry Processing Unit (MPPU), which directly reaches the poultry farms. The aim of this review is to analyse the requisites and economic efficiency of a MPPU prototype in Italy; further, the related animal welfare aspects and the qualitative and sanitary implications are discussed.Nowadays there is an increasing demand for poultry products from alternative rearing systems. These systems, commonly named pastured poultry production (PPP), are more expensive than intensive rearing system but sustain biodiversity, local economies and farm multi-functionality besides providing meat to which consumers attribute high ethical value and quality. PPP generally uses large outdoor runs, small number of animals and requires chickens adapted to natural environment. One of the most relevant obstacles to further development of PPP systems is related to the slaughtering of animals economically and at the same time complying with the sanitary regulations to maintain food safety standards. A possible solution could be represented by a Mobile Poultry Processing Unit (MPPU), which directly reaches the poultry farms. MPPU can consider a good compromise for the niche production providing an opportunity to small farmers to exploit the full potential of their production system. The aim of this review is to analyse the essential requisites and MPPU economic viability in an Italian system. Qualitative, societal aspects are discussed together with bird welfare and hygiene implications. The case study indicates the viability of MPPUs but notes that up scaling to medium sized operations would not be permissible under current EU regulations. Poultry production has a lower environmental impact when compared to other livestock production chains , mainly 2/chicken), small number of animals and requires chickens adapted to a variable environment, without the strict control of temperature, humidity and ventilation of in the intensive systems [A side-effect of this process is the reduction of genetic variability  and the  systems .It is widely known that the access to free-range areas greatly improves the welfare of poultry and that the presence of shrubs and trees in the pastures further increases the use of runs . For theChickens and orchards mutually benefit each other; chickens improve soil quality by adding organic matter and control both insect pests and weeds, while trees protect the chickens from adverse weather conditions as well as raptors and provide additional revenue for the farm .Even though the pasture offers only a modest supply of energy and proteins—the pasture in PPP represent only 10–15% of the total feed intake—it provides many bioactive compounds, such as xanthophylls, antioxidants and vitamins ,15. AccoAs previously reported, PPP requires chickens that are adapted to the natural environment (high kinetic activity and foraging behaviour), with a well-developed immune system and adequate body conformation and skeletal development ,21,22,23Contrary to the popular belief, there are several disadvantages with respect to PPP that preclude further development and reduce the production capacity of this system. The main disadvantages are reported below:Cost of production—The production cost of this meat is much higher than with a conventional system, mainly due to the lower growth performance and the breast meat yield of slow-growing genotypes.Risk of predation—PPP systems are attractive to predators . Permanent fencing is expensive and is not always effective at excluding predators from the pasture. Rules formulated for large-scale poultry farms—Sanitary rules and technical standards of poultry production are often based on large-scale farms. Small farmers cannot afford to invest in requirements and protocols unsuited to their system of production [oduction .Consequently, up and down-stream infrastructures , services  are lacking. In particular, one of the major bottlenecks is the slaughterhouse. During the last 20 years in western countries, there has been a huge decrease in the number of poultry slaughterhouses coupled with an increase in size of the existing ones. Moreover, nowadays slaughterhouses generally belong to food companies and are not available to other farms. The lack of slaughterhouses strongly discourages the use of PPP and many farmers limit their production to less than 500 or 1000 birds per year. This quantity, according to European (853/2004) and USA (62) regulations, is considered to be primary production which can be sold directly to consumers without controlled slaughter. However, the restrictions on sales and the lack of small-scale poultry slaughterhouses prevent the creation of specialised poultry farms. Small-scale farmers who wish to sell poultry products locally must have them slaughtered and processed in inspected facilities that are usually far from the farms.A possible solution which increases the use of PPP systems could be a Mobile Poultry Processing Unit (MPPU) mounted on a small truck or van which goes directly to the poultry farms. A MPPU is excluded from continuous inspections by the Food Safety Authorities but it is still required to meet all sanitation and requirements. These MPPUs are designed to eliminate regulatory impasses and increases marketability and profitability for small-farmers. The MPPU reaches the farm directly on the day of slaughtering and then another advantage is the absence of transport of live animals to the slaughterhouse. This positively influences animal welfare and meat quality see .The main characteristics of MPPU are described later in the Beside the economic aspects, there are also social aspects connected with the use of PPP and MPPUs. In a sound productive chain, the system of production should be followed by a coherent transfer of goods and services (from farm to consumer). Each productive system should develop a proper system. For example, intensive poultry production has developed not only a proper production system but also a typical structure for exchange. Accordingly, standards arising from industrialised agriculture may be at odds with the principles of small-scale poultry systems .Rural sociology suggests a general framework in which exist a correspondence between production systems and the structure for exchange. PPP, as other local production system, requires the creation of specific short and decentralised circuits that link the production with the consumption of food. This pattern is completely different from highly centralised paths constituted by large food processing and trading companies which operate on a large scale . Our opinion is that the exchange structures promoted by industrialised processing may not be able to handle all the benefits of PPP and they could negatively influence its internal equilibrium . ConversAccording to this view, a MPPU could be considered not only a solution to the slaughtering problem but also a resource to enhance the emergence of food circuits , which cannot feature within the global food chains ,31,32. IEssential requirements of a MPPUOperation and economic efficiencyAnimal welfare aspectsQualitative and sanitary implications.Moreover, through use of a MPPU, the cost of each farm owning a slaughterhouse  is avoided. European legislation recognises and authorises on-farm slaughter but the slaughterhouse must be used only for animals raised on the farm. This causes high initial investment for each farmer. In the light of what is reported, the aim of this paper is to review the current MPPU technologies by examining:In the USA, several types of MPPU have been available for about 10 years ,34, wherDuring the last 10 years, National Authorities have pointed out rules to allow the activity of these MPPU. The basic principles of slaughtering in the EU include the need to fulfil several requisites, specified in the Regulation EC/853/2004  and by the Sanitary Authority which eventually authorises the use of the MPPUs on different farms. In this way, it is possible to share the MPPU among several farms, thus reducing the slaughtering cost of each chicken.Furthermore, the structure needs to be properly designed to avoid cross-contamination and it should be placed in a specific area of the farm where drinking water and electric power are available (unless a drinking water tank and a generator are present to directly supply the MPPU), regular pest control is performed and waste (water and slaughter by-products) can be easily managed.The MPPU must be built with materials and equipment that are easy to clean by Sanitation Standard Operating Procedures (SSOP) and there must be adequate site management and appropriate personnel hygiene and clothing. Personnel operating in the MPPU must be trained in slaughter procedures and a proper HACCP  plan needs to be implemented in the MPPU.With regard to the slaughter procedure, stunning, bleeding and plucking must be performed separately from evisceration. Stunning must be performed according to Regulation EC/1099/2009. Chilling and storage of carcasses and meat must take place immediately in the MPPU or on the farm. If chillers, generally static chillers, are available on the farm, they must be placed near the MPPU and a suitable system for protecting the carcasses during transport from the slaughter site to the chiller needs to be adopted to avoid exogenous contamination.Animal by-products must be managed according to Regulation EC 1069/2009. Cleaning and disinfection of the MPPU must be performed at the end of each slaughtering session, eitherat the farm or in a specific staging area. Meat must be labelled with the date of slaughter, farm code and farm address. A proper traceability system has to be set up. Not all poultry farms have these facilities and an evaluation of the best site on the farm for slaughter, supply of water and management of wastewater, is needed. In the United States, the hygiene requirements and SSOP are almost the same as in the EU . Although the local area is considered as the State and the maximum number of birds slaughtered is higher than 10,000.The MPPU can be used on poultry farms producing less than 10,000 birds per year (EU State-Regions) ;The meat processed in a MPPU can only be sold in neighbouring areas  and this is not valid for all States of the EU;The buyer should be a retailer, that is, selling directly to the consumer.The other restrictions imposed by law in the EU are:According to this set of rules, production from a MPPU is small, local and subjected to severe numerical and geographical restrictions, confirming this system as a close and small one.At the short term, the geographical and numerical limitations imposed by EU regulations do not permit future development of MPPUs for medium- or large-scale production. Moreover, even if some technical  or regulatory improvements  of MPPUs were advisable, European legislation strictly limits further improvements. Indeed, the change of regulatory system, at least in EU, is very long and complex and needs multiple level of decision .Nonetheless, other countries could take advantage of the European experience and improve MPPUs according to national legislation.According to these requirements, a MPPU has been planned and built in central Italy . This tyThe small dimension of this MPPU has made it possible to put the equipment in a small truck, which can be handled with a standard driving license. It is also possible to add a refrigerated trailer for the farmer to deliver the carcasses directly to the market after slaughtering.The innovative point of this process consist in the absence of animals transport, in fact the MPPU reaches the farm the day of the slaughter improving the pre-slaughtering operations. The slaughter process begins by a withdrawing feed of 8–10 h and a sanitary control of animals. One hour before slaughter, all of the chickens are captured, caged and placed on the MPPU’s external platform a.-Dirty area;-Clean area; so at least two operators are needed, one for each area.The truck is internally divided into two areas as required by the regulations: The employee in the dirty area carries out all the operations from stunning to plucking; in particular he takes the animals one at a time from the cage, electrically stuns them and places them in the bleeding cone.The subsequent phases involve the processing of four animals at a time that are placed in the scalder at a temperature of 58–60 °C for 30–60 s to loosen the feathers and in a drum plucker for 40–50 s.At the end the carcasses are hung in hooks and transferred to the clean area where the second operator provides to the eviscerating. The final two steps are represented by the refrigeration and packaging. The working capacity of this MPPU is about of 50 chickens/hour.Since a MPPU requires substantial investment by the farmers, an evaluation of the economic feasibility of a MPPU compared to the current processing methods would allow farmers to plan their production method . Different MPPUs—from basic to more automated and expensive ones—have been developed worldwide, mainly in the USA. Naturally, the cost of the equipment can vary substantially . Starting from the case-study shown above, we calculated the cost of chicken processing . In our The equipment for the slaughter of poultry was separated into two areas: “dirty area” and “clean area” . The “diAs required by official controls on food safety, at least two people have to work in the MPPU, one in the clean area and the other in the dirty area. The number of birds/hour which can be processed is around 50.The total cost of the equipment (truck + van) is roughly €150,000, which can be shared among different farms. In a case scenario of 10 farms, the cost would be reduced to about €14–15,000 per farm, compared with a cost of about €50–80,000 for a farm slaughterhouse. In addition, the MPPU cuts out the costs related to the transport of live animals from the farm to the slaughterhouse and the subsequent transport of the refrigerated carcasses back to the farm or stores. Typically, the transport of live animals and carcasses must be carried out by different vehicles, the first one complying with the regulations concerning animal welfare, the second one complying with the hygienic-sanitary requirements for meat which mainly involves refrigeration. It should also be taken into consideration that EU and National funds, which support the improvement of competition and the modernization of farm facilities, could partially cover (30–50% of the eligible cost) the purchase of a MPPU. It should be underlined that the avoidance of transportation permits to improvement in the welfare of chicken, see the next section. Naturally, the care of animals during catching and caging is also particularly important in a MPPU. To avoid excessive chicken shackling, the chickens should be caged just before slaughter. Caged animals are placed in the rear platform of the truck equipped with a cover, which serves as a rest area where the veterinarian can perform the pre-slaughter inspection of animals.These costs are based on an actual Italian case study. According to Angioloni et al.  showed a-transport of live animals by authorised vehicle €1–1.50/chicken (depending on the distance of the slaughterhouse from the farm);-slaughtering process 0.50 €/kg of live weight, therefore, an average of €1.50/chicken;-transport of carcass by refrigerated vehicle, €1.50/carcass.The cost of conventional slaughter includes:In summary, the cost of slaughter for each animal ranges from €3.50 to €4.50.In conclusion, the economic analysis indicates the cost of slaughter using a MPPU is, on average, on the same scale as the cost of an on farm stationary processing system when the number of animals is higher than 10,000 year (the maximum admitted for this stationary plan) and lower than costs involved with a commercial slaughterhouse.As previously reported, slaughterhouses are becoming bigger and the distance between farms and slaughterhouses is, in some cases, very large.European law sets out several compulsory requirements on the transfer of poultry to slaughterhouses: density in the crates; allowing drinking and feeding if more than 12 h are needed to reach the abattoir; limits to faecal matter falling from animals in upper layers to the underlying crates; and temperature and ventilation in the trucks during transport. These rules mainly aimed at fast-growing broilers produced on intensive farms. However, very little data are available with respect to transport of birds from free-range systems . It is ePoultry transport to the slaughterhouse is one of the critical factors affecting animal welfare, quality and meat hygiene. These different stressing situations can reduce bird welfare and increases the risk of body injuries  and mortality . ChickenMany studies have focused on the effects of transport stress on different blood traits ,39. ZhanThus, time spent in transit to the slaughterhouse is a major concern in terms of welfare and meat quality. The effect of transport duration on animal welfare and the resulting meat quality in broilers have been well researched but data on the interaction between genetic strain and transport duration are sparse. It has been reported that the effect of stress could be different in fast- and slow-growing poultry strains . Fast-growing strains tend to produce meat with a slower pH decline, higher ultimate pH and, consequently, greater water-holding capacity . On the Our previous results  suggest The introduction of a MPPU could have an impact on the quality and hygiene/safety traits of the meat based on three main paradigms: reduction of pre-slaughter stress, transport procedures and proper implementation of the slaughter process . ante-mortem stresses can affect post-mortem metabolism and, therefore, meat quality [Currently, it is understood that that the reduction of pre-slaughtering stress, especially catching, crating and transport, could affect meat traits. The increased level of epinephrine and glucocorticoids in animals exposed to  quality . Pre-sla quality . Further quality . Despite there is not a general consensus, these stressful events could therefore affect conversion of muscle to meat and the related protein functionality, following a reduced consumer acceptability and processing functionality of the meat caused by the changes in the water holding capacity, colour, tenderness, texture and shelf-life of meat and derived products . Thigh mAs previously reported, studies on the effects of pre-slaughtering practices on meat quality have mainly been conducted in fast-growing broilers, where muscle abnormalities  were also recorded but when slow-growing strains were considered, they seemed more subjected to stress than fast-growing genotypes due to high kinetic activity during catching, transport and wing-flapping during slaughter . CastellA PPP system together with a MPPU, when slow-growing strains are used and reduction in the number of chickens to be caught and slaughtered, combined with the absence of transport limits the time spent struggling in crates and, therefore, improves/preserves meat quality.Campylobacter spp. [From a hygiene point of view, there is a large consensus that pre-slaughter stress increases the spread of infectious diseases . The strter spp.  and its ter spp. .Campylobacter spp. at the slaughterhouse and catching of the birds for crating further increases Campylobacter spp. contamination [Previous thinning of the flocks was considered as a major risk factor for contamination of chicken carcasses with mination .Campylobacter contamination [Campylobacter from the processing plant can survive on crates for a period sufficient to contaminate the majority of farms in the catchment (it survives for at least 3 h after sanitisation) [In addition, transport vehicles and crates can be considered to be a source of mination . Campyloisation)  and poseisation) ,58. ReduSalmonella spp., environmental stress could weaken the immune response of birds, with an increase in number of pathogens on the crates [With regard to e crates . For thiCampylobacter spp. [Campylobacter spp., even without transport, were observed [Nonetheless, it is reported that the older age of the animals at slaughter, generally adopted in PPP, increased the contamination of caeca by ter spp. ,61. Furtobserved . Salmonella spp., as different authors reported no shedding animals and no positive carcasses in PPP systems and MPPUs, respectively [The same consideration was not so for ectively ,62. With regard to the slaughter practices in a MPPU, all the procedures are carried out on a manual basis instead of using industrial-scale, automated commercial processing lines . FurtherReports on the effect of a MPPU on sanitary traits in poultry meat are scarce ,63. It sSalmonella and Campylobacter spp. [Other specific aspects on the possible contamination route inside a MPPU are dependent on structure and equipment. Scalding, defeathering, evisceration and chilling are considered to be the major routes of contamination by both ter spp.  and haveIn particular, due to the limited space inside a MPPU, chilling could be carried out in two steps (pre-chilling and chilling) which could be performed within the MPPU and in the farm, respectively . This coThe use of an air chiller could be more practical for a MPPU, even if counter-flow water-chilling and decontamination strategies, when allowed by national legislation, could be more effective in reducing carcass contamination ,65. HighSalmonella and Campylobacter showed that Campylobacter prevalence was significantly higher in MPPUs and this was partly due to wastewater and compost. In view of this, the processing of waste should be improved for optimum control of human pathogens. In the USA, a technical survey on In Europe, animal by-products must be disposed of as quickly as possible to avoid contamination of the meat for human consumption (Regulation EC 1069/2009), thus providing proper protection of the environment from food-borne pathogens.The prototype of MPPU shown here was provided by a detailed HACCP manual, with a risk assessment based on hazard probability and severity at each step of the process, validated during the first three months of slaughter and after one year of activity. One of the operators of the MPPU should be responsible for the HACCP plan, including SSOPs. Cleaning and disinfection of the truck and equipment and assessment of the risk of carcass contamination due to scalding, defeathering and evisceration steps (GMPs) and carcass chilling, as the real CCP  able to prevent the growth of pathogens, also have to be taken into consideration. Salmonella on the carcasses, as well as counts of Campylobacter spp., following the criteria lay down by EC Regulation 2073/2005, could be adopted in a MPPU as evidence of the hygiene level, as already performed in conventional industrial slaughterhouses. A reliable carcass sampling could be planned, according to EC Regulation 2073/2005, with 50 samples which should be derived from 10 consecutive sampling sessionsThe absence of Place and day of slaughtering must be provided to the veterinarian officer to permit Official controls of MPPU. MPPUs are designed to eliminate regulatory impasses and increase marketability and profitability for small-farmers. In addition to economic and technical aspects, there are also other ethical aspects connected with the use of MPPUs.Nevertheless, positive conclusions exist concerning the effect of MPPUs on animal welfare and product quality. However, inconsistent findings are available regarding sanitary aspects due different equipment and procedures. However, considering that this system practically removes the need to transport poultry and it is used for small quantities of chickens, it is expected that the sanitary aspect can also be improved.The MPPU could be judged a first step in the development of a new model of alternative poultry production, because it favours different types of change, from farmer to consumers and between the individual stakeholders. In Italy the difficulty to slaughter a low number of animals negatively affect the local productions. The MPPU beyond that to improve the marketing products could increase the connection between the small farms. Developing a network starting from the sharing of the MPPU could ameliorate the collaborations among small farms.Concerning the Italian poultry sector, the farms have lost her entrepreneurship for the presence of the big companies that control all the production chain. According to this view, MPPUs can be considered not only as a solution but also as a resource to emphasise the emergence of food circuits  which cannot feature within the global food chain. Despite the improvement in poultry welfare (no transport or limited period of transport), the geographical and numerical limitations imposed by EU regulations mean that MPPU development for medium- or large-scale poultry production is unlikely to occur. European legislation has limited further improvement of MPPUs , confining PPP meat to local production and selling. Nonetheless, other countries could take advantage of the European experience and improve MPPUs according to national legislation.In developing countries where the demand for livestock products is strongly increased and in many case the society is organized in small and poorly connected units, the MPPU could represent a real and feasible opportunity of progress.