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Tasnim Hossain A, Hazel EA, Rahman AE, Koon AD, Jue Wong H, Maïga A, Akseer N, Tam Y, Walker N, Jiwani SS, Munos MK, El Arifeen S, Black R, Amouzou A. Effective multi-sectoral approach for rapid reduction in maternal and neonatal mortality: the exceptional case of Bangladesh. BMJ Glob Health 2024; 9:e011407. [PMID: 38770805 PMCID: PMC11085986 DOI: 10.1136/bmjgh-2022-011407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/20/2023] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Bangladesh experienced impressive reductions in maternal and neonatal mortality over the past several decades with annual rates of decline surpassing 4% since 2000. We comprehensively assessed health system and non-health factors that drove Bangladesh's success in mortality reduction. METHODS We operationalised a comprehensive conceptual framework and analysed available household surveys for trends and inequalities in mortality, intervention coverage and quality of care. These include 12 household surveys totalling over 1.3 million births in the 15 years preceding the surveys. Literature and desk reviews permitted a reconstruction of policy and programme development and financing since 1990. These were supplemented with key informant interviews to understand implementation decisions and strategies. RESULTS Bangladesh prioritised early population policies to manage its rapidly growing population through community-based family planning programmes initiated in mid-1970s. These were followed in the 1990s and 2000s by priority to increase access to health facilities leading to rapid increases in facility delivery, intervention coverage and access to emergency obstetric care, with large contribution from private facilities. A decentralised health system organisation, from communities to the central level, openness to private for-profit sector growth, and efficient financing allocation to maternal and newborn health enabled rapid progress. Other critical levers included poverty reduction, women empowerment, rural development, and culture of data generation and use. However, recent empirical data suggest a slowing down of mortality reductions. CONCLUSION Bangladesh demonstrated effective multi-sectoral approach and persistent programming, testing and implementation to achieve rapid gains in maternal and neonatal mortality reduction. The slowing down of recent mortality trends suggests that the country will need to revise its strategies to achieve the Sustainable Development Goals. As fertility reached replacement level, further gains in maternal and neonatal mortality will require prioritising universal access to quality facility delivery, and addressing inequalities, including reaching the rural poor.
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Affiliation(s)
- Aniqa Tasnim Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Elizabeth A Hazel
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ahmed Ehsanur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Adam D Koon
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Heather Jue Wong
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Abdoulaye Maïga
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nadia Akseer
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Yvonne Tam
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Neff Walker
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Safia S Jiwani
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Melinda Kay Munos
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Robert Black
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Agbessi Amouzou
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Afrifa-Yamoah E, Nunfam VF, Kwanin BA, Frimpong K. Ecology of emergency care in lower-tier healthcare providers in Ghana: an empirical data-driven Bayesian network analytical approach. Intern Emerg Med 2024:10.1007/s11739-024-03607-6. [PMID: 38684643 DOI: 10.1007/s11739-024-03607-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 04/03/2024] [Indexed: 05/02/2024]
Abstract
The healthcare landscape in Ghana is primarily composed of lower-tier providers, which serve as the initial point of contact for most medical emergencies. This study aimed to assess the emergency care preparedness and readiness of primary healthcare providers using a robust evaluation approach. A multicentre retrospective cross-sectional study was conducted on 460 healthcare facilities using the standardised Health Facilities Emergency Preparedness Assessment Tool (HeFEPAT). Data were analysed via Bayesian Belief network. Emergency preparedness was associated with facility location, type, ownership, and in-charge personnel. Over 70% of facilities lacked specialised emergency/critical care personnel. Although 65% of in-charges reported protocol knowledge, only 7.8% could execute cardiopulmonary resuscitation. 90% of facilities lacked onsite defibrillators, and over 80% had no cerebrovascular accident medications. Road traffic accident protocols were largely unavailable, with an estimated 53% probability of lacking such protocols. Private-owned facilities were more likely to lack protocols for road traffic accidents (76% vs 20% probability) and general acute care (62% vs 32%) compared to government-owned facilities. Significant gaps in emergency preparedness were identified across the studied health facilities, indicating limited capacity to manage critical situations effectively. Urgent investments in emergency medicine training, essential resources, and evidence-based protocols are needed. Standardised emergency preparedness assessments should be implemented for accreditation and quality improvement. Further research can inform the development of national guidelines and targeted interventions to strengthen emergency response capacities.
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Affiliation(s)
| | - Victor Fannam Nunfam
- Social Development, Takoradi Technical University, Sekondi-Takoradi, Ghana
- School of Arts and Humanities, Edith Cowan University, Perth, WA, Australia
| | - Bernard Agyei Kwanin
- Social Development, Takoradi Technical University, Sekondi-Takoradi, Ghana.
- Health Facilities Regulatory Agency, Greater Accra, Accra, Ghana.
| | - Kwasi Frimpong
- School of Public Service and Governance, Ghana Institute of Management and Public Administration, Achimota, Accra, Ghana
- School of Medical and Health Sciences, Edith Cowan University, Perth, WA, Australia
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Macharia PM, Joseph NK, Snow RW, Sartorius B, Okiro EA. The impact of child health interventions and risk factors on child survival in Kenya, 1993-2014: a Bayesian spatio-temporal analysis with counterfactual scenarios. BMC Med 2021; 19:102. [PMID: 33941185 PMCID: PMC8094495 DOI: 10.1186/s12916-021-01974-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/25/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND During the millennium development goals period, reduction in under-five mortality (U5M) and increases in child health intervention coverage were characterised by sub-national disparities and inequities across Kenya. The contribution of changing risk factors and intervention coverage on the sub-national changes in U5M remains poorly defined. METHODS Sub-national county-level data on U5M and 43 factors known to be associated with U5M spanning 1993 and 2014 were assembled. Using a Bayesian ecological mixed-effects regression model, the relationships between U5M and significant intervention and infection risk ecological factors were quantified across 47 sub-national counties. The coefficients generated were used within a counterfactual framework to estimate U5M and under-five deaths averted (U5-DA) for every county and year (1993-2014) associated with changes in the coverage of interventions and disease infection prevalence relative to 1993. RESULTS Nationally, the stagnation and increase in U5M in the 1990s were associated with rising human immunodeficiency virus (HIV) prevalence and reduced maternal autonomy while improvements after 2006 were associated with a decline in the prevalence of HIV and malaria, increase in access to better sanitation, fever treatment-seeking rates and maternal autonomy. Reduced stunting and increased coverage of early breastfeeding and institutional deliveries were associated with a smaller number of U5-DA compared to other factors while a reduction in high parity and fully immunised children were associated with under-five lives lost. Most of the U5-DA occurred after 2006 and varied spatially across counties. The highest number of U5-DA was recorded in western and coastal Kenya while northern Kenya recorded a lower number of U5-DA than western. Central Kenya had the lowest U5-DA. The deaths averted across the different regions were associated with a unique set of factors. CONCLUSION Contributions of interventions and risk factors to changing U5M vary sub-nationally. This has important implications for targeting future interventions within decentralised health systems such as those operated in Kenya. Targeting specific factors where U5M has been high and intervention coverage poor would lead to the highest likelihood of sub-national attainment of sustainable development goal (SDG) 3.2 on U5M in Kenya.
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Affiliation(s)
- Peter M. Macharia
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Noel K. Joseph
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Robert W. Snow
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Benn Sartorius
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA USA
| | - Emelda A. Okiro
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Banerjee S, Sar AK, Pandey S. Improved yet Unsafe: An Aquatic Perspective of Indian Infant Mortality. JOURNAL OF HEALTH MANAGEMENT 2020. [DOI: 10.1177/0972063420908379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Infant mortality rate (IMR) is an important development indicator and a vital component of millennium development goals (MDGs) set by United Nations Development Programme (UNDP). According to UNDP, so far India has only fared moderately in reducing IMR (Goal 4 of MDGs). India (32) ranks 144th among 196 countries regarding IMR as per the 2017 data availed from World Development Indicators. Its adjacent countries such as Bhutan (25.6), Bangladesh (26.9) and Nepal (27.8) have fared much better regarding infant survival. Numbers within the parentheses indicate the IMR of the respective country. The United Nations Children’s Fund (UNICEF) has identified that IMR among families with better access to improved drinking water sources and toilet is much lower than those bereft of the same. This inference has been drawn from National Family Health Survey 3 data (NFHS III). The present study investigates into the aforementioned relation analysing NFHS IV data. The result depicts that contrary to UNICEF’s findings, IMR increases with better accessibility to improved water sources. Further to this, the article shows that an additional aqua-related practice together with improved drinking water sources might lead to the betterment of IMR for India.
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Affiliation(s)
| | - Ashok Kumar Sar
- Kalinga Institute of Industrial Technology, Bhubaneshwar, Odisha, India
| | - Shilpa Pandey
- Amity Business School, Amity University Chhattisgarh, India
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Dolan CB, BenYishay A, Grépin KA, Tanner JC, Kimmel AD, Wheeler DC, McCord GC. The impact of an insecticide treated bednet campaign on all-cause child mortality: A geospatial impact evaluation from the Democratic Republic of Congo. PLoS One 2019; 14:e0212890. [PMID: 30794694 PMCID: PMC6386397 DOI: 10.1371/journal.pone.0212890] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/11/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To test the impact of a nationwide Long-Lasting Insecticidal Nets [LLINs] distribution program in the Democratic Republic of Congo [DRC] on all-cause under-five child mortality exploiting subnational variation in malaria endemicity and the timing in the scale-up of the program across provinces. DESIGN Geospatial Impact Evaluation using a difference-in-differences approach. SETTING Democratic Republic of the Congo. PARTICIPANTS 52,656 children sampled in the 2007 and 2013/2014 DRC Demographic and Health Surveys. INTERVENTIONS The analysis provides plausibly causal estimates of both average treatment effects of the LLIN distribution campaign and geospatial heterogeneity in these effects based on malaria endemicity. It compares the under-five, all-cause mortality for children pre- and post-LLIN campaign relative to children in those areas that had not yet been exposed to the campaign using a difference-in-differences model and controlling for year- and province-fixed effects, and province-level trends in mortality. RESULTS We find that the campaign led to a 41% decline [3.7 percentage points, 95% CI 1.3 to 6.0] in under-5 mortality risk among children living in rural areas with malaria ecology above the sample median. Results were robust to controlling for household assets and the presence of other health aid programs. No effect was detected in children living in areas with malaria ecology below the median. CONCLUSION The findings of this paper make important contributions to the evidence base for the effectiveness of large scale-national LLIN campaigns against malaria. We found that the program was effective in areas of the DRC with the highest underlying risk of malaria. Targeting bednets to areas with greatest underlying risk for malaria may help to increase the efficiency of increasingly limited malaria resources but should be balanced against other malaria control concerns.
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Affiliation(s)
- Carrie B. Dolan
- Department of Kinesiology and Health Sciences, William and Mary, Williamsburg, Virginia, United States of America
| | - Ariel BenYishay
- Department of Economics, William and Mary, Williamsburg, Virginia, United States of America
| | - Karen A. Grépin
- Department of Health Sciences, Wilfrid Laurier University, Waterloo, Ontario, Canada
| | - Jeffery C. Tanner
- Independent Evaluation Group, World Bank, Washington, DC, United States of America
| | - April D. Kimmel
- Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, United States of America
| | - David C. Wheeler
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia, United States of America
| | - Gordon C. McCord
- School of Global Policy and Strategy, University of California San Diego, San Diego, California, United States of America
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Anthopolos R, Simmons R, O'Meara WP. A retrospective cohort study to quantify the contribution of health systems to child survival in Kenya: 1996-2014. Sci Rep 2017; 7:44309. [PMID: 28290505 PMCID: PMC5349518 DOI: 10.1038/srep44309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 02/06/2017] [Indexed: 12/02/2022] Open
Abstract
Globally, the majority of childhood deaths in the post-neonatal period are caused by infections that can be effectively treated or prevented with inexpensive interventions delivered through even very basic health facilities. To understand the role of inadequate health systems on childhood mortality in Kenya, we assemble a large, retrospective cohort of children (born 1996–2013) and describe the health systems context of each child using health facility survey data representative of the province at the time of a child’s birth. We examine the relationship between survival beyond 59 months of age and geographic distribution of health facilities, quality of services, and cost of services. We find significant geographic heterogeneity in survival that can be partially explained by differences in distribution of health facilities and user fees. Higher per capita density of health facilities resulted in a 25% reduction in the risk of death (HRR = 0.73, 95% CI:0.58 to 0.91) and accounted for 30% of the between-province heterogeneity in survival. User fees for sick-child visits increased risk by 30% (HRR = 1.30, 95% CI:1.11 to 1.53). These results implicate health systems constraints in child mortality, quantify the contribution of specific domains of health services, and suggest priority areas for improvement to accelerate reductions in child mortality.
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McCord GC, Conley D, Sachs JD. Malaria ecology, child mortality & fertility. ECONOMICS AND HUMAN BIOLOGY 2017; 24:1-17. [PMID: 27838563 PMCID: PMC6124668 DOI: 10.1016/j.ehb.2016.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 10/11/2016] [Accepted: 10/30/2016] [Indexed: 05/22/2023]
Abstract
The broad determinants of fertility are thought to be reasonably well identified by demographers, though the detailed quantitative drivers of fertility levels and changes are less well understood. This paper uses a novel ecological index of malaria transmission to study the effect of child mortality on fertility. We find that temporal variation in the ecology of the disease is well-correlated to mortality, and pernicious malaria conditions lead to higher fertility rates. We then argue that most of this effect occurs through child mortality, and estimate the effect of child mortality changes on fertility. Our findings add to the literature on disease and fertility, and contribute to the suggestive evidence that child mortality reductions have a causal effect on fertility changes.
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Affiliation(s)
- Gordon C McCord
- School of Global Policy and Strategy, University of California, San Diego, 9500 Gilman Drive #0519, La Jolla, CA 92093, United States.
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