1
|
Morema EN, Ouma C, Egessa R, Nyachiro L, Shisanya M. Self-reported Provision of Preconception Care and Associated Factors. East Afr Health Res J 2024; 8:58-66. [PMID: 39234337 PMCID: PMC11371014 DOI: 10.24248/eahrj.v8i1.749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 03/28/2024] [Indexed: 09/06/2024] Open
Abstract
Background Preconception care (PCC) is the provision of health interventions to women and couples before conception occurs and is valuable in promoting healthy maternal, birth, and neonatal health outcomes. In Africa, more so in Kenya, maternal and neonatal health indicators have remained poor. The key constraint limiting progress is the gap between what is needed and what exists in terms of skills and availability of human resources & infrastructures in the face of increased demand. This gap was yet to be measured for PCC in Kenya, more so in Kisumu County. Methods Using a cross-sectional design, this study specifically sought to determine the rate of self-reported PCC provision and to illustrate how it is influenced by health provider characteristics. Structured interviews were conducted with health providers (n=476) to ascertain their knowledge, perceptions and practice of PCC care. The significance of the differences in means was determined by the Student's t test and linear regression were used to show the relationship between the health provider characteristics and the PCC provision rate. Results Self-reported PCC provision was estimated at 39%. There was a significant difference in the mean for cadres {nurses (M=70.04, SD=8.951) and non-nurses (M=71.90, SD=8.732); t (473) =-2.23, P=.026)}, years of experience up to 5 years (M=72.04, SD=8.417) and more than 5 years (M=69.89, SD=9.283); t (465) =2.63, P=.009, the mean provision per level (M=60.21, SD=4.902; t (26)=-5.06, P<.001) and type of service (M=69.36, SD=4.924; t (26) =4.63, P<.001). A significant regression model was found, and the model statistics were F (2,464) =5.97, P=.003, R2=.03. Only cadre (b=0.01, t (464) =2.23, P=.026) and years of experience (b=-0.13, t (464) =-2.79, P=.005) were significant determinants of PCC provision. The health workers felt PCC was an important service whose provision was low due to inadequate human capital investment. Conclusion Self-reported provision of PCC by health workers was relatively low and was influenced by the cadre of health workers and their years of experience. It specifically demonstrated the importance of various aspects of human capital, i.e., knowledge, perceptions, competence and adequacy of training in the provision of this care. Furthermore, it showed that the nursing cadre has a higher probability of providing this care. Investing in on-the-job training for health providers, especially nurses, and providing care in primary health facilities in rural areas can improve PCC service delivery.
Collapse
Affiliation(s)
- Everlyne N Morema
- School of Nursing Midwifery and Paramedic sciences, Masinde Muliro University of Science and Technology, Kenya
| | - Collins Ouma
- School of Public Health and Community Development, Maseno University, Kenya
| | - Robert Egessa
- School of Nursing Midwifery and Paramedic sciences, Masinde Muliro University of Science and Technology, Kenya
| | - Lydia Nyachiro
- School of Nursing Midwifery and Paramedic sciences, Masinde Muliro University of Science and Technology, Kenya
| | | |
Collapse
|
2
|
Odhus CO, Kapanga RR, Oele E. Barriers to and enablers of quality improvement in primary health care in low- and middle-income countries: A systematic review. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002756. [PMID: 38236832 PMCID: PMC10796071 DOI: 10.1371/journal.pgph.0002756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 12/06/2023] [Indexed: 01/22/2024]
Abstract
The quality of health care remains generally poor across primary health care settings, especially in low- and middle-income countries where tertiary care tends to take up much of the limited resources despite primary health care being the first (and often the only) point of contact with the health system for nearly 80 per cent of people in these countries. Evidence is needed on barriers and enablers of quality improvement initiatives. This systematic review sought to answer the question: What are the enablers of and barriers to quality improvement in primary health care in low- and middle-income countries? It adopted an integrative review approach with narrative evidence synthesis, which combined qualitative and mixed methods research studies systematically. Using a customized geographic search filter for LMICs developed by the Cochrane Collaboration, Scopus, Academic Search Ultimate, MEDLINE, CINAHL, PSYCHINFO, EMBASE, ProQuest Dissertations and Overton.io (a new database for LMIC literature) were searched in January and February 2023, as were selected websites and journals. 7,077 reports were retrieved. After removing duplicates, reviewers independently screened titles, abstracts and full texts, performed quality appraisal and data extraction, followed by analysis and synthesis. 50 reports from 47 studies were included, covering 52 LMIC settings. Six themes related to barriers and enablers of quality improvement were identified and organized using the model for understanding success in quality (MUSIQ) and the consolidated framework for implementation research (CFIR). These were: microsystem of quality improvement, intervention attributes, implementing organization and team, health systems support and capacity, external environment and structural factors, and execution. Decision makers, practitioners, funders, implementers, and other stakeholders can use the evidence from this systematic review to minimize barriers and amplify enablers to better the chances that quality improvement initiatives will be successful in resource-limited settings. PROSPERO registration: CRD42023395166.
Collapse
Affiliation(s)
- Camlus Otieno Odhus
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom
| | | | - Elizabeth Oele
- County Department of Health, County Government of Kisumu, Kisumu, Kenya
| |
Collapse
|
3
|
Sudhinaraset M, Giessler KM, Nakphong MK, Munson MM, Golub GM, Diamond-Smith NG, Opot J, Green CE. Can a quality improvement intervention improve person-centred maternity care in Kenya? Sex Reprod Health Matters 2023; 31:2175448. [PMID: 36857118 PMCID: PMC9980034 DOI: 10.1080/26410397.2023.2175448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
Few evidence-based interventions exist to improve person-centred maternity care in low-resource settings. This study aimed to understand whether a quality improvement (QI) intervention could improve person-centred maternity care (PCMC) experiences for women delivering in public health facilities in Kenya. A pre-post design was used to examine changes in PCMC scores across three intervention and matched control facilities at baseline (n = 491) and endline (n = 677). A QI intervention, using the Model for Improvement, was implemented in three public health facilities in Nairobi and Kiambu Counties in Kenya. Difference-in-difference analyses using models that included main effects of both treatment group and survey round was conducted to understand the impact of the intervention on PCMC scores. Findings suggest that intervention facilities' average total PCMC score decreased by 5.3 points post-intervention compared to baseline (95% CI: -8.8, -1.9) and relative to control facilities, holding socio-demographic and facility variables constant. Additionally, the intervention was significantly associated with a 1.8-point decrease in clinical quality index pre-post-intervention (95% CI: -2.9, -0.7), decreased odds of provider visits, and less likelihood to plan to use postpartum family planning. While improving the quality of women's experiences during childbirth is a critical component to ensure comprehensive, high-quality maternity care experiences and outcomes, further research is required to understand which intervention methods may be most appropriate to improve PCMC in resource-constrained settings.
Collapse
Affiliation(s)
- May Sudhinaraset
- Associate Professor, Community Health Sciences, Los Angeles (UCLA), University of California, Los Angeles, CA, USA
| | - Katie M. Giessler
- Senior Research Analyst, Institute for Global Health Sciences, San Francisco (UCSF), University of California, San Francisco, CA, USA
| | - Michelle Kao Nakphong
- Doctoral Student, Community Health Sciences, Los Angeles (UCLA), University of California, Los Angeles, CA, USA
| | | | - Ginger M. Golub
- Senior Research and Business Development Manager, Innovations for Poverty Action, Nairobi, Kenya
| | - Nadia G. Diamond-Smith
- Assistant Professor, Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - James Opot
- Senior Research Associate, Innovations for Poverty Action, Nairobi, Kenya
| | - Cathy E. Green
- Senior Improvement Advisor, Jacaranda Health, Nairobi, Kenya
| |
Collapse
|
4
|
Hill Z, Keraga D, Kiflie Alemayehu A, Schellenberg J, Magge H, Estifanos A. 'The objective was about not blaming one another': a qualitative study to explore how collaboration is experienced within quality improvement collaboratives in Ethiopia. Health Res Policy Syst 2023; 21:48. [PMID: 37312225 DOI: 10.1186/s12961-023-00986-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 04/28/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Quality improvement collaboratives are a common approach to improving quality of care. They rely on collaboration across and within health facilities to enable and accelerate quality improvement. Originating in high-income settings, little is known about how collaboration transfers to low-income settings, despite the widespread use of these collaboratives. METHOD We explored collaboration within quality improvement collaboratives in Ethiopia through 42 in-depth interviews with staff of two hospitals and four health centers and three with quality improvement mentors. Data were analysed thematically using a deductive and inductive approach. RESULTS There was collaboration at learning sessions though experience sharing, co-learning and peer pressure. Respondents were used to a blaming environment, which they contrasted to the open and non-blaming environment at the learning sessions. Respondents formed new relationships that led to across facility practical support. Within facilities, those in the quality improvement team continued to collaborate through the plan-do-study-act cycles, although this required high engagement and support from mentors. Few staff were able to attend learning sessions and within facility transfer of quality improvement knowledge was rare. This affected broader participation and led to some resentment and resistance. Improved teamwork skills and behaviors occurred at individual rather than facility or systems level, with implications for sustainability. Challenges to collaboration included unequal participation, lack of knowledge transfer, high workloads, staff turnover and a culture of dependency. CONCLUSION We conclude that collaboration can occur and is valued within a traditionally hierarchical system, but may require explicit support at learning sessions and by mentors. More emphasis is needed on ensuring quality improvement knowledge transfer, buy-in and system level change. This could include a modified collaborative design to provide facility-level support for spread.
Collapse
Affiliation(s)
- Zelee Hill
- Institute for Global Health, University College London, Guilford St, WC1N 1EH, London, United Kingdom.
| | - Dorka Keraga
- Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Joanna Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom
| | - Hema Magge
- Institute for Healthcare Improvement, Addis Ababa, Ethiopia
- Division of Global Health Equity, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, United States of America
| | - Abiy Estifanos
- Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| |
Collapse
|
5
|
Procureur F, Estifanos AS, Keraga DW, Kiflie Alemayehu AK, Hailemariam NW, Schellenberg J, Magge H, Hill Z. "Quality teaches you how to use water. It doesn't provide a water pump": a qualitative study of context and mechanisms of action in an Ethiopian quality improvement program. BMC Health Serv Res 2023; 23:381. [PMID: 37076845 PMCID: PMC10116784 DOI: 10.1186/s12913-023-09341-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/25/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Quality improvement collaboratives are a common approach to bridging the quality-of-care gap, but little is known about implementation in low-income settings. Implementers rarely consider mechanisms of change or the role of context, which may explain collaboratives' varied impacts. METHODS To understand mechanisms and contextual influences we conducted 55 in-depth interviews with staff from four health centres and two hospitals involved in quality improvement collaboratives in Ethiopia. We also generated control charts for selected indicators to explore any impacts of the collaboratives. RESULTS The cross facility learning sessions increased the prominence and focus on quality, allowed learning from experts and peers and were motivational through public recognition of success or a desire to emulate peers. Within facilities, new structures and processes were created. These were fragile and sometimes alienating to those outside the improvement team. The trusted and respected mentors were important for support, motivation and accountability. Where mentor visits were infrequent or mentors less skilled, team function was impacted. These mechanisms were more prominent, and quality improvement more functional, in facilities with strong leadership and pre-existing good teamwork; as staff had shared goals, an active approach to problems and were more willing and able to be flexible to implement change ideas. Quality improvement structures and processes were more likely to be internally driven and knowledge transferred to other staff in these facilities, which reduced the impact of staff turnover and increased buy-in. In facilities which lacked essential inputs, staff struggled to see how the collaborative could meaningfully improve quality and were less likely to have functioning quality improvement. The unexpected civil unrest in one region strongly disrupted the health system and the collaborative. These contextual issues were fluid, with multiple interactions and linkages. CONCLUSIONS The study confirms the need to carefully consider context in the implementation of quality improvement collaboratives. Facilities that implement quality improvement successfully may be those that already have characteristics that foster quality. Quality improvement may be alienating to those outside of the improvement team and implementers should not assume the organic spread or transfer of quality improvement knowledge.
Collapse
Affiliation(s)
- F Procureur
- Institute for Global Health, University College London, Guilford St, London, WC1N 1EH, UK
| | - A S Estifanos
- Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - D W Keraga
- Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | | | | | - J Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - H Magge
- Institute for Healthcare Improvement, Addis Ababa, Ethiopia
- Brigham and Women's Hospital, Division of Global Health Equity, 75 Francis Street, Boston, MA, 02115, USA
| | - Z Hill
- Institute for Global Health, University College London, Guilford St, London, WC1N 1EH, UK.
| |
Collapse
|
6
|
Diamond-Smith N, Walker D, Afulani PA, Donnay F, Lin SPY, Peca E, Stanton ME. The Case for Using a Behavior Change Model to Design Interventions to Promote Respectful Maternal Care. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2200278. [PMID: 36853643 PMCID: PMC9972382 DOI: 10.9745/ghsp-d-22-00278] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/05/2023] [Indexed: 01/26/2023]
Abstract
Applying a behavior change framework to guide the design of interventions to improve respectful maternity care (RMC) could accelerate and unify the implementation and evaluation of diverse RMC interventions.
Collapse
Affiliation(s)
- Nadia Diamond-Smith
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA.
- Institute for Global Health Sciences and University of California, San Francisco, San Francisco, CA, USA
| | - Dilys Walker
- Institute for Global Health Sciences and University of California, San Francisco, San Francisco, CA, USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Patience A Afulani
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
- Institute for Global Health Sciences and University of California, San Francisco, San Francisco, CA, USA
| | | | - Sunny Pei Yi Lin
- Institute for Global Health Sciences and University of California, San Francisco, San Francisco, CA, USA
| | - Emily Peca
- University Research Co., LLC., Chevy Chase, MD, USA
| | | |
Collapse
|
7
|
Associations between self-reported obstetric complications and experience of care: a secondary analysis of survey data from Ghana, Kenya, and India. Reprod Health 2023; 20:7. [PMID: 36609381 PMCID: PMC9817240 DOI: 10.1186/s12978-022-01546-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 12/08/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Although several indicators have been proposed to measure women's experience of care in health facilities during the intrapartum period, it is unknown if these indicators perform differently in the context of obstetric emergencies. We examined the relationship between experience of care indicators from the Person-Centered Maternity Care (PCMC) scale and obstetric complications. METHODS We used data from four cross-sectional surveys conducted in Kenya (rural: N = 873; urban: N = 531), Ghana (N = 531), and India (N = 2018) between August 2016 and October 2017. The pooled sample included 3953 women aged 15-49 years who gave birth within 9 weeks prior to the survey. Experience of care was measured using the PCMC scale. Univariate, bivariate, and multivariable analyses were conducted to examine the associations between the composite and 31 individual PCMC indicators with (1) obstetric complications; (2) severity of complications; and (3) delivery by cesarean section (c-section). RESULTS 16% (632) of women in the pooled sample reported obstetric complications; and 4% (132) reported having given birth via c-Sect. (10.5% among those with complications). The average standardized PCMC scores (range 0-100) were 63.5 (SD = 14.1) for the full scale, 43.2 (SD = 20.6) for communication and autonomy, 67.8 (SD = 14.1) for supportive care, and 80.1 (SD = 18.2) for dignity and respect sub-scales. Women with complications had higher communication and autonomy scores (45.6 [SD = 20.2]) on average compared to those without complications (42.7 [SD = 20.6]) (p < 0.001), but lower supportive care scores, and about the same scores for dignity and respect and for the overall PCMC. 18 out of 31 experience of care indicators showed statistically significant differences by complications, but the magnitudes of the differences were generally small, and the direction of the associations were inconsistent. In general, women who delivered by c-section reported better experiences. CONCLUSIONS There is insufficient evidence based on our analysis to suggest that women with obstetric complications report consistently better or worse experiences of care than women without. Women with complications appear to experience better care on some indicators and worse care on others. More studies are needed to understand the relationship between obstetric complications and women's experience of care and to explore why women who deliver by c-section may report better experience of care.
Collapse
|
8
|
Diamond-Smith N, Lin S, Peca E, Walker D. A landscaping review of interventions to promote respectful maternal care in Africa: Opportunities to advance innovation and accountability. Midwifery 2022; 115:103488. [PMID: 36191382 DOI: 10.1016/j.midw.2022.103488] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/15/2022] [Accepted: 09/12/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE In the past decade, global recognition of the need to address disrespect and abuse (also described as mistreatment of women) and promote respectful maternal care in facility-based childbirth has increased. While many studies have documented gaps in respectful maternal care, little is known about the design and implementation of these interventions. Our aim was to summarize and describe respectful maternal care -promoting interventions during childbirth implemented in Africa. DESIGN We identified respectful maternal care -promoting interventions in Africa through a rapid scoping of peer-reviewed articles and gray literature, and a crowdsourcing survey distributed through stakeholder networks. SETTING Africa PARTICIPANTS: NA MEASUREMENTS AND FINDINGS: We identified 43 unique interventions implemented in 16 African countries, gathered from a crowdsourcing survey, gray and published literature between 2010 and 2020. Most interventions were implemented in East Africa (N = 13). The interventions had various targets and were categorized into nine approaches, 60% of interventions focused on training providers about respectful maternal care and practice. About two thirds included multiple intervention approaches, and about two thirds addressed respectful maternal care beyond the period of childbirth. Few publications presented data on the effectiveness of the intervention, and those that did used a wide variety of indicators. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE There is a reliance on provider training approaches to promote respectful maternal care and there are few examples of either engaging women in the community or adopting social accountability approaches. We encourage implementors to develop interventions targeting multiple approaches beyond provider training and consider delivery across pre-pregnancy, pregnancy, birth, and the postnatal periods. Finally, in order to effectively move from documenting respectful maternal care gaps to action and scale, we need global consensus on common indicators and measures of effectiveness for interventions promoting respectful care across the life course.
Collapse
Affiliation(s)
- Nadia Diamond-Smith
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States of America
| | - Sunny Lin
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States of America.
| | - Emily Peca
- University Research Co., LLC., Chevy Chase, Maryland, United States of America
| | - Dilys Walker
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States of America; Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States of America
| |
Collapse
|
9
|
Sudhinaraset M, Giessler K, Nakphong MK, Roy KP, Sahu AB, Sharma K, Montagu D, Green C. Can changes to improve person-centred maternity care be spread across public health facilities in Uttar Pradesh, India? Sex Reprod Health Matters 2021; 29:1-15. [PMID: 33704027 PMCID: PMC8011686 DOI: 10.1080/26410397.2021.1892570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Poor quality person-centred maternity care (PCMC) leads to delays in care and adverse maternal and newborn outcomes. This study describes the impact of spreading a Change Package, or interventions that other health facilities had previously piloted and identified as successful, to improve PCMC in public health facilities in Uttar Pradesh, India. A quasi-experimental design was used including matched control-intervention facilities and pre-post data collection. This study took place in Uttar Pradesh, India in 2018-2019. Six large public health facilities participated in the evaluation of the spread study, including three intervention and three control facilities. Intervention facilities were introduced to a quality improvement (QI) Change Package to improve PCMC. In total, 1200 women participated in the study, including 600 women at baseline and 600 women at endline. Difference-in-difference estimators are used to examine the impact of spreading a QI Change Package across spread sites vs. control sites and at baseline and endline using a validated PCMC scale. Out of a 100-point scale, a 24.93 point improvement was observed in overall PCMC scores among spread facilities compared to control facilities from baseline to endline (95% CI: 22.29, 27.56). For the eight PCMC indicators that the Change Package targeted, spread facilities increased 33.86 points (95% CI: 30.91, 36.81) relative to control facilities across survey rounds. Findings suggest that spread of a PCMC Change Package results in improved experiences of care for women as well as secondary outcomes, including clinical quality, nurse and doctor visits, and decreases in delivery problems.Trial registration: ClinicalTrials.gov identifier: NCT04208841..
Collapse
Affiliation(s)
- May Sudhinaraset
- Associate Professor, Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA. Correspondence:
| | - Katie Giessler
- Associate Director, Institute for Global Health Sciences, University of California, San Francisco, CA, USA
| | - Michelle Kao Nakphong
- Doctoral Student, Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Kali Prosad Roy
- Associate Director-Research & Metrics, Population Services International, New Delhi, India
| | | | - Kovid Sharma
- Senior Specialist, Population Services International, New Delhi, India
| | - Dominic Montagu
- Professor, Institute for Global Health Sciences, University of California, San Francisco, CA, USA
| | - Cathy Green
- Independent Improvement Consultant, Western Cape, South Africa
| |
Collapse
|