Scaling up primary health services for improving reproductive, maternal, and child health: a multisectoral collaboration in the conflict setting of Afghanistan

Recommendations to improve maternal mortality among Rohingya women in Bangladeshi refugee camps

Despite current humanitarian efforts, The Rohingya in Bangladesh's refugee camps have among the highest maternal mortality worldwide. The authors review maternal mortality within Rohingya refugee populations in Bangladesh, citing the camp conditions and cultural norms that affect the Maternal Mortality Ratio (MMR). Next, the authors review current humanitarian efforts made by the UNFPA toward improving reproductive health. Finally, the authors recommend a three-pronged approach to reducing maternal mortality among the Rohingya in Bangladeshi refugee camps. We suggest using Maternity Waiting Homes, Mama Rickshaws, and Traditional Birth Attendants to improve maternal health. These solutions address the three-delays model and place ownership into the community. Ultimately, the authors address a much-needed gap in the literature addressing Rohingya maternal mortality.

Efficiency analysis of primary healthcare facilities in Afghanistan

Background

Afghanistan’s health system is unique in that primary healthcare is delivered by non-governmental organizations funded by multilateral or bilateral donors, not the government. Given the wide range of implementers providing the basic package of health services, there may be performance differences in service delivery. This study assessed the relative technical efficiency of different levels of primary healthcare services and explored its determinants.

Method

Data envelopment analysis was used to assess the relative technical efficiency of three levels of primary healthcare facilities (comprehensive, basic, and sub-health centers). The inputs included personnel and capital expenditure, while the outputs were measured by the number of facility visits. Data on inputs and outputs were obtained from national health information databases for 1263 healthcare facilities in 31 provinces. Bivariate analysis was conducted to assess the correlation of various elements with efficiency scores. Regression models were used to identify potential factors associated with efficiency scores at the health facility level.

Results

The average efficiency score of health facilities was 0.74 when pooling all 1,263 health facilities, with 102 health facilities (8.1%) having efficiency scores of 1 (100% efficient). The lowest quintile of health facilities had an average efficiency score of 0.36, while the highest quintile had a score of 0.96. On average, efficiency scores of comprehensive health centers were higher than basic and sub-health centers by 0.11 and .07, respectively. In addition, the difference between efficiency scores of facilities in the highest and lowest quintiles was highest in facilities that offer fewer services. Thus, they have the largest room for improvement.

Conclusions

Our findings show that public health facilities in Afghanistan that provide more comprehensive primary health services use their resources more efficiently and that smaller facilities have more room for improvement. A more integrated delivery model would help improve the efficiency of providing primary healthcare in Afghanistan.

Determination of frequency, multiple antibiotic resistance index and resistotype of Salmonella spp. in chicken meat collected from southeast of Iran

BACKGROUND

Zoonotic food-borne pathogens such as Salmonella spp., which can be hosted by some raw foods, play a crucial role in ranking the public health of a country OBJECTIVES: The present study was conducted to assess the frequency, antibiotic resistance pattern and index of multiple antibiotic resistance (MAR) of Salmonella spp. in chicken meat METHODS: A cross-sectional survey was conducted from October 2017 to March 2018. One-hundred and fifty chicken meat samples were collected from meat stores in Zahedan, southeast of Iran and screened for contamination with Salmonella spp. using the polymerase chain reaction assay targeting the inv-A gene. Antimicrobial susceptibility testing was performed against 11 commonly prescribed antimicrobial agents in the veterinary treatment to calculate the MAR index RESULTS: The contamination rate was 2.7% (4/150). The antimicrobial resistance rate was 100% (n = 4) against penicillin, tylosin, tetracycline, erythromycin and tiamulin, 50% (n = 2) against trimethoprim/sulfamethoxazole, difloxacin and lincomycin/spectinomycin and 25% (n = 1) against flumequine and florfenicol. All isolates were sensitive to fosfomycin. Interestingly, all isolates (n = 4) exhibited different MAR patterns. Furthermore, the MAR index ranged from 0.45 to 0.81 CONCLUSIONS: In addition to the MAR index, which indicated that the isolate originated from a source where antibiotics were used to a great degree and/or in large amounts, the results showed that the chicken meat hosted resistant strains of Salmonella spp. in the study area. Overall, the findings indicated an important public health problem. To reduce this alarming signal, the poultry industry should implement control measures in the study area.

Exposure to conflicts and the continuum of maternal healthcare: Analyses of pooled cross-sectional data for 452,192 women across 49 countries and 82 surveys

BACKGROUND

Violent conflicts are observed in many parts of the world and have profound impacts on the lives of exposed individuals. The limited evidence available from specific country or region contexts suggest that conflict exposure may reduce health service utilization and have adverse affects on health. This study focused on identifying the association between conflict exposure and continuum of care (CoC) services that are crucial for achieving improvements in reproductive, maternal, newborn, and child health and nutrition (RMNCHN).

METHODS AND FINDINGS

We combined data from 2 sources, the Demographic Health Surveys (DHS) and the Uppsala Conflict Data Program's (UCDP) Georeferenced Event Dataset, for a sample of 452,192 women across 49 countries observed over the period 1997 to 2018. We utilized 2 consistent measures of conflict-incidence and intensity-and analyzed their association with maternal CoC in 4 key components: (i) at least 1 antenatal care (ANC) visit; (ii) 4 or more ANC visits; (iii) 4 or more ANC visits and institutional delivery; and (iv) 4 or more ANC visits, institutional delivery, and receipt of postnatal care (PNC) either for the mother or the child within 48 hours after birth. To identify the association between conflict exposure and components of CoC, we estimated binary logistic regressions, controlling for a large set of individual and household-level characteristics and year-of-survey and country/province fixed-effects. This empirical setup allows us to draw comparisons among observationally similar women residing in the same locality, thereby mitigating the concerns over unobserved heterogeneity. Around 39.6% (95% CI: 39.5% to 39.7%) of the sample was exposed to some form of violent conflict at the time of their pregnancy during the study period (2003 to 2018). Although access to services decreased for each additional component of CoC in maternal healthcare for all women, the dropout rate was significantly higher among women who have been exposed to conflict, relative to those who have not had such exposure. From logistic regression estimates, we observed that relative to those without exposure to conflict, the odds of utilization of each of the components of CoC was lower among those women who were exposed to at least 1 violent conflict. We estimated odds ratios of 0.86 (95% CI: 0.82 to 0.91, p < 0.001) for at least 1 ANC; 0.95 (95% CI: 0.91 to 0.98, p < 0.005) for 4 or more ANC; and 0.92 (95% CI: 0.89 to 0.96, p < 0.001) for 4 or more ANC and institutional delivery. We showed that both the incidence of exposure to conflict as well as its intensity have profound negative implications for CoC. Study limitations include the following: (1) We could not extend the CoC scale beyond PNC due to inconsistent definitions and the lack of availability of data for all 49 countries across time. (2) The measure of conflict intensity used in this study is based on the number of deaths due to the absence of information on other types of conflict-related harms.

CONCLUSIONS

This study showed that conflict exposure is statistically significantly and negatively associated with utilization of maternal CoC services, in each component of the CoC scale. These findings have highlighted the challenges in achieving the Sustainable Development Goal 3 in conflict settings, and the need for more concerted efforts in ensuring CoC, to mitigate its negative implications on maternal and child health.

Factors influencing the scale-up of public health interventions in low- and middle-income countries: a qualitative systematic literature review

To achieve universal health coverage, the scale-up of high impact public health interventions is essential. However, scale-up is challenging and often not successful. Therefore, a systematic review was conducted to provide insights into the factors influencing the scale-up of public health interventions in low- and middle-income countries (LMICs). Two databases were searched for studies with a qualitative research component. The GRADE-CERQual approach was applied to assess the confidence in the evidence for each key review finding. A multi-level perspective on transition was applied to ensure a focus on vertical scale-up for sustainability. According to this theory, changes in the way of organizing (structure), doing (practice) and thinking (culture) need to take place to ensure the scale-up of an intervention. Among the most prominent factors influencing scale-up through changes in structure was the availability of financial, human and material resources. Inadequate supply chains were often barriers to scale-up. Advocacy activities positively influenced scale-up, and changes in the policy environment hindered or facilitated scale-up. The most outstanding factors influencing scale-up through changes in practice were the availability of a strategic plan for scale-up and the way in which training and supervision was conducted. Furthermore, collaborations such as community participation and partnerships facilitated scale-up, as well as the availability of research and monitoring and evaluation data. Factors influencing scale-up through a change in culture were less prominent in the literature. While some studies articulated the acceptability of the intervention in a given sociocultural environment, more emphasis was placed on the importance of stakeholders feeling a need for a specific intervention to facilitate its scale-up. All identified factors should be taken into account when scaling up public health interventions in LMICs. The different factors are strongly interlinked, and most of them are related to one crucial first step: the development of a scale-up strategy before scaling up.

National and subnational estimates of coverage and travel time to emergency obstetric care in Afghanistan: Modeling of spatial accessibility

In Afghanistan, the risk of maternal death is among the highest in the world, with wide variation across the country. One explanation may be wide geographic disparities in access and use of maternal health care services. This study describes the spatial distribution of public facilities providing maternal health care in Afghanistan, specifically emergency obstetric care (EmOC), and the differences in travel time estimates using different transportation modes from 2010 to 2015 at the national and subnational levels. We conducted mapping and spatial analyses to measure the proportion of pregnant women able to access any EmOC health facility within 2 h by foot, animal, motor vehicle and a combination of transport modes. In 2015, adequate coverage of active public health facilities within 2 h of travel time was 36.6% by foot and 71.2% by a combination of transport modes. We found an 8.3% and 63.2% increase in access to EmOC facilities within 2 h of travel time by a combination of transport modes and by foot only, respectively, by 2015. Access to a combination of transportation options such as motor vehicles and animals may benefit pregnant women in reaching health facilities efficiently. Afghanistan made impressive gains in maternal healthcare access; despite these improvements, large disparities remain in geographic access by province and overall access to facilities is still poor.

Impact of conflict on maternal and child health service delivery: a country case study of Afghanistan

Introduction

Since decades, the health system of Afghanistan has been in disarray due to ongoing conflict. We aimed to explore the direct effects of conflict on provision of reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH&N) services and describe the contextual factors influencing these services.

Method

We conducted a quantitative analysis of secondary data on RMNCAH&N indicators and undertook a supportive qualitative study to help understand processes and contextual factors. For quantitative analysis, we stratified the various provinces of Afghanistan into minimal-, moderate- and severe conflict categories based on battle-related deaths from Uppsala Conflict Data Program (UCDP) and through accessibility of health services using a Delphi methodology. The coverage of RMNCAH&N indicators across the continuum of care were extracted from the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Survey (MICS). The qualitative data was captured by conducting key informant interviews of multi-sectoral stakeholders working in government, NGOs and UN agencies.

Results

Comparison of various provinces based on the severity of conflict through Delphi process showed that the mean coverage of various RMNCAH&N indicators including antenatal care (OR: 0.42, 95%CI: 0.32–0.55), facility delivery (OR: 0.42, 95%CI: 0.32–0.56), skilled birth attendance (OR: 0.43, 95%CI: 0.33–0.57), DPT3 (OR: 0.26, 95% CI: 0.20–0.33) and oral rehydration therapy (OR: 0.37, 95% CI: 0.25–0.55) was significantly lower for severe conflict provinces when compared to minimal conflict provinces. The qualitative analysis identified various factors affecting decision making and service delivery including insecurity, cultural norms, unavailability of workforce, poor monitoring, lack of funds and inconsistent supplies. Other factors include weak stewardship, capacity gap at the central level and poor coordination at national, regional and district level.

Conclusion

RMNCAH&N service delivery has been significantly hampered by conflict in Afghanistan over the last several years. This has been further compromised by poor infrastructure, weak stewardship and poor capacity and collaboration at all levels. With the potential of peace and conflict resolution in Afghanistan, we would underscore the importance of continued oversight and integrated implementation of sustainable, grass root RMNCAH&N services with a focus on reaching the most marginalized.

Large and persistent subnational inequalities in reproductive, maternal, newborn and child health intervention coverage in sub-Saharan Africa

Subnational inequalities have received limited attention in the monitoring of progress towards national and global health targets during the past two decades. Yet, such data are often a critical basis for health planning and monitoring in countries, in support of efforts to reach all with essential interventions. Household surveys provide a rich basis for interventions coverage indicators on reproductive, maternal, newborn and child health (RMNCH) at the country first administrative level (regions or provinces). In this paper, we show the large subnational inequalities that exist in RMNCH coverage within 39 countries in sub-Saharan Africa, using a composite coverage index which has been used extensively by Countdown to 2030 for Women's, Children's and Adolescent's Health. The analyses show the wide range of subnational inequality patterns such as low overall national coverage with very large top inequality involving the capital city, intermediate national coverage with bottom inequality in disadvantaged regions, and high coverage in all regions with little inequality. Even though nearly half of the 34 countries with surveys around 2004 and again around 2015 appear to have been successful in reducing subnational inequalities in RMNCH coverage, the general picture shows persistence of large inequalities between subnational units within many countries. Poor governance and conflict settings were identified as potential contributing factors. Major efforts to reduce within-country inequalities are required to reach all women and children with essential interventions.

Association of Exposure to Civil Conflict With Maternal Resilience and Maternal and Child Health and Health System Performance in Afghanistan

IMPORTANCE

Current studies examining the effects of Afghanistan's conflict transition on the performance of health systems, health service delivery, and health outcomes are outdated and small in scale and do not span all essential reproductive, maternal, newborn, and child health interventions.

OBJECTIVE

To evaluate associations of conflict severity with improvement of health system performance, use of health services, and child nutrition outcomes in Afghanistan during the 2003 to 2018 reconstruction period.

DESIGN, SETTING, AND PARTICIPANTS

This population-based survey study included a sequential cross-sectional analysis of individual-level panel data across 2 periods (2003-2010 and 2010-2018) and a difference-in-differences design. Surveys included the 2003 to 2004 and 2010 to 2011 Multiple Indicator Cluster Surveys and the 2018 Afghanistan Health Survey. Afghanistan's 2013 National Nutrition Survey was used to assess nutritional outcomes, and the annual Balanced Scorecard data sets were used to evaluate health system performance. Participants included girls and women aged 12 to 49 years and children younger than 5 years who completed nationally representative household surveys. All analyses were conducted from January 1 through April 30, 2019.

EXPOSURES

Provinces were categorized as experiencing minimal-, moderate-, and severe-intensity conflict using battle-related death data from the Uppsala Conflict Data Program.

MAIN OUTCOMES AND MEASURES

Health intervention coverage was examined using 10 standard indicators: contraceptive method (any or modern); antenatal care by a skilled health care professional; facility delivery; skilled birth attendance (SBA); bacille Calmette-Guérin vaccination (BCG); diphtheria, pertussis, and tetanus vaccination (DPT3) or DPT3 plus hepatitis B and poliomyelitis (penta); measles vaccination; care-seeking for acute respiratory infection; oral rehydration therapy for diarrhea; and the Composite Coverage Index. The health system performance was analyzed using the following standard Balanced Scorecard composite domains: client and community, human resources, physical capacity, quality of service provision, management systems, and overall mission. Child stunting, wasting, underweight, and co-occurrence of stunting and wasting were estimated using World Health Organization growth reference cutoffs.

RESULTS

Responses from 64 815 women (mean [SD] age, 31.0 [8.5] years) were analyzed. Provinces with minimal-intensity conflict had greater gains in contraceptive use (mean annual percentage point change [MAPC], 1.3% vs 0.5%; P < .001), SBA (MAPC, 2.7% vs 1.5%; P = .005), BCG vaccination (MAPC, 3.3% vs -0.5%; P = .002), measles vaccination (MAPC, 1.9% vs -1.0%; P = .01), and DPT3/penta vaccination (MAPC, 1.0% vs -2.0%; P < .001) compared with provinces with moderate- to severe-intensity conflict after controlling for confounders. Provinces with severe-intensity conflict fared significantly worse than those with minimal-intensity conflict in functioning infrastructure (MAPC, -1.6% [95% CI, -2.4% to -0.8%]) and the client background and physical assessment index (MAPC, -1.0% [95% CI, -0.8% to 2.7%]) after adjusting for confounders. Child wasting was significantly worse in districts with greater conflict severity (full adjusted β for association between logarithm of battle-related deaths and wasting, 0.33 [95% CI, 0.01-0.66]; P = .04).

CONCLUSIONS AND RELEVANCE

Associations between conflict and maternal and child health in Afghanistan differed by health care intervention and delivery domain, with several key indicators lagging behind in areas with higher-intensity conflict. These findings may be helpful for planning and prioritizing efforts to reach the United Nations' Sustainable Development Goals in Afghanistan.