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Sutarsa IN, Campbell L, Ariawan IMD, Kasim R, Marten R, Rajan D, Hall Dykgraaf S. Multisectoral interventions and health system performance: a systematic review. Bull World Health Organ 2024; 102:521-532F. [PMID: 38933474 PMCID: PMC11197648 DOI: 10.2471/blt.23.291246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/13/2024] [Accepted: 03/20/2024] [Indexed: 06/28/2024] Open
Abstract
Objective To conduct a systematic review on the effects of multisectoral interventions for health on health system performance. Methods We conducted a systematic review according to the preferred reporting items for systematic review and meta-analysis protocols. We searched for peer-reviewed journal articles in PubMed®, Scopus, Web of Science, Cumulated Index to Nursing and Allied Health Literature, and the Cochrane Database of Systematic Reviews on 31 August 2023 (updating on 28 February 2024). We removed duplicates, screened titles and abstracts, and then conducted a full-text eligibility and quality assessment. Findings We identified an initial 1118 non-duplicate publications, 62 of which met our inclusion and exclusion criteria. The largest proportions of reviewed studies focused on multisectoral interventions directly related to specific health outcomes (66.1%; 41 studies) and/or social determinants of health (48.4%; 30 studies), but without explicit reference to overall health system performance. Most reviewed publications did not address process indicators (83.9%; 52/62) or discuss sustainability for multisectoral interventions in health (72.6%; 45/62). However, we observed that the greatest proportion (66.1%; 41/62) considered health system goals: health equity (68.3%; 28/41) and health outcomes (63.4%; 26/41). Although the greatest proportion (64.5%; 40/62) proposed mechanisms explaining how multisectoral interventions for health could lead to the intended outcomes, none used realistic evaluations to assess these. Conclusion Our review has established that multisectoral interventions influence health system performance through immediate improvements in service delivery efficiency, readiness, acceptability and affordability. The interconnectedness of these effects demonstrates their role in addressing the complexities of modern health care.
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Affiliation(s)
- I Nyoman Sutarsa
- School of Medicine and Psychology, College of Health and Medicine, Australian National University, 54 Mills Road, Acton 2601, Australia
| | - Lachlan Campbell
- School of Medicine and Psychology, College of Health and Medicine, Australian National University, 54 Mills Road, Acton 2601, Australia
| | - I Made Dwi Ariawan
- Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University, Indonesia
| | - Rosny Kasim
- School of Medicine and Psychology, College of Health and Medicine, Australian National University, 54 Mills Road, Acton 2601, Australia
| | - Robert Marten
- European Observatory on Health Systems and Policies, Brussels, Belgium
| | - Dheepa Rajan
- European Observatory on Health Systems and Policies, Brussels, Belgium
| | - Sally Hall Dykgraaf
- School of Medicine and Psychology, College of Health and Medicine, Australian National University, 54 Mills Road, Acton 2601, Australia
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Ahmed S, Islam TT, Huda FA, Alam A, Akter R, Rahman QSU, Nahar Q, El Arifeen S, Chowdhury ME. Decision-making process in seeking antenatal care: A cohort study in a poor urban and a typical rural area in Bangladesh. J Glob Health 2024; 14:04097. [PMID: 38752678 PMCID: PMC11103271 DOI: 10.7189/jogh.14.04097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
Background Decision-making in choosing and using maternal health care among different care-seeking options is a complex process influenced by multilevel factors. Existing evidence on maternal health care-seeking behaviour stems primarily from cross-sectional studies with limited information. Therefore, we designed a cohort study to better understand the decision-making process in antenatal care (ANC) seeking. Methods We conducted this mixed-methods study among pregnant women at <27 weeks of gestation in a poor urban area (n = 1320) and a typical rural area of Bangladesh (n = 1239) whom we followed up till eight weeks after delivery. In view of quantitative methods, we interviewed all enrolled women 5-6 times four weeks apart. For the qualitative approach, we conducted 70 case studies in the urban area and 46 in the rural area by interviewing the participants and their close family members. Results In the urban area, about one-third of the pregnant women (38.4%) sought ANC at non-governmental organisations, and nearly an equal proportion went to public facilities (36.6%). In both the situations, women preferred facilities with one-stop services at a reasonable cost. In contrast, the lack of readiness in public facilities of the rural area pushed women (77.8%) toward private facilities for ANC. The reputation of the facilities, availability of skilled care providers, diagnostic tests, and ultrasonography services therein were the key influencing factors in the participants' decisions to seek ANC services from specific facilities. Conclusions The availability of one-stop services was a key factor for participants' choosing of a facility for ANC. For the urban setting, there is a need to establish large public facilities with one-stop service provision in different zones, along with supporting non-governmental organisations in poor areas. For the rural setting, there is an urgent need to strengthen ANC service provision in public facilities at the community- and the sub-district level to redirect women from the private to the public sector to ensure low cost, quality services.
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Affiliation(s)
- Shakil Ahmed
- Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh
| | | | | | - Anadil Alam
- Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh
| | - Rashida Akter
- Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh
| | | | - Quamrun Nahar
- Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh
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Binagwaho A, VanderZanden A, Garcia PJ, Huda FA, Maskey M, Sall M, Sayinzoga F, Subedi RK, Teklu AM, Donahoe K, Frisch M, Ntawukuriryayo JT, Udoh K, Hirschhorn LR. Cross-country analysis of contextual factors and implementation strategies in under-5 mortality reduction in six low- and middle-income countries 2000-2015. BMC Pediatr 2024; 23:652. [PMID: 38413879 PMCID: PMC10900537 DOI: 10.1186/s12887-023-03906-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 02/13/2023] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND The Exemplars in Under-5 Mortality (U5M) was a multiple cases study of how six low- and middle-income countries (LMICs), Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal, implemented health system-delivered evidence-based interventions (EBIs) to reduce U5M between 2000 and 2015 more effectively than others in their regions or with similar economic growth. Using implementation research, we conducted a cross-country analysis to compare decision-making pathways for how these countries chose, implemented, and adapted strategies for health system-delivered EBIs that mitigated or leveraged contextual factors to improve implementation outcomes in reducing amenable U5M. METHODS The cross-country analysis was based on the hybrid mixed methods implementation research framework used to inform the country case studies. The framework included a common pathway of Exploration, Preparation, Implementation, Adaptation, and Sustainment (EPIAS). From the existing case studies, we extracted contextual factors which were barriers, facilitators, or determinants of strategic decisions; strategies to implement EBIs; and implementation outcomes including acceptability and coverage. We identified common factors and strategies shared by countries, and individual approaches used by countries reflecting differences in contextual factors and goals. RESULTS We found the six countries implemented many of the same EBIs, often using similar strategies with adaptations to local context and disease burden. Common implementation strategies included use of data by decision-makers to identify problems and prioritize EBIs, determine implementation strategies and their adaptation, and measure outcomes; leveraging existing primary healthcare systems; and community and stakeholder engagement. We also found common facilitators included culture of donor and partner coordination and culture and capacity of data use, while common barriers included geography and culture and beliefs. We found evidence for achieving implementation outcomes in many countries and EBIs including acceptability, coverage, equity, and sustainability. DISCUSSION We found all six countries used a common pathway to implementation with a number of strategies common across EBIs and countries which contributed to progress, either despite contextual barriers or by leveraging facilitators. The transferable knowledge from this cross-country study can be used by other countries to more effectively implement EBIs known to reduce amenable U5M and contribute to strengthening health system delivery now and in the future.
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Affiliation(s)
| | | | - Patricia J Garcia
- School of Public Health at Cayetano Heredia University, Lima, Peru
- Global Health Department, University of Washington, Seattle, USA
| | | | | | | | | | | | | | | | | | | | - Kelechi Udoh
- University of Global Health Equity, Kigali, Rwanda
| | - Lisa R Hirschhorn
- University of Global Health Equity, Kigali, Rwanda
- Northwestern University, Chicago, USA
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4
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Tuladhar S, Delius M, Siebeck M, Oberhauser C, Paudel D, Rehfuess E. Standards of care and determinants of women's satisfaction with delivery services in Nepal: a multi-perspective analysis using data from a health facility-based survey. BMC Pregnancy Childbirth 2024; 24:132. [PMID: 38350883 PMCID: PMC10863287 DOI: 10.1186/s12884-024-06301-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 01/29/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Compliance with standards of care is required for sustained improvement in the quality of delivery services. It thus represents a key challenge to improving maternal survival and meeting the Sustainable Development Goal (SDG) target of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. This study examines the extent to which normal low-risk health facility deliveries in Nepal meet the standards of quality of care and assesses the effect of the standards of quality of care and various contextual factors on women's satisfaction with the services they receive. METHODS Drawing on the 2021 Nepal Health Facility Survey, the sample comprised 320 women who used health facilities for normal, low-risk delivery services. A weighted one-sample t-test was applied to examine the proportion of deliveries meeting the eight standards of care. Women's overall satisfaction level was computed from seven satisfaction variables measured on a Likert scale, using principal component analysis. The composite measure was then dichotomized. Binary logistic regression was used to analyze the determinants of women's satisfaction with delivery care services. RESULTS Deliveries complying with the eight standards of care and its 53 indicators varied widely; output indicators were more frequently met than input indicators. Of the eight standards of care, the "functional referral system" performed highest (92.0%), while "competent, motivated human resources" performed the least (52.4%). Women who were attended by a provider when they called for support (AOR: 5.29; CI: 1.18, 23.64), who delivered in health facilities that displayed health statistics (AOR 3.16; CI: 1.87, 5.33), who experienced caring behaviors from providers (AOR: 2.59; CI: 1.06, 6.30) and who enjoyed audio-visual privacy (AOR 2.13; CI: 1.04, 4.38) had higher satisfaction levels compared to their counterparts. The implementation of the Maternity Incentive Scheme and presence of a maternal waiting room in health facilities, however, were associated with lower satisfaction levels. CONCLUSIONS Nepal performed moderately well in meeting the standards of care for normal, low-risk deliveries. To meet the SDG target Nepal must accelerate progress. It needs to focus on people-centered quality improvement to routinely assess the standards of care, mobilize available resources, improve coordination among the three tiers of government, and implement high-impact programs.
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Affiliation(s)
- Sabita Tuladhar
- Teaching & Training Unit, Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU, Munich, Germany.
- Center for International Health, LMU, Munich, Germany.
| | - Maria Delius
- Department of Obstetrics and Gynecology, University Hospital, LMU, Munich, Germany
| | - Matthias Siebeck
- Institute of Medical Education, LMU University Hospital, LMU, Munich, Germany
| | - Cornelia Oberhauser
- Institute for Medical Information Processing, Biometry, and Epidemiology, LMU, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | | | - Eva Rehfuess
- Institute for Medical Information Processing, Biometry, and Epidemiology, LMU, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
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Wakabayashi M, Hachiya M, Fujita N, Komada K, Obara H, Nozaki I, Okawa S, Saito E, Katsuma Y, Iso H. How did COVID-19 impact development assistance for health? - The trend for country-specific disbursement between 2015 and 2020. Glob Health Med 2023; 5:328-335. [PMID: 38162427 PMCID: PMC10730919 DOI: 10.35772/ghm.2023.01049] [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: 04/05/2023] [Revised: 09/18/2023] [Accepted: 10/24/2023] [Indexed: 01/03/2024]
Abstract
This study aimed to examine the changes that took place between 2015-2019 and 2020 and reveal how the COVID-19 pandemic affected financial contributions from donors. We used the Creditor Reporting System database of the Organization for Economic Cooperation and Development to investigate donor disbursement. Focusing on the Group of Seven (G7) countries and the Bill and Melinda Gates Foundation (BMGF), we analyzed their development assistance for health (DAH) in 2020 and the change in their disbursement between 2015 and 2020. As a result, total disbursements for all sectors increased by 14% for the G7 and the BMGF. In 2020, there was an increase in DAH for the BMGF and the G7 except for the United States. The total disbursement amount for the "COVID-19" category by G7 countries and the BMGF was approximately USD 3 billion in 2020, which was 3 times larger than for Malaria, 8.5 times larger for Tuberculosis, and 60% smaller for STDs including HIV/AIDS for the same year. In 2020 as well, the United States, the United Kingdom, Japan, Italy, and Canada saw their disbursements decline for more than half of 26 sectors. In conclusion, the impact of COVID-19 was observed in the changes in DAH disbursement for three major infectious diseases and other sectors. To consistently address the health needs of low- and middle-income countries, it is important to perform a follow-up analysis of their COVID-19 disbursements and the influence of other DAH areas.
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Affiliation(s)
- Mami Wakabayashi
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masahiko Hachiya
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Noriko Fujita
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - Kenichi Komada
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiromi Obara
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Ikuma Nozaki
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Sumiyo Okawa
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Eiko Saito
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yasushi Katsuma
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
- Graduate School of Asia-Pacific Studies, Waseda University, Tokyo, Japan
- Master's Graduate Program in Global Leadership, Vietnam-Japan University, Vietnam National University, Hanoi, Vietnam
- Institute for the Advanced Study of Sustainability, United Nations University, Tokyo, Japan
| | - Hiroyasu Iso
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
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Mishra M, Desul S, Santos CAG, Mishra SK, Kamal AHM, Goswami S, Kalumba AM, Biswal R, da Silva RM, dos Santos CAC, Baral K. A bibliometric analysis of sustainable development goals (SDGs): a review of progress, challenges, and opportunities. ENVIRONMENT, DEVELOPMENT AND SUSTAINABILITY 2023:1-43. [PMID: 37362966 PMCID: PMC10164369 DOI: 10.1007/s10668-023-03225-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 03/31/2023] [Indexed: 06/28/2023]
Abstract
The Sustainable Development Goals (SDGs) are a global appeal to protect the environment, combat climate change, eradicate poverty, and ensure access to a high quality of life and prosperity for all. The next decade is crucial for determining the planet's direction in ensuring that populations can adapt to climate change. This study aims to investigate the progress, challenges, opportunities, trends, and prospects of the SDGs through a bibliometric analysis from 2015 to 2022, providing insight into the evolution and maturity of scientific research in the field. The Web of Science core collection citation database was used for the bibliometric analysis, which was conducted using VOSviewer and RStudio. We analyzed 12,176 articles written in English to evaluate the present state of progress, as well as the challenges and opportunities surrounding the SDGs. This study utilized a variety of methods to identify research hotspots, including analysis of keywords, productive researchers, and journals. In addition, we conducted a comprehensive literature review by utilizing the Web of Science database. The results show that 31% of SDG-related research productivity originates from the USA, China, and the UK, with an average citation per article of 15.06. A total of 45,345 authors around the world have contributed to the field of SDGs, and collaboration among authors is also quite high. The core research topics include SDGs, climate change, Agenda 2030, the circular economy, poverty, global health, governance, food security, sub-Saharan Africa, the Millennium Development Goals, universal health coverage, indicators, gender, and inequality. The insights gained from this analysis will be valuable for young researchers, practitioners, policymakers, and public officials as they seek to identify patterns and high-quality articles related to SDGs. By advancing our understanding of the subject, this research has the potential to inform and guide future efforts to promote sustainable development. The findings indicate a concentration of research and development on SDGs in developed countries rather than in developing and underdeveloped countries. Graphical abstract
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Affiliation(s)
- Manoranjan Mishra
- Department of Geography, Fakir Mohan University, Vyasa Vihar, Nuapadhi, Balasore, Odisha 756089 India
- Department of Environment Studies, Berhampur University, Berhampur, Odisha 760007 India
| | - Sudarsan Desul
- Department of Library and Information Science, Berhampur University, Berhampur, Odisha 760007 India
- Department of Library and Information Science, Tripura University, Agartala, 799022 India
| | | | | | - Abu Hena Mustafa Kamal
- Faculty of Fisheries and Food Science, Universiti Malaysia Terengganu, 21030 Kuala Nerus, Terengganu, Malaysia
| | - Shreerup Goswami
- Department of Geology, Utkal University, Vani Vihar, Bhubaneswar, Odisha 751004 India
| | - Ahmed Mukalazi Kalumba
- Department of Geography and Environmental Science, Faculty of Science and Agriculture, University of Fort Hare, Alice, 5700 South Africa
| | - Ramakrishna Biswal
- Department of Humanities and Social Sciences, NIT Rourkela, Rourkela, 769008 India
| | | | | | - Kabita Baral
- Department of Environment Studies, Berhampur University, Berhampur, Odisha 760007 India
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Black RE, Liu L, Hartwig FP, Villavicencio F, Rodriguez-Martinez A, Vidaletti LP, Perin J, Black MM, Blencowe H, You D, Hug L, Masquelier B, Cousens S, Gove A, Vaivada T, Yeung D, Behrman J, Martorell R, Osmond C, Stein AD, Adair LS, Fall CHD, Horta B, Menezes AMB, Ramirez-Zea M, Richter LM, Patton GC, Bendavid E, Ezzati M, Bhutta ZA, Lawn JE, Victora CG. Health and development from preconception to 20 years of age and human capital. Lancet 2022; 399:1730-1740. [PMID: 35489357 PMCID: PMC9061873 DOI: 10.1016/s0140-6736(21)02533-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 08/02/2021] [Accepted: 11/11/2021] [Indexed: 12/13/2022]
Abstract
Optimal health and development from preconception to adulthood are crucial for human flourishing and the formation of human capital. The Nurturing Care Framework, as adapted to age 20 years, conceptualises the major influences during periods of development from preconception, through pregnancy, childhood, and adolescence that affect human capital. In addition to mortality in children younger than 5 years, stillbirths and deaths in 5-19-year-olds are important to consider. The global rate of mortality in individuals younger than 20 years has declined substantially since 2000, yet in 2019 an estimated 8·6 million deaths occurred between 28 weeks of gestation and 20 years of age, with more than half of deaths, including stillbirths, occurring before 28 days of age. The 1000 days from conception to 2 years of age are especially influential for human capital. The prevalence of low birthweight is high in sub-Saharan Africa and even higher in south Asia. Growth faltering, especially from birth to 2 years, occurs in most world regions, whereas overweight increases in many regions from the preprimary school period through adolescence. Analyses of cohort data show that growth trajectories in early years of life are strong determinants of nutritional outcomes in adulthood. The accrual of knowledge and skills is affected by health, nutrition, and home resources in early childhood and by educational opportunities in older children and adolescents. Linear growth in the first 2 years of life better predicts intelligence quotients in adults than increases in height in older children and adolescents. Learning-adjusted years of schooling range from about 4 years in sub-Saharan Africa to about 11 years in high-income countries. Human capital depends on children and adolescents surviving, thriving, and learning until adulthood.
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Affiliation(s)
- Robert E Black
- Institute for International Programs, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Li Liu
- Institute for International Programs, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Fernando P Hartwig
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas Brazil
| | - Francisco Villavicencio
- Institute for International Programs, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Centre for Demographic Studies, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Andrea Rodriguez-Martinez
- Medical Research Council Centre for Environment and Health, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Luis P Vidaletti
- International Center for Equity in Health, Federal University of Pelotas, Pelotas Brazil
| | - Jamie Perin
- Institute for International Programs, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Maureen M Black
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA; RTI International, Research Triangle Park, NC, USA
| | - Hannah Blencowe
- Maternal Adolescent Reproductive & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Danzhen You
- Data and Analytics Section, UNICEF, New York, NY, USA
| | - Lucia Hug
- Data and Analytics Section, UNICEF, New York, NY, USA
| | - Bruno Masquelier
- Centre de Recherche en Démographie, Université Catholique de Louvain, Louvain, Belgium
| | - Simon Cousens
- Maternal Adolescent Reproductive & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Amber Gove
- RTI International, Research Triangle Park, NC, USA
| | - Tyler Vaivada
- Center for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Diana Yeung
- Institute for International Programs, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Jere Behrman
- Department of Economics, Population Studies Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Reynaldo Martorell
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Clive Osmond
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Aryeh D Stein
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Linda S Adair
- Nutrition Department, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Caroline H D Fall
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Bernardo Horta
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas Brazil
| | - Ana M B Menezes
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas Brazil
| | - Manuel Ramirez-Zea
- Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | - Linda M Richter
- Department of Science and Innovation, National Research Foundation Centre of Excellence in Human Development, University of the Witwatersrand, Parktown, South Africa
| | - George C Patton
- Centre for Adolescent Health, Murdoch Children's Research Institute, Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia
| | - Eran Bendavid
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Majid Ezzati
- Medical Research Council Centre for Environment and Health, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Zulfiqar A Bhutta
- Center for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada; Centre for Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Joy E Lawn
- Maternal Adolescent Reproductive & Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Cesar G Victora
- International Center for Equity in Health, Federal University of Pelotas, Pelotas Brazil
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8
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Ahmad D, Mohanty I, Niyonsenga T. Improving birth preparedness and complication readiness in rural India through an integrated microfinance and health literacy programme: evidence from a quasi-experimental study. BMJ Open 2022; 12:e054318. [PMID: 35190433 PMCID: PMC8860014 DOI: 10.1136/bmjopen-2021-054318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Recently, a novel community health programme-the integrated microfinance and health literacy (IMFHL) programme was implemented through microfinance-based women's only self-help groups (SHGs) in India to promote birth preparedness and complication readiness (BPCR) to improve maternal health. The study evaluated the impact of the IMFHL programme on BPCR practice by women in one of India's poorest states-Uttar Pradesh-adjusting for the community, household and individual variables. The paper also examined for any diffusion of knowledge of BPCR from SHG members receiving the health literacy intervention to non-members in programme villages. DESIGN Quasi-experimental study using cross-sectional survey data. SETTINGS Secondary survey data from the IMFHL programme were used. PARTICIPANTS Survey data were collected from 17 244 women in households with SHG member and non-member households in rural India. PRIMARY OUTCOMES Multivariable logistic regression was used to estimate main and adjusted IMFHL programme effects on maternal BPCR practice in their last pregnancy. RESULTS Membership in SHGs alone is positively associated with BPCR practice, with 17% higher odds (OR=1.17, 95% CI 1.07 to 1.29, p<0.01) of these women practising BPCR compared with women in villages without the programmes. Furthermore, the odds of practising complete BPCR increase to almost 50% (OR=1.48, 95% CI 1.35 to 1.63, p<0.01) when a maternal health literacy component is added to the SHGs. A diffusion effect was found for BPCR practice from SHG members to non-members when the health literacy component was integrated into the SHG model. CONCLUSIONS The results suggest that SHG membership exerts a positive impact on planned health behaviour and a diffusion effect of BPCR practice from members to non-members when SHGs are enriched with a health literacy component. The study provides evidence to guide the implementation of community health programmes seeking to promote BPCR practise in low resource settings.
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Affiliation(s)
- Danish Ahmad
- Health Research Institute, Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
- Indian Institute of Public Health Gandhinagar (IIPH-G), Gandhinagar, Gujarat, India
- Public Health Foundation of India, New Delhi, India
| | - Itismita Mohanty
- Health Research Institute, Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Theophile Niyonsenga
- Health Research Institute, Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
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9
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Hirschhorn LR, Frisch M, Ntawukuriryayo JT, VanderZanden A, Donahoe K, Mathewos K, Sayinzoga F, Binagwaho A. Development and application of a hybrid implementation research framework to understand success in reducing under-5 mortality in Rwanda. Gates Open Res 2021; 5:72. [PMID: 35079696 PMCID: PMC8688814 DOI: 10.12688/gatesopenres.13214.3] [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] [Accepted: 12/13/2021] [Indexed: 11/29/2022] Open
Abstract
Background: We describe the development and testing of a hybrid implementation research (IR) framework to understand the pathways, successes, and challenges in addressing amenable under-5 mortality (U5M) - deaths preventable through health system-delivered evidence-based interventions (EBIs) - in low- and middle-income countries (LMICs). Methods: We reviewed existing IR frameworks to develop a hybrid framework designed to better understand U5M reduction in LMICs from identification of leading causes of amenable U5M, to EBI choice, identification, and testing of strategies, work to achieve sustainability at scale, and key contextual factors. We then conducted a mixed-methods case study of Rwanda using the framework to explore its utility in understanding the steps the country took in EBI-related decision-making and implementation between 2000-2015, key contextual factors which hindered or facilitated success, and to extract actionable knowledge for other countries working to reduce U5M. Results: While relevant frameworks were identified, none individually covered the scope needed to understand Rwanda's actions and success. Building on these frameworks, we combined and adapted relevant frameworks to capture exploration, planning, implementation, contextual factors in LMICs such as Rwanda, and outcomes beyond effectiveness and coverage. Utilizing our hybrid framework in Rwanda, we studied multiple EBIs and identified a common pathway and cross-cutting strategies and contextual factors that supported the country's success in reducing U5M through the health system EBIs. Using these findings, we identified transferable lessons for other countries working to accelerate reduction in U5M. Conclusions: We found that a hybrid framework building on and adapting existing frameworks was successful in guiding data collection and interpretation of results, emerging new insights into how and why Rwanda achieved equitable introduction and implementation of health system EBIs that contributed to the decline in U5M, and generated lessons for countries working to drop U5M.
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Affiliation(s)
- Lisa R. Hirschhorn
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Miriam Frisch
- University of Global Health Equity, Kigali, 6955, Rwanda
| | | | | | - Kateri Donahoe
- University of Global Health Equity, Kigali, 6955, Rwanda
| | | | - Felix Sayinzoga
- Maternal, Child, and Community Health Division, Rwanda Biomedical Center, Kigali, 7162, Rwanda
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Tukay SM, Pasape L, Tani K, Manzi F. Evaluation of the Direct Health Facility Financing Program in Improving Maternal Health Services in Pangani District, Tanzania. Int J Womens Health 2021; 13:1227-1242. [PMID: 34916854 PMCID: PMC8669272 DOI: 10.2147/ijwh.s333900] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/13/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Maternal morbidity and mortality remain significant public health concerns globally, with Tanzania reporting 398 deaths per 100,000 live births annually. While national level data provide some insights into the issue, a focus on sub-national levels is required because of differences in contexts such as rural-urban disparities in maternal mortality. This study examined Direct Health Facility Financing (DHFF) and its effects on the quality of maternal health services in Pangani, a rural district in Tanzania. METHODS This study was conducted in Pangani district of Tanga region in Tanzania. The study used both qualitative and quantitative methods, including 16 in-depth interviews with the council health management teams, facility in charges, maternity nurse in charge, and 5 focus group discussions with community health governing committee members. The number of deliveries that occurred in health facilities, as well as medical supplies, equipment, and reagents purchased by the facilities, were compared using descriptive statistics before and after the DHFF implementation. RESULTS Direct disbursement of funds from the central government through the Ministry of Finance and Planning to the primary health facilities reduced delays in procurement, improved community outreach services, and improved community leaders' engagements. Deliveries occurring at health facilities increased by 33.6% (p < 0.001) one year after the HDFF implementation. Various medicines, delivery kits, and some reagents increased significantly (p < 0.05). However, the lack of computers and poor internet connectivity, an insufficient supply of medical equipment and unstable stock of the Medical Stores Department increased the difficulty of obtaining the missed items from the selected prime vendor. CONCLUSION Overall, this study shows a positive impact of the DHFF on maternal health service delivery in Pangani district. Specifically, an increase in the number of medical supplies, equipment, and reagents necessary to provide maternal health services contributed to the observed increase in facility deliveries by 33.6%. Moreover, the system minimizes unnecessary delays in the procurement processes of required drugs, supplies, and other facility reagents. To maximize the impact of the HDFF system, lack of computers, unstable internet, limited knowledge of the staff about the system, and inadequate health workforce should be addressed. Therefore, strengthening the DHFF system and staff training in-service and on the job is essential for smooth implementation.
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Affiliation(s)
- Samwel Marco Tukay
- The Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania
- Pangani District Council, Tanga, Tanzania
- Ifakara Health Institute (IHI), Dar es Salaam, Tanzania
| | - Liliane Pasape
- The Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania
| | - Kassimu Tani
- Ifakara Health Institute (IHI), Dar es Salaam, Tanzania
| | - Fatuma Manzi
- Ifakara Health Institute (IHI), Dar es Salaam, Tanzania
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Hirschhorn LR, Frisch M, Ntawukuriryayo JT, VanderZanden A, Donahoe K, Mathewos K, Sayinzoga F, Binagwaho A. Development and application of a hybrid implementation research framework to understand success in reducing under-5 mortality in Rwanda. Gates Open Res 2021; 5:72. [PMID: 35079696 PMCID: PMC8688814 DOI: 10.12688/gatesopenres.13214.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 11/09/2023] Open
Abstract
Background: We describe the development and testing of a hybrid implementation research (IR) framework to understand the pathways, successes, and challenges in addressing amenable under-5 mortality (U5M) - deaths preventable through health system-delivered evidence-based interventions (EBIs) - in low- and middle-income countries (LMICs). Methods: We reviewed existing IR frameworks to develop a hybrid framework designed to better understand U5M reduction in LMICs from identification of leading causes of amenable U5M, to EBI choice, identification, and testing of strategies, work to achieve sustainability at scale, and key contextual factors. We then conducted a mixed-methods case study of Rwanda using the framework to explore its utility in understanding the steps the country took in EBI-related decision-making and implementation between 2000-2015, key contextual factors which hindered or facilitated success, and to extract actionable knowledge for other countries working to reduce U5M. Results: While relevant frameworks were identified, none individually covered the scope needed to understand Rwanda's actions and success. Building on these frameworks, we combined and adapted relevant frameworks to capture exploration, planning, implementation, contextual factors in LMICs such as Rwanda, and outcomes beyond effectiveness and coverage. Utilizing our hybrid framework in Rwanda, we studied multiple EBIs and identified a common pathway and cross-cutting strategies and contextual factors that supported the country's success in reducing U5M through the health system EBIs. Using these findings, we identified transferable lessons for other countries working to accelerate reduction in U5M. Conclusions: We found that a hybrid framework building on and adapting existing frameworks was successful in guiding data collection and interpretation of results, emerging new insights into how and why Rwanda achieved equitable introduction and implementation of health system EBIs that contributed to the decline in U5M, and generated lessons for countries working to drop U5M.
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Affiliation(s)
- Lisa R. Hirschhorn
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Miriam Frisch
- University of Global Health Equity, Kigali, 6955, Rwanda
| | | | | | - Kateri Donahoe
- University of Global Health Equity, Kigali, 6955, Rwanda
| | | | - Felix Sayinzoga
- Maternal, Child, and Community Health Division, Rwanda Biomedical Center, Kigali, 7162, Rwanda
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Kibira D, Asiimwe C, Muwonge M, van den Ham HA, Reed T, Leufkens HG, Mantel-Teeuwisse AK. Donor Commitments and Disbursements for Sexual and Reproductive Health Aid in Kenya, Tanzania, Uganda and Zambia. Front Public Health 2021; 9:645499. [PMID: 33959580 PMCID: PMC8093629 DOI: 10.3389/fpubh.2021.645499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/05/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Sexual and Reproductive Health and Rights (SRHR) investments are critical to people's well-being. However, despite the demonstrated returns on investments, underfunding of SRHR still persists. The objective of this study was to characterize donor commitments and disbursements to SRH aid in four sub-Saharan countries of Kenya, Tanzania, Uganda and Zambia and to compare trends in donor aids with SRH outcome and impact indicators for each of these countries. Methods: The study is a secondary analysis of data from the Organization for Economic Co-operation and Development's Assistance creditor reporting system and SRH indicator data from the Global Health Observatory and country demographic health surveys for a 16-year period (2002-2017). We downloaded and compared commitments to disbursements of all donors for population policies, programs and reproductive health for the four African countries. SRH indicators were stratified into health facility level process/outcome indicators (modern contraceptive prevalence rate, unmet need for family planning, antenatal care coverage and skilled birth attendance) and health impact level indicators (maternal mortality ratio, newborn mortality rate, infant mortality rate and under five mortality rate). Results: Donor commitments for SRH aid grew on average by 20% while disbursements grew by 21% annually between 2002 and 2017. The overall disbursement rate was 93%. Development Assistance Cooperation (DAC) countries donated the largest proportion (79%) of aid. Kenya took 33% of total aid, followed by Tanzania 26%, Uganda 23% and then Zambia (18%). There was improvement in all SRH outcome and impact indicators, but not enough to meet targets. Conclusion: Donor aid to SRH grew over time and in the same period indicators improved, but improvement remained slow. Unpredictability and insufficiency of aid may be disruptive to recipient country planning. Donors and low- and middle-income countries should increase funding in order to meet global SRHR targets.
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Affiliation(s)
- Denis Kibira
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
- Coalition for Health Promotion and Social Development (HEPS-Uganda), Kampala, Uganda
| | | | | | - Hendrika A. van den Ham
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - Tim Reed
- Health Action International, Amsterdam, Netherlands
| | - Hubert G. Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - Aukje K. Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Centre for Pharmaceutical Policy and Regulation, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
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Hirschhorn LR, Frisch M, Ntawukuriryayo JT, VanderZanden A, Donahoe K, Mathewos K, Sayinzoga F, Binagwaho A. Development and application of a hybrid implementation research framework to understand success in reducing under-5 mortality in Rwanda. Gates Open Res 2021; 5:72. [PMID: 35079696 PMCID: PMC8688814 DOI: 10.12688/gatesopenres.13214.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2021] [Indexed: 11/09/2023] Open
Abstract
Background: We describe the development and testing of a hybrid implementation research (IR) framework to understand the pathways, successes, and challenges in addressing amenable under-5 mortality (U5M) - deaths preventable through health system-delivered evidence-based interventions (EBIs) - in low- and middle-income countries (LMICs). Methods: We reviewed existing IR frameworks to develop a hybrid framework designed to better understand U5M reduction in LMICs from identification of leading causes of amenable U5M, to EBI choice, identification and testing of strategies, work to achieve sustainability at scale and key contextual factors. We then conducted a mixed-methods case study of Rwanda using the framework to explore its utility in understanding the steps the country took in EBI-related decision-making and implementation between 2000-2015, key contextual factors which hindered or facilitated success, and extract actionable knowledge for other countries working to reduce U5M. Results: While relevant frameworks were identified, none individually covered the scope needed to understand Rwanda's actions and success. Building on these frameworks, we combined and adapted relevant frameworks to capture exploration, planning, implementation, contextual factors in LMICs such as Rwanda, and outcomes beyond effectiveness and coverage. Utilizing our hybrid framework in Rwanda, we studied multiple EBIs and identified a common pathway and cross-cutting strategies and contextual factors that supported the country's success in reducing U5M through the health system EBIs. Using these findings, we identified transferable lessons for other countries working to accelerate reduction in U5M. Conclusions: We found that a hybrid framework building on and adapting existing frameworks was successful in guiding data collection and interpretation of results, emerging new insights into how and why Rwanda achieved equitable introduction and implementation of health system EBIs that contributed to the decline in U5M, and generated lessons for countries working to drop U5M.
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Affiliation(s)
- Lisa R. Hirschhorn
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Miriam Frisch
- University of Global Health Equity, Kigali, 6955, Rwanda
| | | | | | - Kateri Donahoe
- University of Global Health Equity, Kigali, 6955, Rwanda
| | | | - Felix Sayinzoga
- Maternal, Child, and Community Health Division, Rwanda Biomedical Center, Kigali, 7162, Rwanda
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Schlüter BS, Masquelier B. Space-time smoothing of mortality estimates in children aged 5-14 in Sub-Saharan Africa. PLoS One 2021; 16:e0245596. [PMID: 33465127 PMCID: PMC7815126 DOI: 10.1371/journal.pone.0245596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/04/2021] [Indexed: 11/19/2022] Open
Abstract
To meet the SDG requirement of spatial disaggregation of indicators, several methods have been developed to generate estimates of under-five mortality at the sub-national level. The reliability of sub-national mortality estimates in children aged 5-14 with the available survey data has not been evaluated so far. We generate Admin-1 sub-national estimates of the risk of dying in children aged less than five (5q0) and those aged 5 to 14 years old (10q5). We use 96 Demographic and Health Surveys (DHS) in 20 Sub-Saharan countries having at least 3 surveys designed to be representative at a sub-national level. The estimates account for the complex sample design of DHS and HIV-related biases in young children. A Bayesian space-time model previously developed for under-five mortality is used to smooth estimates across space and time in both age groups to reduce problems associated with data sparsity. The posterior distributions of the probability 10q5 are used to compute coefficients of variation and assess precision. Sufficiently precise estimates are retained to study the sub-national relationship between age-specific mortality rates (5q0 and 10q5), accounting for uncertainty in sub-national levels. Out of 1,132 space-time estimates, 62.3% are considered sufficiently precise with high heterogeneity across countries. Across all periods, sub-national estimates of mortality in children aged 0-4 are highly correlated with those in older children and young adolescents but this correlation is largely driven by the mortality decline. Within specific periods of time, it is often impossible to assess the relationship between mortality rates in the two age groups at the sub-national level, except in Nigeria, Ethiopia, Cameroon, Senegal and Zambia. As increased attention is devoted to survival after age 5, more research is needed to ensure that sub-national areas with specific interventions required for older children can be correctly identified.
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Affiliation(s)
| | - Bruno Masquelier
- Université Catholique de Louvain-la-Neuve (UCLouvain), Louvain-la-Neuve, Belgium
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15
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Colomé-Hidalgo M, Campos JD, de Miguel ÁG. Exploring wealth-related inequalities in maternal and child health coverage in Latin America and the Caribbean. BMC Public Health 2021; 21:115. [PMID: 33423659 PMCID: PMC7798299 DOI: 10.1186/s12889-020-10127-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 12/23/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Maternal and child health have shown important advances in the world in recent years. However, national averages indicators hide large inequalities in access and quality of care in population subgroups. We explore wealth-related inequalities affecting health coverage and interventions in reproductive, maternal, newborn, and child health in Latin America and the Caribbean. METHODS We analyzed representative national surveys from 15 countries conducted between 2001 and 2016. We estimated maternal-child health coverage gaps using the Composite Coverage Index - a weighted average of interventions that include family planning, maternal and newborn care, immunizations, and treatment of sick children. We measured absolute and relative inequality to assess gaps by wealth quintile. Pearson's correlation coefficient was used to test the association between the coverage gap and population attributable risk. RESULTS The Composite Coverage Index showed patterns of inequality favoring the wealthiest subgroups. In eight countries the national coverage was higher than the global median (78.4%; 95% CI: 73.1-83.6) and increased significantly as inequality decreased (Pearson r = 0.9; p < 0.01). CONCLUSIONS There are substantial inequalities between socioeconomic groups. Reducing inequalities will improve coverage indicators for women and children. Additional health policies, programs, and practices are required to promote equity.
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Affiliation(s)
| | | | - Ángel Gil de Miguel
- Instituto Tecnológico de Santo Domingo, Universidad Rey Juan Carlos, Madrid, Spain
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16
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Hirose A, Kajungu D, Tusubira V, Waiswa P, Alfven T, Hanson C. Postneonatal under-5 mortality in peri-urban and rural Eastern Uganda, 2005-2015. BMJ Glob Health 2020; 5:e003762. [PMID: 33334903 PMCID: PMC7747610 DOI: 10.1136/bmjgh-2020-003762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/29/2020] [Accepted: 11/17/2020] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Community and individual sociodemographic characteristics play an important role in child survival. However, a question remains how urbanisation and demographic changes in sub-Saharan Africa affect community-level determinants for child survival. METHODS Longitudinal data from the Iganga/Mayuge Health and Demographic Surveillance Site was used to obtain postneonatal under-5 mortality rates between March 2005 and February 2015 in periurban and rural areas separately. Multilevel survival analysis models were used to identify factors associated with mortality. RESULTS There were 43 043 postneonatal under-5 children contributing to 116 385 person years of observation, among whom 1737 died. Average annual crude mortality incidence rate (IR) differed significantly between periurban and rural areas (9.0 (8.1 to 10.0) per 1000 person-years vs 18.1 (17.1 to 19.0), respectively). In periurban areas, there was evidence for decreasing mortality from IR=11.3 (7.7 to 16.6) in 2006 to IR=4.5 (3.0 to 6.9) in 2015. The mortality fluctuated with no evidence for reduction in rural areas (IR=19.0 (15.8 to 22.8) in 2006; IR=15.5 (13.0 to 18.6) in 2015). BCG vaccination was associated with reduced mortality in periurban and rural areas (adjusted rate ratio (aRR)=0.45; 95% CI 0.30 to 0.67 and aRR=0.56; 95% CI 0.41 to 0.76, respectively). Maternal education level within the community was associated with reduced mortality in both periurban and rural sites (aRR=0.83; 95% CI 0.70 to 0.99; aRR=0.90; 95% CI 0.81 to 0.99). The proportion of households in the poorest quintile within the community was associated with mortality in rural areas only (aRR=1.08; 95% CI 1.00 to 1.18). In rural areas, a large disparity existed between the least poor and the poorest (aRR=0.50; 95% CI 0.27 to 0.92). CONCLUSION We found evidence for a mortality decline in peri-urban but not rural areas. Investments in the known key health (eg, vaccination) and socio-economic interventions (education, and economic development) continue to be crucial for mortality declines. Focused strategies to eliminate the disparity between wealth quintiles are also warranted. There may be equitable access to health services in peri-urban areas but improved metrics of socioeconomic position suitable for peri-urban residents may be needed.
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Affiliation(s)
- Atsumi Hirose
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- School of Public Health, Imperial College London, London, UK
| | - Dan Kajungu
- Makerere University Centre for Health and Population Research, Kampala, Uganda
| | - Valerie Tusubira
- Makerere University Centre for Health and Population Research, Kampala, Uganda
| | - Peter Waiswa
- School of Public Health, Makerere University, Kampala, Uganda
| | - Tobias Alfven
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Disease Control, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
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Chan GJ, Getnet M, Olowojesiku R, Min-Swe T, Hunegnaw B, Bekele D. Scoping review protocol on maternal, newborn and child health research in Ethiopia. BMJ Open 2020; 10:e034307. [PMID: 32616486 PMCID: PMC7333800 DOI: 10.1136/bmjopen-2019-034307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION There has been a tremendous reduction in maternal and child mortality in the last decade. However, a significant number of deaths still occur disproportionately in low-income country settings. Ethiopia is the second-most populous nation in sub-Saharan Africa with a high maternal mortality rate of 412 deaths per 100 000 live births and an under-five mortality rate of 55 per 1000 live births. This study presents a scoping review protocol to describe the current knowledge of maternal and child health in Ethiopia to identify gaps for prioritisation of future maternal, newborn and child health research. METHODS AND ANALYSES A search strategy will be conducted in PubMed/MEDLINE, EMBASE and the WHO African Index Medicus. Researchers will independently screen title and abstracts followed by full texts for inclusion. Study characteristics, research topics, exposures and outcomes will be abstracted from articles meeting inclusion criteria using standardised forms. Descriptive analysis of abstracted data will be conducted. ETHICS AND DISSEMINATION Data will be abstracted from published manuscripts and no additional ethical approval is required. The results of the review will be shared with maternal and child health experts in Ethiopia through stakeholder meetings to prioritise research questions. Findings will be submitted to a peer-reviewed journal for publication, in addition to national-level and global-level disseminations.
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Affiliation(s)
- Grace J Chan
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Misrak Getnet
- Health Systems Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Ronke Olowojesiku
- Department of Epidemiology, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Thein Min-Swe
- Department of Epidemiology, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Bezawit Hunegnaw
- Department of Pediatrics, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Delayehu Bekele
- Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
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Sabot K, Blanchet K, Berhanu D, Spicer N, Schellenberg J. Professional advice for primary healthcare workers in Ethiopia: a social network analysis. BMC Health Serv Res 2020; 20:551. [PMID: 32552727 PMCID: PMC7302001 DOI: 10.1186/s12913-020-05367-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In an era of increasingly competitive funding, governments and donors will be looking for creative ways to extend and maximise resources. One such means can include building upon professional advice networks to more efficiently introduce, scale up, or change programmes and healthcare provider practices. This cross-sectional, mixed-methods, observational study compared professional advice networks of healthcare workers in eight primary healthcare units across four regions of Ethiopia. Primary healthcare units include a health centre and typically five satellite health posts. METHODS One hundred sixty staff at eight primary healthcare units were interviewed using a structured tool. Quantitative data captured the frequency of healthcare worker advice seeking and giving on providing antenatal, childbirth, postnatal and newborn care. Network and actor-level metrics were calculated including density (ratio of ties between actors to all possible ties), centrality (number of ties incident to an actor), distance (average number of steps between actors) and size (number of actors within the network). Following quantitative network analyses, 20 qualitative interviews were conducted with network study participants from four primary healthcare units. Qualitative interviews aimed to interpret and explain network properties observed. Data were entered, analysed or visualised using Excel 6.0, UCINET 6.0, Netdraw, Adobe InDesign and MaxQDA10 software packages. RESULTS The following average network level metrics were observed: density .26 (SD.11), degree centrality .45 (SD.08), distance 1.94 (SD.26), number of ties 95.63 (SD 35.46), size of network 20.25 (SD 3.65). Advice networks for antenatal or maternity care were more utilised than advice networks for post-natal or newborn care. Advice networks were typically limited to primary healthcare unit staff, but not necessarily to supervisors. In seeking advice, a colleague's level of training and knowledge were valued over experience. Advice exchange primarily took place in person or over the phone rather than over email or online fora. There were few barriers to seeking advice. CONCLUSION Informal, inter-and intra-cadre advice networks existed. Fellow primary healthcare unit staff were preferred, particularly midwives, but networks were not limited to the primary healthcare unit. Additional research is needed to associate network properties with outcomes and pilot network interventions with central actors.
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Affiliation(s)
- Kate Sabot
- The Centre for Maternal, Adolescent, Reproductive and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK. .,Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Karl Blanchet
- Department of Global Health, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Della Berhanu
- The Centre for Maternal, Adolescent, Reproductive and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Neil Spicer
- Department of Global Health, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Joanna Schellenberg
- The Centre for Maternal, Adolescent, Reproductive and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Lawn JE, Ashish KC. Learning from Nepal's Progress to Inform the Path to the Sustainable Development Goals for Health, Leaving No-One Behind. Matern Child Health J 2020; 24:1-4. [PMID: 32086635 PMCID: PMC7048866 DOI: 10.1007/s10995-020-02899-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Joy E Lawn
- MARCH Centre, London School of Hygiene & Tropical Medicine, London, UK.
| | - K C Ashish
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
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Acharya K, Paudel YR, Dharel D. The trend of full vaccination coverage in infants and inequalities by wealth quintile and maternal education: analysis from four recent demographic and health surveys in Nepal. BMC Public Health 2019; 19:1673. [PMID: 31830944 PMCID: PMC6909493 DOI: 10.1186/s12889-019-7995-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 11/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite policy intention to reach disadvantaged populations, inequalities in health care resource use and health outcomes persist in Nepal. The current study aimed to investigate the trend of full vaccination coverage among infants and its equity gaps between Nepal Demographic and Health Surveys (NDHS) 2001 and 2016. METHODS Using data from NDHS conducted in 2001, 2006, 2011 and 2016, we investigated the trend of coverage of six antigens: Bacille Calmette Guerin (BCG), Diptheria, Pertussis, Tetanus (DPT), Polio, and Measles during their infancy among children aged 12-23 months. We presented trends and correlates of full vaccination coverage by different socio-demographic factors. We measured inequalities in full vaccination coverage by wealth quintile and maternal education using absolute measure (slope index of inequality) and relative measures (Relative index of inequality, concentration index) of inequalities. RESULTS Full vaccination coverage among infants steadily increased from 65.6% in 2001 to 87.0% in 2011; however, it decreased to 77.8% in 2016. Province 2 had a significantly lower full vaccination coverage compared to Province1.Although decreasing over time, there were significant inequalities by household wealth quintiles and maternal educational status. The slope index of inequality (SII) for wealth quintiles decreased from - 32.3 [- 45.5,-19.1] in 2001 to an SII of-8.4 [- 18.6,-1.7] in 2016. Similarly, the SII for education decreased from - 61.8 [- 73.5,-50.1] in 2001 to an SII of - 30.5 [- 40.7,-20.2] in 2016. Similarly, the relative index of inequality (RII) also showed an improvement over time, indicating the narrowing equity gap. Additionally, concentration index on full vaccination coverage by wealth quintiles dropped from 0.21 (0.12-0.28) in 2001 to 0.054 (- 0.01-0.12) in 2016. Absolute and relative inequalities were persistently larger by maternal educational status compared to household wealth quintiles throughout the study period. CONCLUSION Full vaccination coverage in Nepal increased from 2001 until 2011 but saw a significant decrement away from the national target after 2011. However, the equity gap by household wealth quintile and maternal education status has narrowed over time. National Immunization programs need to give higher emphasis to infants born to mothers with less education, those born in the poorer wealth quintile households, and those living in Province 2.
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Affiliation(s)
| | - Yuba Raj Paudel
- School of Public Health, University of Alberta, Edmonton, Canada
| | - Dinesh Dharel
- Cumming School of Medicine, University of Calgary, Calgary, Canada
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21
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Haley CA, Brault MA, Mwinga K, Desta T, Ngure K, Kennedy SB, Maimbolwa M, Moyo P, Vermund SH, Kipp AM. Promoting progress in child survival across four African countries: the role of strong health governance and leadership in maternal, neonatal and child health. Health Policy Plan 2019; 34:24-36. [PMID: 30698696 PMCID: PMC6479825 DOI: 10.1093/heapol/czy105] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2018] [Indexed: 11/12/2022] Open
Abstract
Despite numerous international and national efforts, only 12 countries in the World Health Organization's African Region met the Millennium Development Goal #4 (MDG#4) to reduce under-five mortality by two-thirds by 2015. Given the variability across sub-Saharan Africa, a four-country study was undertaken to examine barriers and facilitators of child survival prior to 2015. Liberia and Zambia were chosen to represent countries making substantial progress towards MDG#4, while Kenya and Zimbabwe represented countries making less progress. Our individual case studies suggested that strong health governance and leadership (HGL) was a significant driver of the greater success in Liberia and Zambia compared with Kenya and Zimbabwe. To elucidate specific components of national HGL that may have substantially influenced the pace of reductions in child mortality, we conducted a cross-country analysis of national policies and strategies pertaining to maternal, neonatal and child health (MNCH) and qualitative interviews with individuals working in MNCH in each of the four study countries. The three aspects of HGL identified in this study which most consistently contributed to the different progress towards MDG#4 among the four study countries were (1) establishing child survival as a top national priority backed by a comprehensive policy and strategy framework and sufficient human, financial and material resources; (2) bringing together donors, strategic partners, health and non-health stakeholders and beneficiaries to collaborate in strategic planning, decision-making, resource-allocation and coordination of services; and (3) maintaining accountability through a 'monitor-review-act' approach to improve MNCH. Although child mortality in sub-Saharan Africa remains high, this comparative study suggests key health leadership and governance factors that can facilitate reduction of child mortality and may prove useful in tackling current Sustainable Development Goals.
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Affiliation(s)
- Connie A Haley
- Vanderbilt Institute for Global Health, Vanderbilt University, 2525 West End Avenue, Nashville, TN, USA.,Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA
| | - Marie A Brault
- Department of Anthropology, University of Connecticut, 354 Mansfield Road, Storrs, CT, USA
| | - Kasonde Mwinga
- World Health Organization, Regional Office for Africa, Cite du Djoue, Brazzaville, Congo
| | - Teshome Desta
- World Health Organization, Inter-country Support Team for East and Southern Africa, Harare, Zimbabwe
| | - Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Stephen B Kennedy
- University of Liberia-Pacific Institute for Research & Evaluation (UL-PIRE) Africa Center, University of Liberia, Monrovia, Liberia
| | | | - Precious Moyo
- Collaborative Research Program, University of Zimbabwe/University of California, San Francisco, Harare, Zimbabwe
| | - Sten H Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University, 2525 West End Avenue, Nashville, TN, USA.,Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, TN, USA
| | - Aaron M Kipp
- Vanderbilt Institute for Global Health, Vanderbilt University, 2525 West End Avenue, Nashville, TN, USA.,Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA
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Munabi-Babigumira S, Nabudere H, Asiimwe D, Fretheim A, Sandberg K. Implementing the skilled birth attendance strategy in Uganda: a policy analysis. BMC Health Serv Res 2019; 19:655. [PMID: 31500636 PMCID: PMC6734264 DOI: 10.1186/s12913-019-4503-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 08/30/2019] [Indexed: 12/05/2022] Open
Abstract
Background Uganda, a low resource country, implemented the skilled attendance at birth strategy, to meet a key target of the 5th Millenium Development Goal (MDG), 75% reduction in maternal mortality ratio. Maternal mortality rates remained high, despite the improvement in facility delivery rates. In this paper, we analyse the strategies implemented and bottlenecks experienced as Uganda’s skilled birth attendance policy was rolled out. These experiences provide important lessons for decision makers as they implement policies to further improve maternity care. Methods This is a case study of the implementation process, involving a document review and in-depth interviews among key informants selected from the Ministry of Health, Professional Organisations, Ugandan Parliament, the Health Service Commission, the private not-for-profit sector, non-government organisations, and District Health Officers. The Walt and Gilson health policy triangle guided data collection and analysis. Results The skilled birth attendance policy was an important priority on Uganda’s maternal health agenda and received strong political commitment, and support from development partners and national stakeholders. Considerable effort was devoted to implementation of this policy through strategies to increase the availability of skilled health workers for instance through expanded midwifery training, and creation of the comprehensive nurse midwife cadre. In addition, access to emergency obstetric care improved to some extent as the physical infrastructure expanded, and distribution of medicines and supplies improved. However, health worker recruitment was slow in part due to the restrictive staff norms that were remnants of previous policies. Despite considerable resources allocated to creating the comprehensive nurse midwife cadre, this resulted in nurses that lacked midwifery skills, while the training of specialised midwives reduced. The rate of expansion of the physical infrastructure outpaced the available human resources, equipment, blood infrastructure, and several health facilities were not fully functional. Conclusion Uganda’s skilled birth attendance policy aimed to increase access to obstetric care, but recruitment of human resources, and infrastructural capacity to provide good quality care remain a challenge. This study highlights the complex issues and unexpected consequences of policy implementation. Further evaluation of this policy is needed as decision-makers develop strategies to improve access to skilled care at birth. Electronic supplementary material The online version of this article (10.1186/s12913-019-4503-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Susan Munabi-Babigumira
- Global Health Unit, Division for Health Services, Norwegian Institute of Public Health, P.O. Box 4404, Nydalen, N-0403, Oslo, Norway. .,University of Oslo, P.O. Box 1130, Blindern, 0318, Oslo, Norway.
| | - Harriet Nabudere
- Uganda National Health Research Organization, Plot 2, Berkeley Lane, P.O. Box 465, Entebbe, Uganda
| | - Delius Asiimwe
- Kabano Research and Development Centre, Plot 487, Kyengera, Masanda Zone, P.O Box 35906, Kampala, Uganda
| | - Atle Fretheim
- Global Health Unit, Division for Health Services, Norwegian Institute of Public Health, P.O. Box 4404, Nydalen, N-0403, Oslo, Norway.,University of Oslo, P.O. Box 1130, Blindern, 0318, Oslo, Norway
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23
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Zhang J, Mou Y, Liao J, Xiong H, Duan Z, Huang Y, Ronsmans C. Uptake of maternal care and childhood immunization among ethnic minority and Han populations in Sichuan province: a study based on the 2003, 2008 and 2013 health service surveys. BMC Pregnancy Childbirth 2019; 19:250. [PMID: 31311501 PMCID: PMC6636102 DOI: 10.1186/s12884-019-2371-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 06/24/2019] [Indexed: 12/14/2022] Open
Abstract
Background China has made remarkable progress in maternal and child health (MCH) over the last thirty years, but socio-economic inequalities persist. Ethnicity has become an important determinant of poor MCH outcomes, but little rigorous analytical work has been done in this area. To understand the socio-economic factors that explain ethnic variation in uptake of MCH care, we report the findings from an analysis in Sichuan province. Methods We linked data from the 2003, 2008 and 2013 National Health Service Surveys in Sichuan Province. The ethnic disparities in uptake of maternal care (completing 5 antenatal visits, giving birth in hospital and receiving a caesarean section) and childhood immunization (Bacillus Calmette Guerin (BCG), three doses of diphtheria (DPT) and measles immunization) were examined by geographical (Han district/county vs. ethnic minority county) and individual-based (Han women/children vs. ethnic minority women/children) comparisons. We also examined variation by distance to township and county hospitals, women’s education, parity and age using weighted multilevel Poisson regressions with random intercept at district/county level. Results Ethnic inequalities in maternal care were marked, both at the geographical (district/county) and the individual level. The % of births in hospital was 90.7% among women in Han districts, compared to 83.3% among women living in Han counties (crude RR 0.93; 95% CI 0.75–1.15), 53.8% among Han women living in ethnic minority counties (crude RR 0.57; 95% CI 0.36–0.93), and 13.5% among ethnic minority women living in ethnic minority counties (crude RR 0.18; 95% CI 0.06–0.57). Adjusting the analysis for survey year, education, parity and distance to county level hospital weakened the association between geographical/individual ethnicity and uptake of maternity care, but associations remained remarkably strong. Coverage of childhood immunization was much higher than uptake of maternity care, and inequalities by ethnicity were much less pronounced. Conclusion Lessons can be learned from China’s successful immunization programme to further reduce inequalities in access to maternity care among ethnic minority populations in remote areas. Bringing the services closer to the women’s homes and strengthening health promotion from the township to the village level may encourage more women to seek antenatal care and give birth in hospital. Electronic supplementary material The online version of this article (10.1186/s12884-019-2371-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Juying Zhang
- Department of Epidemiology and Biostatistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yuchan Mou
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jiaqiang Liao
- Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, and State Key Laboratory of Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Huaying Xiong
- Department of Epidemiology and Biostatistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhanqi Duan
- Sichuan Health Information Center, Chengdu, Sichuan, China
| | - Yuan Huang
- School of Public Health, Kunming Medical University, Kunming, Yunnan, China
| | - Carine Ronsmans
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
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Mejía-Guevara I, Zuo W, Bendavid E, Li N, Tuljapurkar S. Age distribution, trends, and forecasts of under-5 mortality in 31 sub-Saharan African countries: A modeling study. PLoS Med 2019; 16:e1002757. [PMID: 30861006 PMCID: PMC6413894 DOI: 10.1371/journal.pmed.1002757] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 02/01/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Despite the sharp decline in global under-5 deaths since 1990, uneven progress has been achieved across and within countries. In sub-Saharan Africa (SSA), the Millennium Development Goals (MDGs) for child mortality were met only by a few countries. Valid concerns exist as to whether the region would meet new Sustainable Development Goals (SDGs) for under-5 mortality. We therefore examine further sources of variation by assessing age patterns, trends, and forecasts of mortality rates. METHODS AND FINDINGS Data came from 106 nationally representative Demographic and Health Surveys (DHSs) with full birth histories from 31 SSA countries from 1990 to 2017 (a total of 524 country-years of data). We assessed the distribution of age at death through the following new demographic analyses. First, we used a direct method and full birth histories to estimate under-5 mortality rates (U5MRs) on a monthly basis. Second, we smoothed raw estimates of death rates by age and time by using a two-dimensional P-Spline approach. Third, a variant of the Lee-Carter (LC) model, designed for populations with limited data, was used to fit and forecast age profiles of mortality. We used mortality estimates from the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) to adjust, validate, and minimize the risk of bias in survival, truncation, and recall in mortality estimation. Our mortality model revealed substantive declines of death rates at every age in most countries but with notable differences in the age patterns over time. U5MRs declined from 3.3% (annual rate of reduction [ARR] 0.1%) in Lesotho to 76.4% (ARR 5.2%) in Malawi, and the pace of decline was faster on average (ARR 3.2%) than that observed for infant (IMRs) (ARR 2.7%) and neonatal (NMRs) (ARR 2.0%) mortality rates. We predict that 5 countries (Kenya, Rwanda, Senegal, Tanzania, and Uganda) are on track to achieve the under-5 sustainable development target by 2030 (25 deaths per 1,000 live births), but only Rwanda and Tanzania would meet both the neonatal (12 deaths per 1,000 live births) and under-5 targets simultaneously. Our predicted NMRs and U5MRs were in line with those estimated by the UN IGME by 2030 and 2050 (they overlapped in 27/31 countries for NMRs and 22 for U5MRs) and by the Institute for Health Metrics and Evaluation (IHME) by 2030 (26/31 and 23/31, respectively). This study has a number of limitations, including poor data quality issues that reflected bias in the report of births and deaths, preventing reliable estimates and predictions from a few countries. CONCLUSIONS To our knowledge, this study is the first to combine full birth histories and mortality estimates from external reliable sources to model age patterns of under-5 mortality across time in SSA. We demonstrate that countries with a rapid pace of mortality reduction (ARR ≥ 3.2%) across ages would be more likely to achieve the SDG mortality targets. However, the lower pace of neonatal mortality reduction would prevent most countries from achieving those targets: 2 countries would reach them by 2030, 13 between 2030 and 2050, and 13 after 2050.
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Affiliation(s)
- Iván Mejía-Guevara
- Department of Biology, Stanford University, Stanford, California, United States of America
- Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, United States of America
| | - Wenyun Zuo
- Department of Biology, Stanford University, Stanford, California, United States of America
| | - Eran Bendavid
- Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California, United States of America
- Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, United States of America
| | - Nan Li
- United Nations Population Division, New York, New York, United States of America
| | - Shripad Tuljapurkar
- Department of Biology, Stanford University, Stanford, California, United States of America
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25
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Sarrassat S, Meda N, Badolo H, Ouedraogo M, Somé H, Cousens S. Distance to care, care seeking and child mortality in rural Burkina Faso: findings from a population-based cross-sectional survey. Trop Med Int Health 2018; 24:31-42. [PMID: 30347129 PMCID: PMC6378618 DOI: 10.1111/tmi.13170] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Objective Although distance has been identified as an important barrier to care, evidence for an effect of distance to care on child mortality is inconsistent. We investigated the association of distance to care with self‐reported care seeking behaviours, neonatal and post‐neonatal under‐five child mortality in rural areas of Burkina Faso. Methods We performed a cross‐sectional survey in 14 rural areas from November 2014 to March 2015. About 100 000 women were interviewed on their pregnancy history and about 5000 mothers were interviewed on their care seeking behaviours. Euclidean distances to the closest facility were calculated. Mixed‐effects logistic and Poisson regressions were used respectively to compute odds ratios for care seeking behaviours and rate ratios for child mortality during the 5 years prior to the survey. Results Thirty per cent of the children lived more than 7 km from a facility. After controlling for confounding factors, there was a strong evidence of a decreasing trend in care seeking with increasing distance to care (P ≤ 0.005). There was evidence for an increasing trend in early neonatal mortality with increasing distance to care (P = 0.028), but not for late neonatal mortality (P = 0.479) and post‐neonatal under‐five child mortality (P = 0.488). In their first week of life, neonates living 7 km or more from a facility had an 18% higher mortality rate than neonates living within 2 km of a facility (RR = 1.18; 95%CI 1.00, 1.39; P = 0.056). In the late neonatal period, despite the lack of evidence for an association of mortality with distance, it is noteworthy that rate ratios were consistent with a trend and similar to or larger than estimates in early neonatal mortality. In this period, neonates living 7 km or more from a facility had an 18% higher mortality rate than neonates living within 2 km of a facility (RR = 1.18; 95%CI 0.92, 1.52; P = 0.202). Thus, the lack of evidence may reflect lower power due to fewer deaths rather than a weaker association. Conclusion While better geographic access to care is strongly associated with increased care seeking in rural Burkina Faso, the impact on child mortality appears to be marginal. This suggests that, in addition to improving access to services, attention needs to be paid to quality of those services.
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Affiliation(s)
- S Sarrassat
- Centre for Maternal Adolescent Reproductive and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, UK
| | - N Meda
- Centre Muraz, Bobo Dioulasso, Burkina Faso
| | - H Badolo
- Centre Muraz, Bobo Dioulasso, Burkina Faso
| | | | - H Somé
- Africsanté, Bobo Dioulasso, Burkina Faso
| | - S Cousens
- Centre for Maternal Adolescent Reproductive and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, UK
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Labasangzhu, Bjertness E, McNeil EB, Deji, Guo Y, Songwathana P, Chongsuvivatwong V. Progress and challenges in improving maternal health in the Tibet Autonomous Region, China. Risk Manag Healthc Policy 2018; 11:221-231. [PMID: 30532605 PMCID: PMC6241686 DOI: 10.2147/rmhp.s170445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The maternal mortality ratio (MMR) of the Tibet Autonomous Region (hereinafter “Tibet”) is still five times higher than the national average. This study aims to identify the successes and pitfalls of the health system that might be related to the high mortality rate based on the WHO health system building blocks, focusing on human resources for health and health infrastructure and the impact on maternal health and outcomes. Methods Sources of information include China’s central government and Tibet’s local government policies and regulations, health statistical yearbooks, maternal and child health routine reporting system, and English and Chinese online research articles. Joinpoint analysis was applied for MMR and maternal health service trends, and correlation test was used to test the relationship between maternal health services and outcomes. Results Between 2000 and 2015, public health spending in Tibet increased 67-fold, the hospital delivery rate increased 70.1%, and the MMR dropped from 466.9 to 100.1 per 100,000 live births. However, the total number of health workers, qualified medical doctors, and registered nurses per 1,000 people were 4.4, 1.4, and 1.0, respectively, much lower than the national average (5.8, 1.8, and 2.4). In Tibet, there were 80 basic and 16 comprehensive emergency obstetric care (EOC) centers. On average, there were 12 basic and 2.5 comprehensive EOC centers per 500,000 of the population. Though it met the WHO’s recommendation, it might remain inadequate in the low population density of the area like Tibet. Conclusion The shortage of health professionals and EOC centers and health information in predominantly remote rural areas with a scattered population still needs to be rectified.
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Affiliation(s)
- Labasangzhu
- Department of Preventive Medicine, Tibet University Medical College, Lhasa, Tibet, China.,Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand,
| | - E Bjertness
- Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - E B McNeil
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand,
| | - Deji
- Department of Preventive Medicine, Tibet University Medical College, Lhasa, Tibet, China
| | - Y Guo
- Department of Health Policies and Management, School of Public Health, Peking University Health and Science Center, Beijing, China
| | - P Songwathana
- Department of Adult and Elderly Nursing, Faculty of Nursing, Prince of Songkla University, Hatyai, Songkhla, Thailand
| | - V Chongsuvivatwong
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand,
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Brault MA, Kennedy SB, Haley CA, Clarke AT, Duworko MC, Habimana P, Vermund SH, Kipp AM, Mwinga K. Factors influencing rapid progress in child health in post-conflict Liberia: a mixed methods country case study on progress in child survival, 2000-2013. BMJ Open 2018; 8:e021879. [PMID: 30327401 PMCID: PMC6196853 DOI: 10.1136/bmjopen-2018-021879] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/11/2018] [Accepted: 05/11/2018] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Only 12 countries in the WHO's African region met Millennium Development Goal 4 (MDG 4) to reduce under-five mortality by two-thirds by 2015. Given the variability across the African region, a four-country mixed methods study was undertaken to examine barriers and facilitators of child survival prior to 2015. Liberia was selected for an in-depth case study due to its success in reducing under-five mortality by 73% and thus successfully meeting MDG 4. Liberia's success was particularly notable given the civil war that ended in 2003. We examined some factors contributing to their reductions in under-five mortality. DESIGN A case study mixed methods approach drawing on data from quantitative indicators, national documents and qualitative interviews was used to describe factors that enabled Liberia to rebuild their maternal, neonatal and child health (MNCH) programmes and reduce under-five mortality following the country's civil war. SETTING The interviews were conducted in Monrovia (Montserrado County) and the areas in and around Gbarnga, Liberia (Bong County, North Central region). PARTICIPANTS Key informant interviews were conducted with Ministry of Health officials, donor organisations, community-based organisations involved in MNCH and healthcare workers. Focus group discussions were conducted with women who have experience accessing MNCH services. RESULTS Three prominent factors contributed to the reduction in under-five mortality: national prioritisation of MNCH after the civil war; implementation of integrated packages of services that expanded access to key interventions and promoted intersectoral collaborations; and use of outreach campaigns, community health workers and trained traditional midwives to expand access to care and improve referrals. CONCLUSIONS Although Liberia experiences continued challenges related to limited resources, Liberia's effective strategies and rapid progress may provide insights for reducing under-five mortality in other post-conflict settings.
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Affiliation(s)
- Marie A Brault
- Department of Anthropology, University of Connecticut, Storrs, Connecticut, USA
| | - Stephen B Kennedy
- University of Liberia-Pacific Institute for Research and Evaluation (UL-PIRE) Africa Center, University of Liberia, Monrovia, Liberia
| | - Connie A Haley
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Musu C Duworko
- Liberia Country office, World Health Organization, Monrovia, Liberia
| | - Phanuel Habimana
- Regional Office for Africa, World Health Organization, Brazzaville, Congo
| | - Sten H Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, USA
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aaron M Kipp
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kasonde Mwinga
- Regional Office for Africa, World Health Organization, Brazzaville, Congo
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Fahim SM, Bhuayan TA, Hassan MZ, Abid Zafr AH, Begum F, Rahman MM, Alam S. Financing health care in Bangladesh: Policy responses and challenges towards achieving universal health coverage. Int J Health Plann Manage 2018; 34:e11-e20. [PMID: 30238490 DOI: 10.1002/hpm.2666] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 08/26/2018] [Indexed: 11/08/2022] Open
Abstract
Bangladesh has attained notable progress in most of the health indicators, but still, health system of the country is suffering badly from poor funding. Issues like burden of out-of-pocket expenditure, low per capita share in health, inadequate service facilities, and financial barriers in reducing malnutrition are being overlooked due to inadequacy and inappropriate utilization of allocated funds. We aimed to review the current status of health care spending in Bangladesh in response to national health policy (NHP) and determine the future challenges towards achieving universal health coverage (UHC). National health policy suggested a substantial increase in budgetary allocation for health care, although government health care expenditures in proportion to total public spending plummeted down from 6.2% to 4.04% in the past 8 years. Overall, 67% of the health care cost is being paid by people, whereas global standard is below 32%. Only one hospital bed is allocated per 1667 people, and 34% of total posts in health sector are vacant due to scarcity of funds. The country is experiencing demographic dividend with a concurrent rise of aged people, but there seems no financial protection schemes for the aged and working age populations. Such situation results in multiple obstacles in achieving financial risk protection as well as UHC. Policy makers must think effectively to develop and adapt systems in order to achieve UHC and ensure health for all.
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Affiliation(s)
| | | | | | | | - Farhana Begum
- Directorate of Secondary and Higher Education, Ministry of Education, Dhaka, Bangladesh
| | - Md Mizanur Rahman
- Department of Global Health Policy, School of International Health, University of Tokyo, Japan
| | - Shahinul Alam
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
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Schneider H, Maleka N. Patterns of authorship on community health workers in low-and-middle-income countries: an analysis of publications (2012-2016). BMJ Glob Health 2018; 3:e000797. [PMID: 29765777 PMCID: PMC5950650 DOI: 10.1136/bmjgh-2018-000797] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 03/23/2018] [Accepted: 04/06/2018] [Indexed: 02/07/2023] Open
Abstract
Introduction Studies of authorship provide a barometer of local research capacity and ownership of research, considered key to defining appropriate research priorities, developing contextualised responses to health problems and ensuring that research informs policy and practice. This paper reports on an analysis of patterns of research authorship of the now substantial literature on community health workers (CHWs) in low-and-middle-income countries (LMICs) for the 5-year period: 2012–2016. Methods A search of five databases identified a total of 649 indexed publications reporting on CHWs in LMICs and meeting the inclusion criteria. The country, region and income classification of studies, affiliations (country, organisation) of lead (first) and last authors, proportions of all authors locally affiliated, programme area (eg, maternal child health) and funding source were extracted. Results The 649 papers reported experiences from 51 countries, 55% from middle-income countries (MICs) and 32% from low-income countries (LICs), with the remaining 13% multicountry studies. Overall, 47% and 54% of all the papers had a high-income country (HIC) lead and last author, respectively. Authorship followed three patterns: (1) a concentrated HIC pattern, with US-based authors numerically dominating LIC-based and multicountry studies; (2) an MIC pattern of autonomy, with a handful of countries—India, South Africa and Brazil, in particular—leading >70% of their CHW publications and (3) a pattern of unevenness among LICs in their lead authorship of publications varying from 14% (Malawi) to 54% (Uganda). Region, programme area and funding source were all associated with the distribution of authorship across country income categories. Conclusion The findings in this analysis mirror closely that of other authorship studies in global health. Collectively these provide a common message—that investments in global health programmes in the Millennium Development Goal era may have benefited health but not necessarily capacity for knowledge generation in LMICs.
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Affiliation(s)
- Helen Schneider
- School of Public Health and SAMRC/UWC Health Services to Systems Research Unit, University of the Western Cape, Cape Town, South Africa
| | - Nelisiwe Maleka
- School of Public Health, University of the Western Cape, Cape Town, South Africa
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Ruducha J, Mann C, Singh NS, Gemebo TD, Tessema NS, Baschieri A, Friberg I, Zerfu TA, Yassin M, Franca GA, Berman P. How Ethiopia achieved Millennium Development Goal 4 through multisectoral interventions: a Countdown to 2015 case study. LANCET GLOBAL HEALTH 2018; 5:e1142-e1151. [PMID: 29025635 PMCID: PMC5640803 DOI: 10.1016/s2214-109x(17)30331-5] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/26/2017] [Accepted: 08/08/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND 3 years before the 2015 deadline, Ethiopia achieved Millennium Development Goal 4. The under-5 mortality decreased 69%, from 205 deaths per 1000 livebirths in 1990 to 64 deaths per 1000 livebirths in 2013. To understand the underlying factors that contributed to the success in achieving MDG4, Ethiopia was selected as a Countdown to 2015 case study. METHODS We used a set of complementary methods to analyse progress in child health in Ethiopia between 1990 and 2014. We used Demographic Health Surveys to analyse trends in coverage and equity of key reproductive, maternal health, and child health indicators. Standardised tools developed by the Countdown Health Systems and Policies working group were used to understand the timing and content of health and non-health policies. We assessed longitudinal trends in health-system investment through a financial analysis of National Health Accounts, and we used the Lives Saved Tool (LiST) to assess the contribution of interventions towards reducing under-5 mortality. FINDINGS The annual rate of reduction in under-5 mortality increased from 3·3% in 1990-2005 to 7·8% in 2005-13. The prevalence of stunting decreased from 60% in 2000 to 40% in 2014. Overall levels of coverage of reproductive, maternal health, and child health indicators remained low, with disparities between the lowest and highest wealth quintiles despite improvement in coverage for essential health interventions. Coverage of child immunisation increased the most (21% of children in 2000 vs 80% of children in 2014), followed by coverage of satisfied demand for family planning by women of reproductive age (19% vs 63%). Provision of antenatal care increased from 10% of women in 2000 to 32% of women in 2014, but only 15% of women delivered with a skilled birth attendant by 2014. A large upturn occurred after 2005, bolstered by a rapid increase in health funding that facilitated the accelerated expansion of health infrastructure and workforce through an innovative community-based delivery system. The LiST model could explain almost 50% of the observed reduction in child mortality between 2000 and 2011; and changes in nutritional status were responsible for about 50% of the 469 000 lives saved between 2000 and 2011. These developments occurred within a multisectoral policy platform, integrating child survival and stunting goals within macro-level policies and programmes for reducing poverty and improving agricultural productivity, food security, water supply, and sanitation. INTERPRETATION The reduction of under-5 mortality in Ethiopia was the result of combined activities in health, nutrition, and non-health sectors. However, Ethiopia still has high neonatal and maternal morbidity and mortality from preventable causes and an unfinished agenda in reducing inequalities, improving coverage of effective interventions, and strengthening multisectoral partnerships for further progress. FUNDING Bill & Melinda Gates Foundation and Government of Canada.
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Affiliation(s)
| | - Carlyn Mann
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Neha S Singh
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Tsegaye D Gemebo
- School of Public Health, Woliata Sodo University, Woliata Sodo, SNNPR, Ethiopia
| | | | - Angela Baschieri
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Taddese A Zerfu
- Maternal and Child Health Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia; Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Mohammed Yassin
- Amhara Regional Health Bureau, South Wollo and Dessie City, Ethiopia
| | | | - Peter Berman
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
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Golding N, Burstein R, Longbottom J, Browne AJ, Fullman N, Osgood-Zimmerman A, Earl L, Bhatt S, Cameron E, Casey DC, Dwyer-Lindgren L, Farag TH, Flaxman AD, Fraser MS, Gething PW, Gibson HS, Graetz N, Krause LK, Kulikoff XR, Lim SS, Mappin B, Morozoff C, Reiner RC, Sligar A, Smith DL, Wang H, Weiss DJ, Murray CJL, Moyes CL, Hay SI. Mapping under-5 and neonatal mortality in Africa, 2000-15: a baseline analysis for the Sustainable Development Goals. Lancet 2017; 390:2171-2182. [PMID: 28958464 PMCID: PMC5687451 DOI: 10.1016/s0140-6736(17)31758-0] [Citation(s) in RCA: 175] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/03/2017] [Accepted: 06/26/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND During the Millennium Development Goal (MDG) era, many countries in Africa achieved marked reductions in under-5 and neonatal mortality. Yet the pace of progress toward these goals substantially varied at the national level, demonstrating an essential need for tracking even more local trends in child mortality. With the adoption of the Sustainable Development Goals (SDGs) in 2015, which established ambitious targets for improving child survival by 2030, optimal intervention planning and targeting will require understanding of trends and rates of progress at a higher spatial resolution. In this study, we aimed to generate high-resolution estimates of under-5 and neonatal all-cause mortality across 46 countries in Africa. METHODS We assembled 235 geographically resolved household survey and census data sources on child deaths to produce estimates of under-5 and neonatal mortality at a resolution of 5 × 5 km grid cells across 46 African countries for 2000, 2005, 2010, and 2015. We used a Bayesian geostatistical analytical framework to generate these estimates, and implemented predictive validity tests. In addition to reporting 5 × 5 km estimates, we also aggregated results obtained from these estimates into three different levels-national, and subnational administrative levels 1 and 2-to provide the full range of geospatial resolution that local, national, and global decision makers might require. FINDINGS Amid improving child survival in Africa, there was substantial heterogeneity in absolute levels of under-5 and neonatal mortality in 2015, as well as the annualised rates of decline achieved from 2000 to 2015. Subnational areas in countries such as Botswana, Rwanda, and Ethiopia recorded some of the largest decreases in child mortality rates since 2000, positioning them well to achieve SDG targets by 2030 or earlier. Yet these places were the exception for Africa, since many areas, particularly in central and western Africa, must reduce under-5 mortality rates by at least 8·8% per year, between 2015 and 2030, to achieve the SDG 3.2 target for under-5 mortality by 2030. INTERPRETATION In the absence of unprecedented political commitment, financial support, and medical advances, the viability of SDG 3.2 achievement in Africa is precarious at best. By producing under-5 and neonatal mortality rates at multiple levels of geospatial resolution over time, this study provides key information for decision makers to target interventions at populations in the greatest need. In an era when precision public health increasingly has the potential to transform the design, implementation, and impact of health programmes, our 5 × 5 km estimates of child mortality in Africa provide a baseline against which local, national, and global stakeholders can map the pathways for ending preventable child deaths by 2030. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Nick Golding
- School of BioSciences, University of Melbourne, Parkville, VIC, Australia
| | - Roy Burstein
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Joshua Longbottom
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Annie J Browne
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Nancy Fullman
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | | | - Lucas Earl
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Samir Bhatt
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK; Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Ewan Cameron
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Daniel C Casey
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Laura Dwyer-Lindgren
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Tamer H Farag
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Abraham D Flaxman
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Maya S Fraser
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Peter W Gething
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Harry S Gibson
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Nicholas Graetz
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | | | - Xie Rachel Kulikoff
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Stephen S Lim
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Bonnie Mappin
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Chloe Morozoff
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Robert C Reiner
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Amber Sligar
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - David L Smith
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Haidong Wang
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Daniel J Weiss
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | | | - Catherine L Moyes
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Simon I Hay
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK; Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
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Effective nutrition education and communication for sustainable maternal and child health. Proc Nutr Soc 2017; 76:504-515. [PMID: 28662730 DOI: 10.1017/s0029665117001070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Maternal and child health (MCH) consists of an interdependent reproductive system that collectively determines the survival of the mother during childbirth, and determines the health and survival of the child. This interdependency underscores the importance of appropriate and timely interventions during pregnancy through the first 1000 d at the minimum. The Millennium Development Goals (MDG) recommended the use of the continuum of care for the development of interventions by addressing all the stages of MCH. The purpose of the present paper is to review the factors that contributed to the attainment of the MDG 4 and MDG 5 by analysing the interventions conducted by the countries that achieved at least 5·0 and 5·5 %, respectively, and determine the level of their intervention based on the MCH conceptual framework. Out of the eighteen selected countries discussed, fifteen countries achieved their target for either MDG 4 or MDG 5 or both, while three countries did not achieve their target. The countries that were more likely to achieve their targets addressed the societal, underlying and direct causes, and implemented country wide policies. In contrast, the countries that did not succeed were more likely to address the direct causes with poor policy implementation. Understanding the motivation and limitations of the target population, including nutrition education and targeting behaviour change has the potential to result in sustainable MCH. This information has the potential to enlighten the policymakers as we progress to the sustainable development goals, specifically goals 2 and 3.
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Pitt C, Grollman C, Martínez-Álvarez M, Arregoces L, Lawn JE, Borghi J. Countdown to 2015: an analysis of donor funding for prenatal and neonatal health, 2003-2013. BMJ Glob Health 2017; 2:e000205. [PMID: 28589020 PMCID: PMC5435259 DOI: 10.1136/bmjgh-2016-000205] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 01/05/2017] [Accepted: 01/11/2017] [Indexed: 01/07/2023] Open
Abstract
Background In 2015, 5.3 million babies died in the third trimester of pregnancy and first month following birth. Progress in reducing neonatal mortality and stillbirth rates has lagged behind the substantial progress in reducing postneonatal and maternal mortality rates. The benefits to prenatal and neonatal health (PNH) from maternal and child health investments cannot be assumed. Methods We analysed donor funding for PNH over the period 2003–2013. We used an exhaustive key term search followed by manual review and classification to identify official development assistance and private grant (ODA+) disbursement records in the Countdown to 2015 ODA+ Database. Results The value of ODA+ mentioning PNH or an activity that would directly benefit PNH increased from $105 million in 2003 to $1465 million in 2013, but this included a 3% decline between 2012 and 2013. Projects exclusively benefitting PNH reached just $6 million in 2013. Records mentioning PNH accounted for 3% of the $2708 million disbursed in 2003 for maternal, newborn and child health (MNCH) and increased to 13% of the $9287 million disbursed for MNCH in 2013. In 11 years, only nine records ($6 million) mentioned stillbirth, miscarriage, or the fetus, although the two leading infectious causes of stillbirth were mentioned in records worth $832 million. The USA disbursed the most ODA+ mentioning PNH ($2848 million, 40% of the total) and Unicef disbursed the most ODA+ exclusively benefitting PNH ($18 million, 30%). We found evidence that funding mentioning and exclusively benefitting PNH was targeted to countries with greater economic needs, but the evidence of targeting to health needs was weak and inconsistent. Conclusions Newborn health rose substantially on the global agenda between 2003 and 2013, but prenatal health received minimal attention in donor funding decisions. Declines in 2013 and persistently low funding exclusively benefitting PNH indicate a need for caution and continued monitoring of donors' support for newborn health.
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Affiliation(s)
- Catherine Pitt
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Christopher Grollman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Melisa Martínez-Álvarez
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Leonardo Arregoces
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Joy E Lawn
- Maternal, Adolescent, Reproductive, and Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Berman P, Requejo J, Bhutta ZA, Singh NS, Owen H, Lawn JE. Countries’ progress for women’s and children’s health in the Millennium Development Goal era: the Countdown to 2015 experience. BMC Public Health 2016. [PMCID: PMC5025817 DOI: 10.1186/s12889-016-3398-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Singh NS, Huicho L, Afnan-Holmes H, John T, Moran AC, Colbourn T, Grundy C, Matthews Z, Maliqi B, Mathai M, Daelmans B, Requejo J, Lawn JE. Countdown to 2015 country case studies: systematic tools to address the "black box" of health systems and policy assessment. BMC Public Health 2016; 16 Suppl 2:790. [PMID: 27634035 PMCID: PMC5025822 DOI: 10.1186/s12889-016-3402-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Evaluating health systems and policy (HSP) change and implementation is critical in understanding reproductive, maternal, newborn and child health (RMNCH) progress within and across countries. Whilst data for health outcomes, coverage and equity have advanced in the last decade, comparable analyses of HSP changes are lacking. We present a set of novel tools developed by Countdown to 2015 (Countdown) to systematically analyse and describe HSP change for RMNCH indicators, enabling multi-country comparisons. METHODS International experts worked with eight country teams to develop HSP tools via mixed methods. These tools assess RMNCH change over time (e.g. 1990-2015) and include: (i) Policy and Programme Timeline Tool (depicting change according to level of policy); (ii) Health Policy Tracer Indicators Dashboard (showing 11 selected RMNCH policies over time); (iii) Health Systems Tracer Indicators Dashboard (showing four selected systems indicators over time); and (iv) Programme implementation assessment. To illustrate these tools, we present results from Tanzania and Peru, two of eight Countdown case studies. RESULTS The Policy and Programme Timeline tool shows that Tanzania's RMNCH environment is complex, with increased funding and programmes for child survival, particularly primary-care implementation. Maternal health was prioritised since mid-1990s, yet with variable programme implementation, mainly targeting facilities. Newborn health only received attention since 2005, yet is rapidly scaling-up interventions at facility- and community-levels. Reproductive health lost momentum, with re-investment since 2010. Contrastingly, Peru moved from standalone to integrated RMNCH programme implementation, combined with multi-sectoral, anti-poverty strategies. The HSP Tracer Indicators Dashboards show that Peru has adopted nine of 11 policy tracer indicators and Tanzania has adopted seven. Peru costed national RMNCH plans pre-2000, whereas Tanzania developed a national RMNCH plan in 2006 but only costed the reproductive health component. Both countries included all lifesaving RMNCH commodities on their essential medicines lists. Peru has twice the health worker density of Tanzania (15.4 vs. 7.1/10,000 population, respectively), although both are below the 22.8 WHO minimum threshold. CONCLUSIONS These are the first HSP tools using mixed methods to systematically analyse and describe RMNCH changes within and across countries, important in informing accelerated progress for ending preventable maternal, newborn and child mortality in the post-2015 era.
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Affiliation(s)
- Neha S. Singh
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
| | - Luis Huicho
- Centro de Investigación para el Desarrollo Integral y Sostenible, Universidad Peruana Cayetano Heredia, Lima, Peru
- School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
- Instituto Nacional de Salud del Niño, Lima, Peru
| | | | - Theopista John
- World Health Organisation, PO Box 9292, Dar es Salaam, Tanzania
| | - Allisyn C. Moran
- US Agency for International Development, Bureau of Global Health, Office of Health, Infectious Disease and Nutrition, Washington DC, USA
| | - Tim Colbourn
- Institute for Global Health, University College London, London, SW7 2AZ UK
| | - Chris Grundy
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
| | - Zoe Matthews
- Division of Social Statistics and Demography, University of Southampton, Highfield, Southampton SO17 1BJ UK
| | - Blerta Maliqi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva 27, 1211 Switzerland
| | - Matthews Mathai
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva 27, 1211 Switzerland
| | - Bernadette Daelmans
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva 27, 1211 Switzerland
| | - Jennifer Requejo
- Partnership for Maternal, Newborn & Child Health, Geneva 27, 1211 Switzerland
| | - Joy E. Lawn
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
| | - On behalf of the Countdown to 2015 Health Systems and Policies Technical Working Group
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
- Centro de Investigación para el Desarrollo Integral y Sostenible, Universidad Peruana Cayetano Heredia, Lima, Peru
- School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
- Instituto Nacional de Salud del Niño, Lima, Peru
- Independent consultant, London, UK
- World Health Organisation, PO Box 9292, Dar es Salaam, Tanzania
- US Agency for International Development, Bureau of Global Health, Office of Health, Infectious Disease and Nutrition, Washington DC, USA
- Institute for Global Health, University College London, London, SW7 2AZ UK
- Division of Social Statistics and Demography, University of Southampton, Highfield, Southampton SO17 1BJ UK
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva 27, 1211 Switzerland
- Partnership for Maternal, Newborn & Child Health, Geneva 27, 1211 Switzerland
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Mann C, Ng C, Akseer N, Bhutta ZA, Borghi J, Colbourn T, Hernández-Peña P, Huicho L, Malik MA, Martinez-Alvarez M, Munthali S, Salehi AS, Tadesse M, Yassin M, Berman P. Countdown to 2015 country case studies: what can analysis of national health financing contribute to understanding MDG 4 and 5 progress? BMC Public Health 2016; 16 Suppl 2:792. [PMID: 27634209 PMCID: PMC5025819 DOI: 10.1186/s12889-016-3403-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Countdown to 2015 (Countdown) supported countries to produce case studies that examine how and why progress was made toward the Millennium Development Goals (MDGs) 4 and 5. Analysing how health-financing data explains improvements in RMNCH outcomes was one of the components to the case studies. METHODS This paper presents a descriptive analysis on health financing from six Countdown case studies (Afghanistan, Ethiopia, Malawi, Pakistan, Peru, and Tanzania), supplemented by additional data from global databases and country reports on macroeconomic, health financing, demographic, and RMNCH outcome data as needed. It also examines the effect of other contextual factors presented in the case studies to help interpret health-financing data. RESULTS Dramatic increases in health funding occurred since 2000, where the MDG agenda encouraged countries and donors to invest more resources on health. Most low-income countries relied on external support to increase health spending, with an average 20-64 % of total health spending from 2000 onwards. Middle-income countries relied more on government and household spending. RMNCH funding also increased since 2000, with an average increase of 119 % (2005-2010) for RMNH expenditures (2005-2010) and 165 % for CH expenditures (2005-2011). Progress was made, especially achieving MDG 4, even with low per capita spending; ranging from US$16 to US$44 per child under 5 years among low-income countries. Improvements in distal factors were noted during the time frame of the analysis, including rapid economic growth in Ethiopia, Peru, and Tanzania and improvements in female literacy as documented in Malawi, which are also likely to have contributed to MDG progress and achievements. CONCLUSIONS Increases in health and RMNCH funding accompanied improvements in outcomes, though low-income countries are still very reliant on external financing, and out-of-pocket comprising a growing share of funds in middle-income settings. Enhancements in tracking RMNCH expenditures across countries are still needed to better understand whether domestic and global health financing initiatives lead to improved outcomes as RMNCH continues to be a priority under the Sustainable Development Goals.
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Affiliation(s)
- Carlyn Mann
- Global Health and Population Department, Harvard T.H. Chan School of Public Health, Boston, MA 02115 USA
| | - Courtney Ng
- Global Health and Population Department, Harvard T.H. Chan School of Public Health, Boston, MA 02115 USA
| | - Nadia Akseer
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, M5G 1X8 Canada
| | - Zulfiqar A Bhutta
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, 74800 Pakistan
- Centre for Global Child Health, The Hospital for Sick Children, 686 Bay Street, Toronto, Ontario M5G 0A4 Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Josephine Borghi
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
| | - Tim Colbourn
- Institute for Global Health, University College London, London, WC1N 1EH UK
| | - Patricia Hernández-Peña
- Netherlands Interdisciplinary Demographic Institute (NIDI), The Hague, NL-2511 CV The Netherlands
| | - Luis Huicho
- Centro de Investigación para el Desarrollo Integral y Sostenible and School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
- School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
- Instituto Nacional de Salud del Niño, Lima, Peru
| | - Muhammad Ashar Malik
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, 74800 Pakistan
| | | | - Spy Munthali
- Economics Department, University of Malawi, Zomba, Malawi
| | | | - Mekonnen Tadesse
- Ethiopian Public Health Institute, Health System Research, Addis Ababa, Ethiopia
| | - Mohammed Yassin
- Ethiopian Public Health Institute, Health System Research, Addis Ababa, Ethiopia
| | - Peter Berman
- Global Health and Population Department, Harvard T.H. Chan School of Public Health, Boston, MA 02115 USA
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Barroso C, Lichuma W, Mason E, Lehohla P, Paul VK, Pkhakadze G, Wickremarathne D, Yamin AE. Accountability for women’s, children’s and adolescents’ health in the Sustainable Development Goal era. BMC Public Health 2016. [PMCID: PMC5025826 DOI: 10.1186/s12889-016-3399-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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