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Melesse DY, Tadele A, Mulu S, Spicer N, Tadelle T, Wado YD, Gajaa M, Arja A, Blumenberg C, Manaye T, Gonfa G, du Plessis E, Hamilton E, Mihretu A, Usamael A, Mengesha M, Kassahun Gelaw S, Worku A, Woldie M, Abate B, Getachew T, Wondirad N, Zelalem M, Tollera G, Boerma T. Learning from Ethiopia's success in reducing maternal and neonatal mortality through a health systems lens. BMJ Glob Health 2024; 9:e011911. [PMID: 38770809 PMCID: PMC11085893 DOI: 10.1136/bmjgh-2023-011911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/29/2023] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND This study aimed to enhance insights into the key characteristics of maternal and neonatal mortality declines in Ethiopia, conducted as part of a seven-country study on Maternal and Newborn Health (MNH) Exemplars. METHODS We synthesised key indicators for 2000, 2010 and 2020 and contextualised those with typical country values in a global five-phase model for a maternal, stillbirth and neonatal mortality transition. We reviewed health system changes relevant to MNH over the period 2000-2020, focusing on governance, financing, workforce and infrastructure, and assessed trends in mortality, service coverage and systems by region. We analysed data from five national surveys, health facility assessments, global estimates and government databases and reports on health policies, infrastructure and workforce. RESULTS Ethiopia progressed from the highest mortality phase to the third phase, accompanied by typical changes in terms of fertility decline and health system strengthening, especially health infrastructure and workforce. For health coverage and financing indicators, Ethiopia progressed but remained lower than typical in the transition model. Maternal and neonatal mortality declines and intervention coverage increases were greater after 2010 than during 2000-2010. Similar patterns were observed in most regions of Ethiopia, though regional gaps persisted for many indicators. Ethiopia's progress is characterised by a well-coordinated and government-led system prioritising first maternal and later neonatal health, resulting major increases in access to services by improving infrastructure and workforce from 2008, combined with widespread community actions to generate service demand. CONCLUSION Ethiopia has achieved one of the fastest declines in mortality in sub-Saharan Africa, with major intervention coverage increases, especially from 2010. Starting from a weak health infrastructure and low coverage, Ethiopia's comprehensive approach provides valuable lessons for other low-income countries. Major increases towards universal coverage of interventions, including emergency care, are critical to further reduce mortality and advance the mortality transition.
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Affiliation(s)
- Dessalegn Y Melesse
- Countdown to 2030 for Women's, Children's and Adolescents' Health, Institute for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Epidemiology and Biostatistics, School of Public Health, Bahir Dar University, Bahir Dar, Ethiopia
| | - Ashenif Tadele
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Shegaw Mulu
- Maternal and Child Health Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Neil Spicer
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Tefera Tadelle
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Yohannes D Wado
- African Population and Health Research Center, Nairobi, Kenya
| | - Mulugeta Gajaa
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Asrat Arja
- National Data Management Center for Health, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Cauane Blumenberg
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- causale consultoria, Pelotas, Brazil
| | - Tewabe Manaye
- Maternal and Child Health Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Geremew Gonfa
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Elsabe du Plessis
- Countdown to 2030 for Women's, Children's and Adolescents' Health, Institute for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Elisabeth Hamilton
- Countdown to 2030 for Women's, Children's and Adolescents' Health, Institute for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Awoke Mihretu
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Abdurehman Usamael
- Maternal and Child Health Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Magdelawit Mengesha
- Maternal and Child Health Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Solomon Kassahun Gelaw
- Maternal and Child Health Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Aschale Worku
- Maternal and Child Health Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Mirkuzie Woldie
- Maternal and Child Health Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Biruk Abate
- Maternal and Child Health Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Theodros Getachew
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Naod Wondirad
- Policy, Planning, Monitoring & Evaluation Directorate, Ethiopia Ministry of Health, Addis Ababa, Ethiopia
| | - Meseret Zelalem
- Maternal, Child and Adolescent Health Lead Executive, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Getachew Tollera
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Ties Boerma
- Countdown to 2030 for Women's, Children's and Adolescents' Health, Institute for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Chaze M, Mériade L, Rochette C, Bailly M, Bingula R, Blavignac C, Duclos M, Evrard B, Fournier AC, Pelissier L, Thivel D. Relying on the French territorial offer of thermal spa therapies to build a care pathway for long COVID-19 patients. PLoS One 2024; 19:e0302392. [PMID: 38640090 PMCID: PMC11029631 DOI: 10.1371/journal.pone.0302392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 03/26/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Work on long COVID-19 has mainly focused on clinical care in hospitals. Thermal spa therapies represent a therapeutic offer outside of health care institutions that are nationally or even internationally attractive. Unlike local care (hospital care, general medicine, para-medical care), their integration in the care pathways of long COVID-19 patients seems little studied. The aim of this article is to determine what place french thermal spa therapies can take in the care pathway of long COVID-19 patients. METHODS Based on the case of France, we carry out a geographic mapping analysis of the potential care pathways for long COVID-19 patients by cross-referencing, over the period 2020-2022, the available official data on COVID-19 contamination, hospitalisations in intensive care units and the national offer of spa treatments. This first analysis allows us, by using the method for evaluating the attractiveness of an area defined by David Huff, to evaluate the accessibility of each French department to thermal spas. RESULTS Using dynamic geographical mapping, this study describes two essential criteria for the integration of the thermal spa therapies offer in the care pathways of long COVID-19 patients (attractiveness of spa areas and accessibility to thermal spas) and three fundamental elements for the success of these pathways (continuity of the care pathways; clinical collaborations; adaptation of the financing modalities to each patient). Using a spatial attractiveness method, we make this type of geographical analysis more dynamic by showing the extent to which a thermal spa is accessible to long COVID-19 patients. CONCLUSION Based on the example of the French spa offer, this study makes it possible to place the care pathways of long COVID-19 patients in a wider area (at least national), rather than limiting them to clinical and local management in a hospital setting. The identification and operationalization of two geographical criteria for integrating a type of treatment such as a spa cure into a care pathway contributes to a finer conceptualization of the construction of healthcare pathways.
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Affiliation(s)
- Milhan Chaze
- University of Clermont Auvergne, “Santé et Territoires” Resarch Chair, CleRMa, Clermont-Ferrand, France
| | - Laurent Mériade
- University of Clermont Auvergne, “Santé et Territoires” Resarch Chair, CleRMa, Clermont-Ferrand, France
| | - Corinne Rochette
- University of Clermont Auvergne, “Santé et Territoires” Resarch Chair, CleRMa, Clermont-Ferrand, France
| | - Mélina Bailly
- University of Clermont Auvergne, CRNH, AME2P, Clermont-Ferrand, France
| | - Rea Bingula
- CHU Clermont-Ferrand, Service d’Immunologie, CHU Gabriel-Montpied, Clermont-Ferrand, France
- University of Clermont Auvergne, INRA, UMR 1019, Clermont-Ferrand, France
| | - Christelle Blavignac
- Centre Imagerie Cellulaire Santé, University of Clermont Auvergne, Clermont-Ferrand, France
| | - Martine Duclos
- University of Clermont Auvergne, INRA, UMR 1019, Clermont-Ferrand, France
- Service de Médecine du Sport et des Explorations Fonctionnelles, CHU de Clermont-Ferrand, Université Clermont Auvergne, INRA, UNH, Unité de Nutrition Humaine, CRNH Auvergne, Clermont-Ferrand, France
| | - Bertrand Evrard
- CHU Clermont-Ferrand, Service d’Immunologie, CHU Gabriel-Montpied, Clermont-Ferrand, France
- University of Clermont Auvergne, INRA, UMR 1019, Clermont-Ferrand, France
| | | | - Lena Pelissier
- University of Clermont Auvergne, CRNH, AME2P, Clermont-Ferrand, France
| | - David Thivel
- University of Clermont Auvergne, CRNH, AME2P, Clermont-Ferrand, France
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Creanga AA, Dohlsten MA, Stierman EK, Moran AC, Mary M, Katwan E, Maliqi B. Maternal health policy environment and the relationship with service utilization in low- and middle-income countries. J Glob Health 2023; 13:04025. [PMID: 36892948 PMCID: PMC9997690 DOI: 10.7189/jogh.13.04025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023] Open
Abstract
Background The extent to which a favorable policy environment influences health care utilization and outcomes for pregnant and postpartum women is largely unknown. In this study, we aimed to describe the maternal health policy environment and examines its relationship with maternal health service utilization in low- and middle-income countries (LMICs). Methods We used data from World Health Organization's 2018-2019 sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH) policy survey linked with key contextual variables from global databases, as well as UNICEF data on antenatal care (ANC), institutional delivery, and postnatal care (PNC) utilization in 113 LIMCs. We grouped maternal health policy indicators into four categories - national supportive structures and standards, service access, clinical guidelines, and reporting and review systems. For each category and overall, we calculated summative scores accounting for available policy indicators in each country. We explored variations of policy indicators by World Bank income group using χ2 tests and fitted logistic regression models for ≥85% coverage for each of four or more antenatal care visits (ANC4+), institutional delivery, PNC for the mothers, and for all ANC4+, institutional delivery, and PNC for mothers, adjusting for policy scores and contextual variables. Results The average scores for the four policy categories were as follows: 3 for national supportive structures and standards (score range = 0-4), 5.5 for service access (score range = 0-7), 6. for clinical guidelines (score range = 0-10), and 5.7 for reporting and review systems (score range = 0-7), for an average total policy score of 21.1 (score range = 0-28) across LMICs. After adjusting for country context variables, for each unit increase in the maternal health policy score, the odds of ANC4+>85% increased by 37% (95% confidence interval (CI) = 1.13-1.64) and the odds of all ANC4+, institutional deliveries and PNC>85% by 31% (95% CI = 1.07-1.60). Conclusions Despite the availability of supportive structures and free maternity service access policies, there is a dire need for stronger policy support for clinical guidelines and practice regulations, as well as national reporting and review systems for maternal health. A more favorable policy environment for maternal health can improve adoption of evidence-based interventions and increase utilization of maternal health services in LMICs.
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Affiliation(s)
- Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Martin Aj Dohlsten
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Elizabeth K Stierman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Allisyn C Moran
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Meighan Mary
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth Katwan
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Blerta Maliqi
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
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Mary M, Maliqi B, Stierman EK, Dohlsten MA, Moran AC, Katwan E, Creanga AA. Assessing the neonatal health policy landscape in low- and middle-income countries: Findings from the 2018 WHO SRMNCAH policy survey. J Glob Health 2023; 13:04024. [PMID: 36867415 PMCID: PMC9983710 DOI: 10.7189/jogh.13.04024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
Background We aimed to describe the availability of newborn health policies across the continuum of care in low- and middle-income countries (LMICs) and to assess the relationship between the availability of newborn health policies and their achievement of global Sustainable Development Goal and Every Newborn Action Plan (ENAP) neonatal mortality and stillbirth rate targets in 2019. Methods We used data from World Health Organization's 2018-2019 sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) Policy Survey and extracted key newborn health service delivery and cross-cutting health systems policies that align with the WHO health system building blocks. We constructed composite measures to represent packages of newborn health policies for five components along the continuum of care: antenatal care (ANC), childbirth, postnatal care (PNC), essential newborn care (ENC), and management of small and sick newborns (SSNB). We used descriptive analyses to present the differences in the availability of newborn health service delivery policies by World Bank income group in 113 LMICs. We employed logistic regression analysis to assess the relationship between the availability of each composite newborn health policy package and achievement of global neonatal mortality and stillbirth rate targets by 2019. Results In 2018, most LMICs had existing policies regarding newborn health across the continuum of care. However, policy specifications varied widely. While the availability of the ANC, childbirth, PNC, and ENC policy packages was not associated with having achieved global NMR targets by 2019, LMICs with existing policy packages on the management of SSNB were 4.4 times more likely to have reached the global NMR target (adjusted odds ratio (aOR) = 4.40; 95% confidence interval (CI) = 1.09-17.79) after controlling for income group and supporting health systems policies. Conclusions Given the current trajectory of neonatal mortality in LMICs, there is a dire need for supportive health systems and policy environments for newborn health across the continuum of care. Adoption and implementation of evidence-informed newborn health policies will be a crucial step in putting LMICs on track to meet global newborn and stillbirth targets by 2030.
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Affiliation(s)
- Meighan Mary
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Blerta Maliqi
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Elizabeth K Stierman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Martin Aj Dohlsten
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Allisyn C Moran
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Elizabeth Katwan
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Stierman EK, Maliqi B, Mary M, Dohlsten MA, Katwan E, Moran AC, Creanga AA. Changes in the health systems and policy environment for maternal and newborn health, 2008-2018: An analysis of data from 78 low-income and middle-income countries. Soc Sci Med 2023; 321:115765. [PMID: 36801755 PMCID: PMC10024243 DOI: 10.1016/j.socscimed.2023.115765] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 12/31/2022] [Accepted: 02/08/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Political, social, economic, and health system determinants play an important role in creating an enabling environment for maternal and newborn health. This study assesses changes in health systems and policy indicators for maternal and newborn health across 78 low- and middle-income countries (LMICs) during 2008-2018, and examines contextual factors associated with policy adoption and systems changes. METHODS We compiled historical data from WHO, ILO, and UNICEF surveys and databases to track changes in ten maternal and newborn health systems and policy indicators prioritized for tracking by global partnerships. Logistic regression was used to examine the odds of systems and policy change based on indicators of economic growth, gender equality, and country governance with available data from 2008 to 2018. RESULTS From 2008 to 2018, many LMICs (44/76; 57·9%) substantially strengthened systems and policies for maternal and newborn health. The most frequently adopted policies were national guidelines for kangaroo mother care, national guidelines for use of antenatal corticosteroids, national policies for maternal death notification and review, and the introduction of priority medicines in Essential Medicines Lists. The odds of policy adoption and systems investments were significantly greater in countries that experienced economic growth, had strong female labor participation, and had strong country governance (all p < 0·05). CONCLUSIONS The widespread adoption of priority policies over the past decade is a notable step in creating an environment supportive for maternal and newborn health, but continued leadership and resources are needed to ensure robust implementation that translates into improved health outcomes.
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Affiliation(s)
- Elizabeth K Stierman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA; International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA.
| | - Blerta Maliqi
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Avenue Appia 20, 1211 Geneva, Switzerland
| | - Meighan Mary
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA; International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA
| | - Martin Aj Dohlsten
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Avenue Appia 20, 1211 Geneva, Switzerland
| | - Elizabeth Katwan
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Avenue Appia 20, 1211 Geneva, Switzerland
| | - Allisyn C Moran
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Avenue Appia 20, 1211 Geneva, Switzerland
| | - Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA; International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA; Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, 733 N. Broadway, Baltimore, MD 21205, USA
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Jacobs C, Musukuma M, Sikapande B, Chooye O, Wehrmeister FC, Boerma T, Michelo C, Blanchard AK. How Zambia reduced inequalities in under-five mortality rates over the last two decades: a mixed-methods study. BMC Health Serv Res 2023; 23:170. [PMID: 36805693 PMCID: PMC9940360 DOI: 10.1186/s12913-023-09086-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 01/19/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Zambia experienced a major decline in under-five mortality rates (U5MR), with one of the fastest declines in socio-economic disparities in sub-Saharan Africa in the last two decades. We aimed to understand the extent to which, and how, Zambia has reduced socio-economic inequalities in U5MR since 2000. METHODS Using nationally-representative data from Zambia Demographic Health Surveys (2001/2, 2007, 2013/14 and 2018), we examined trends and levels of inequalities in under-five mortality, intervention coverage, household water and sanitation, and fertility. This analysis was integrated with an in-depth review of key policy and program documents relevant to improving child survival in Zambia between 1990 and 2020. RESULTS The under-five mortality rate (U5MR) declined from 168 to 64 deaths per 1000 live births between 2001/2 and 2018 ZDHS rounds, particularly in the post-neonatal period. There were major reductions in U5MR inequalities between wealth, education and urban-rural residence groups. Yet reduced gaps between wealth groups in estimated absolute income or education levels did not simultaneously occur. Inequalities reduced markedly for coverage of reproductive, maternal, newborn and child health (RMNCH), malaria and human immunodeficiency virus interventions, but less so for water or sanitation and fertility levels. Several policy and health systems drivers were identified for reducing RMNCH inequalities: policy commitment to equity in RMNCH; financing with a focus on disadvantaged groups; multisectoral partnerships and horizontal programming; expansion of infrastructure and human resources for health; and involvement of community stakeholders and service providers. CONCLUSION Zambia's major progress in reducing inequalities in child survival between the poorest and richest people appeared to be notably driven by government policies and programs that centrally valued equity, despite ongoing gaps in absolute income and education levels. Future work should focus on sustaining these gains, while targeting families that have been left behind to achieve the sustainable development goal targets.
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Affiliation(s)
- Choolwe Jacobs
- School of Public Health, University of Zambia, Box 50110, Lusaka, Zambia.
| | - Mwiche Musukuma
- School of Public Health, University of Zambia, Box 50110, Lusaka, Zambia
| | | | | | | | | | - Charles Michelo
- School of Public Health, University of Zambia, Box 50110, Lusaka, Zambia
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Syed U, Kinney MV, Pestvenidze E, Vandy AO, Slowing K, Kayita J, Lewis AF, Kenneh S, Moses FL, Aabroo A, Thom E, Uzma Q, Zaka N, Rattana K, Cheang K, Kanke RM, Kini B, Epondo JBE, Moran AC. Advancing maternal and perinatal health in low- and middle-income countries: A multi-country review of policies and programmes. Front Glob Womens Health 2022; 3:909991. [PMID: 36299801 PMCID: PMC9589433 DOI: 10.3389/fgwh.2022.909991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
The Sustainable Development Goals prioritize maternal mortality reduction, with a global average target of < 70 per 100,000 live births by 2030. Current pace of reduction is far short of what is needed to achieve the global target. It is estimated that globally there are 300,000 maternal deaths, 2.4 million newborn deaths and 2 million stillbirths annually. Majority of these deaths occur in low-and-middle-income countries. Global initiatives like, Ending Preventable Maternal Mortality (EPMM) and Every Newborn Action Plan (ENAP), have outlined the broad strategies for maternal and newborn health programmes. A set of coverage targets and ten milestones were launched to support low-and-middle-income countries in accelerating progress in improving maternal, perinatal and newborn health and wellbeing. WHO, UNICEF and UNFPA, undertook a scoping review to understand how country strategies evolved in different contexts over the past two decades to improve maternal survival and wellbeing, and how countries in similar settings could accelerate progress considering the changing epidemiology and demography. Case studies were conducted to inform countries in similar settings and various global initiatives. Six countries were selected based on standard criteria-Cambodia, Democratic Republic of the Congo, Georgia, Guatemala, Pakistan and Sierra Leone representing different stages of the obstetric transition. A conceptual framework, encapsulating the interrelated factors impacting maternal health outcomes, was used to organize data collection and analysis. While all six countries made remarkable progress in improving maternal and perinatal health, the pace of progress and the factors influencing the successes and challenges varied across the countries. The context, opportunities and challenges varied from country to country. Two strategic directions were identified for next steps including the need to implement and evaluate innovative service delivery models using an updated obstetric transition as an organizing framework and expanding our vision to address equity and well-being.
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Affiliation(s)
- Uzma Syed
- World Health Organization, Geneva, Switzerland
| | - Mary V. Kinney
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | | | | | - Karin Slowing
- Pan American Health Organization, Guatemala City, Guatemala
| | - Janet Kayita
- World Health Organization, Freetown, Sierra Leone
| | | | - Sartie Kenneh
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | | | | | - Ellen Thom
- World Health Organization, Islamabad, Pakistan
| | - Qudsia Uzma
- World Health Organization, Islamabad, Pakistan
| | - Nabila Zaka
- World Health Organization, Islamabad, Pakistan
| | - Kim Rattana
- National Maternal and Child Health Centre, Phnom Penh, Cambodia
| | | | - Robert M. Kanke
- World Health Organization, Kinshasa, Democratic Republic of Congo
| | - Brigitte Kini
- World Health Organization, Kinshasa, Democratic Republic of Congo
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Singh NS, Blanchard AK, Blencowe H, Koon AD, Boerma T, Sharma S, Campbell OMR. Zooming in and out: a holistic framework for research on maternal, late foetal and newborn survival and health. Health Policy Plan 2022; 37:565-574. [PMID: 34888635 PMCID: PMC9113153 DOI: 10.1093/heapol/czab148] [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: 10/06/2021] [Revised: 12/05/2021] [Accepted: 12/08/2021] [Indexed: 12/03/2022] Open
Abstract
Research is needed to understand why some countries succeed in greater improvements in maternal, late foetal and newborn health (MNH) and reducing mortality than others. Pathways towards these health outcomes operate at many levels, making it difficult to understand which factors contribute most to these health improvements. Conceptual frameworks provide a cognitive means of rendering order to these factors and how they interrelate to positively influence MNH. We developed a conceptual framework by integrating theories and frameworks from different disciplines to encapsulate the range of factors that explain reductions in maternal, late foetal and neonatal mortality and improvements in health. We developed our framework iteratively, combining our interdisciplinary research team's knowledge, experience and review of the literature. We present a framework that includes health policy and system levers (or intentional actions that policy-makers can implement) to improve MNH; service delivery and coverage of interventions across the continuum of care; and epidemiological and behavioural risk factors. The framework also considers the role of context in influencing for whom and where health and non-health efforts have the most impact, to recognize 'the causes of the causes' at play at the individual/household, community, national and transnational levels. Our framework holistically reflects the range of interrelated factors influencing improved MNH and survival. The framework lends itself to studying how different factors work together to influence these outcomes using an array of methods. Such research should inform future efforts to improve MNH and survival in different contexts. By re-orienting research in this way, we hope to equip policy-makers and practitioners alike with the insight necessary to make the world a safer and fairer place for mothers and their babies.
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Affiliation(s)
- Neha S Singh
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Andrea K Blanchard
- Department of Community Health Sciences, University of Manitoba, R070-771 McDermot Avenue, Winnipeg, MB R3E 0T6, Canada
| | - Hannah Blencowe
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Adam D Koon
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - Ties Boerma
- Department of Community Health Sciences, University of Manitoba, R070-771 McDermot Avenue, Winnipeg, MB R3E 0T6, Canada
| | - Sudha Sharma
- CIWEC Hospital and Travel Medical Center, G.P.O. Box 12895, Kapurdhara Marg, Kathmandu 44600, Nepal
| | - Oona M R Campbell
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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Effect of health systems context on infant and child mortality in sub-Saharan Africa from 1995 to 2015, a longitudinal cohort analysis. Sci Rep 2021; 11:16263. [PMID: 34381150 PMCID: PMC8357794 DOI: 10.1038/s41598-021-95886-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 07/29/2021] [Indexed: 11/28/2022] Open
Abstract
Each year, > 3 million children die in sub-Saharan Africa before their fifth birthday. Most deaths are preventable or avoidable through interventions delivered in the primary healthcare system. However, evidence regarding the impact of health system characteristics on child survival is sparse. We assembled a retrospective cohort of > 250,000 children in seven countries in sub-Saharan Africa. We described their health service context at the subnational level using standardized surveys and employed parametric survival models to estimate the effect of three major domains of health services—quality, access, and cost—on infant and child survival, after adjusting for child, maternal, and household characteristics. Between 1995 and 2015 we observed 13,629 deaths in infants and 5149 in children. In fully-adjusted models, the largest effect sizes were related to fees for services. Immunization fees were correlated with poor child survival (HR = 1.20, 95% CI 1.12–1.28) while delivery fees were correlated with poor infant survival (HR = 1.11, 95% CI 1.01–1.21). Accessibility of facilities and greater concentrations of private facilities were associated with improved infant and child survival. The proportion of facilities with a doctor was correlated with increased risk of death in children and infants. We quantify the impact of health service environment on survival up to five years of age. Reducing health care costs and improving the accessibility of health facilities should remain a priority for improving infant and child survival. In the absence of these fundamental investments, more specialized interventions may not achieve their desired impact.
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Kumar N, Adhikari T, Singh JK, Tiwari N, Acharya AS. Health data from diaries used in low-income communities, north India. Bull World Health Organ 2021; 99:446-454. [PMID: 34108755 PMCID: PMC8164179 DOI: 10.2471/blt.20.264325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 03/01/2021] [Accepted: 03/04/2021] [Indexed: 12/01/2022] Open
Abstract
Objective To determine the acceptability of keeping a self-written health diary among members of low-income communities, with the aim of generating needed health data. Methods We identified three different types of impoverished communities (tribal, inner-city slum and rural) in north India, and conducted a baseline survey to establish the sociodemographic properties of the members of 595 (tribal), 446 (slum) and 51 (rural) households. We designed health diaries with a single page to fill in per month, each with a carbon duplicate, and distributed diaries to willing participants. Health volunteers visited households each month to assist with diary completion and to collect duplicate pages for a period of one year. We compared the frequency of illnesses reported in health diaries with baseline survey data. Findings A total of 4881 diary users (tribal: 2205; slum: 2185; rural: 491) participated in our project. In terms of acceptability, 49.6% (1093/2205), 64.7% (1413/2185) and 79.0% (388/491) at the tribal, slum and rural sites, respectively, expressed satisfaction with the scheme and a willingness to continue. In the tribal and slum areas, we observed increased reporting of illnesses from health diaries when compared with baseline data. We observed that influenza-like illnesses were reported with the highest frequency of 58.9% (2972/5044) at the tribal site. Conclusion We observed high levels of acceptability and participation among the communities. From our initial field studies, we have observed the benefits to both our study participants (timely preventive education and referrals) and to service providers (obtaining health data to allow improved planning).
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Affiliation(s)
- Neeta Kumar
- Indian Council of Medical Research, Ansari Nagar, New Delhi 110029, India
| | - Tulsi Adhikari
- National Institute of Medical Statistics, New Delhi, India
| | - Jiten Kh Singh
- National Institute of Medical Statistics, New Delhi, India
| | - Nidhi Tiwari
- Indian Council of Medical Research, Ansari Nagar, New Delhi 110029, India
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Shah N, Mathew S, Pereira A, Nakaima A, Sridharan S. The role of evaluation in iterative learning and implementation of quality of care interventions. Glob Health Action 2021; 14:1882182. [PMID: 34148508 PMCID: PMC8216261 DOI: 10.1080/16549716.2021.1882182] [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: 05/17/2020] [Accepted: 12/22/2020] [Indexed: 11/01/2022] Open
Abstract
Background: The Lancet Global Health Commission (LGHC) has argued that quality of care (QoC) is an emergent property that requires an iterative process to learn and implement. Such iterations are required given that health systems are complex adaptive systems.Objective: This paper explores the multiple roles that evaluations need to play in order to help with iterative learning and implementation. We argue evaluation needs to shift from a summative focus toward an approach that promotes learning in complex systems. A framework is presented to help guide the iterative learning, and includes the dimensions of clinical care, person-centered care, continuum of care, and 'more than medicine. Multiple roles of evaluation corresponding to each of the dimensions are discussed.Methods: This paper is informed by reviews of the literature on QoC and the roles of evaluation in complex systems. The proposed framework synthesizes the multiple views of QoC. The recommendations of the roles of evaluation are informed both by review and experience in evaluating multiple QoC initiatives.Results: The specific roles of different evaluation approaches, including summative, realist, developmental, and participatory, are identified in relationship to the dimensions in our proposed framework. In order to achieve the potential of LGHC, there is a need to discuss how different evaluation approaches can be combined in a coherent way to promote iterative learning and implementation of QoC initiatives.Conclusion: One of the implications of the QoC framework discussed in the paper is that time needs to be spent upfront in recognizing areas in which knowledge of a specific intervention is not complete at the outset. This, of course, implies taking stock of areas of incompleteness in knowledge of context, theory of change, support structures needed in order for the program to succeed in specific settings. The role of evaluation should not be limited to only providing an external assessment, but an important goal in building evaluation capacity should be to promote adaptive management among planners and practitioners. Such iterative learning and adaptive management are needed to achieve the goals of sustainable development goals.
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Affiliation(s)
- Nikhil Shah
- The Evaluation Centre for Complex Health Interventions, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Sharon Mathew
- The Evaluation Centre for Complex Health Interventions, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Amanda Pereira
- The Evaluation Centre for Complex Health Interventions, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - April Nakaima
- The Evaluation Centre for Complex Health Interventions, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Maswanya E, Muganyizi P, Kilima S, Mogella D, Massaga J. Practice of emergency obstetric care signal functions and reasons for non-provision among health centers and hospitals in Lake and Western zones of Tanzania. BMC Health Serv Res 2018; 18:944. [PMID: 30518357 PMCID: PMC6282302 DOI: 10.1186/s12913-018-3685-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 11/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Lake and Western Zones of Tanzania that encompass eight regions namely; Kagera, Geita, Simiyu, Shinyanga, Mwanza, Mara Tabora and Kigoma have consistently been reported with the poorest Maternal Newborn and Child Health (MNCH) indicators in the country. This study sought to establish the provision of Emergency Obstetric Care (EmOC) signal functions and reasons for the failure to do so among health centers and hospitals in the two zones. METHODS All the 261 public and private hospitals and health centers providing Obstetric Care services in Lake and Western Zones were surveyed in 2014. Data were collected using questionnaires adapted from the Averting Maternal Deaths and Disabilities (AMDD) tool to assess EmOC indicators. Managers in all facilities were interviewed and services, medicines and equipment were observed. Spatial Mapping was done using a calibrated Global Positioning System (GPS) Essential Software for Android and coordinates represented on digitalized map with Arc Geographical Information System (GIS) software. Population data were according to the 2012 Housing and Population National Census. RESULTS In total 261 health facilities were identified as providers of Obstetric care services, including 69 hospitals and 192 health centres which constitute an overall facility density of 8 per 500,000 population. The three most common EmOC signal functions available in the 3 months preceding the survey were oxytocics (95.7%), injectable antibiotics (88.9%) and basic newborn resuscitation (83.4%). The lowest proportions of facilities performed Cesarean section (25.7%) and blood transfusion (34.6%). Policy restrictions were the most frequent reasons given in relation to nonperformance of blood transfusion and Cesarean section when needed. Lack of training and supplies were the most common reasons for non availability of assisted vaginal delivery and uterine evacuation. Overall the Direct Case fatality Rate for direct obstetric causes was 3%. The referral system highly depended on hired or shared ambulance. CONCLUSION The provision of EmOC signal functions in Lake and Western zones of Tanzania is inconsistent, being mainly compromised by policy restrictions, lack of supplies and professional development, and by operating under lowly developed referral services.
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Affiliation(s)
- Edward Maswanya
- National Institute for Medical Research (NIMR)-Headquarters, PO Box 9356, Dar-es-Salaam, Tanzania.
| | - Projestine Muganyizi
- Muhimbili University of Health and Allied Sciences (MUHAS), PO Box 65001, Dar-es-Salaam, Tanzania
| | - Stella Kilima
- National Institute for Medical Research (NIMR)-Headquarters, PO Box 9356, Dar-es-Salaam, Tanzania
| | - Deus Mogella
- National Blood Transfusion Unit, Ministry of Health, Social Development, Gender, Elderly and Children, PO Box 65019, Dar-es-Salaam, Tanzania
| | - Julius Massaga
- National Institute for Medical Research (NIMR)-Headquarters, PO Box 9356, Dar-es-Salaam, Tanzania
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Ali M, Farron M, Ramachandran Dilip T, Folz R. Assessment of Family Planning Service Availability and Readiness in 10 African Countries. GLOBAL HEALTH: SCIENCE AND PRACTICE 2018; 6:473-483. [PMID: 30213877 PMCID: PMC6172130 DOI: 10.9745/ghsp-d-18-00041] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 06/26/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Access to family planning services and appropriate contraceptive methods is crucial for ensuring good health outcomes for women and adolescent girls. The World Health Organization worked with the U.S. Agency for International Development to develop the Service Availability and Readiness Assessment (SARA) survey to measure health facility capacity to provide end users with appropriate, high-quality health care. In this study, we looked at the service availability and readiness of health facilities to provide contraception in 10 African countries: Benin, Burkina Faso, the Democratic Republic of the Congo, Djibouti, Mauritania, Niger, Sierra Leone, Tanzania, Togo, and Uganda. METHODS This study compared SARA survey data on family planning services from each of the 10 countries. We conducted a descriptive analysis of variations in facility readiness and the availability of services, contraceptive methods, trained staff, family planning guidelines, and basic health care equipment. RESULTS Overall, many of the countries surveyed had a relatively high availability of at least 1 contraceptive method. Rural facilities tended to have more availability of contraception than urban facilities, and government facilities tended to have higher availability of family planning than other providers. The countries differed in their particular dominant contraceptive method, and stock-outs of contraceptive methods were observed. Countries had overall low levels of all 6 tracer items (availability of family planning guidelines, staff trained in family planning, blood pressure apparatuses, combined oral contraceptive, injectable contraceptives, and male condoms on the day of the assessment), indicating low health system readiness. There were discrepancies between reported and observed availability of blood pressure apparatuses and family planning guides and having at least 1 staff member trained to use these tools. In all countries, unmarried adolescents appeared to have less access to family planning than the general population. CONCLUSION Stock-outs and logistics management problems were common among the countries surveyed. Critical gaps between reported and actual availability of products and services often makes it difficult for end users to access appropriate family planning methods. To address many of the issues, additional health worker training is needed and more effort to target and support adolescents should be undertaken. To achieve universal health coverage targets for family planning, gaps in the availability and readiness of health systems to provide contraceptive products and services must be reduced.
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Affiliation(s)
- Moazzam Ali
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
| | - Madeline Farron
- University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | | - Rachel Folz
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Singh NS, Smith J, Aryasinghe S, Khosla R, Say L, Blanchet K. Evaluating the effectiveness of sexual and reproductive health services during humanitarian crises: A systematic review. PLoS One 2018; 13:e0199300. [PMID: 29980147 PMCID: PMC6035047 DOI: 10.1371/journal.pone.0199300] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 06/05/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND An estimated 32 million women and girls of reproductive age living in emergency situations, all of whom require sexual and reproductive health (SRH) information and services. This systematic review assessed the effect of SRH interventions, including the Minimum Initial Service Package (MISP) on a range of health outcomes from the onset of emergencies. METHODS AND FINDINGS We searched EMBASE, Global Health, MEDLINE and PsychINFO databases from January 1, 1980 to April 10, 2017. This review was registered with the PROSPERO database with identifier number CRD42017082102. We found 29 studies meet the inclusion criteria. We found high quality evidence to support the effectiveness of specific SRH interventions, such as home visits and peer-led educational and counselling, training of lower-level health care providers, community health workers (CHWs) to promote SRH services, a three-tiered network of health workers providing reproductive and maternal health services, integration of HIV and SRH services, and men's discussion groups for reducing intimate partner violence. We found moderate quality evidence to support transport-based referral systems, community-based SRH education, CHW delivery of injectable contraceptives, wider literacy programmes, and birth preparedness interventions. No studies reported interventions related to fistulae, and only one study focused on abortion services. CONCLUSIONS Despite increased attention to SRH in humanitarian crises, the sector has made little progress in advancing the evidence base for the effectiveness of SRH interventions, including the MISP, in crisis settings. A greater quantity and quality of more timely research is needed to ascertain the effectiveness of delivering SRH interventions in a variety of humanitarian crises.
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Affiliation(s)
- Neha S. Singh
- Health in Humanitarian Crises Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Maternal, Adolescent, Reproductive and Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - James Smith
- Health in Humanitarian Crises Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sarindi Aryasinghe
- Centre for Maternal, Adolescent, Reproductive and Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Rajat Khosla
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Lale Say
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Karl Blanchet
- Health in Humanitarian Crises Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Keats EC, Macharia W, Singh NS, Akseer N, Ravishankar N, Ngugi AK, Rizvi A, Khaemba EN, Tole J, Bhutta ZA. Accelerating Kenya's progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015. BMJ Glob Health 2018; 3:e000655. [PMID: 29862055 PMCID: PMC5969726 DOI: 10.1136/bmjgh-2017-000655] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 04/14/2018] [Accepted: 04/16/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Despite recent gains, Kenya did not achieve its Millennium Development Goal (MDG) target for reducing under-five mortality. To accelerate progress to 2030, we must understand what impacted mortality throughout the MDG period. METHODS Trends in the under-five mortality rate (U5MR) were analysed using data from nationally representative Demographic and Health Surveys (1989-2014). Comprehensive, mixed-methods analyses of health policies and systems, workforce and health financing were conducted using relevant surveys, government documents and key informant interviews with country experts. A hierarchical multivariable linear regression analysis was undertaken to better understand the proximal determinants of change in U5MR over the MDG period. RESULTS U5MR declined by 50% from 1993 to 2014. However, mortality increased between 1990 and 2000, following the introduction of facility user fees and declining coverage of essential interventions. The MDGs, together with Kenya's political changes in 2003, ushered in a new era of policymaking with a strong focus on children under 5 years of age. External aid for child health quadrupled from 40 million in 2002 to 180 million in 2012, contributing to the dramatic improvement in U5MR throughout the latter half of the MDG period. Our multivariable analysis explained 44% of the decline in U5MR from 2003 to 2014, highlighting maternal literacy, household wealth, sexual and reproductive health and maternal and infant nutrition as important contributing factors. Children living in Nairobi had higher odds of child mortality relative to children living in other regions of Kenya. CONCLUSIONS To attain the Sustainable Development Goal targets for child health, Kenya must uphold its current momentum. For equitable access to health services, user fees must not be reintroduced in public facilities. Support for maternal nutrition and reproductive health should be prioritised, and Kenya should acknowledge its changing demographics in order to effectively manage the escalating burden of poor health among the urban poor.
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Affiliation(s)
- Emily C Keats
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Neha S Singh
- Centre for Maternal, Adolescent, Reproductive, and Child Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Nadia Akseer
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | - Anthony K Ngugi
- Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya
| | - Arjumand Rizvi
- Division of Woman and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - John Tole
- Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Woman and Child Health, Aga Khan University, Karachi, Pakistan
- Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Countdown to 2030: tracking progress towards universal coverage for reproductive, maternal, newborn, and child health. Lancet 2018; 391:1538-1548. [PMID: 29395268 DOI: 10.1016/s0140-6736(18)30104-1] [Citation(s) in RCA: 269] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/11/2017] [Accepted: 12/14/2017] [Indexed: 01/04/2023]
Abstract
Building upon the successes of Countdown to 2015, Countdown to 2030 aims to support the monitoring and measurement of women's, children's, and adolescents' health in the 81 countries that account for 95% of maternal and 90% of all child deaths worldwide. To achieve the Sustainable Development Goals by 2030, the rate of decline in prevalence of maternal and child mortality, stillbirths, and stunting among children younger than 5 years of age needs to accelerate considerably compared with progress since 2000. Such accelerations are only possible with a rapid scale-up of effective interventions to all population groups within countries (particularly in countries with the highest mortality and in those affected by conflict), supported by improvements in underlying socioeconomic conditions, including women's empowerment. Three main conclusions emerge from our analysis of intervention coverage, equity, and drivers of reproductive, maternal, newborn, and child health (RMNCH) in the 81 Countdown countries. First, even though strong progress was made in the coverage of many essential RMNCH interventions during the past decade, many countries are still a long way from universal coverage for most essential interventions. Furthermore, a growing body of evidence suggests that available services in many countries are of poor quality, limiting the potential effect on RMNCH outcomes. Second, within-country inequalities in intervention coverage are reducing in most countries (and are now almost non-existent in a few countries), but the pace is too slow. Third, health-sector (eg, weak country health systems) and non-health-sector drivers (eg, conflict settings) are major impediments to delivering high-quality services to all populations. Although more data for RMNCH interventions are available now, major data gaps still preclude the use of evidence to drive decision making and accountability. Countdown to 2030 is investing in improvements in measurement in several areas, such as quality of care and effective coverage, nutrition programmes, adolescent health, early childhood development, and evidence for conflict settings, and is prioritising its regional networks to enhance local analytic capacity and evidence for RMNCH.
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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: 82] [Impact Index Per Article: 13.7] [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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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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Moucheraud C, Owen H, Singh NS, Ng CK, Requejo J, Lawn JE, Berman P. Countdown to 2015 country case studies: what have we learned about processes and progress towards MDGs 4 and 5? BMC Public Health 2016; 16 Suppl 2:794. [PMID: 27633919 PMCID: PMC5025828 DOI: 10.1186/s12889-016-3401-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Countdown to 2015 was a multi-institution consortium tracking progress towards Millennium Development Goals (MDGs) 4 and 5. Case studies to explore factors contributing to progress (or lack of progress) in reproductive, maternal, newborn and child health (RMNCH) were undertaken in: Afghanistan, Bangladesh, China, Ethiopia, Kenya, Malawi, Niger, Pakistan, Peru, and Tanzania. This paper aims to identify cross-cutting themes on how and why these countries achieved or did not achieve MDG progress. Methods Applying a standard evaluation framework, analyses of impact, coverage and equity were undertaken, including a mixed methods analysis of how these were influenced by national context and coverage determinants (including health systems, policies and financing). Results The majority (7/10) of case study countries met MDG-4 with over two-thirds reduction in child mortality, but none met MDG-5a for 75 % reduction in maternal mortality, although six countries achieved >75 % of this target. None achieved MDG-5b regarding reproductive health. Rates of reduction in neonatal mortality were half or less that for post-neonatal child mortality. Coverage increased most for interventions administered at lower levels of the health system (e.g., immunisation, insecticide treated nets), and these experienced substantial political and financial support. These interventions were associated with ~30–40 % of child lives saved in 2012 compared to 2000, in Ethiopia, Malawi, Peru and Tanzania. Intrapartum care for mothers and newborns -- which require higher-level health workers, more infrastructure, and increased community engagement -- showed variable increases in coverage, and persistent equity gaps. Countries have explored different approaches to address these problems, including shifting interventions to the community setting and tasks to lower-level health workers. Conclusions These Countdown case studies underline the importance of consistent national investment and global attention for achieving improvements in RMNCH. Interventions with major global investments achieved higher levels of coverage, reduced equity gaps and improvements in associated health outcomes. Given many competing priorities for the Sustainable Development Goals era, it is essential to maintain attention to the unfinished RMNCH agenda, particularly health systems improvements for maternal and neonatal outcomes where progress has been slower, and to invest in data collection for monitoring progress and for rigorous analyses of how progress is achieved in different contexts. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3401-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Corrina Moucheraud
- University of California Fielding School of Public Health, Los Angeles, CA, 90095, USA.
| | - Helen Owen
- Centre for Maternal, Adolescent, Reproductive & Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Neha S Singh
- Centre for Maternal, Adolescent, Reproductive & Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | | | - Jennifer Requejo
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Joy E Lawn
- Centre for Maternal, Adolescent, Reproductive & Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Peter Berman
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
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Armstrong CE, Martínez-Álvarez M, Singh NS, John T, Afnan-Holmes H, Grundy C, Ruktanochai CW, Borghi J, Magoma M, Msemo G, Matthews Z, Mtei G, Lawn JE. Subnational variation for care at birth in Tanzania: is this explained by place, people, money or drugs? BMC Public Health 2016; 16 Suppl 2:795. [PMID: 27634353 PMCID: PMC5025821 DOI: 10.1186/s12889-016-3404-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Tanzania achieved the Millennium Development Goal for child survival, yet made insufficient progress for maternal and neonatal survival and stillbirths, due to low coverage and quality of services for care at birth, with rural women left behind. Our study aimed to evaluate Tanzania's subnational (regional-level) variations for rural care at birth outcomes, i.e., rural women giving birth in a facility and by Caesarean section (C-section), and associations with health systems inputs (financing, health workforce, facilities, and commodities), outputs (readiness and quality of care) and context (education and GDP). METHODS We undertook correlation analyses of subnational-level associations between health system inputs, outputs, context, and rural care at birth outcomes; and constructed implementation readiness barometers using benchmarks for each health system input indicator. We used geographical information system (GIS) mapping to visualise subnational variations in care at birth for rural women, with a focus on service availability and readiness, and collected qualitative data to investigate financial flows from national to council level to understand variation in financing inputs. RESULTS We found wide subnational variation for rural care at birth outcomes, health systems inputs, and contextual indicators. There was a positive association between rural women giving birth in a facility and by C-section; maternal education; workforce and facility density; and quality of care. There was a negative association between these outcomes and proportion of all births to rural women, total fertility rate, and availability of essential commodities at facilities. Per capita recurrent expenditure was positively associated with facility births (correlation coefficient = 0.43; p = 0.05) but not with C-section. Qualitative results showed that the health financing system is complex and insufficient for providing care at birth services. Bottlenecks for care at birth included low density of health workers, poor availability of essential commodities, and low health financing in Lake and Western Zones. CONCLUSIONS No region meets the benchmarks for the four health systems building blocks including health finance, health workforce, health facilities, and commodities. Strategies for addressing health system inequities, including overall increases in health expenditure, are needed in rural populations and areas of highest unmet need for family planning to improve coverage of care at birth for rural women in Tanzania.
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Affiliation(s)
- Corinne E. Armstrong
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
- Evidence for Action, Dar es Salaam, Tanzania
| | - Melisa Martínez-Álvarez
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
| | - Neha S. Singh
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
| | - Theopista John
- World Health Organization, 1 Luthuli Street, PO Box 9292, Dar es Salaam, Tanzania
| | - Hoviyeh Afnan-Holmes
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
- Independent consultant, London, UK
| | - Chris Grundy
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
| | - Corrine W. Ruktanochai
- Department of Geography & Environment, University of Southampton, Highfield, Southampton, SO17 1BJ UK
| | - Josephine Borghi
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
| | - Moke Magoma
- Evidence for Action, Dar es Salaam, Tanzania
| | - Georgina Msemo
- Ministry of Health and Social Welfare, Dar es Salaam, Tanzania
| | - Zoe Matthews
- Division of Social Statistics and Demography & Centre for Global Health, Population, Poverty and Policy, Faculty of Social and Human Sciences, University of Southampton, Highfield, Southampton, UK
| | - Gemini Mtei
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Joy E. Lawn
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT UK
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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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