Subnational mapping of under-5 and neonatal mortality trends in India: the Global Burden of Disease Study 2000–17

BACKGROUND: Despite progress toward meeting the Sustainable Development Goals, a large burden of maternal and neonatal mortality persists for the most vulnerable people in rural areas. We assessed coverage, coverage change and inequity for 8 maternal and newborn health care indicators in parts of rural Nigeria, Ethiopia and India. METHODS: We examined coverage changes and inequity in 2012 and 2015 in 3 high-burden populations where multiple actors were attempting to improve outcomes. We conducted cluster-based household surveys using a structured questionnaire to collect 8 priority indicators, disaggregated by relative household socioeconomic status. Where there was evidence of a change in coverage between 2012 and 2015, we used binomial regression models to assess whether the change reduced inequity. RESULTS: In 2015, we interviewed women with a birth in the previous 12 months in Gombe, Nigeria (n = 1100 women), Ethiopia (n = 404) and Uttar Pradesh, India (n = 584). Among the 8 indicators, 2 positive coverage changes were observed in each of Gombe and Uttar Pradesh, and 5 in Ethiopia. Coverage improvements occurred equally for all socioeconomic groups, with little improvement in inequity. For example, in Ethiopia, coverage of facility delivery almost tripled, increasing from 15% (95% confidence interval [CI] 9%–25%) to 43% (95% CI 33%–54%). This change was similar across socioeconomic groups (p = 0.2). By 2015, the poorest women had about the same facility delivery coverage as the least poor women had had in 2012 (32% and 36%, respectively), but coverage for the least poor had increased to 60%. INTERPRETATION: Although coverage increased equitably because of various community-based interventions, underlying inequities persisted. Action is needed to address the needs of the most vulnerable women, particularly those living in the most rural areas.

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Coverage and equity of maternal and newborn health care in rural Nigeria, Ethiopia and India

ObjectivesTo achieve universal health coverage, health systems need to be strengthened to support the consistent delivery of high-quality, evidence-informed care at scale. The aim of the National Institute for Health Research (NIHR) Global Research Unit on HeAlth System StrEngThening in Sub-Saharan Africa (ASSET) is to address this need in a four-year programme spanning three healthcare platforms (primary health care for the integrated treatment of chronic conditions in adults, maternal and newborn, surgical care) involving eight work packages. This paper describes the pre-implementation phase research protocols that assess: (1) barriers to accessing care; (2) health system bottlenecks in care process and pathways; (3) quality of care, and; (4) people centredness. Findings from this research are used to engage stakeholders and to inform the selection of a set of health system strengthening interventions (HSSIs) and subsequent methodology for evaluation. SettingsPublicly funded health systems in rural and urban areas in Ethiopia, Sierra Leone, South Africa, and Zimbabwe. PopulationStakeholders including patients and their caregivers, community representatives, clinicians, managers, administrators, and policymakers. Study methodologies and deliveryIn each work package, we apply a mixed-methods approach, including: literature reviews; situation analyses; cohort studies; cross-sectional surveys; ethnographic observations; semi-structured interviews, and; focus group discussions. At the end of the pre-implementation phase, findings are fed back to stakeholders in participatory theory of change workshops that are used to select/adapt an initial set of contextually relevant HSSIs. To ensure a theory-informed approach across ASSET, implementation science determinant frameworks are also applied, to help identify any additional contextual barriers and enablers and complementary HSSIs. Outputs from these activities are used to finalise underlying assumptions, potential unintended consequences, process indicators and implementation and clinical outcomes. ConclusionsASSET places a strong emphasis of the pre-implementation phase of the programme in order to provide an in-depth and systematic diagnosis of the existing heath system functioning, needs for strengthening and active stakeholder engagement. This approach will inform the design and evaluation of the HSSIs to increase effectiveness across work packages and contexts, to better understand what works, for whom, and how. Strengths and limitations of this studyO_LIThe National Health Institute of Research (NIHR) Global Research Unit on Health System Strengthening in sub-Saharan Africa (ASSET) is a four-year programme (2017-2021) that is closely aligned with the SDG goal of UHC, and the recommendations of the Lancet Commission for High Quality Health Systems. C_LIO_LIThe aim of ASSET is to develop and evaluate effective and sustainable HSSIs, promoting consistent delivery of high-quality, people-centred care. C_LIO_LIThe ASSET programme is being conducted in two phases including the diagnostic pre-implementation and piloting/rolling implementation phase. C_LIO_LIThe purpose of this paper is to describe the methodology for the pre-implementation phase, which has the core aim of mapping comprehensive care pathways of a patients journey though the health system including the community, different providers), and health facilities, documenting what care is provided at what level of the health system and the associated health system bottlenecks. C_LIO_LIAt the end of the pre-implementation phase of ASSET, it is hoped the common approach taken across different countries, care platforms and health conditions will facilitate cross platform learning and understanding of how differences in health systems and broader contextual influences shaped the development of the interventions. C_LIO_LIThe overarching expectation is that by using an in-depth participatory process to engage with the stakeholders and map care pathways to and through the health system, we develop a HSS programme that can be implemented at scale that meets the needs and priorities of the local community. C_LI

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HeAlth System StrEngThening in Four Sub_Saharan African Countries (ASSET) to Achieve High-quality, Evidence-informed Surgical, Maternal and Newborn, and Primary Care: Protocol for Pre-implementation Phase Studies

Health systems strengthening is at the forefront of the global health agenda. Many health systems in low-resource settings face profound challenges, and robust causal evidence on the effects of health systems reforms is lacking. Decentralization has been one of the most prominent reforms, and after more than 50 years of implementation and hundreds of studies, we still know little about whether these policies improve, harm or are inconsequential for the performance of health systems in less-developed countries. A persistent problem in existing studies is the inability to isolate the effect of decentralization on health outcomes, struggling with heterogeneous meanings of decentralization and missing counterfactuals. We address these shortcomings with a quasi-experimental, longitudinal research design that takes advantage of a unique staggered reform process in Honduras. Using three waves of household survey data over 10 years for a matched sample of 65 municipalities in Honduras, we estimated difference-in-difference models comparing changes in outcomes over time between local health systems that were decentralized using one of three types of organizations [municipal governments, associations of mayors or non-governmental organization (NGOs)] and those that remained centrally administered. We find evidence of overall improvements between 2005 and 2016 in several service delivery-related outcomes, and additional improvements in decentralized municipalities governed by NGOs. NGO-led municipalities saw a 15% decrease in home delivery relative to centralized municipalities in 2016, a 12.5% increase in MCH facility delivery and a 7% increase in the use of a skilled birth attendant. There were no detectable positive treatment effects for vaccination, and a slight decline in the weight-for-length z-scores in NGO municipalities, but we find no systematic evidence of decentralization negatively impacting any maternal and child health outcomes. These findings highlight the importance of considering implementation context, namely organization type, when assessing the effects of decentralization reform.

Organizations matter in local governance: evidence from health sector decentralization in Honduras.

To achieve universal health coverage, health system strengthening (HSS) is required to support the of delivery of high-quality care. The aim of the National Institute for Health Research Global Research Unit on HeAlth System StrEngThening in Sub-Saharan Africa (ASSET) is to address this need in a four-year programme, with three healthcare platforms involving eight work-packages. Key to effective health system strengthening (HSS) is the pre-implementation phase of research where efforts focus on applying participatory methods to embed the research programme within the existing health system. To conceptualise the approach, we provide an overview of the key methods applied across work-package to address this important phase of research conducted between 2017 and 2021.Work-packages are being undertaken in publicly funded health systems in rural and urban areas in Ethiopia, Sierra Leone, South Africa, and Zimbabwe. Stakeholders including patients and their caregivers, community representatives, clinicians, managers, administrators, and policymakers are the main research participants.In each work-package, initial activities engage stakeholders and build relationships to ensure co-production and ownership of HSSIs. A mixed-methods approach is then applied to understand and address determinants of high-quality care delivery. Methods such as situation analysis, cross-sectional surveys, interviews and focus group discussions are adopted to each work-package aim and context. At the end of the pre-implementation phase, findings are disseminated using focus group discussions and participatory Theory of Change workshops where stakeholders from each work package use findings to select HSSIs and develop a programme theory.ASSET places a strong emphasis of the pre-implementation phase in order to provide an in-depth and systematic diagnosis of the existing heath system functioning, needs for strengthening and stakeholder engagement. This common approach will inform the design and evaluation of the HSSIs to increase effectiveness across work packages and contexts, to better understand what works, for whom, and how. 

HeAlth System StrEngThening in four sub-Saharan African countries (ASSET) to achieve high-quality, evidence-informed surgical, maternal and newborn, and primary care: protocol for pre-implementation phase studies

Bellagio Declaration on high-quality health systems: from a quality moment to a quality movement.

Background As the largest professional group, nurses and midwives play instrumental roles in healthcare delivery, supporting the smooth administration and operation of the health system. Consequently, the withdrawal of nursing and midwifery services via strike action has direct and indirect detrimental effects on access to healthcare. Objective The current study examined the impact of strike action by nurses and midwives with respect to access to and use of health services. Method Data were collected retrospectively from a total of 181 health facilities from all the 16 administrative regions of Ghana, with the support of field officers. Because the strike lasted for 3 days, the data collection span three consecutive days before the strike, three days of the strike and three consecutive days after the strike. Data analysis was focused comparing the utilization of healthcare services before, during and after strike. Data were analysed and presented on the various healthcare services. This was done separately for the health facility type and the 16 administrative regions. Findings The results showed that; (1) the average number of patients or clients who accessed healthcare services reduced drastically during the strike period, compared with before the strike. Majority of the regions recorded more than 70% decrease in service use during the strike period; (2) the average number of patients or clients who accessed healthcare services after the strike increased by more than 100% across majority of the regions. Conclusion The study showed that strike action by nurses and midwives negatively affected access to and utilization of healthcare services.

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The impact of strike action by Ghana registered nurses and midwives on the access to and utilization of healthcare services

Repurposing an integrated national influenza platform for genomic surveillance of SARS-CoV-2 in Ghana: a molecular epidemiological analysis

Genomic Surveillance of SARS-CoV-2 in Ghana: Leveraging an Integrated National Influenza and SARS-CoV-2 Platform

Olive Cocoman and colleagues argue that national leadership for quality of care requires working in a co-leadership model such that quality and programme units have equal standing and clearly defined individual roles and responsibilities

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Ernest Konadu Asiedu

Papers

Bellagio Declaration on high-quality health systems: from a quality moment to a quality movement.

The impact of strike action by Ghana registered nurses and midwives on the access to and utilization of healthcare services

Repurposing an integrated national influenza platform for genomic surveillance of SARS-CoV-2 in Ghana: a molecular epidemiological analysis

Genomic Surveillance of SARS-CoV-2 in Ghana: Leveraging an Integrated National Influenza and SARS-CoV-2 Platform

Facilitators of co-leadership for quality care