Showing papers in "Journal of Global Health in 2016"

Health system resilience: Lebanon and the Syrian refugee crisis.

Abstract: Background Between 2011 and 2013, the Lebanese population increased by 30% due to the influx of Syrian refugees. While a sudden increase of such magnitude represents a shock to the health system, threatening the continuity of service delivery and destabilizing governance, it also offers a unique opportunity to study resilience of a health system amidst ongoing crisis. Methods We conceptualized resilience as the capacity of a health system to absorb internal or external shocks (for example prevent or contain disease outbreaks and maintain functional health institutions) while sustaining achievements. We explored factors contributing to the resilience of the Lebanese health system, including networking with stakeholders, diversification of the health system, adequate infrastructure and health human resources, a comprehensive communicable disease response and the integration of the refugees within the health system. Results In studying the case of Lebanon we used input-process-output-outcome approach to assess the resilience of the Lebanese health system. This approach provided us with a holistic view of the health system, as it captured not only the sustained and improved outcomes, but also the inputs and processes leading to them. Conclusion Our study indicates that the Lebanese health system was resilient as its institutions sustained their performance during the crisis and even improved.

What is kangaroo mother care? Systematic review of the literature.

Abstract: Globally, 44% of under–five deaths occur during the neonatal period, and the proportion of under–five deaths due to neonatal causes continues to rise [1,2]. Preterm birth (before 37 weeks gestation) accounts for 35% of neonatal deaths. Low birth weight (defined as <2500 g) is commonly used as a surrogate measure of preterm birth [3]. Preterm and low birth weight infants who survive the neonatal period are more likely to experience neonatal morbidities including acute respiratory, gastrointestinal, immunologic, central nervous system, hearing and vision problems than both term and normal weight infants [4]. A significant proportion of deaths among preterm and low birth weight infants is preventable. There is evidence that kangaroo mother care (KMC), when compared to conventional neonatal care in resource–limited settings, significantly reduces the risk of mortality in infants born in facilities who are clinically stable and weighing less than 2000 g [5]. KMC also reduces the risk of hypothermia, severe illness, nosocomial infection, and length of hospital stay, and improves growth, breastfeeding, and maternal–infant attachment [5,6]. Despite strong evidence for mortality and morbidity reduction in low– and middle–income settings and endorsement from the World Health Organization (WHO), country–level adoption and implementation of KMC has been limited. In a systematic assessment of health system bottlenecks among countries with a high burden of neonatal deaths, KMC was identified as an intervention with significant health systems barriers to scale–up including leadership and governance, health financing, health workforce, health service delivery, health information systems, and community ownership and partnership [7]. Health intervention priority–setting tools, such as the Lives Saved Tool and Child Health and Nutrition Research Initiative methodology, have identified KMC as a high priority intervention based on criteria such as mortality benefit and equity [8,9]. In response to limited global uptake of KMC, in 2013, a group of newborn health stakeholders led by the Bill and Melinda Gates Foundation and Save the Children’s Saving Newborn Lives Program launched a global KMC Acceleration Convening. The goal was to address barriers to implementation, increase uptake of KMC as part of an integrated Reproductive Maternal Newborn and Child Health package, and identify research priorities [10]. In addition to implementation barriers, a lack of a clear definition of KMC has made effective coverage at scale of KMC challenging. A multi–country study in Africa found variation in KMC implementation across facilities in countries with national commitment to KMC [11]. Regional, country, and facility differences in health worker capacity, financial resources, leadership, health information systems, and cultural and community structures create challenges to developing and adopting a global definition of KMC. The WHO has defined KMC as early, continuous, and prolonged skin–to–skin contact (SSC) between the mother and preterm babies; exclusive breastfeeding or breast milk feeding; early discharge after hospital–initiated KMC with continuation at home; and adequate support and follow–up for mothers at home [12]. While the WHO provides guidance on the components of KMC, guidance on the operationalization and clinical implementation of KMC are needed. There are significant variations in the timing of initiation, duration of SSC, positioning, necessary equipment and supplies, discharge criteria, follow–up frequency, indicators and measurement, and health workforce needs. The variations in these components have differential effects on preterm and low birth weight outcomes. As the global newborn health community begins to accelerate implementation of KMC, a standardized operational definition is needed. We conducted a systematic review of the KMC literature to 1) describe the current definitions of KMC in various settings, 2) analyze the presence or absence of WHO KMC components in each definition, and 3) present a core definition of KMC–common components that are present in at least 70% of all studies and programs–and describe how KMC definitions vary by context. This review provides a basis for development of an operational definition and clinical standards to accelerate the uptake of KMC globally.

Approaches, tools and methods used for setting priorities in health research in the 21(st) century.

Abstract: BACKGROUND: Health research is difficult to prioritize, because the number of possible competing ideas for research is large, the outcome of research is inherently uncertain, and the impact of research is difficult to predict and measure. A systematic and transparent process to assist policy makers and research funding agencies in making investment decisions is a permanent need. METHODS: To obtain a better understanding of the landscape of approaches, tools and methods used to prioritize health research, I conducted a methodical review using the PubMed database for the period 2001-2014. RESULTS: A total of 165 relevant studies were identified, in which health research prioritization was conducted. They most frequently used the CHNRI method (26%), followed by the Delphi method (24%), James Lind Alliance method (8%), the Combined Approach Matrix (CAM) method (2%) and the Essential National Health Research method (<1%). About 3% of studies reported no clear process and provided very little information on how priorities were set. A further 19% used a combination of expert panel interview and focus group discussion ("consultation process") but provided few details, while a further 2% used approaches that were clearly described, but not established as a replicable method. Online surveys that were not accompanied by face-to-face meetings were used in 8% of studies, while 9% used a combination of literature review and questionnaire to scrutinise the research options for prioritization among the participating experts. CONCLUSION: The number of priority setting exercises in health research published in PubMed-indexed journals is increasing, especially since 2010. These exercises are being conducted at a variety of levels, ranging from the global level to the level of an individual hospital. With the development of new tools and methods which have a well-defined structure - such as the CHNRI method, James Lind Alliance Method and Combined Approach Matrix - it is likely that the Delphi method and non-replicable consultation processes will gradually be replaced by these emerging tools, which offer more transparency and replicability. It is too early to say whether any single method can address the needs of most exercises conducted at different levels, or if better results may perhaps be achieved through combination of components of several methods.

Patterns and determinants of antenatal care utilization: analysis of national survey data in seven countdown countries.

Abstract: Antenatal care (ANC), defined as the care provided to a woman during her pregnancy, is an essential component of reproductive health care. ANC can serve as a platform for the delivery of highly–effective health interventions that can reduce preventable maternal and newborn deaths [1,2]. ANC services offer pregnant women an entry point to the health care system, providing appropriate screening, intervention and treatment throughout pregnancy, and encouraging women to seek a skilled birth attendant for their delivery [3]. Furthermore, using ANC allows women to receive information about improving maternal health through proper nutrition and self–care during pregnancy; and throughout the postpartum period, such as the benefits of exclusive breastfeeding and counseling on family planning methods [4]. The current World Health Organization (WHO) recommendation is that each woman receives a minimum of four goal–oriented or focused ANC visits for low–risk deliveries, to be supervised or attended by a skilled ANC attendant [4]. The timing of the first visit should be before 16 weeks of pregnancy, the second visit should be between 24 and 26 weeks, the third visit between 30 and 32 weeks, and the fourth visit between 36 and 38 weeks [5]. WHO defines a thorough set of essential elements for each visit (Box 1). Box 1 The evolution of World Health Organization guidelines for antenatal care visits The concept of antenatal care originated in Europe in the early decades of the 20th century. It is believed that the ANC model and the recommendations set at that time formed the foundation for ANC programs worldwide. The model indicated that visits should begin around 16 weeks of gestation, followed by visits at 24 and 28 weeks, then fortnightly visits until 36 weeks, and finally, weekly visits until delivery [6]. This ‘Western model’ was implemented for developing countries without taking into consideration contextual factors, which are especially important in low–resource settings [7]. WHO therefore developed a new model of ANC, consisting of a reduced number of visits and specifying the evidence–based interventions to be provided at each visit, including: assessment of the pregnant woman; screening for pre–eclampsia, anemia, syphilis, and HIV; provision of preventive measures such as checking of iron and folate dosage, tetanus toxoid immunization, anti–malarial precautions, and advice on labor or danger signs; advise on proper self–care, nutrition, and substance abuse; and counseling on the importance of family planning [5]. These recommendations are referred to as “focused” or “goal–oriented” ANC. Clinical evidence at the time the recommendations were released indicated that health outcomes were similar for women who received the four focused visits and women who received standard ANC with more visits [7,8]. Dowswell and colleagues [6] in an updated Cochrane systematic review using new methods of assessment, showed a statistically significant increase in perinatal mortality in low– and middle–income settings among women who received focused ANC compared to women who received standard ANC. In a 2011 statement, WHO acknowledged this and planned to provide updated guidelines for ANC based on their findings to be generated from additional secondary analyses [9]. The results of a secondary analysis looking at the WHO ANC trial were published in 2013, again showing a substantial increase in perinatal mortality among women receiving the focused ANC compared to those receiving the standard package, especially between 32 and 36 weeks of gestation. However, the findings also showed high levels of heterogeneity between the populations in the trials, and suggested that differences in perinatal mortality between the control and intervention groups could be attributed to different settings, populations or even quality of care received [10]. The WHO is re–evaluating its ANC guidelines, an exercise which is expected to be completed by the end of 2015 [11]. Coverage of ANC has been used globally as one of the indicators to track progress towards Target 5.B (achieving universal access to reproductive health by 2015) under Millennium Development Goal 5 (MDG 5) to improve maternal health [12]. The official ANC indicators for global tracking are: (1) the proportion of women with a recent live birth who report at least one ANC visit with skilled health personnel (ANC 1+); and (2) the proportion of women with a recent live birth who report at least four ANC visits with any provider (ANC 4+) [12].The Countdown to 2015 for Maternal, Newborn and Child Survival, a global movement that tracks coverage for evidence–based interventions in 75 countries that account for more than 95% of maternal and child deaths [13], also reports on the ANC 1+ and ANC 4+ indicators. There have been numerous studies of the determinants of ANC use in low– and middle–income countries. Fewer studies have examined the determinants of use by frequency of antenatal care visits, comparatively, and through inferential analyses [14-21]. There have also been several analyses of equity in utilization of ANC services. Relevant articles stratify utilization by urban/rural place of residence [16,22–24], and less frequently, by mother’s education [15,25], wealth [15,26], income [25], and ethnicity [25]. However, little is known about the frequency of ANC visits in general, especially as a comparative presentation across countries. No previous study, to our knowledge, has examined utilization in terms of what the globally measured ANC indicators might be missing with respect to associations between women’s characteristics and their patterns of visits. Moreover, qualitative studies, or studies that use both qualitative and quantitative methods, are fewer in number [27]. These studies focus on contextual aspects such as the presence of health care workers in the community, availability of affordable care, household characteristics and perceived distance from the health care facility, waiting time at the facility [27], women’s perceptions about ANC, and their experiences, attitudes, beliefs and perceived need for services [27,28]. For this paper, we purposely selected a limited number of Countdown countries to examine and understand the underlying patterns of ANC utilization that are not revealed when relying solely on the globally measured ANC indicators. We identify whether a significant drop–off in utilization occurs after a certain number of visits. We also describe the number of ANC visits by the type of provider, and the content received overall during ANC. We examine the coverage of ANC by three measures of inequality. Finally, we use several environmental, population and individual characteristics to analyze utilization patterns in the selected countries. In addition, contextual information on policy and program structure was collected from the selected countries for the purpose of improving understanding of ANC coverage levels and drop off.

Global disease burden due to antibiotic resistance – state of the evidence

Abstract: Antimicrobial resistance is widely regarded as one of the major public health concerns of the 21 century [1,2], but there are no good estimates of the net global health burden due to resistance of bacteria to antibiotics. Although numerous studies have provided estimates of the burden of resistance of specific combinations of clinical disease, bacterial agent, antibiotic and health care setting (primarily hospitals in developed countries), metrics vary, coverage is patchy and methodologies are inconsistent. Such data have been used to obtain partial estimates of resistance–related mortality and other outcomes for Europe [3], the USA [4] and the world [5], but because of huge information gaps and the need to extrapolate from small–scale studies these estimates, though helpful, should be regarded as tentative at best.

Assessing the validity of indicators of the quality of maternal and newborn health care in Kenya.

Abstract: Nearly 275 000 maternal deaths occurred globally in 2011, nearly all of which took place in low– and middle–income countries (LMIC) [1]. Most of these countries did not reduce maternal mortality to levels targeted in the Millennium Development Goals (MDG5) [1]. Progress has been hindered, in part, by a lack of reliable maternal health data, especially on maternal deaths [2]. Measurement challenges are particularly significant in LMIC with irregular and incomplete health system reporting. To measure progress in maternal health, monitoring agencies have relied on tracking indicators proposed as measures of quality of care, such as the proportion of births attended by a skilled birth attendant, that are assumed to be strongly correlated with maternal mortality [3]. Such indicators are routinely assessed in population––based household survey programs, such as the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), in which female respondents report on events surrounding recent births [4]. Despite their widespread use, the majority of proposed quality of care indicators, including skilled birth attendance, have not been validated [1,5,6]. In fact, numerous researchers have noted the lack of correlation between these indicators and maternal mortality levels [5,7–9]. These researchers argue that information on the category of provider at birth is deficient as a measure of quality of care as it relies on assumptions about provider training and competence as well as access to essential supplies and equipment. It is important therefore to identify alternate indicators that describe the actual content of care, can be reported with accuracy, and have the potential to be included in routine data collection programs. A growing, but still limited, body of research has examined the validity of indicators of the quality of care in the intrapartum and early postpartum period. To our knowledge, however, no study has yet reported on how accurately women can recall the skill level of their provider at birth, although there have been some attempts to look at data quality issues [10]. Furthermore, the few validation studies that have taken place have generally compared maternal self–reports with hospital records, which may be incomplete or inaccurate, or have been conducted in high–income settings, where maternal mortality rates are generally low [11–15]. To address this gap, this study assessed women’s ability to report on a set of quality of maternal and newborn health care indicators that are either currently in use or have the potential to be included in routine survey–based data collection. In spite of its limitations, it seems likely that the “skilled birth attendance” indicator will continue to be used and so we assess how accurately women report on the skill level of their provider during delivery. We compare women’s self–reports of maternal and newborn care received against third party observations during labor and delivery. Finally, we provide suggestions for modifications to data collection procedures that could improve the measurement of maternal and newborn health care.

Setting research priorities to improve global newborn health and prevent stillbirths by 2025.

Abstract: BACKGROUND: In 2013, an estimated 2.8 million newborns died and 2.7 million were stillborn. A much greater number suffer from long term impairment associated with preterm birth, intrauterine growth restriction, congenital anomalies, and perinatal or infectious causes. With the approaching deadline for the achievement of the Millennium Development Goals (MDGs) in 2015, there was a need to set the new research priorities on newborns and stillbirth with a focus not only on survival but also on health, growth and development. We therefore carried out a systematic exercise to set newborn health research priorities for 2013-2025. METHODS: We used adapted Child Health and Nutrition Research Initiative (CHNRI) methods for this prioritization exercise. We identified and approached the 200 most productive researchers and 400 program experts, and 132 of them submitted research questions online. These were collated into a set of 205 research questions, sent for scoring to the 600 identified experts, and were assessed and scored by 91 experts. RESULTS: Nine out of top ten identified priorities were in the domain of research on improving delivery of known interventions, with simplified neonatal resuscitation program and clinical algorithms and improved skills of community health workers leading the list. The top 10 priorities in the domain of development were led by ideas on improved Kangaroo Mother Care at community level, how to improve the accuracy of diagnosis by community health workers, and perinatal audits. The 10 leading priorities for discovery research focused on stable surfactant with novel modes of administration for preterm babies, ability to diagnose fetal distress and novel tocolytic agents to delay or stop preterm labour. CONCLUSION: These findings will assist both donors and researchers in supporting and conducting research to close the knowledge gaps for reducing neonatal mortality, morbidity and long term impairment. WHO, SNL and other partners will work to generate interest among key national stakeholders, governments, NGOs, and research institutes in these priorities, while encouraging research funders to support them. We will track research funding, relevant requests for proposals and trial registers to monitor if the priorities identified by this exercise are being addressed.

Cost of management of severe pneumonia in young children: systematic analysis.

Abstract: Background Childhood pneumonia is a major cause of childhood illness and the second leading cause of child death globally. Understanding the costs associated with the management of childhood pneumonia is essential for resource allocation and priority setting for child health. Methods We conducted a systematic review to identify studies reporting data on the cost of management of pneumonia in children younger than 5 years old. We collected unpublished cost data on non-severe, severe and very severe pneumonia through collaboration with an international working group. We extracted data on cost per episode, duration of hospital stay and unit cost of interventions for the management of pneumonia. The mean (95% confidence interval, CI) and median (interquartile range, IQR) treatment costs were estimated and reported where appropriate. Results We identified 24 published studies eligible for inclusion and supplemented these with data from 10 unpublished studies. The 34 studies included in the cost analysis contained data on more than 95 000 children with pneumonia from both low- and-middle income countries (LMIC) and high-income countries (HIC) covering all 6 WHO regions. The total cost (per episode) for management of severe pneumonia was US$ 4.3 (95% CI 1.5-8.7), US$ 51.7 (95% CI 17.4- 91.0) and US$ 242.7 (95% CI 153.6-341.4)-559.4 (95% CI 268.9-886.3) in community, out-patient facilities and different levels of hospital in-patient settings in LMIC. Direct medical cost for severe pneumonia in hospital inpatient settings was estimated to be 26.6%-115.8% of patients' monthly household income in LMIC. The mean direct non-medical cost and indirect cost for severe pneumonia management accounted for 0.5-31% of weekly household income. The mean length of stay (LOS) in hospital for children with severe pneumonia was 5.8 (IQR 5.3-6.4) and 7.7 (IQR 5.5-9.9) days in LMIC and HIC respectively for these children. Conclusion This is the most comprehensive review to date of cost data from studies on the management of childhood pneumonia and these data should be helpful for health services planning and priority setting by national programmes and international agencies.

Can surveys of women accurately track indicators of maternal and newborn care? A validity and reliability study in Kenya.

Abstract: BACKGROUND Tracking progress on maternal and newborn survival requires accurate information on the coverage of essential interventions. Despite widespread use, most indicators measuring maternal and newborn intervention coverage have not been validated. This study assessed the ability of women delivering in two Kenyan hospitals to recall critical elements of care received during the intrapartum and immediate postnatal period at two time points: hospital discharge and 13-15 months following delivery. METHODS Women's reports of received care were compared against observations by trained third party observers. Indicators selected for validation were either currently in use or have the potential to be included in population-based surveys. We used a mixed-methods approach to validate women's reporting ability. We calculated individual-reporting accuracy using the area under the receiver operating curve (AUC), population-level accuracy using the inflation factor (IF), and compared the accuracy of women's reporting at baseline and follow-up. We also assessed the consistency of women's reporting over time. We used in-depth interviews with a sub-set of women (n = 20) to assess their understanding of key survey terms. RESULTS Of 606 women who participated at baseline and agreed to follow-up, 515 were re-interviewed. Thirty-eight indicators had sufficient sample size for validation analysis; ten met criteria for high or moderate reporting accuracy (0.60

Causes of death in children younger than five years in China in 2015: an updated analysis.

Abstract: Background Substantial progress in reducing the child mortality rate has been made globally in the last two decades. However, for China, the number of children dying from preventable diseases is still very large. It is important to have regularly updated information on the distribution of causes of death (COD) in children to inform policy and research. In this study, we aim to estimate the COD spectrum in children younger than five years old from 2009 to 2015 with a focus on the year 2015 and to provide an updated COD prediction model for China. Methods Updated data of under-five mortality rates (U5MRs) and the number of live births at national and provincial levels were obtained from United Nation's Inter-agency Group for Child Mortality Estimation (UN IGME), Institute for Health Metrics and Evaluation (IHME), and United Nations Population Division (UNPD). Then, we conducted a systematic review across four Chinese and English bibliographic databases and identified high-quality community-based longitudinal studies of COD in children younger than five years in China. We developed a number of single-cause models to predict the number of child death for main COD in different age groups at both national and provincial levels. The jackknife procedure was applied to construct the 95% Uncertainty Ranges (URs). Results From 2009 to 2015, the under-five mortality rates have declined by 37.1%. The leading causes of death in 2015 were preterm birth complications (17.4%), birth asphyxia (15.2%), congenital abnormalities (14.1%), accidents (13.5%) and pneumonia (12.4%) for children under five years old. The COD spectrum varied substantially across Chinese provinces with different development levels. The leading cause in children under five years in the wealthier provinces (with lower U5MRs) was congenital abnormalities (up to 18.9%), while in the poorer provinces (with higher U5MRs), pneumonia was the dominant COD (up to 23.4%). Conclusions This study updates and validates the accuracy of the findings of our previous COD study and proposes a new modelling method to predict proportions for the most common causes of child death in China. These updated COD estimates suggest that current strategies to reduce child mortality should prioritise action on neonatal deaths and target interventions against the top COD according to the local COD spectrum. Special attention should also be given to reducing differences between Chinese provinces and regions with differing development levels.

Digital technology for health sector governance in low and middle income countries: a scoping review.

Abstract: Background Poor governance impedes the provision of equitable and cost-effective health care in many low- and middle-income countries (LMICs). Although systemic problems such as corruption and inefficiency have been characterized as intractable, "good governance" interventions that promote transparency, accountability and public participation have yielded encouraging results. Mobile phones and other Information and Communication Technologies (ICTs) are beginning to play a role in these interventions, but little is known about their use and effects in the context of LMIC health care. Methods Multi-stage scoping review: Research questions and scope were refined through a landscape scan of relevant implementation activities and by analyzing related concepts in the literature. Relevant studies were identified through iterative Internet searches (Google, Google Scholar), a systematic search of academic databases (PubMed, Web of Science), social media crowdsourcing (targeted LinkedIn and Twitter appeals) and reading reference lists and websites of relevant organizations. Parallel expert interviews helped to verify concepts and emerging findings and identified additional studies for inclusion. Results were charted, analyzed thematically and summarized. Results We identified 34 articles from a wide range of disciplines and sectors, including 17 published research articles and 17 grey literature reports. Analysis of these articles revealed 15 distinct ways of using ICTs for good governance activities in LMIC health care. These use cases clustered into four conceptual categories: 1) gathering and verifying information on services to improve transparency and auditability 2) aggregating and visualizing data to aid communication and decision making 3) mobilizing citizens in reporting poor practices to improve accountability and quality and 4) automating and auditing processes to prevent fraud. Despite a considerable amount of implementation activity, we identified little formal evaluative research. Conclusion Innovative digital approaches are increasingly being used to facilitate good governance in the health sectors of LMICs but evidence of their effectiveness is still limited. More empirical studies are needed to measure concrete impacts, document mechanisms of action, and elucidate the political and sociotechnical dynamics that make designing and implementing ICTs for good governance so complex. Many digital good governance interventions are driven by an assumption that transparency alone will effect change; however responsive feedback mechanisms are also likely to be necessary.

Population-level effectiveness of PMTCT Option A on early mother-to-child (MTCT) transmission of HIV in South Africa: implications for eliminating MTCT

Abstract: UNICEF, the National Department of Health, the South African National AIDS Council, European Union (through the National Department of Health), the South African National Research Foundation and the Global Fund.

Linking household and facility data for better coverage measures in reproductive, maternal, newborn, and child health care: systematic review

Abstract: Background Currently many measures of intervention coverage obtained from household surveys do not measure actual health intervention/service delivery, resulting in a need for linking reports of care-seeking with assessments of the service environment in order to improve measurements. This systematic review aims to identify evidence of different methods used to link household surveys and service provision assessments, with a focus on reproductive, maternal, newborn and child health care, in low- and middle-income countries. Methods Using pre-defined search terms, articles published in peer-reviewed journals and the grey literature after 1990 were identified, their reference lists scanned and linking methods synthesized. Findings A total of 59 articles and conference presentations were carefully reviewed and categorized into two groups based on the linking method used: 1) indirect/ecological linking that included studies in which health care-seeking behavior was linked to all or the nearest facilities or providers of certain types within a geographical area, and 2) direct linking/exact matching where individuals were linked with the exact provider or facility where they sought care. The former approach was employed in 51 of 59 included studies, and was particularly common among studies that were based on independent sources of household and facility data that were nationally representative. Only eight of the 59 reviewed studies employed direct linking methods, which were typically done at the sub-national level (eg, district level) and often in rural areas, where the number of providers was more limited compared to urban areas. Conclusions Different linking methods have been reported in the literature, each category has its own set of advantages and limitations, in terms of both methodology and practicality for scale-up. Future studies that link household and provider/facility data should also take into account factors such as sources of data, the timing of surveys, the temporality of data points, the type of services and interventions, and the scale of the study in order to produce valid and reliable results.

Ebola research funding: a systematic analysis, 1997-2015.

Abstract: Background: The latest outbreak of Ebola in West Africa overwhelmed the affected countries, with the impact on health extending far beyond Ebola–related deaths that have exceeded 11?000. The need to promptly mobilise resources to control emerging infections is widely recognized. Yet, data on research funding for emerging infections remains inadequately documented. Methods: We defined research investment as all funding flows for Ebola and/or Marburg virus from 1997 to April 2015 whose primary purpose was to advance knowledge and new technologies to prevent or cure disease. We sourced data directly from funding organizations and estimated the investment in 2015 US dollars (US$). Results: Funding for Ebola and Marburg virus research in 1997 to 2015 amounted to US$ 1.035 billion, including US$ 435.4 million (42.0%) awarded in 2014 and 2015. Public sources of funding invested US$ 758.8 million (73.1%), philanthropic sources US$ 65.1 million (6.3%), and joint public/private/philanthropic ventures accounted for US$ 213.8 million (20.6%). Prior to the Ebola outbreak in 2014, pre–clinical research dominated research with US$ 443.6 million (73.9%) investment. After the outbreak, however, investment for new product development increased 942.7–fold and that for clinical trials rose 23.5–fold. Investment in new tools to control Ebola and Marburg virus amounted to US$ 399.1 million, with 61.3% awarded for vaccine research, 29.2% for novel therapeutics research such as antivirals and convalescent blood products, and 9.5% for diagnostics research. Research funding and bibliometric output were moderately associated (Spearman's ??=?0.5232, P?=?0.0259), however number of Ebola cases in previous outbreaks and research funding (??=?0.1706, P?=?0.4985) and Ebola cases in previous outbreaks and research output (??=?0.3020, P?=?0.0616) were poorly correlated. Conclusion: Significant public and philanthropic funds have been invested in Ebola and Marburg virus research in 2014 and 2015, following the outbreak in West Africa. Long term, strategic vision and leadership are needed to invest in infections with pandemic potential early, including innovative financing measures and open access investment data to promote the development of new therapies and technologies.

Setting health research priorities using the CHNRI method: IV. Key conceptual advances.

Abstract: Introduction Child Health and Nutrition Research Initiative (CHNRI) started as an initiative of the Global Forum for Health Research in Geneva, Switzerland. Its aim was to develop a method that could assist priority setting in health research investments. The first version of the CHNRI method was published in 2007-2008. The aim of this paper was to summarize the history of the development of the CHNRI method and its key conceptual advances. Methods The guiding principle of the CHNRI method is to expose the potential of many competing health research ideas to reduce disease burden and inequities that exist in the population in a feasible and cost-effective way. Results The CHNRI method introduced three key conceptual advances that led to its increased popularity in comparison to other priority-setting methods and processes. First, it proposed a systematic approach to listing a large number of possible research ideas, using the "4D" framework (description, delivery, development and discovery research) and a well-defined "depth" of proposed research ideas (research instruments, avenues, options and questions). Second, it proposed a systematic approach for discriminating between many proposed research ideas based on a well-defined context and criteria. The five "standard" components of the context are the population of interest, the disease burden of interest, geographic limits, time scale and the preferred style of investing with respect to risk. The five "standard" criteria proposed for prioritization between research ideas are answerability, effectiveness, deliverability, maximum potential for disease burden reduction and the effect on equity. However, both the context and the criteria can be flexibly changed to meet the specific needs of each priority-setting exercise. Third, it facilitated consensus development through measuring collective optimism on each component of each research idea among a larger group of experts using a simple scoring system. This enabled the use of the knowledge of many experts in the field, "visualising" their collective opinion and presenting the list of many research ideas with their ranks, based on an intuitive score that ranges between 0 and 100. Conclusions Two recent reviews showed that the CHNRI method, an approach essentially based on "crowdsourcing", has become the dominant approach to setting health research priorities in the global biomedical literature over the past decade. With more than 50 published examples of implementation to date, it is now widely used in many international organisations for collective decision-making on health research priorities. The applications have been helpful in promoting better balance between investments in fundamental research, translation research and implementation research.

Infection prevention and control of Clostridium difficile: a global review of guidelines, strategies, and recommendations.

Abstract: Background Clostridium difficile is the leading cause of health care–associated infections. Given the high incidence of C. difficile infection (CDI) and the lack of primary prevention through immunization, health care professionals should be aware of the most current guidance, as well as strengths and limitations of the evidence base underpinning this guidance.

Addressing the growing burden of non-communicable disease by leveraging lessons from infectious disease management.

Abstract: In recent decades, low– and middle–income countries (LMICs) have achieved decreased morbidity and mortality associated with infectious diseases and poor maternal– and child–health (MCH). However, despite these advances, LMICs now face an additional burden with the inexorable rise of non–communicable diseases (NCDs). Deaths due to NCDs in LMICs are expected to increase from 30.8 million in 2015 to 41.8 million by 2030 [1]. While improvements in life expectancy, lifestyle and urbanisation go some way to explaining why more people in LMICs are affected by NCDs, it is less clear why these populations are contracting NCDs at a younger age and with worse outcomes than in high–income countries (HICs) [2]. Despite having a lower cardiovascular disease risk factor burden, LMIC populations have a four–fold higher mortality rate from cardiovascular events than HIC populations [3] in part due to a lack of access to quality, integrated health services and the poor availability of early interventions and effective NCD prevention programmes. The HIV/AIDS epidemic was the last time the world confronted a global health challenge that so disproportionately caused premature adult deaths in LMICs. The conclusion is unavoidable: the time to act is now. Prevention of NCDs at a population and an individual level is key and requires policy and structural changes. We have a unique opportunity to learn from the successes of infectious disease control programmes in LMICs and leverage these to address the growing NCD burden. Translatable learnings include: 1) emphasizing primary prevention, particularly in those at highest risk; 2) targeting service delivery to high–risk populations; 3) enabling access to adequate, affordable care at community level; 4) engendering patient empowerment and involving people affected by chronic conditions; 5) enabling access to quality drugs and adherence programmes; 6) regularly measuring the effectiveness and impact of programmes to ensure their appropriateness and improvement; and 7) creating an environment of health financing for universal coverage. Innovations to counter the emerging NCD epidemic must encompass both prevention and the delivery of care. Infectious disease programmes have used task–shifting, where less skilled health workers and community members are involved in delivery of health services. In India, we have seen this used for NCDs in the Arogya Kiran model where the existing health workforce was overstretched. Volunteers and teachers successfully delivered diabetes and hypertension screening and management to over 600 000 people [4]. Patient empowerment, and community involvement in health care delivery and governance, will be critical in tackling NCDs, since most are chronic conditions, which initially present silently and require long–term management [5]. In Malawi, recognizing the close relationship of HIV infection and cardiovascular diseases has led to screening for hypertension being integrated into HIV care [6]. In Ghana, decentralised community–based hypertension care, using digital technology, is helping to empower patients to manage their own disease: a model that is again adapted from HIV management [7]. We are also starting to see examples in India of MCH care coupled with life–long NCD screening and awareness programmes [8]. While these examples of managing the dual burden of infectious diseases and NCDs are encouraging, more needs to be done. The largest gap is in NCD prevention. Tackling the obesity epidemic and wrestling with the issues around curbing tobacco sales and smoking are rightly high on the NCD prevention agenda. The greatest opportunity is preventing a tobacco–related epidemic in sub–Saharan Africa where smoking levels are still low. Health budgets and development assistance for health must allocate resources commensurate with the dual disease burden. Health spending of governments in LMICs has tripled over the past 20 years, but remains low [9]. In addition, more health care models should consider diversified revenue streams or hybrid financing (eg, tiered payment schemes) to ensure sustainability. If equity is to be improved, patients need access to quality health care, through sustainable health–financing systems for universal health coverage, while reducing out–of–pocket expenditure for the under–served population. Photo: © Nana Kofi Acquah/Novartis Foundation Implementing such models will require strong government leadership and interventions, and partnerships across the public and private sectors. Some public–private partnerships (PPPs) in infectious diseases have demonstrated their potential to catalyze the delivery of, and access to, prevention and care through providing complementary strengths [10]. The private sector draws on its business and scientific expertise, focusing on strong results–based operations, whereas the public sector brings a wealth of expertise in implementation with equity, management and documentation. The end–users of the services, including patients and health care providers, also need to be included from the outset to ensure that the models are people–centered, co–created, adapted to prevailing contextual nuances, and sustainable. If we build on what we have learnt from infectious disease management, we could have a transformational impact on the growing NCD burden.

Integration of antenatal care services with health programmes in low- and middle-income countries: systematic review.

Abstract: Since 2005, antenatal care (ANC) coverage has risen considerably worldwide [1]. The World Health Organization (WHO) estimates suggest that during 2005–2012 approximately 80.5% of pregnant women globally, including 71.8% of women in low–income countries, had at least one ANC visit during pregnancy [1]. ANC provides an opportunity for women to access effective interventions that reduce risks associated with pregnancy and improve their health and well–being, as well as that of their progeny. However, while there was considerable progress towards the Millennium Development Goals 4 (to reduce child mortality) and 5 (to improve maternal health), maternal and neonatal mortality from preventable pregnancy– and birth–related complications remain high, particularly in low– and middle–income countries (LMICs) [2]. In 2013, around 289 000 women died during and following pregnancy and childbirth–the vast majority in low–resource settings [3]. Between one–third and one–half of these pregnancy–related deaths are due to preventable complications, such as eclampsia and haemorrhage, directly related to inadequate care [4]. Additionally, nearly three million newborns died during their first month of life, in large part due to insufficient provision of postnatal care (PNC) [2,5–8]. Lack of PNC not only affects neonatal mortality, but also has long–term negative impacts on the development of children who survive, as opportunities for promoting healthy home behaviours are missed. The unacceptably high maternal and neonatal mortality rates in LMICs suggest new approaches are needed to expand access to ANC, improve the quality of services provided during ANC contact, and strengthen continuity and quality of care through to the postnatal period. In most LMICs pregnancy often marks a woman’s first encounter with formal health services, and ANC can serve as an effective platform for a broad range of health interventions [9], including for the provision of services for conditions that increase the risk of complications during pregnancy (eg, malaria, sexually transmitted infections (STIs), HIV/AIDS, tuberculosis (TB), tetanus, and malnutrition). Integrating ANC with malaria, STIs, HIV/AIDS and TB services can also expand the reach of these programmes to a broader population [10]. In settings where the prevalence of such conditions is high, integrating ANC with cost–effective services like prevention of mother to child transmission (PMTCT) of HIV [11], intermittent preventative treatment in pregnancy for malaria, and provision of insecticide treated nets [9] would likely improve maternal and child health outcomes. The WHO has identified integration of ANC with other health services, including PNC, as a key strategy for reducing missed opportunities for patient contact and for effectively and comprehensively addressing the health and social needs of pregnant women and their children, thereby improving maternal and child health [5,8,9]. Integration in health systems is variously defined [12–15], referring to establishing joint systems for organisation, financing, management, planning and evaluation of health programmes at different levels of the health system (from health facilities to ministry of health level) to improve the efficiency and effectiveness of health systems [16]. Integrated care has also been defined by WHO as “bringing together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion” in order to “improve services in relation to access, quality, user satisfaction and efficiency” [17,18]. The rationale for integrating health services is to improve user access to health services across the care continuum to meet users’ health needs over time [19,20] and to create positive synergies among investments in health programmes [21]. However, ‘injudicious integration’ may also have harmful consequences for already constrained health systems [22]. For example, provision of multiple services during a single point of contact requires that health care providers be sufficiently trained in all aspects of the services concerned to ensure high quality care. But, in resource constrained systems training can take away health staff from frontline services [23]. Furthermore, provision of multiple services could stretch the already limited capacity, thus leading to long waiting times and hindering access for women who have to travel far to reach health facilities. In an attempt to reduce workload providers may reduce the time spent on consultations, thus compromising service quality. To date few studies have systematically examined how integration of ANC with other services could influence health outcomes, service access, efficiency, or patient satisfaction [19,24–26]. Evidence to guide policy on the best ways to integrate ANC with PNC and other health services for pregnant women and integration impact is limited. This review examines the evidence on how integration of ANC services with PNC or other health services in LMICs affects health outcomes for women and children, health care provision (including processes, outputs, service quality) and costs. The review analyses ways in which the quality of ANC can be improved through integration with PNC and other health services. Specifically, the review focuses on the impact of integrated provision of ANC services, which can take different forms, such as co–location of ANC and PNC or other health services with a single point of access, through a well–connected referral system [27,28], or by merger of services within or across a domain of care [29].

Structure, function and five basic needs of the global health research system.

Abstract: BACKGROUND: Two major initiatives that were set up to support and co-ordinate global health research efforts have been largely discontinued in recent years: the Global Forum for Health Research and World Health Organization's Department for Research Policy and Cooperation. These developments provide an interesting case study into the factors that contribute to the sustainability of initiatives to support and co-ordinate global health research in the 21st century. METHODS: We reviewed the history of attempts to govern, support or co-ordinate research in global health. Moreover, we studied the changes and shifts in funding flows attributed to global health research. This allowed us to map the structure of the global health research system, as it has evolved under the increased funding contributions of the past decade. Bearing in mind its structure, core functions and dynamic nature, we proposed a framework on how to effectively support the system to increase its efficiency. RESULTS: Based on our framework, which charted the structure and function of the global health research system and exposed places and roles for many stakeholders within the system, five basic needs emerged: (i) to co-ordinate funding among donors more effectively; (ii) to prioritize among many research ideas; (iii) to quickly recognize results of successful research; (iv) to ensure broad and rapid dissemination of results and their accessibility; and (v) to evaluate return on investments in health research. CONCLUSION: The global health research system has evolved rapidly and spontaneously. It has not been optimally efficient, but it is possible to identify solutions that could improve this. There are already examples of effective responses for the need of prioritization of research questions (eg, the CHNRI method), quick recognition of important research (eg, systems used by editors of the leading journals) and rapid and broadly accessible publication of the new knowledge (eg, PLoS One journal as an example). It is still necessary to develop tools that could assist donors to co-ordinate funding and ensure more equity between areas in the provided support, and to evaluate the value for money invested in health research.

Improved measurement for mothers, newborns and children in the era of the Sustainable Development Goals.

Abstract: Within the 17 Sustainable Development Goals (SDGs) a total of 169 targets and over 230 indicators have been defined [1]. In alignment with the SDGs, the Global Strategy for Women’s, Children’s and Adolescents’ Health (the Global Strategy) has described an ambitious action and measurement agenda around the three pillars “Survive, Thrive and Transform” [2]. In the immediate future many countries have an unfinished agenda to accelerate the scale–up of cost–effective essential maternal, newborn and child health (MNCH) interventions that save lives as well as help families to thrive [3]. Tracking intervention coverage is a top priority to assist this scale–up so that countries know the extent to which populations in need are benefiting, and delivery strategies are refined as a result [4]. In this paper we examine priorities in coverage measurement of essential MNCH interventions, distinguishing between those that can be measured now and those that require methodological development. Of particular importance is to explicitly acknowledge known measurement challenges across the continuum from pregnancy to childhood [5–7], and categorise indicators that can be measured now using existing methods and tools (“indicators for immediate use”), and those that are high priority in the context of life–saving, quality care but require further methodological development and validation (“priority indicators for development”). Once validated using feasible methods, these priority indicators for development can be further described in global guidance and integrated within existing data collection systems. The remainder of this paper proposes a transparent set of evidence–based considerations for the global MNCH measurement improvement agenda. We draw on evidence supporting cost–effective investments in MNCH [3], recommendations by the Global Strategy [8], and the priorities identified by other initiatives including the Global Reference List of 100 core indicators [9], the World Health Organization’s consultation on quality MNCH [10], the Every Newborn Action Plan (ENAP) [11], and Ending Preventable Maternal Mortality (EPMM) [12].

Factors associated with delay in care–seeking for fatal neonatal illness in the Sylhet district of Bangladesh: results from a verbal and social autopsy study

Abstract: BACKGROUND We conducted a social and verbal autopsy study to determine cultural-, social- and health system-related factors that were associated with the delay in formal care seeking in Sylhet district, Bangladesh. METHODS Verbal and social autopsy interviews were conducted with mothers who experienced a neonatal death between October 2007 and May 2011. We fitted a semi-parametric regression model of the cumulative incidence of seeking formal care first, accounting for competing events of death or seeking informal care first. RESULTS Three hundred and thirty-one neonatal deaths were included in the analysis and of these, 91(27.5%) sought formal care first; 26 (7.9%) sought informal care first; 59 (17.8%) sought informal care only, and 155 (46.8%) did not seek any type of care. There was lower cumulative incidence of seeking formal care first for preterm neonates (sub-hazard ratio SHR 0.61, P = 0.025), and those who delivered at home (SHR 0.52, P = 0.010); and higher cumulative incidence for those who reported less than normal activity (SHR 1.95, P = 0.048). The main barriers to seeking formal care reported by 165 mothers included cost (n = 98, 59.4%), believing the neonate was going to die anyway (n = 29, 17.7%), and believing traditional care was more appropriate (n = 26, 15.8%). CONCLUSIONS The majority of neonates died before formal care could be sought, but formal care was more likely to be sought than informal care. There were economic and social belief barriers to care-seeking. There is a need for programs that educate caregivers about well-recognized danger signs requiring timely care-seeking, particularly for preterm neonates and those who deliver at home.

Setting health research priorities using the CHNRI method: II. Involving researchers

Abstract: Large groups of researchers who agree to offer their research ideas and then score them against pre–defined criteria are at the heart of each CHNRI priority–setting exercise. Although the roles of funders and other stakeholders are also very important, much of the exercise is focused on selecting and engaging a large group of researchers, obtaining their input and analysing it to derive the initial results of the process. In a sense, a CHNRI exercise serves to “visualise” the collective knowledge and opinions of many leading researchers on the status of their own research field. Through a simple “crowdsourcing” process conducted within the relevant research community, the CHNRI approach is able to collate a wide spectrum of research ideas and options, and come to a judgement on their strengths and weaknesses, based on the collective knowledge and opinions of many members of the research community. In doing so, it provides valuable information to funders, stakeholders and researchers themselves, which is obtained at low cost and with little time necessary to conduct the exercise.

Social determinants of child mortality in Niger: Results from the 2012 National Verbal and Social Autopsy Study.

Abstract: With a population over 15 million people in 2011, the Republic of Niger is West Africa’s second–largest country [1]. This landlocked country is characterized by chronic food security issues, natural crises, including droughts, floods and locust infestation, and a level of poverty that reflects more than a decade of periodic political instability. Niger’s poverty rate of 46.3% makes it one of the world’s poorest countries. Per capita income, at $360, puts it at the very bottom of the 187 countries ranked by the United Nations Development Program’s Human Development Index [2]. In this fragile nation, women and children suffer the greatest burden of poor health and inequality [3]. Niger’s social indicators have improved significantly over the past two decades, as progress toward the Millennium Development Goals (MDGs) is a main priority of the government. The Government of Niger’s policies in support of universal access, provision of free health care for pregnant women and children, and strong nutrition programs have enabled the country to decrease child mortality at a pace that exceeded expectations. These policies are enshrined in general principles and international strategies such as primary health care and the Bamako Initiative. Thus, its health system is organized into three administrative and service levels: local/district, intermediary/regional and central/national. At the local level, public sector services are provided by community health posts (Case de Sante), integrated health centers (Centres de Sante Integres), and district hospitals. About 75% of health posts are staffed by CHWs (the rest by a nurse or midwife), and health centers and hospitals are staffed by at least one nurse, midwife or physician. Recently, the Niger countdown case study showed far greater reductions in child mortality than in neighboring West African countries. In tandem with its efforts to tackle malnutrition, the government of Niger has put in place several measures to reduce childhood mortality. For the past few years, children under five have received free health care, while significant progress has been made in immunization coverage, recruitment of health staff and in the number of malaria cases treated. Collectively, these factors have contributed to a rapid reduction in the under–five child mortality rate, from 226 deaths per 1000 live births in 1995, to 128 deaths per 1000 in 2009 – a remarkable 43% reduction [4]. In preparing child mortality–reduction strategies in the post–2015 era, progress in reducing child deaths around the globe will require new and different strategies from those used to get the world to the current point. For instance, it is important for each country to know not only the magnitude of under–five mortality, but also the biological causes and social determinants of these deaths in order to assess needs and develop programs that will reduce avoidable child deaths more quickly. Thus, reliable direct estimates of the causes and the determinants of under–five deaths are needed to efficiently tailor evidence–based policies and programs. A national verbal/social autopsy (VASA) study was conducted in Niger as part of the Child Health Epidemiology Reference Group’s (CHERG) recent efforts to directly measure the causes and determinants of neonatal and child mortality in selected high–priority countries. The current paper aims to complement the recently published verbal autopsy findings [5] and reports on the social autopsy data of post–neonatal deaths. The objective is to provide insights into modifiable family, household, and health system factors that contributed to the deaths of children (1–59 months) from 2007 to 2010 in Niger, information that will be vital to health policymakers in government and non–governmental organizations as they develop new policies and programs for better resource planning in the post–2015 period.

Setting health research priorities using the CHNRI method: V. Quantitative properties of human collective knowledge.

Abstract: Introduction The CHNRI method for setting health research priorities has crowdsourcing as the major component. It uses the collective opinion of a group of experts to generate, assess and prioritize between many competing health research ideas. It is difficult to compare the accuracy of human individual and collective opinions in predicting uncertain future outcomes before the outcomes are known. However, this limitation does not apply to existing knowledge, which is an important component underlying opinion. In this paper, we report several experiments to explore the quantitative properties of human collective knowledge and discuss their relevance to the CHNRI method.

Can innovative ambulance transport avert pregnancy-related deaths? One-year operational assessment in Ethiopia.

Abstract: BACKGROUND:To maximise the potential benefits of maternity care services, pregnant women need to be able to physically get to health facilities in a timely manner. In most of sub-Saharan Africa, tr ...

Setting health research priorities using the CHNRI method: III. Involving stakeholders.

Abstract: Setting health research priorities is a complex and value–driven process. The introduction of the Child Health and Nutrition Research Initiative (CHNRI) method has made the process of setting research priorities more transparent and inclusive, but much of the process remains in the hands of funders and researchers, as described in the previous two papers in this series [1,2]. However, the value systems of numerous other important stakeholders, particularly those on the receiving end of health research products, are very rarely addressed in any process of priority setting. Inclusion of a larger and more diverse group of stakeholders in the process would result in a better reflection of the system of values of the broader community, resulting in recommendations that are more legitimate and acceptable. The CHNRI method, as originally proposed, took into account the importance of stakeholders and made provisions for their participation in the process. Although the involvement of a large and diverse group of stakeholders is desirable, they were not expected to propose research ideas, or score them against the set of pre–defined criteria. Because of this, the original CHNRI method proposed that stakeholders should be allowed to “weigh” pre–defined criteria and set “thresholds” for a minimum acceptable score against each criterion that would be required for a research idea to be considered a “research priority”. In choosing the stakeholders, the context of each exercise will be very important and the goals of the specific exercise should be defined before choosing an appropriate “stakeholder group”. Among stakeholders, we would expect to see those affected by the disease of interest and their family members, their carers and health workers, members of general public, media representatives interested in the topic, community leaders, representatives of the consumer groups and industry, but also potentially researchers and funders themselves. Although the latter two groups – researchers and funders – already have a different role assigned in the CHNRI process, this does not exclude them from also being stakeholders in the process [1,2]. In this paper, we aim to review and analyse the experiences in stakeholder involvement across the 50 CHNRI exercises published in the 10–year period between 2007 and 2016, the proposed approaches to involving stakeholders and their effects on the outcome of the prioritization process. One paper in the original CHNRI method series focused on involving stakeholders [3]. That paper presented practical experiences from three separate attempts to involve stakeholders that took place in 2006. The three groups approached were: (i) members of the global research priority setting network; (ii) a diverse group of national–level stakeholders from South Africa; and (iii) participants at a conference related to international child health held in Washington, DC, USA. Each group was asked to complete a short questionnaire to assess the relative importance of the five original CHNRI criteria. Different versions of the questionnaire were used with each group [3]. The results of this exercise indicated that groups of stakeholders vary in the weights they assigned to the 5 criteria, reflecting divergence in the “value” placed on each criterion by each stakeholder group. The diverse group of respondents within the priority–setting network placed the greatest weight on the criterion of “maximum potential for disease burden reduction” and the most stringent threshold on “answerability in an ethical way”. Among the attendees at the international conference on child health, the criterion of “deliverability, answerability and sustainability” was identified as the most important. Finally, in South Africa, where inequity has been a national problem historically, the greatest weight was placed on the “predicted impact on equity” criterion. This comparative analysis by Kapiriri et al. [3] effectively demonstrated that involving a wide range of stakeholders is an important goal for any research priority setting exercise. The criteria that may be of importance to funders, scientists and other technical experts involved in the process of planning and conducting the exercise may not be well aligned with the values of those who should eventually benefit from health research, or with the sentiments of wider society as a whole [3]. This is an important observation, because if the CHNRI process is conducted without regard for the broader social value or research, then it is unrealistic to expect it to fulfil its purpose of being accepted as a fair, transparent and legitimate process for setting investment priorities for health research.

Innovative financing for HIV response in sub-Saharan Africa.

Abstract: By 2015, around 15 million individuals were accessing life–saving antiretroviral treatment (ART) [1]. Yet, the “AIDS transition” [2] is not in sight–in 2014, there were 36.9 million people living with HIV, 2 million new HIV infections and 1.2 million AIDS–related deaths [3]. The continuing HIV epidemic requires sustained investment to prevent new infections and to provide treatment to those who need ART now and in the future. However, as more individuals access ART, domestic obligations for financing HIV will increase, reaching an estimated US$ 190 billion between 2015 and 2050 and account for as high as 47% of the GDP in high prevalence sub–Saharan African countries such as Malawi [4], creating long term commitments that have to be met. The financial obligations have major implications for the affected countries and donors–not just in economic terms, but also in the way they manage financing of the HIVresponse, which requires empowering countries to take greater responsibility for managing funds from all sources. The return of investment in HIV response as measured by benefit to cost ratio has been estimated at 280% [5], with substantial economic, social and health benefits reported by other studies [6], comparable to benefit to cost ratios reported for maternal and child health investments [7]. However, donor financing, which accounts for a large share of the HIV/AIDS funding in sub–Saharan Africa, is constrained due to the global economic crisis [8]. Domestic financing remains equally challenging, especially in high–prevalence low–income countries that are fiscally constrained. Compounding the financing challenges are inefficiencies in channeling and use of available funds, and the harmful asymmetry between the long–term financing needs for HIV and short–term replenishment cycles of donor institutions [9]. There are opportunities for increasing HIV financing, however. African economies are enjoying economic growth [10]. There are also untapped natural resources that could generate upwards of US$ 4 billion each year [11]. Additional fiscal space could be created in domestic budgets by improving efficiency in allocation both to and within HIV programmes and by co–financing HIV services with funding other economic sectors [12]. Innovative financing could offer new sources of funding. Conceived as a funding source to meet the Millennium Development Goals (MDGs), innovative financing, which provided around US$ 6 billion in total in 2002–2012 [13], is increasingly an important source of funding for global health [14]. We explore how innovative financing could be used to co–finance the long–term HIV obligations by augmenting domestic contributions in sub–Saharan Africa. We analyze how different innovative financing instruments can be operationalised and the institutional arrangements needed for their effective use.

Moving global health forward in academic institutions

Abstract: Global health has attracted growing attention from academic institutions. Its emergence corresponds to the increasing interdependence that characterizes our time and provides a new worldview to address health challenges globally. There is still a large potential to better delineate the limits of the field, drawing on a wide perspective across sciences and geographical areas. As an implementation and integration science, academic global health aims primarily to respond to societal needs through research, education, and practice. From five academic institutions closely engaged with international Geneva, we propose here a definition of global health based on six core principles: 1) cross–border/multilevel approach, 2) inter–/trans–disciplinarity, 3) systems thinking, 4) innovation, 5) sustainability, and 6) human rights/equity. This definition aims to reduce the century–old divide between medicine and public health while extending our perspective to other highly relevant fields. Overall, this article provides an intellectual framework to improve health for all in our contemporary world with implications for academic institutions and science policy. Health and well–being are major challenges for the 21st century. While these key areas of societal development have gained prominence worldwide by receiving more political attention and funding than ever, the expression ‘global health’ has emerged to describe the profound shift in the nature of health within the context of globalization. Becoming ubiquitous, global health has generated increasing interest from academic institutions, which, as places of knowledge innovation, validation, transmission, and application, have a critical role to play in global health education, research, and practice [1,2]. In this article we use the terms ‘academic global health’ (AGH) to focus on the key role of academic institutions including university hospitals in the global health system. As an integration and implementation science [3], the primary goal of AGH is to foster transformative knowledge, which implies both new models of thinking and new types of research. At the operational level, this translates into a process of mutual learning for change and health improvement, through sharing and comparing across systems and cultures, using both qualitative and quantitative methods, validating new evidence internally and externally, and making interdisciplinary and international collaborations a prerequisite. From the viewpoint of five academic institutions closely engaged with Geneva, a leading city in global health and global governance, the present article attempts to reflect on the core principles, definition, and significance of AGH.

Shifting chronic disease management from hospitals to primary care in Estonian health system: analysis of national panel data.

Abstract: Following independence from the Soviet Union in 1991, Estonia introduced a national insurance system, consolidated the number of health care providers, and introduced family medicine centred primary health care (PHC) to strengthen the health system. Using routinely collected health billing records for 2005-2012, we examine health system utilisation for seven ambulatory care sensitive conditions (ACSCs) (asthma, chronic obstructive pulmonary disease [COPD], depression, Type 2 diabetes, heart failure, hypertension, and ischemic heart disease [IHD]), and by patient characteristics (gender, age, and number of co-morbidities). The data set contained 552 822 individuals. We use patient level data to test the significance of trends, and employ multivariate regression analysis to evaluate the probability of inpatient admission while controlling for patient characteristics, health system supply-side variables, and PHC use. Over the study period, utilisation of PHC increased, whilst inpatient admissions fell. Service mix in PHC changed with increases in phone, email, nurse, and follow-up (vs initial) consultations. Healthcare utilisation for diabetes, depression, IHD and hypertension shifted to PHC, whilst for COPD, heart failure and asthma utilisation in outpatient and inpatient settings increased. Multivariate regression indicates higher probability of inpatient admission for males, older patient and especially those with multimorbidity, but protective effect for PHC, with significantly lower hospital admission for those utilising PHC services. Our findings suggest health system reforms in Estonia have influenced the shift of ACSCs from secondary to primary care, with PHC having a protective effect in reducing hospital admissions.

Verbal/social autopsy study helps explain the lack of decrease in neonatal mortality in Niger, 2007–2010

Abstract: The 2010 Niger National Mortality Survey (NNMS) found that from 1998 to 2009 the mortality rate of children less than 5 years old decreased significantly by 43.4%, from 226 (95% confidence interval CI 207–246) to 128 (95% CI 117–140) deaths per 1000 live births, but mortality of neonates less than 28 days old declined insignificantly from 39 (95% CI 32–46) to 33 (95% CI 28–39) deaths per 1000 live births [1,2]. The reduction in child deaths was attributed to improvements in the nutritional status of children less than 2 years old and increased coverage of key child survival interventions, including insecticide–treated bed nets, vitamin A supplementation, treatment of diarrhea with oral rehydration salts and zinc, careseeking for childhood pneumonia and fever or cough, and vaccinations. The rapid uptake of interventions was achieved through government policy decisions to implement the Integrated Management of Childhood Illness (IMCI) approach, integrated community case management for children with fever or malaria, suspected pneumonia and diarrhea, and to provide free health care for all pregnant women and children including scaling up access to a minimum package of high–impact interventions at integrated health centers and health posts. Interventions effective against neonatal mortality that were examined, including antenatal care, maternal tetanus toxoid, skilled birth attendance, early initiation of and exclusive breastfeeding, showed smaller increases in coverage to endpoint levels well below 50%, likely inadequate to decrease neonatal mortality [1]. In addition, an earlier study on the quality of maternal and newborn care found that few health workers present at birth had the knowledge, skills and access to basic equipment needed to effectively manage obstetric and newborn problems. Only 2.5% of Centres de Sante Integres (CSI), which are meant to have at least two nurses or midwives on duty at all times and which are the main health centers throughout the country intended to provide Basic Emergency Obstetric and Neonatal Care (BEmONC), had the full capacity for this service; and the national met need for EmONC stood at 2.3%, varying by region from 1.4% to 6.5% [3]. Health posts (Case de Santes), only about one–fourth of which have a nurse or midwife on staff and are not intended to provide EmONC, were not examined. Neither of these studies, however, examined several other interventions critical to neonatal survival nor did they assess the causes of and events leading up to the deaths of the newborns along the continuum of antenatal and delivery care of the mother and immediate postnatal care of the newborn, maternal complications and the severe newborn illnesses these can lead to, mothers’ perceptions and knowledge of how to respond to such critical events, their careseeking attempts for themselves and their newborns, and factors affecting these behaviors. The fact that maternal complications occur at a fairly constant level, severe enough to kill the mother in about 1.0% to 1.4% of pregnancies and to kill the baby at a much higher rate, and that it cannot be reliably predicted which women will experience these complications, is the basis for the maternal mortality reduction strategy of universal access to skilled birth attendance and emergency obstetric care when needed [4–7]. This strategy is no less important to the survival and health of the neonate, as it has been shown that pregnancy and delivery complications are the most important risk factors for neonatal mortality [8–12], with care directed at the intrapartum period providing the greatest mortality reduction [13]. Integrated maternal–neonatal care packages and linkages of community with facility maternal and newborn care provide further reductions in stillbirths and neonatal deaths [14,15]. The addition of newborn–specific strategies, including fetal monitoring, access to Caesarean section for fetal distress, clean delivery and cord care, neonatal resuscitation, early initiation of and exclusive breastfeeding, timely and appropriate thermal care of the baby, kangaroo mother care for stabilized preterm infants, recognition of and early careseeking for newborn illness, access to quality health care, and urgent referral to neonatal intensive care when needed, are required to maximize newborn survival [13,16–20]. Examining such vital information on maternal and newborn care provided for babies that died is needed to help explain why the deaths occurred and how they might have been prevented. Collecting comparison data for newborns that suffered a severe but non–fatal illness during the same time period as the deaths would require the difficult task of identifying households where such an illness occurred; and the inability to appropriately match deaths with other cases on the basis of illness severity and the timing of clinical signs has led to a misleading situation where one could falsely conclude that treatment increased mortality risk [21]. Moreover, promoting neonatal health and preventing the death of sick newborns requires well–proven interventions for which the population levels established by already–completed surveys can provide reasonable comparisons for the surveyed factors. Social autopsy (SA) is a method of inquiring about deaths that adds questions on household, community and health system determinants of mortality to complement a verbal autopsy (VA) interview on the illness signs and symptoms used to establish the biological cause of death [22]. We undertook to assess the biological causes and social determinants of recent neonatal deaths in Niger by conducting a verbal/social autopsy (VASA) study of neonatal deaths that occurred in 2007–2010 and were identified by the 2010 NNMS. Where possible, we compared the VASA findings for the deaths to the same factors for surviving children from the same cohort determined by recent population surveys. In this way, we sought to further explain the reasons for the limited decrease in neonatal mortality in Niger from 2007 to 2010.