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OBJECTIVES In Nepal, where difficult geography and an under-resourced health system contribute to poor health care access, the government has increased the number of trained skilled birth attendants (SBAs) and posted them in newly constructed birthing centres attached to peripheral health facilities that are available to women 24h a day. This study describes their views on their enabling environment. METHODS Qualitative methods included semi-structured interviews with 22 SBAs within Palpa district, a hill district in the Western Region of Nepal; a focus group discussion with ten SBA trainees, and in-depth interviews with five key informants. RESULTS Participants identified the essential components of an enabling environment as: relevant training; ongoing professional support; adequate infrastructure, equipment and drugs; and timely referral pathways. All SBAs who practised alone felt unable to manage obstetric complications because quality management of life-threatening complications requires the attention of more than one SBA. CONCLUSIONS Maternal health guidelines should account for the provision of an enabling environment in addition to the deployment of SBAs. In Nepal, referral systems require strengthening, and the policy of posting SBAs alone, in remote clinics, needs to be reconsidered to achieve the goal of reducing maternal deaths through timely management of obstetric complications. [ABSTRACT FROM AUTHOR]

Background: Cambodia has made considerable improvements in mortality rates for children under the age of five and neonates. These improvements may, however, mask considerable disparities between subnational populations. In this paper, we examine the extent of the country's child mortality inequalities. Methods: Mortality rates for children under-five and neonates were directly estimated using the 2000, 2005 and 2010 waves of the Cambodian Demographic Health Survey. Disparities were measured on both absolute and relative scales using rate differences and ratios, and where applicable, slope and relative indices of inequality by levels of rural/urban location, regions and household wealth. Findings: Since 2000, considerable reductions in under-five and to a lesser extent in neonatal mortality rates have been observed. This mortality decline has, however, been accompanied by an increase in relative inequality in both rates of child mortality for geography-related stratifying markers. For absolute inequality amongst regions, most trends are increasing, particularly for neonatal mortality, but are not statistically significant. The only exception to this general pattern is the statistically significant positive trend in absolute inequality for under-five mortality in the Coastal region. For wealth, some evidence for increases in both relative and absolute inequality for neonates is observed. Conclusion: Despite considerable gains in reducing under-five and neonatal mortality at a national level, entrenched and increased geographical and wealth-based inequality in mortality, at least on a relative scale, remain. As expected, national progress seems to be associated with the period of political and macroeconomic stability that started in the early 2000s. However, issues of quality of care and potential non-inclusive economic growth might explain remaining disparities, particularly across wealth and geography markers. A focus on further addressing key supply and demand side barriers to accessing maternal and child health care and on the social determinants of health will be essential in narrowing inequalities. [ABSTRACT FROM AUTHOR]

Background: Over recent years there has been a strong movement towards the improvement of vital statistics and other types of health data that inform evidence-based policies. Collecting such data is not cost free. To date there is no systematic framework to guide investment decisions on methods of data collection for vital statistics or health information in general. We developed a framework to systematically assess the comparative costs and outcomes/benefits of the various data methods for collecting vital statistics. Methodology: The proposed framework is four-pronged and utilises two major economic approaches to systematically assess the available data collection methods: cost-effectiveness analysis and efficiency analysis. We built a stylised example of a hypothetical low-income country to perform a simulation exercise in order to illustrate an application of the framework. Findings: Using simulated data, the results from the stylised example show that the rankings of the data collection methods are not affected by the use of either cost-effectiveness or efficiency analysis. However, the rankings are affected by how quantities are measured. Conclusion: There have been several calls for global improvements in collecting useable data, including vital statistics, from health information systems to inform public health policies. Ours is the first study that proposes a systematic framework to assist countries undertake an economic evaluation of DCMs. Despite numerous challenges, we demonstrate that a systematic assessment of outputs and costs of DCMs is not only necessary, but also feasible. The proposed framework is general enough to be easily extended to other areas of health information. [ABSTRACT FROM AUTHOR]

As a part of the Millennium Development Goals, India seeks to substantially reduce its burden of childhood mortality. The success or failure of this goal may depend on outcomes within India's most populous state, Uttar Pradesh. This study examines the level of disparities in under-five and neonatal mortality across a range of equity markers within the state. Estimates of under-five and neonatal mortality rates were computed using five datasets, from three available sources: sample registration system, summary birth histories in surveys, and complete birth histories. Disparities were evaluated via comparisons of mortality rates by rural-urban location, ethnicity, wealth, and districts. While Uttar Pradesh has experienced declines in both rates of under-five (162-108 per 1,000 live births) and neonatal (76-49 per 1,000 live births) mortality, the rate of decline has been slow (averaging 2 % per annum). Mortality trends in rural and urban areas are showing signs of convergence, largely due to the much slower rate of change in urban areas. While the gap between rich and poor households has decreased in both urban and rural areas, trends suggest that differences in mortality will remain. Caste-related disparities remain high and show no signs of diminishing. Of concern are also the signs of stagnation in mortality amongst groups with greater ability to access services, such as the urban middle class. Notwithstanding the slow but steady reduction of absolute levels of childhood mortality within Uttar Pradesh, the distribution of the mortality by sub-state populations remains unequal. Future progress may require significant investment in quality of care provided to all sections of the community. [ABSTRACT FROM AUTHOR]

Background: India has the world's highest total number of under-five deaths of any nation. While progress towards Millennium Development Goal 4 has been documented at the state level, little information is available for greater disaggregation of child health markers within states. In 2000, new states were created within the country as a partial response to political pressures. State-level information on child health trends in the new states of Chhattisgarh and Jharkhand is scarce. To fill this gap, this article examines under-five and neonatal mortality across various equity markers within these two new states, pre-and post-split. Methods: Both direct and indirect estimation using pooled data from five available sources were undertaken. Inter-population disparities were evaluated by mortality data stratification of rural-urban location, ethnicity, wealth and districts. Results: Both states experienced an overall reduction in under-five and neonatal mortality, however, this has stagnated post-2001 and various disparities persist. In cases where disparities have declined, such as between urban-rural populations and low- and high-income groups, this has been driven by modest declines within the disadvantaged groups (i.e. low-income rural households) and stagnation or worsening of outcomes within the advantaged groups. Indeed, rising trends in mortality are most prevalent in urban middle-income households. Conclusions: The results suggest that rural health improvements may have come at the expense of urban areas, where poor performance may be attributed to factors such as lack of access to quality private health facilities. In addition, the disparities may in part be associated with geographical access, traditional practices and district-level health resource allocation. [ABSTRACT FROM AUTHOR]

Background Few previous studies have examined non-wealth-based inequalities in child mortality within developing countries. This study estimates changes in under-5-year-olds and neonatal mortality in Nepal across a range of subnational levels, which allows us to assess the degree of equity in Nepal’s progress towards Millennium Development Goal 4.Methods Direct estimates of under-5-year-olds and neonatal death rates were generated for 1990–2005using three Demographic and Health Surveys and two Living Standards Surveys by the following levels:national, rural/urban location, ecological region,development region, ethnicity and wealth. Absolute and relative inequalities were measured by rate differences and rate ratios, respectively. Additionally, wealth-related inequality was calculated using slope and relative indexes of inequality and concentration indices.Results Estimates suggest that while most rates of under-5-year-olds and neonatal mortality have declined across the different equity markers, leading to a downward trend in absolute inequalities, relative inequalities appear to have remained stable over time.The decline in absolute inequalities is strongest for under-5-year-olds’ mortality, with no statisticallysignificant trend in either relative or absolute inequalities found for neonatal mortality. A possible increase in inequalities, at least in relative terms, was found across development regions, where death rates remain high in the mid-western region.Conclusions By 2015, our estimates suggest that more than 65% of deaths of under-5-year-olds will occur in the neonatal period, with stable trends in neonatal mortality inequalities. These findings along with the fact that health outcomes for neonates are more highly dependent on health systems, suggest further equitable reductions in under-5-year-olds mortality will require broad health-system strengthening, with a focus on the improvement of healthcare services provided for mothers and newborns. Other inequities suggest continued special attention for vulnerable subpopulations is warranted, particularly to overcome social exclusion and financial barriers to care in urban areas. [ABSTRACT FROM AUTHOR]

Introduction: The Millennium Development Goals prompted renewed international efforts to reduce under-five mortality and measure national progress. However, scant evidence exists about the distribution of child mortality at low sub-national levels, which in diverse and decentralized countries like India are required to inform policy-making. This study estimates changes in child mortality across a range of markers of inequalities in Orissa and Madhya Pradesh, two of India's largest, poorest, and most disadvantaged states. Methods: Estimates of under-five and neonatal mortality rates were computed using seven datasets from three available sources - sample registration system, summary birth histories in surveys, and complete birth histories. Inequalities were gauged by comparison of mortality rates within four sub-state populations defined by the following characteristics: rural-urban location, ethnicity, wealth, and district. Results: Trend estimates suggest that progress has been made in mortality rates at the state levels. However, reduction rates have been modest, particularly for neonatal mortality. Different mortality rates are observed across all the equity markers, although there is a pattern of convergence between rural and urban areas, largely due to inadequate progress in urban settings. Inter-district disparities and differences between socioeconomic groups are also evident. Conclusions: Although child mortality rates continue to decline at the national level, our evidence shows that considerable disparities persist. While progress in reducing under-five and neonatal mortality rates in urban areas appears to be levelling off, polices targeting rural populations and scheduled caste and tribe groups appear to have achieved some success in reducing mortality differentials. The results of this study thus add weight to recent government initiatives targeting these groups. Equitable progress, particularly for neonatal mortality, requires continuing efforts to strengthen health systems and overcome barriers to identify and reach vulnerable groups. [ABSTRACT FROM AUTHOR]

The authors discuss research on determinants of childhood mortality, published within the issue. They report that reduction of childhood mortality rate in sub-Saharan Africa and southern Asia remains slow. In addition to national income, the factors associated with childhood mortality include access to sanitation, political instability, and HIV prevalence. The public health-related challenges that need to be addressed by policymakers are also noted.

Background: India has the world's highest total number of under-five deaths of any nation. While progress towards Millennium Development Goal 4 has been documented at the state level, little information is available for greater disaggregation of child health markers within states. In 2000, new states were created within the country as a partial response to political pressures. State-level information on child health trends in the new states of Chhattisgarh and Jharkhand is scarce. To fill this gap, this article examines under-five and neonatal mortality across various equity markers within these two new states, pre-and post-split.Methods: Both direct and indirect estimation using pooled data from five available sources were undertaken. Inter-population disparities were evaluated by mortality data stratification of rural-urban location, ethnicity, wealth and districts.Results: Both states experienced an overall reduction in under-five and neonatal mortality, however, this has stagnated post-2001 and various disparities persist. In cases where disparities have declined, such as between urban-rural populations and low- and high-income groups, this has been driven by modest declines within the disadvantaged groups (i.e. low-income rural households) and stagnation or worsening of outcomes within the advantaged groups. Indeed, rising trends in mortality are most prevalent in urban middle-income households.Conclusions: The results suggest that rural health improvements may have come at the expense of urban areas, where poor performance may be attributed to factors such as lack of access to quality private health facilities. In addition, the disparities may in part be associated with geographical access, traditional practices and district-level health resource allocation. [ABSTRACT FROM AUTHOR]

Background: Without addressing the constraints specific to disadvantaged populations, national health policies such as universal health coverage risk increasing equity gaps. Health system constraints often have the greatest impact on disadvantaged populations, resulting in poor access to quality health services among vulnerable groups.Methods: The Investment Cases in Indonesia, Nepal, Philippines, and the state of Orissa in India were implemented to support evidence-based sub-national planning and budgeting for equitable scale-up of quality MNCH services. The Investment Case framework combines the basic setup of strategic problem solving with a decision-support model. The analysis and identification of strategies to scale-up priority MNCH interventions is conducted by in-country planners and policymakers with facilitation from local and international research partners.Results: Significant variation in scaling-up constraints, strategies, and associated costs were identified between countries and across urban and rural typologies. Community-based strategies have been considered for rural populations served predominantly by public providers, but this analysis suggests that the scaling-up of maternal, newborn, and child health services requires health system interventions focused on 'getting the basics right'. These include upgrading or building facilities, training and redistribution of staff, better supervision, and strengthening the procurement of essential commodities. Some of these strategies involve substantial early capital expenditure in remote and sparsely populated districts. These supply-side strategies are not only the 'best buys', but also the 'required buys' to ensure the quality of health services as coverage increases. By contrast, such public supply strategies may not be the 'best buys' in densely populated urbanised settings, served by a mix of public and private providers. Instead, robust regulatory and supervisory mechanisms are required to improve the accessibility and quality of services delivered by the private sector. They can lead to important maternal mortality reductions at relatively low costs.Conclusions: National strategies that do not take into consideration the special circumstances of disadvantaged areas risk disempowering local managers and may lead to a "business-as-usual" acceptance of unreachable goals. To effectively guide health service delivery at a local level, national plans should adopt typologies that reflect the different problems and strategies to scale up key MNCH interventions. [ABSTRACT FROM AUTHOR]

This study uses five waves of the Indonesian Demographic Health Surveys to analyse decentralisation and geographical inequality in health services delivery. Accounting for unobserved community-level heterogeneity with random effects and correlated random effects models, we link facility-based birth delivery to the period of decentralisation and Indonesia’s major island groups using a pooled sample of 71,815 children. We also generate direct estimates of neonatal mortality from 1990 to 2007. The results show that the implementation of decentralisation has accorded with a marked expansion in both health service and outcome inequalities in Indonesia, at least with respect to neonates. Systemic funding failures for health and decision-space issues resulting from decentralisation are likely to have greater impact in disadvantaged regions where local capacity is weakest. The need to address these fundamental issues to reduce inequalities and improve general health outcomes appears supportable. [ABSTRACT FROM PUBLISHER]

Background: Many priority countries in the countdown to the millennium development goals deadline are lagging in progress towards maternal and child health (MCH) targets. Papua New Guinea (PNG) is one such country beset by challenges of geographical inaccessibility, inequity and health system weakness. Several countries, however, have made progress through focused initiatives which align with the burden of disease and overcome specific inequities. This study identifies the potential impact on maternal and child mortality through increased coverage of prioritised interventions within the PNG health system. Methods: The burden of disease and health system environment of PNG was documented to inform prioritised MCH interventions at community, outreach, and clinical levels. Potential reductions in maternal and child mortality through increased intervention coverage to close the geographical equity gap were estimated with the lives saved tool. Results: A set community-level interventions, with highest feasibility, would yield significant reductions in newborn and child mortality. Adding the outreach group delivers gains for maternal mortality, particularly through family planning. The clinical services group of interventions demands greater investment but are essential to reach MCH targets. Cumulatively, the increased coverage is estimated to reduce the rates of under-five mortality by 19 %, neonatal mortality by 26 %, maternal mortality ratio by 10 % and maternal mortality by 33 %. Conclusions: Modest investments in health systems focused on disadvantaged populations can accelerate progress in maternal and child survival even in fragile health systems like PNG. The critical approach may be to target interventions and implementation appropriately to the sensitive context of lagging countries. [ABSTRACT FROM AUTHOR]

Background: Geography poses serious challenges to delivery of health services and is a well documented marker of inequity. Maternal, newborn and child health (MNCH) outcomes are poorer in mountainous regions of low and lower-middle income countries due to geographical inaccessibility combined with other barriers: poorer quality services, persistent cultural and traditional practices and lower socioeconomic and educational status. Reaching universal coverage goals will require attention for remote mountain settings. This study aims to identify strategies to address barriers to reproductive MNCH (RMNCH) service utilisation in difficult-to-reach mountainous regions in low and lower-middle income settings worldwide. Methods: A systematic literature review drawing from MEDLINE, Web of Science, Scopus, Google Scholar, and Eldis. Inclusion was based on; testing an intervention for utilisation of RMNCH services; remote mountain settings of low- and lower-middle income countries; selected study designs. Studies were assessed for quality and analysed to present a narrative review of the key themes. Findings: From 4,130 articles 34 studies were included, from Afghanistan, Bolivia, Ethiopia, Guatemala, Indonesia, Kenya, Kyrgyzstan, Nepal, Pakistan, Papua New Guinea and Tajikistan. Strategies fall into four broad categories: improving service delivery through selected, trained and supported community health workers (CHWs) to act alongside formal health workers and the distribution of critical medicines to the home; improving the desirability of existing services by addressing the quality of care, innovative training and supervision of health workers; generating demand by engaging communities; and improving health knowledge for timely care-seeking. Task shifting, strengthened roles of CHWs and volunteers, mobile teams, and inclusive structured planning forums have proved effective. Conclusions: The review highlights where known evidence-based strategies have increased the utilisation of RMNCH services in low income mountainous areas. While these are known strategies in public health, in such disadvantaged settings additional supports are required to address both supply and demand barriers. [ABSTRACT FROM AUTHOR]

Background: The probability of survival through childhood continues to be unequal in middle-income countries. This study uses data from the Philippines to assess trends in the prevalence and distribution of child mortality and to evaluate the country's socioeconomic-related child health inequality. Methodology: Using data from four Demographic and Health Surveys we estimated levels and trends of neonatal, infant, and under-five mortality from 1990 to 2007. Mortality estimates at national and subnational levels were produced using both direct and indirect methods. Concentration indices were computed to measure child health inequality by wealth status. Multivariate regression analyses were used to assess the contribution of interventions and socioeconomic factors to wealth-related inequality. Findings: Despite substantial reductions in national under-five and infant mortality rates in the early 1990s, the rates of declines have slowed in recent years and neonatal mortality rates remain stubbornly high. Substantial variations across urban-rural, regional, and wealth equity-markers are evident, and suggest that the gaps between the best and worst performing sub-populations will either be maintained or widen in the future. Of the variables tested, recent wealth-related inequalities are found to be strongly associated with social factors (e.g. maternal education), regional location, and access to health services, such as facility-based delivery. Conclusion: The Philippines has achieved substantial progress towards Millennium Development Goal 4, but this success masks substantial inequalities and stagnating neonatal mortality trends. This analysis supports a focus on health interventions of high quality -- that is, not just facility-based delivery, but delivery by trained staff at well-functioning facilities and supported by a strong referral system -- to re-start the long term decline in neonatal mortality and to reduce persistent within-country inequalities in child health. [ABSTRACT FROM AUTHOR]

Background: Unmet need for family planning is responsible for 7.4 million disability-adjusted life years and 30% of the maternity-related disease burden. An estimated 35% of births are unintended and some 200 million couples state a desire to delay pregnancy or cease fertility but are not using contraception. Unmet need is higher among the poorest, lesser educated, rural residents and women under 19 years. The barriers to, and successful strategies for, satisfying all demand for modern contraceptives are heavily influenced by context. Successfully overcoming this to increase the uptake of family planning is estimated to reduce the risk of maternal death by up to 58% as well as contribute to poverty reduction, women's empowerment and educational, social and economic participation, national development and environmental protection. Methods: To strengthen health systems for delivery of context-specific, equity-focused reproductive, maternal, newborn and child health services (RMNCH), the Investment Case study was applied in the Asia-Pacific region. Staff of local and central government and non-government organisations analysed data indicative of health service delivery through a supply-demand oriented framework to identify constraints to RMNCH scale-up. Planners developed contextualised strategies and the projected coverage increases were modelled for estimates of marginal impact on maternal mortality and costs over a five year period. Results: In Indonesia, Philippines and Nepal the constraints behind incomplete coverage of family planning services included: weaknesses in commodities logistic management; geographical inaccessibility; limitations in health worker skills and numbers; legislation; and religious and cultural ideologies. Planned activities included: streamlining supply systems; establishment of Community Health Teams for integrated RMNCH services; local recruitment of staff and refresher training; task-shifting; and follow-up cards. Modelling showed varying marginal impact and costs for each setting with potential for significant reductions in the maternal mortality rate; up to 28% (25.1-30.7) over five years, costing up to a marginal USD 1.34 (1.32-1.35) per capita in the first year. Conclusion: Local health planners are in a prime position to devise feasible context-specific activities to overcome constraints and increase met need for family planning to accelerate progress towards MDG 5. [ABSTRACT FROM AUTHOR]

: David Hipgrave and colleagues argue that we must find more effective, equitable, feasible and affordable ways to engage the public in health priority setting in developing countries. Please see later in the article for the Editors' Summary [ABSTRACT FROM AUTHOR]

Background: Local health departments are often at the forefront of a disaster response, attending to the immediate trauma inflicted by the disaster and also the long term health consequences. As the frequency and severity of disasters are projected to rise, monitoring and evaluation (M&E) efforts are critical to help local health departments consolidate past experiences and improve future response efforts. Local health departments often conduct M&E work post disaster, however, many of these efforts fail to improve response procedures.Methods: We undertook a rapid realist review (RRR) to examine why M&E efforts undertaken by local health departments do not always result in improved disaster response efforts. We aimed to complement existing frameworks by focusing on the most basic and pragmatic steps of a M&E cycle targeted towards continuous system improvements. For these purposes, we developed a theoretical framework that draws on the quality improvement literature to 'frame' the steps in the M&E cycle. This framework encompassed a M&E cycle involving three stages (i.e., document and assess, disseminate and implement) that must be sequentially completed to learn from past experiences and improve future disaster response efforts. We used this framework to guide our examination of the literature and to identify any context-mechanism-outcome (CMO) configurations which describe how M&E may be constrained or enabled at each stage of the M&E cycle.Results: This RRR found a number of explanatory CMO configurations that provide valuable insights into some of the considerations that should be made when using M&E to improve future disaster response efforts. Firstly, to support the accurate documentation and assessment of a disaster response, local health departments should consider how they can: establish a culture of learning within health departments; use embedded training methods; or facilitate external partnerships. Secondly, to enhance the widespread dissemination of lessons learned and facilitate inter-agency learning, evaluation reports should use standardised formats and terminology. Lastly, to increase commitment to improvement processes, local health department leaders should possess positive leadership attributes and encourage shared decision making.Conclusion: This study is among the first to conduct a synthesis of the CMO configurations which facilitate or hinder M&E efforts aimed at improving future disaster responses. It makes a significant contribution to the disaster literature and provides an evidence base that can be used to provide pragmatic guidance for improving M&E efforts of local health departments.Trial Registration: PROSPERO 2015: CRD42015023526 . [ABSTRACT FROM AUTHOR]

Objectives: In recent years, the government of the Philippines embarked upon an ambitious Universal Health Care program, underpinned by the rapid scale-up of subsidized insurance coverage for poor and vulnerable populations. With a view of reducing the stubbornly high maternal mortality rates in the country, the program has a strong focus on maternal health services and is supported by a national policy of universal facility-based delivery (FBD). In this study, we examine the impact that recent reforms expanding health insurance coverage have had on FBD. Results: Data from the most recent Philippines 2013 Demographic Health Survey was employed. This study applies quasi-experimental methods using propensity scores along with alternative matching techniques and weighted regression to control for self-selection and investigate the impact of health insurance on the utilization of FBD. Findings: Our findings reveal that the likelihood of FBD for women who are insured is between 5 to 10 percent higher than for those without insurance. The impact of health insurance is more pronounced amongst rural and poor women for whom insurance leads to a 9 to 11 per cent higher likelihood of FBD. Conclusions: We conclude that increasing health insurance coverage is likely to be an effective approach to increase women’s access to FBD. Our findings suggest that when such coverage is subsidized, as it is the case in the Philippines, women from poor and rural populations are likely to benefit the most. [ABSTRACT FROM AUTHOR]

Background: Despite achieving some success, wealth-related disparities in the utilisation of maternal and child health services persist in the Philippines. The aim of this study is to decompose the principal factors driving the wealth-based utilisation gap.Methods: Using national representative data from the 2013 Philippines Demographic and Health Survey, we examine the extent overall differences in the utilisation of maternal health services can be explained by observable factors. We apply nonlinear Blinder-Oaxaca-type decomposition methods to quantify the effect of differences in measurable characteristics on the wealth-based coverage gap in facility-based delivery.Results: The mean coverage of facility-based deliveries was respectively 41.1 % and 74.6 % for poor and non-poor households. Between 67 and 69 % of the wealth-based coverage gap was explained by differences in observed characteristics. After controlling for factors characterising the socioeconomic status of the household (i.e. the mothers' and her partners' education and occupation), the birth order of the child was the major factor contributing to the disparity. Mothers' religion and the subjective distance to the health facility were also noteworthy.Conclusions: This study has found moderate wealth-based disparities in the utilisation of institutional delivery in the Philippines. The results confirm the importance of recent efforts made by the Philippine government to implement equitable, pro-poor focused health programs in the most deprived geographic areas of the country. The importance of addressing the social determinants of health, particularly education, as well as developing and implementing effective strategies to encourage institutional delivery for higher order births, should be prioritised. [ABSTRACT FROM AUTHOR]

Background: One of the greatest obstacles facing efforts to address quality of care in low and middle income countries is the absence of relevant and reliable data. This article proposes a methodology for creating a single “Quality Index” (QI) representing quality of maternal and neonatal health care based upon data collected as part of the Demographic and Health Survey (DHS) program. Methods: Using the 2012 Indonesian Demographic and Health Survey dataset, indicators of quality of care were identified based on the recommended guidelines outlined in the WHO Integrated Management of Pregnancy and Childbirth. Two sets of indicators were created; one set only including indicators available in the standard DHS questionnaire and the other including all indicators identified in the Indonesian dataset. For each indicator set composite indices were created using Principal Components Analysis and a modified form of Equal Weighting. These indices were tested for internal coherence and robustness, as well as their comparability with each other. Finally a single QI was chosen to explore the variation in index scores across a number of known equity markers in Indonesia including wealth, urban rural status and geographical region. Results: The process of creating quality indexes from standard DHS data was proven to be feasible, and initial results from Indonesia indicate particular disparities in the quality of care received by the poor as well as those living in outlying regions. Conclusions: The QI represents an important step forward in efforts to understand, measure and improve quality of MNCH care in developing countries. [ABSTRACT FROM AUTHOR]

Background: Health-related within-country inequalities continue to be a matter of great interest and concern to both policy makers and researchers. This study aims to assess the level and the distribution of child mortality outcomes in the Philippines across geographical and socioeconomic indicators. Methodology: Data on 159,130 children ever borne were analysed from five waves of the Philippine Demographic and Health Survey. Direct estimation was used to construct under-five and neonatal mortality rates for the period 1980–2013. Rate differences and ratios, and where possible, slope and relative indices of inequality were calculated to measure disparities on absolute and relative scales. Stratification was undertaken by levels of rural/urban location, island groups and household wealth. Findings: National under-five and neonatal mortality rates have shown considerable albeit differential reductions since 1980. Recently released data suggests that neonatal mortality has declined following a period of stagnation. Declines in under-five mortality have been accompanied by decreases in wealth and geography-related absolute inequalities. However, relative inequalities for the same markers have remained stable over time. For neonates, mixed evidence suggests that absolute and relative inequalities have remained stable or may have risen. Conclusion: In addition to continued reductions in under-five mortality, new data suggests that the Philippines have achieved success in addressing the commonly observed stagnated trend in neonatal mortality. This success has been driven by economic improvement since 2006 as well as efforts to implement a nationwide universal health care campaign. Yet, such patterns, nonetheless, accorded with persistent inequalities, particularly on a relative scale. A continued focus on addressing universal coverage, the influence of decentralisation and armed conflict, and issues along the continuum of care is advocated. [ABSTRACT FROM AUTHOR]

A rapid reduction in under-five mortality has put Bangladesh on-track to reach Millennium Development Goal 4. Little research, however, has been conducted into neonatal reductions and sub-national rates in the country, with considerable disparities potentially masked by national reductions. The aim of this paper is to estimate national and sub-national rates of neonatal mortality to compute relative and absolute inequalities between sub-national groups and draw comparisons with rates of under-five mortality. Mortality rates for under-five children and neonates were estimated directly for 1980-1981 to 2010-2011 using data from six waves of the Demographic and Health Survey. Rates were stratified by levels of rural/urban location, household wealth and maternal education. Absolute and relative inequalities within these groups were measured by rate differences and ratios, and where possible, slope and relative indices of inequality. National mortality was shown to have decreased dramatically although at differential rates for under-fives and neonates. Across all equity markers, a general pattern of declining absolute but constant relative inequalities was found. For mortality rates stratified by education and wealth mixed evidence suggests that relative inequalities may have also fallen. Although disparities remain, Bangladesh has achieved a rare combination of substantive reductions in mortality levels without increases in relative inequalities. A coalescence of substantial increases in coverage and equitable distribution of key child and neonatal interventions with widespread health sectoral and policy changes over the last 30 years may in part explain this exceptional pattern. [ABSTRACT FROM AUTHOR]

While established that geographical inaccessibility is a key barrier to the utilisation of health services, it remains unknown whether disparities are driven only by limited access to these services, or are also attributable to health behaviour. Significant disparities exist in health outcomes and the coverage of many critical health services between the mountains region of Nepal and the rest of the country, yet the principal factors driving these regional disparities are not well understood. Using national representative data from the 2011 Nepal Demographic and Health Survey, we examine the extent to which observable factors explain the overall differences in the utilisation of maternal health services. We apply nonlinear Blinder-Oaxaca-type decomposition methods to quantify the effect that differences in measurable characteristics have on the regional coverage gap in facility-based delivery. The mean coverage of facility-based deliveries was 18.6 and 36.3 % in the mountains region and the rest of Nepal, respectively. Between 54.8 and 74.1 % of the regional coverage gap was explained by differences in observed characteristics. Factors influencing health behaviours (proxied by mothers' education, TV viewership and tobacco use, and household wealth) and subjective distance to the health facility were the major factors, contributing between 52.9 and 62.5 % of the disparity. Mothers' birth history was also noteworthy. Policies simultaneously addressing access and health behaviours appear necessary to achieve greater coverage and better health outcomes for women and children in isolated areas. [ABSTRACT FROM AUTHOR]

Objectives:Efforts to scale-up maternal and child health services in lower and middle income countries will fail if services delivered are not of good quality. Although there is evidence of strategies to increase the quality of health services, less is known about the way these strategies affect health system goals and outcomes. We conducted a systematic review of the literature to examine this relationship. Methods:We undertook a search of MEDLINE, SCOPUS and CINAHL databases, limiting the results to studies including strategies specifically aimed at improving quality that also reported a measure of quality and at least one indicator related to health system outcomes. Variation in study methodologies prevented further quantitative analysis; instead we present a narrative review of the evidence. Findings:Methodologically, the quality of evidence was poor, and dominated by studies of individual facilities. Studies relied heavily on service utilisation as a measure of strategy success, which did not always correspond to improved quality. The majority of studies targeted the competency of staff and adequacy of facilities. No strategies addressed distribution systems, public-private partnership or equity. Key themes identified were the conflict between perceptions of patients and clinical measures of quality and the need for holistic approaches to health system interventions. Conclusion:Existing evidence linking quality improvement strategies to improved MNCH outcomes is extremely limited. Future research would benefit from the inclusion of more appropriate indicators and additional focus on non-facility determinants of health service quality such as health policy, supply distribution, community acceptability and equity of care. [ABSTRACT FROM AUTHOR]

Background: The goal of malaria elimination faces numerous challenges. New tools are required to support the scale up of interventions and improve national malaria programme capacity to conduct detailed surveillance. This study investigates the cost factors influencing the development and implementation of a spatial decision support system (SDSS) for malaria elimination in the two elimination provinces of Isabel and Temotu, Solomon Islands. Method: Financial and economic costs to develop and implement a SDSS were estimated using the Solomon Islands programme's financial records. Using an ingredients approach, verified by stakeholders and operational reports, total costs for each province were quantified. A budget impact sensitivity analysis was conducted to investigate the influence of variations in standard budgetary components on the costs and to identify potential cost savings. Results: A total investment of US$ 96,046 (2012 constant dollars) was required to develop and implement the SDSS in two provinces (Temotu Province US$ 49,806 and Isabel Province US$ 46,240). The single largest expense category was for computerized equipment totalling approximately US$ 30,085. Geographical reconnaissance was the most expensive phase of development and implementation, accounting for approximately 62% of total costs. Sensitivity analysis identified different cost factors between the provinces. Reduced equipment costs would deliver a budget saving of approximately 10% in Isabel Province. Combined travel costs represented the greatest influence on the total budget in the more remote Temotu Province. Conclusion: This study provides the first cost analysis of an operational surveillance tool used specifically for malaria elimination in the South-West Pacific. It is demonstrated that the costs of such a decision support system are driven by specialized equipment and travel expenses. Such factors should be closely scrutinized in future programme budgets to ensure maximum efficiencies are gained and available resources are allocated effectively. [ABSTRACT FROM AUTHOR]

Background: Considerable improvements in life expectancy and other human development indicators in Indonesia are thought to mask considerable disparities between populations in the country. We examine the existence and extent of these disparities by measuring trends and inequalities in the under-five mortality rate and neonatal mortality rate across wealth, education and geography. Methodology: Using data from seven waves of the Indonesian Demographic and Health Surveys, direct estimates of under-five and neonatal mortality rates were generated for 1980–2011. Absolute and relative inequalities were measured by rate differences and ratios, and where possible, slope and relative indices of inequality. Disparities were assessed by levels of rural/urban location, island groups, maternal education and household wealth. Findings: Declines in national rates of under-five and neonatal mortality have accorded with reductions of absolute inequalities in clusters stratified by wealth, maternal education and rural/urban location. Across these groups, relative inequalities have generally stabilised, with possible increases with respect to mortality across wealth subpopulations. Both relative and absolute inequalities in rates of under-five and neonatal mortality stratified by island divisions have widened. Conclusion: Indonesia has made considerable gains in reducing under-five and neonatal mortality at a national level, with the largest reductions happening before the Asian financial crisis (1997–98) and decentralisation (2000). Hasty implementation of decentralisation reforms may have contributed to a slowdown in mortality rate reduction thereafter. Widening inequities between the most developed provinces of Java-Bali and those of other island groupings should be of particular concern for a country embarking on an ambitious plan for universal health coverage by 2019. A focus on addressing the key supply side barriers to accessing health care and on the social determinants of health in remote and disadvantaged regions will be essential for this plan to be realised. [ABSTRACT FROM AUTHOR]

Background: Responsibility for planning and delivery of health services in the Philippines is devolved to the local government level. Given the recognised need to strengthen capacity for local planning and budgeting, we implemented Investment Cases (IC) for Maternal, Neonatal and Child Health (MNCH) in three selected sub-national units: two poor, rural provinces and one highly-urbanised city. The IC combines structured problem-solving by local policymakers and planners to identify key health system constraints and strategies to scale-up critical MNCH interventions with a decision-support model to estimate the cost and impact of different scaling-up scenarios. Methods: We outline how the initiative was implemented, the aspects that worked well, and the key limitations identified in the sub-national application of this approach. Results: Local officials found the structured analysis of health system constraints helpful to identify problems and select locally appropriate strategies. In particular the process was an improvement on standard approaches that focused only on supply-side issues. However, the lack of data available at the local level is a major impediment to planning. While the majority of the strategies recommended by the IC were incorporated into the 2011 plans and budgets in the three study sites, one key strategy in the participating city was subsequently reversed in 2012. Higher level systemic issues are likely to have influenced use of evidence in plans and budgets and implementation of strategies. Conclusions: Efforts should be made to improve locally-representative data through routine information systems for planning and monitoring purposes. Even with sound plans and budgets, evidence is only one factor influencing investments in health. Political considerations at a local level and issues related to decentralisation, influence prioritisation and implementation of plans. In addition to the strengthening of capacity at local level, a parallel process at a higher level of government to relieve fund channelling and coordination issues is critical for any evidence-based planning approach to have a significant impact on health service delivery. [ABSTRACT FROM AUTHOR]

Background: Recent assessments show continued decline in child mortality in Papua New Guinea (PNG), yet complete subnational analyses remain rare. This study aims to estimate under-five mortality in PNG at national and subnational levels to examine the importance of geographical inequities in health outcomes and track progress towards Millennium Development Goal (MDG) 4. Methodology: We performed retrospective data validation of the Demographic and Health Survey (DHS) 2006 using 2000 Census data, then applied advanced indirect methods to estimate under-five mortality rates between 1976 and 2000. Findings: The DHS 2006 was found to be unreliable. Hence we used the 2000 Census to estimate under-five mortality rates at national and subnational levels. During the period under study, PNG experienced a slow reduction in national under-five mortality from approximately 103 to 78 deaths per 1,000 live births. Subnational analyses revealed significant disparities between rural and urban populations as well as inter- and intra-regional variations. Some of the provinces that performed the best (worst) in terms of under-five mortality included the districts that performed worst (best), with district-level underfive mortality rates correlating strongly with poverty levels and access to services. Conclusions: The evidence from PNG demonstrates substantial within-province heterogeneity, suggesting that under-five mortality needs to be addressed at subnational levels. This is especially relevant in countries, like PNG, where responsibility for health services is devolved to provinces and districts. This study presents the first comprehensive estimates of under-five mortality at the district level for PNG. The results demonstrate that for countries that rely on few data sources even greater importance must be given to the quality of future population surveys and to the exploration of alternative options of birth and death surveillance [ABSTRACT FROM AUTHOR]