Search

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]

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: 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: 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]

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]

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: 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]

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]

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, policies 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.