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This study examines the impact of accredited social health activists (ASHAs), on increasing rates of institution-based deliveries among Indian women with a specific focus on the nine low-performing, empowered action group states and Assam (EAGA) in India. Using the latest round of the National Family Health Survey-V (2019-21), we first investigate the association between the use of ASHA services and socio-demographic attributes of women using a multivariate logistic regression. We then use propensity-score matching (PSM) to address observable selection bias in the data and assess the impact of ASHA services on the likelihood of institution-based deliveries using a generalized estimating equations model. Of the 232,920 women in our sample, 55.5% lived in EAGA states. Overall, 63.3% of women (70.6% in EAGA states) reported utilizing ASHA services, and 88.6% had an institution-based delivery (84.0% in EAGA states). Younger women from the poorest wealth index were more likely to use ASHA services and women in rural areas had a two-fold likelihood. Conversely, women with health insurance were less likely to use ASHA services compared to those without. Using PSM, the average treatment effect of using ASHA services on institution-based deliveries was 5.1% for all India (EAGA = 7.4%). The generalized estimating equations model indicated that the use of ASHA services significantly increased the likelihood of institution-based delivery by 1.6 times (95%CI = 1.5-1.7) for all India (EAGA = 1.8; 95%CI = 1.7-1.9). Our study finds that ASHAs are effective in enhancing the uptake of maternal services particularly institution-based deliveries. These findings underscore the necessity for continual, systematic investments to strengthen the ASHA program and to optimize the program's effectiveness in varied settings that rely on the community health worker model, thereby advancing child and maternal health outcomes.

The COVID-19 pandemic has disproportionately affected vulnerable populations. With its intensity expected to be cyclical over the foreseeable future, and much of the impact estimates still modeled, it is imperative that we accurately assess the impact to date, to help with the process of targeted rebuilding of services. We collected data from administrative health information systems in six South Asian countries (Afghanistan, Bangladesh, Nepal, India, Pakistan and Sri Lanka), to determine essential health services coverage disruptions between January-December 2020, and January-June 2021, compared to the same calendar months in 2019, and estimated the impact of this disruption on maternal and child mortality using the Lives Saved Tool. We also modelled impact of prolonged school closures on continued enrollment, as well as potential sequelae for the cohort of girls who have likely dropped out. Coverage of key maternal and child health interventions, including antenatal care and immunizations, decreased by up to 60%, with the largest disruptions observed between April and June 2020. This was followed by a period of recovery from July 2020 to March 2021, but a reversal of most of these gains in April/May 2021, likely due to the delta variant-fueled surge in South Asia at the same time. We estimated that disruption of essential health services between January 2020 and June 2021 potentially resulted in an additional 19,000 maternal and 317,000 child deaths, an increase of 19% and 13% respectively, compared to 2019. Extended school closures likely resulted in 9 million adolescents dropping out permanently, with 40% likely being from poorest households, resulting in decreased lifetime earnings. A projected increase in early marriages for girls who dropped out could result in an additional 500,000 adolescent pregnancies, 153,000 low birthweight births, and 27,000 additional children becoming stunted by age two years. To date, the increase in maternal and child mortality due to health services disruption has likely exceeded the overall number of COVID-19 deaths in South Asia. The indirect effects of the pandemic were disproportionately borne by the most vulnerable populations, and effects are likely to be long-lasting, permanent and in some cases inter-generational, unless policies aimed at alleviating these impacts are instituted at scale and targeted to reach the poorest of the poor. There are also implications for future pandemic preparedness.

Cost-effectiveness rankings of health interventions are useful inputs for national healthcare planning and budgeting. Previous comprehensive rankings for low- and middle- income countries were undertaken in 2005 and 2006, accompanying the development of strategies for the Millennium Development Goals. We update the rankings using studies published since 2000, as strategies are being considered for the Sustainable Development Goals.Expert systematic searches of the literature were undertaken for a broad range of health interventions. Cost-effectiveness results using Disability Adjusted Life-Years (DALYs) as the health outcome were standardized to 2012 US dollars.149 individual studies of 93 interventions qualified for inclusion. Interventions for Reproductive, Maternal, Newborn and Child Health accounted for 37% of interventions, and major infectious diseases (AIDS, TB, malaria and neglected tropical diseases) for 24%, consistent with the priorities of the Millennium Development Goals. More than half of the interventions considered cost less than $200 per DALY and hence can be considered for inclusion in Universal Health Care packages even in low-income countries.Important changes have occurred in rankings since 2006. Priorities have changed as a result of new technologies, new methods for changing behavior, and significant price changes for some vaccines and drugs. Achieving the Sustainable Development Goals will require LMICs to study a broader range of health interventions, particularly in adult health. Some interventions are no longer studied, in some cases because they have become usual care, in other cases because they are no longer relevant. Updating cost-effectiveness rankings on a regular basis is potentially a valuable exercise.