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Introduction: Socialprotection programmes are considered HIV-sensitive when addressing risk, vulnerability or impact of HIV infection. Socio-economic interventions, like livelihood and employability programmes, address HIV vulnerabilities like poverty and gender inequality. We explored the HIV-sensitivity of socio-economic interventions for unemployed and out-of-school young women aged 15 to 30 years, in Fast and Southern Africa, a key population for HIV infection. Methods: We conducted a systematic review using a narrative synthesis method and the Mixed Methods AppraisalTool for quality appraisal. Interventions of interest were work skills training, microfinance, and employment support. Outcomes of interest were socio-economic outcomes (income, assets, savings, skills, (self-) employment) and HIV-related outcomes (behaviouraland biological). We searched published and grey literature (January 2005 to November 2019; English/French) in MFDLINF, Scopus, Web of Science and websites of relevant internationalorganizations. Results: We screened 3870 titles and abstracts and 188 full-text papers to retain 18 papers, representing 12 projects. Projects offered different combinations of HIV-sensitive socialprotection programmes, complemented with mentors, safe space and training (HIV, reproductive health and gender training). All 12 projects offered work skills training to improve life and business skills. Six offered formal(n = 2) or informal(n = 5) livelihood training. Fleven projects offered microfinance, including microgrants (n = 7), microcredit (n = 6) and savings (n = 4). One project offered employment support in the form of apprenticeships. In general, microgrants, savings, business and life skills contributed improved socio-economic and HIV-related outcomes. Most livelihood training contributed positive socio-economic outcomes, but only two projects showed improved HIV-related outcomes. Microcredit contributed little to either outcome. Programmes were effective when (i) sensitive to beneficiaries' age, needs, interests and economic vulnerability; (ii) adapted to local-implementation contexts; and (iii) included life skills. Programme delivery through mentorship and safe space increased social capital and may be critical to improve the HIV-sensitivity of socio-economic programmes. Conclusions: A wide variety of livelihood and employability programmes were leveraged to achieve improved socio-economic and HIV-related outcomes among unemployed and out-of-school young women. To be HIV-sensitive, programmes should be designed around their interests, needs and vulnerability, adapted to local implementation contexts, and include life skills. Fmployment support received little attention in this literature. Keywords: adolescent girls and young women; Africa region; HIV prevention; social support; structural drivers; structural interventions, 1 | INTRODUCTION In 2018, East and Southern Africa represented nearly one half of global human immunodeficiency virus (HIV) incident cases [1]. Adolescent girls and young women (AGYW) aged 15 [...]

Promotive social protection programs aim to increase income and capabilities and could help address structural drivers of HIV-vulnerability like poverty, lack of education and gender inequality. Unemployed and out-of-school young women bear the brunt of HIV infection in Botswana, but rarely benefit from such economic empowerment programs. Using a qualitative exploratory study design and a participatory research approach, we explored factors affecting perceived program benefit and potential solutions to barriers. Direct stakeholders (n = 146) included 87 unemployed and out-of-school young women and 59 program and technical officers in five intervention districts. Perceived barriers were identified in 20 semi-structured interviews (one intervention district) and 11 fuzzy cognitive maps. Co-constructed improvement recommendations were generated in deliberative dialogues. Analysis relied on Framework and the socioecological model. Overall, participants viewed existing programs in Botswana as ineffective and inadequate to empower vulnerable young women socially or economically. Factors affecting perceived program benefit related to programs, program officers, the young women, and their social and structural environment. Participants perceived barriers at every socioecological level. Young women's lack of life and job skills, unhelpful attitudes, and irresponsible behaviors were personal-level barriers. At an interpersonal level, competing care responsibilities, lack of support from boyfriends and family, and negative peer influence impeded program benefit. Traditional venues for information dissemination, poverty, inequitable gender norms, and lack of coordination were community- and structural-level barriers. Improvement recommendations focused on improved outreach and peer approaches to implement potential solutions. Unemployed and out-of-school young women face multidimensional, interacting barriers that prevent benefit from available promotive social protection programs in Botswana. To become HIV-sensitive, these socioeconomic empowerment programs would need to accommodate or preferentially attract this key population. This requires more generous and comprehensive programs, a more client-centered program delivery, and improved coordination. Such structural changes require a holistic, intersectoral approach to HIV-sensitive social protection. [ABSTRACT FROM AUTHOR]

Equity monitoring is a priority for Gavi, the Vaccine Alliance, and for those implementing The2030agenda for sustainable development. For its new phase of operations, Gavi reassessed its approach to monitoring equity in vaccination coverage. To help inform this effort, we made a systematic analysis of inequalities in vaccination coverage across 45 Gavi-supported countries and compared results from different measurement approaches. Based on our findings, we formulated recommendations for Gavi's equity monitoring approach. The approach involved defining the vulnerable populations, choosing appropriate measures to quantify inequalities, and defining equity benchmarks that reflect the ambitions of the sustainable development agenda. In this article, we explain the rationale for the recommendations and for the development of an Improved equity monitoring tool. Gavi's previous approach to measuring equity was the difference in vaccination coverage between a country's richest and poorest wealth quintiles. In addition to the wealth index, we recommend monitoring other dimensions of vulnerability (maternal education, place of residence, child sex and the multidimensional poverty index). For dimensions with multiple subgroups, measures of inequality that consider information on all subgroups should be used. We also recommend that both absolute and relative measures of inequality be tracked over time. Finally, we propose that equity benchmarks target complete elimination of inequalities. To facilitate equity monitoring, we recommend the use of a data display tool--the equity dashboard--to support decision-making in the sustainable development period. We highlight its key advantages using data from Cote d'Ivoire and Haiti. Le suivi de l'equite est une priorite pour Gavi, l'Alliance du Vaccin et pour ceux qui mettent en oeuvre le Programme de developpement durable a l'horizon 2030. Dans le cadre de sa nouvelle phase d'operations, Gavi a repense son approche relative au suivi de l'equite en matiere de couverture vaccinale. Afin de contribuer a cet effort, nous avons realise une analyse systematique des inegalites en matiere de couverture vaccinale dans 45 pays soutenus par Gavi et compare les resultats obtenus a partir de differentes methodes de mesure. Nous nous sommes appuyes sur nos conclusions pour formuler des recommandations concernant l'approche adoptee par Gavi pour suivre l'equite. Cette approche impliquait de definir les populations vulnerables, de choisir des mesures appropriees pour quantifier les inegalites et d'etablir des criteres en matiere d'equite qui refletent les ambitions du programme de developpement durable. Dans le present article, nous expliquons la raison d'etre de nos recommandations et le but de l'elaboration d'un meilleur outil de suivi de l'equite. L'approche precedemment utilisee par Gavi pour mesurer l'equite consistait a calculer la difference en matiere de couverture vaccinale entre les quintiles de richesse les plus eleves et les plus bas d'un pays. Nous recommandons de suivre des dimensions de la vulnerabilite (education maternelle, lieu de residence, sexe des enfants et indice de pauvrete multidimensionnelle) autres que l'indice de richesse. Lorsqu'une dimension inclut divers sous-groupes, il convient d'utiliser des mesures de l'inegalite prenant en compte les informations relatives a tous les sous-groupes. Nous conseillons egalement de suivre les mesures absolues mais aussi relatives d'inegalite au fil du temps. Enfin, nous suggerons que les criteres en matiere d'equite visent l'elimination complete des inegalites. Afin de faciliter le suivi de l'equite, nous recommandons l'utilisation d'un outil d'affichage de donnees--le tableau de bord de l'equite--pour favoriser la prise de decision dans le cadre du programme de developpement durable. Nous mettons en avant les principaux avantages de cet outil a l'aide de donnees provenant de Cote d'ivoire et d'Haiti. La supervision de la equidad es una prioridad para la Gavi, la Vaccine Alliance y para los que implementan la Agenda 2030 para el Desarrollo Sostenible. Para su nueva fase de operaciones, la Gavi reevaluo su enfoque para supervisar la equidad en la cobertura de vacunacion. Para ayudar a informar este esfuerzo, se realizo un analisis sistematico de desigualdades en la cobertura de vacunacion en 45 paises apoyados por la Gavi y se compararon los resultados desde distintos enfoques de medicion. En base a los resultados, se formularon recomendaciones para el enfoque de supervision de equidad de la Gavi. El enfoque implico la definicion de las poblaciones vulnerables, la seleccion de las medidas adecuadas para cuantificar las desigualdades y la definicion de las referencias de equidad que reflejan las ambiciones de la agencia de desarrollo sostenible. En este articulo, se explican los motivos de las recomendaciones y el desarrollo de una herramienta mejorada de supervision de la equidad. El anterior enfoque de la Gavi para la medicion de la equidad era la diferencia de la cobertura de vacunacion entre los sectores demograficos mas ricos y mas pobres de un pais. Ademas del indice patrimonial, se recomienda supervisar otras dimensiones de vulnerabilidad (educacion de la madre, lugar de residencia, sexo de los ninos y el indice de pobreza multidimensional). Para las dimensiones con multiples subgrupos, deberian utilizarse medidas de desigualdad que tienen en cuenta informacion acerca de todos los subgrupos.Tambien se recomienda que, con el paso del tiempo, se haga un seguimiento tanto de la medida de desigualdad absoluta como relativa. Por ultimo, se propone que las referencias de equidad tengan como objetivo la eliminacion completa de la desigualdad. Para facilitar la supervision de la equidad, se recomienda utilizar una herramienta de indicacion de datos (el tablero de equidad) para apoyar la toma de decisiones durante el periodo de desarrollo sostenible. Se destacan sus ventajas basicas utilizando datos de Cote d'ivoire y de Haiti., Introduction The 2030 agenda for sustainable development calls upon the international community to prioritize the needs and rights of the most vulnerable, so that no one is left behind. (1) [...]

Objective To quantify the impact on mortality of offering a hypothetical set of technically feasible, high-impact interventions for maternal and child survival during India's 2010-2013 measles supplementary immunization activity. Methods We developed Lives Saved Tool models for 12 Indian states participating in the supplementary immunization, based on state-and sex-specific data on mortality from India's Million Deaths Study and on health services coverage from Indian household surveys. Potential add-on interventions were identified through a literature review and expert consultations. We quantified the number of lives saved for a campaign offering measles vaccine alone versus a campaign offering measles vaccine with six add-on interventions (nutritional screening and complementary feeding for children, vitamin A and zinc supplementation for children, multiple micronutrient and calcium supplementation in pregnancy, and free distribution of insecticide-treated bednets). Findings The measles vaccination campaign saved an estimated 19 016 lives of children younger than 5 years. A hypothetical campaign including measles vaccine with add-on interventions was projected to save around 73 900 lives (range: 70 200-79 300), preventing 73 700 child deaths (range: 70 000-79 000) and 300 maternal deaths (range: 200-400). The most effective interventions in the whole package were insecticide-treated bednets, measles vaccine and preventive zinc supplementation. Girls accounted for 66% of expected lives saved (12 712/19 346) for the measles vaccine campaign, and 62% of lives saved (45 721/74 367) for the hypothetical campaign including add-on interventions. Conclusion In India, a measles vaccination campaign including feasible, high-impact interventions could substantially increase the number of lives saved and mitigate gender-related inequities in child mortality. Objectif Quantifier l'impact sur la mortalite d'un hypothetique ensemble d'interventions a fort impact et techniquement realisables pour la survie de la mere et de l'enfant lors d'une activite de vaccination antirougeoleuse supplementaire menee en Inde de 2010 a 2013. Methodes Pour 12 des Etats indiens participant a l'activite de vaccination supplementaire, nous avons elabore des modeles LiST (Lives Saved Tool--Outil de Vies Sauvees) en fonction de donnees ventilees par Etat et par sexe sur la mortalite--tirees de l'etude indienne Million Deaths Study--, et sur la couverture des services de sante--tirees d'enquetes aupres des menages indiens. Des interventions supplementaires potentielles ont ete identifiees a l'aide d'un examen de la litterature et de consultations d'experts. Nous avons quantifie le nombre de vies sauvees dans le cadre d'une campagne de vaccination antirougeoleuse seule par rapport a une campagne de vaccination antirougeoleuse comportant six interventions supplementaires (analyse nutritionnelle et alimentation d'appoint pour les enfants, supplementation en vitamine A et en zinc pour les enfants, supplementation en micronutriments multiples et en calcium au cours de la grossesse et distribution gratuite de moustiquaires impregnees d'insecticide). Resultats D'apres nos estimations, la campagne de vaccination antirougeoleuse a permis de sauver 19 016 enfants ages de moins de 5 ans. Il a ete calcule qu'une hypothetique campagne de vaccination antirougeoleuse incluant des interventions supplementaires permet de sauver quelque 73 900 vies (etendue: 70 200-79 300), prevenant le deces de 73 700 enfants (etendue: 70 000-79 000) et de 300 meres (etendue: 200-400). Les interventions les plus efficaces se sont averees etre les moustiquaires impregnees, le vaccin contre la rougeole et la supplementation preventive en zinc. Les filles representaient 66% des vies sauvees escomptees (12712/19 346) dans le cadre de la campagne de vaccination antirougeoleuse et 62% des vies sauvees (45 721/74 367) dans le cadre de la campagne hypothetique incluant des interventions supplementaires. Conclusion En Inde, une campagne de vaccination antirougeoleuse comportant des interventions realisables a fort impact pourrait considerablement accroitre le nombre de vies sauvees et reduire les inegalites entre les sexes concernant la mortalite infantile. Objetivo Cuantificar el impacto en la mortalidad del hecho de ofrecer un conjunto hipotetico de intervenciones tecnicamente viables y de alto impacto para la supervivencia de madres e hijos durante la actividad de inmunizacion suplementaria antisarampionosa en la India entre 2010 y 2013. Metodos Se desarrollaron los modelos de la herramienta 'Uve Saved Tool' para 12 estados indios participantes en la inmunizacion suplementaria, en base a informacion segun el estado y el sexo sobre la mortalidad recopilada en el estudio 'Million Deaths Study' de la India y sobre la cobertura de servicios sanitarios de las encuestas domesticas realizadas en la India. Se identificaron posibles intervenciones adicionales a traves de un analisis de documentos y consultas a expertos. Se cuantifico el numero de vidas salvadas durante una campana que ofrecia la vacuna antisarampionosa frente a una campana que ofrecia la vacuna antisarampionosa con seis intervenciones adicionales (revision nutricional y alimentacion complementaria para ninos, suplementos de vitamina A y zinc para ninos, varios micronutrientes, suplemento de calcio durante el embarazo y distribucion gratuita de mosquiteros tratados con insecticida). Resultados La campana de vacunacion antisarampionosa salvo unas 19016 vidas de ninos menores de 5 anos. Se estimo que una campana hipotetica que incluia la vacuna antisarampionosa e intervenciones adicionales salvaria unas 73 900 vidas (alcance: 70 200-79 300), evitando 73 700 muertes infantiles (alcance: 70000-79000) y 300 muertes maternas (alcance: 200-400). Las intervenciones mas eficaces de todo el paquete fueron los mosquiteros tratados con insecticida, la vacuna antisarampionosa y el suplemento preventivo de zinc. Las ninas representaron un 66% de las vidas salvadas (12 712/19 346) durante la campana de vacuna antisarampionosa y un 62% de las vidas salvadas (45 721/74 367) durante la campana hipotetica que incluye las intervenciones adicionales. Conclusion En la India, una campana de vacunacion antisarampionosa que Incluya intervenciones viables y de gran impacto podria incrementar enormemente el numero de vidas salvadas y mitigar la desigualdad de genero en la mortalidad infantil., Introduction Measles vaccination made an important contribution to the millennium development goal to reduce under-5 mortality (MDG4), (1) accounting for 23% of the estimated worldwide decline in all-cause child mortality [...]

Objective To investigate which strategies to increase demand for vaccination are effective in increasing child vaccine coverage in low- and middle-income countries. Methods We searched MEDLINE, EMBASE, Cochrane library, POPLINE, ECONLIT, CINAHL, LILACS, BDSP, Web of Science and Scopus databases for relevant studies, published in English, French, German, Hindi, Portuguese and Spanish up to 25 March 2014. We included studies of interventions intended to increase demand for routine childhood vaccination. Studies were eligible if conducted in low- and middle-income countries and employing a randomized controlled trial, non-randomized controlled trial, controlled before-and-after or interrupted time series design. We estimated risk of bias using Cochrane collaboration guidelines and performed random-effects meta-analysis. Findings We identified 11 studies comprising four randomized controlled trials, six cluster randomized controlled trials and one controlled before-and-after study published in English between 1996 and 2013. Participants were generally parents of young children exposed to an eligible intervention. Six studies demonstrated low risk of bias and five studies had moderate to high risk of bias. We conducted a pooled analysis considering all 11 studies, with data from 11512 participants. Demand-side interventions were associated with significantly higher receipt of vaccines, relative risk (RR): 1.30, (95% confidence Interval, CI: 1.17-1.44). Subgroup analyses also demonstrated significant effects of seven education and knowledge translation studies, RR: 1.40 (95% CI: 1.20-1.63) and of four studies which used incentives, RR: 1.28 (95% CI: 1.12-1.45). Conclusion Demand-side interventions lead to significant gains in child vaccination coverage in low- and middle-income countries. Educational approaches and use of incentives were both effective strategies. Objectif Determiner, parmi les strategies visant a accroitre la demande de vaccination, celles qui sont efficaces pour augmenter la couverture vaccinale des enfants dans les pays a revenu faible et intermediaire. Methodes Nous avons recherche, dans les bases de donnees MEDLINE, EMBASE, de la bibliotheque Cochrane, POPLINE, ECONLIT, CINAHL, LILACS, BDSP, Web of Science et Scopus, des etudes a ce sujet, publiees en allemand, en anglais, en espagnol, en francais, en hindi, et en portugais, jusqu'au 25 mars 2014. Nous avons inclus les etudes relatives a des interventions visant a accroitre la demande de vaccination systematique des enfants. Les etudes etaient recevables si elles avaient ete menees dans des pays a revenu faible et intermediaire et si elles etaient de type essai controle randomise, essai controle non randomise, controle avant et apres ou etude de series temporelles Interrompues. Nous avons estime le risque de biais suivant les directives de la collaboration Cochrane et avons realise une meta-analyse a effets aleatoires. Resultats Nous avons releve 11 etudes, comprenant quatre essais controles randomises, six essais controles randomises en grappes et une etude controlee avant et apres, qui ont ete publiees en anglais entre 1996 et 2013. Les participants etaient generalement les parents de jeunes enfants exposes a une intervention eligible. Six etudes montraient un faible risque de biais et cinq etudes avalent un risque de biais moyen a eleve. Nous avons realise une analyse combinee en tenant compte des 11 etudes, avec des donnees provenant de 11 512 participants. Les interventions axees sur la demande etaient associees a une administration de vaccins sensiblement plus elevee, risque relatif (RR) : 1,30; intervalle de confiance de 95%, IC : 1,17-1,44). L'analyse de sous-groupes a egalement montre des effets importants pour sept etudes decrivant des interventions d'education ou d'application des connaissances, RR: 1,40 (IC de 95%: 1,20-1,63) et pour quatre etudes decrivant le recours a des incitations, RR: 1,28 (IC de 95%: 1,12-1,45). Conclusion Les interventions axees sur la demande entrainent des avantages notables pour la vaccination des enfants dans les pays a revenu faible et intermediaire. Les demarches educatives ainsi que le recours a des incitations etaient tous deux des strategies efficaces. Objetivo Investigar que estrategias para incrementar la demanda de vacunacion son efectivas en el incremento de la cobertura de vacunacion infantil en paises de ingresos bajos y medios. Metodos Se realizaron busquedas en las bases de datos de MEDLINE, EMBASE, Cochrane Library, POPLINE, ECONLIT, CINAHL, LILACS, BDSP, Web of Science y Scopus para encontrar estudios pertinentes, publicados en aleman, espanol, frances, hindi, ingles y portugues hasta el 25 de marzo de 2014. Se incluyeron estudios de intervenciones con el objetivo de Incrementar la demanda de vacunacion infantil sistematica. Los estudios fueron elegibles si se realizaron en paises de ingresos bajos y medios y utilizaron un diseno de ensayo controlado aleatorizado, ensayo controlado no aleatorizado, controlado antes y despues o de serles temporales interrumpidas. Se estimo un riesgo de sesgo mediante las directrices de colaboracion de Cochrane y se realizaron metanalisis de efectos aleatorios. Resultados Se identificaron 11 estudios que abarcan cuatro ensayos controlados aleatorizados, seis ensayos controlados aleatorizados por conglomerados y un estudio controlado antes y despues, publicados en ingles entre 1996 y 2013. En general, los participantes fueron padres de ninos pequenos expuestos a una intervencion elegible. Seis estudios demostraron un bajo riesgo de sesgo y cinco estudios presentaron un riesgo de sesgo entre moderado y elevado. Se realizo un analisis agrupado teniendo en cuenta los 11 estudios, con datos de 11,512 participantes. Las Intervenciones que afectan a la demanda se relacionaron con una recepcion de las vacunas significativamente superior, riesgo relativo (RR): 1,30, (intervalo de confianza, IC, del 95%: 1,17-1,44). Los analisis de los subgrupos tambien demostraron efectos importantes de siete estudios de educacion y traslacion de conocimientos, RR: 1,40 (IC del 95%: 1,20-1,63) y de cuatro estudios que utilizaron incentivos, RR: 1,28 (IC del 95%: 1,12-1,45). Conclusion Las intervenciones que afectan a la demanda llevan a mejoras significativas en la cobertura de vacunacion infantil en paises de ingresos bajos y medios. Los enfoques educativos y el uso de incentivos fueron estrategias efectivas., Introduction Almost 40 years after the launch of the World Health Organization's (WHO's) Expanded Programme on Immunization, one in five children worldwide still does not have access to basic vaccines. [...]

Reaching zero-dose (ZD) children, operationally defined as children who have not received a first dose of the diphtheria, tetanus, and pertussis (DTP1) vaccine, is crucial to increase equitable immunisation coverage and access to primary health care. However, little is known about the approaches already taken by countries to improve immunisation equity. We reviewed all Health System Strengthening (HSS) proposals submitted by Gavi-supported countries from 2014 to 2021 inclusively and extracted information on interventions favouring equity. Pro-equity interventions were mapped to an analytical framework representing Gavi 5.0 programmatic guidance on reaching ZD children and missed communities. Data from keyword searches and manual screening were extracted into an Excel database. Open format responses were analysed using inductive and deductive thematic coding. Data analysis was conducted using Excel and R. Of the 56 proposals included, 51 (91%) included at least one pro-equity intervention. The most common interventions were conducting outreach sessions, tailoring the location of service delivery, and partnerships. Many proposals had "bundles" of interventions, most often involving outreach, microplanning and community-level education activities. Nearly half prioritised remote-rural areas and only 30% addressed gender-related barriers to immunisation. The findings can help identify specific interventions on which to focus future evidence syntheses, case studies and implementation research and inform discussions on what may or may not need to change to better reach ZD children and missed communities moving forward. [ABSTRACT FROM AUTHOR]

Poverty, lack of education and gender inequality make unemployed and out-of-school young women extremely vulnerable to HIV infection. Promotive social protection programmes aim to increase livelihood and capabilities and could empower this priority population to act on HIV prevention choices. In Botswana, they rarely benefit from such programmes. A modified Policy Delphi engaged a panel of 22 unemployed and out-of-school young women and eight frontline service providers to consider alternative policy and practice options, and tailor available programmes to their own needs and social situation. The panel assessed the desirability and feasibility of improvement proposals and, in a second round, ranked them for relative importance. Nearly all 40 improvement proposals were considered very desirable and definitely, or possibly, feasible, and panellists prioritised a wide range of proposals. Frontline service providers stressed foundational skills, like life skills and second chance education. Young women preferred options with more immediate benefits. Overall, panellists perceived positive role models for programme delivery, access to land and water, job skills training, and stipends as most important to empower HIV-vulnerable young women. Results suggest ample policy space to make existing social protection programmes in Botswana more inclusive of unemployed and out-of-school young women, hence more HIV-sensitive. [ABSTRACT FROM AUTHOR]

Background: Global immunization inequities persist, reflected in the 25 million underimmunized and 18 million zero-dose children in 2021. To identify country approaches to reach underimmunized and zero-dose children, we undertook a structured synthesis of pro-equity strategies across 61 countries receiving programmatic support from Gavi, the Vaccine Alliance. Methods: We extracted data from 174 Country Joint Appraisals and Multi-Stakeholder Dialogue reports (2016–2020). We identified strategies via a targeted keyword search, informed by a determinants of immunization coverage framework. Strategies were synthesized into themes consolidated from UNICEF's Journey to Health and Immunization (JTHI) and the Global Routine Immunization Strategies and Practices (GRISP) frameworks. Results: We found 607 unique strategies across 61 countries and 24 themes. Strategies to improve care at the point of service (44%); to improve knowledge, awareness and beliefs (25%); and to address preparation, cost and effort barriers (13%) were common. Fewer strategies targeted experience of care (8%), intent, (7%) and after-service (3%). We also identified strategies addressing gender-related barriers to immunization and targeting specific types of communities. Conclusions: We summarize the range of pro-equity immunization strategies employed in Gavi-supported countries and interpret them thematically. Findings are incorporated into a searchable database which can be used to inform equity-driven immunization programs, policies and decision-making which target underimmunized and zero-dose communities. [ABSTRACT FROM AUTHOR]

This article discusses the challenges of designing a new, efficient AIDS surveillance system to monitor the epidemic in the United States. The authors examine several alternatives, such as name-reporting systems, systems of case reports based upon unique identifiers, and a model which provides incidence data bases upon 'snapshot estimates.'

In India, strict public health measures to suppress COVID-19 transmission and reduce burden have been rapidly adopted. Pandemic containment and confinement measures impact societies and economies; their costs and benefits must be assessed holistically. This study provides an evolving portrait of the health, economic and social consequences of the COVID-19 pandemic on vulnerable populations in India. Our analysis focuses on 100 days early in the pandemic from 13 March to 20 June 2020. We developed a conceptual framework based on the human right to health and the UN Sustainable Development Goals (SDGs). We analysed people's experiences recorded and shared via mobile phone on the voice platforms operated by the Gram Vaani COVID-19 response network, a service for rural and low-income populations now being deployed to support India's COVID-19 response. Quantitative and visual methods were used to summarize key features of the data and explore relationships between factors. In its first 100 days, the platform logged over 1.15 million phone calls, of which 793 350 (69%) were outbound calls related largely to health promotion in the context of COVID-19. Analysis of 6636 audio recordings by network users revealed struggles to secure the basic necessities of survival, including food (48%), cash (17%), transportation (10%) and employment or livelihoods (8%). Themes were mapped to shortfalls in 10 SDGs and their associated targets. Pre-existing development deficits and weak social safety nets are driving vulnerability during the COVID-19 crisis. For an effective pandemic response and recovery, these must be addressed through inclusive policy design and institutional reforms. [ABSTRACT FROM AUTHOR]

In this article, we employed communication infrastructure theory (CIT) to analyze Gram Vaani’s (“Voice of the Village”) Covid-19 Response Network in India. We reviewed key CIT components (i.e., storytelling network and communication action context) and their applications in civic engagement, health disparities, and crisis mitigation. Our results showed that Gram Vaani’s Covid-19 Response Network merged all three types of CIT application into an integrated whole and extended it to marginalized rural and migrant/resident worker communities in India. In 15 months, 870,000 individuals used the organization’s Mobile Vaani platforms, made 2.5 million calls, recorded 24,880 voice reports, and shared 2,327 impact stories. Taken together, they amplified the voices of the most vulnerable, provided direct assistance, and held government agencies accountable in three major areas: health promotion and healthcare access, livelihood support and working conditions, and safety nets and essential services. We identified (1) storytelling network actors at all levels (micro, meso, interstitial, and macro), (2) enabling and constraining communication action contexts of pandemic community mobilization, and (3) specific impact pathways for different storytelling network actors to overcome barriers and leverage Mobile Vaani as an enabling and empowering communication action context. This first CIT application and articulation of pandemic community mobilization in the Global South holds important implications for better serving the needs of the marginalized and information have-nots. [ABSTRACT FROM AUTHOR]

Abstract Background The governments and citizens of the developed nations are increasingly called upon to contribute financially to health initiatives outside their borders. Although international development assistance for health has grown rapidly over the last two decades, austerity measures related to the 2008 and 2011 global financial crises may impact negatively on aid expenditures. The competition between national priorities and foreign aid commitments raises important ethical questions for donor nations. This paper aims to foster individual reflection and public debate on donor responsibilities for global health. Methods We undertook a critical review of contemporary accounts of justice. We selected theories that: (i) articulate important and widely held moral intuitions; (ii) have had extensive impact on debates about global justice; (iii) represent diverse approaches to moral reasoning; and (iv) present distinct stances on the normative importance of national borders. Due to space limitations we limit the discussion to four frameworks. Results Consequentialist, relational, human rights, and social contract approaches were considered. Responsibilities to provide international assistance were seen as significant by all four theories and place limits on the scope of acceptable national autonomy. Among the range of potential aid foci, interventions for health enjoyed consistent prominence. The four theories concur that there are important ethical responsibilities to support initiatives to improve the health of the worst off worldwide, but offer different rationales for intervention and suggest different implicit limits on responsibilities. Conclusions Despite significant theoretical disagreements, four influential accounts of justice offer important reasons to support many current initiatives to promote global health. Ethical argumentation can complement pragmatic reasons to support global health interventions and provide an important foundation to strengthen collective action.

Abstract Background Violence against women by their male intimate partners (IPV) during pregnancy may lead to negative pregnancy outcomes. We examined the role of IPV as a potential risk factor for miscarriage in Guatemala. Our objectives were: (1) To describe the magnitude and pattern of verbal, physical and sexual violence by male intimate partners in the last 12 months (IPV) in a sample of pregnant Guatemalans; (2) To evaluate the influence of physical or sexual IPV on miscarriage as a pregnancy outcome. Methods All pregnant women reporting to the maternity of a major tertiary care public hospital in Guatemala City from June 1st to September 30th, 2006 were invited to participate in this cross-sectional study. The admitting physician assessed occurrence of miscarriage, defined as involuntary pregnancy loss up to and including 28 weeks gestation. Data on IPV, social and demographic characteristics, risk behaviours, and medical history were collected by interviewer-administered questionnaire. Laboratory testing was performed for HIV and syphilis. The relationship between IPV and miscarriage was assessed through multivariable logistic regression. Results IPV affected 18% of the 1897 pregnant Guatemalan women aged 15-47 in this sample. Verbal IPV was most common (16%), followed by physical (10%) and sexual (3%) victimisation. Different forms of IPV were often co-prevalent. Miscarriage was experienced by 10% of the sample (n = 190). After adjustment for potentially confounding factors, physical or sexual victimisation by a male intimate partner in the last 12 months was significantly associated with miscarriage (ORadj 1.1 to 2.8). Results were robust under a range of analytic assumptions. Conclusions Physical and sexual IPV is associated with miscarriage in this Guatemalan facility-based sample. Results cohere well with findings from population-based surveys. IPV should be recognised as a potential cause of miscarriage. Reproductive health services should be used to screen for spousal violence and link to assistance.

Abstract Background Although highly effective prevention interventions exist, the epidemic of paediatric HIV continues to challenge control efforts in resource-limited settings. We reviewed the cost-effectiveness of interventions to prevent mother-to-child transmission (MTCT) of HIV in low- and middle-income countries (LMICs). This article presents syntheses of evidence on the costs, effects and cost-effectiveness of HIV MTCT strategies for LMICs from the published literature and evaluates their implications for policy and future research. Methods Candidate studies were identified through a comprehensive database search including PubMed, Embase, Cochrane Library, and EconLit restricted by language (English or French), date (January 1st, 1994 to January 17th, 2011) and article type (original research). Articles reporting full economic evaluations of interventions to prevent or reduce HIV MTCT were eligible for inclusion. We searched article bibliographies to identify additional studies. Two authors independently assessed eligibility and extracted data from studies retained for review. Study quality was appraised using a modified BMJ checklist for economic evaluations. Data were synthesised in narrative form. Results We identified 19 articles published in 9 journals from 1996 to 2010, 16 concerning sub-Saharan Africa. Collectively, the articles suggest that interventions to prevent paediatric infections are cost-effective in a variety of LMIC settings as measured against accepted international benchmarks. In concentrated epidemics where HIV prevalence in the general population is very low, MTCT strategies based on universal testing of pregnant women may not compare well against cost-effectiveness benchmarks, or may satisfy formal criteria for cost-effectiveness but offer a low relative value as compared to competing interventions to improve population health. Conclusions and Recommendations Interventions to prevent HIV MTCT are compelling on economic grounds in many resource-limited settings and should remain at the forefront of global HIV prevention efforts. Future cost-effectiveness analyses can help to ensure that pMTCT interventions for LMICs reach their full potential by focussing on unanswered questions in four areas: local assessment of rapidly evolving HIV MTCT options; strategies to improve coverage and reach underserved populations; evaluation of a more comprehensive set of MTCT approaches including primary HIV prevention and reproductive counselling; integration of HIV MTCT and other sexual and reproductive health services.

Abstract Background Post thrombotic syndrome (PTS) is a burdensome and costly complication of deep venous thrombosis (DVT) that develops in 20–40% of patients within 1–2 years after symptomatic DVT. Affected patients have chronic leg pain and swelling and may develop ulcers. Venous valve disruption from the thrombus itself or thrombus-associated mediators of inflammation is considered to be a key initiating event for the development of venous hypertension that often underlies PTS. As existing treatments for PTS are extremely limited, strategies that focus on preventing the development of PTS in patients with DVT are more likely to be effective and cost-effective in reducing its burden. Elastic compression stockings (ECS) could be helpful in preventing PTS; however, data on their effectiveness are scarce and conflicting. Methods/Design The SOX Trial is a randomized, allocation concealed, double-blind multicenter clinical trial. The objective of the study is to evaluate ECS to prevent PTS. A total of 800 patients with proximal DVT will be randomized to one of 2 treatment groups: ECS or placebo (inactive) stockings worn on the DVT-affected leg daily for 2 years. The primary outcome is the incidence of PTS during follow-up. Secondary outcomes are severity of PTS, venous thromboembolism (VTE) recurrence, death from VTE, quality of life and cost-effectiveness. Outcomes will be evaluated during 6 clinic visits and 2 telephone follow ups. At baseline, 1 and 6 months, blood samples will be obtained to evaluate the role of inflammatory mediators and genetic markers of thrombophilia in the development of PTS (Bio-SOX substudy). Discussion The SOX Trial will be the largest study and the first with a placebo control to evaluate the effectiveness of ECS to prevent PTS. It is designed to provide definitive data on the effects of ECS on the occurrence and severity of PTS, as well as DVT recurrence, cost-effectiveness and quality of life. This study will also prospectively evaluate the predictive role of biomarkers that are reflective of putative underlying pathophysiological mechanisms in the development of clinical PTS. As such, our results will impact directly on the care of patients with DVT. Trial Registration NCT00143598 and ISRCTN71334751

Context: Recent randomised controlled trials in Bangladesh and Kenya concluded that household water treatment, alone or in combination with upgraded sanitation and handwashing, did not reduce linear growth faltering or improve other child growth outcomes. Whether these results are applicable in areas with distinct constellations of water, sanitation and hygiene (WaSH) risks is unknown. Analysis of observational data offers an efficient means to assess the external validity of trial findings. We studied whether a water quality intervention could improve child growth in a rural Indian setting with higher levels of circulating pathogens than the original trial sites. Methods: We analysed a cross-sectional dataset including a microbiological measure of household water quality. All households accessed water from an improved source. We applied propensity score methods to emulate a randomised trial investigating the hypothesis that receipt of drinking water meeting Sustainable Development Goal (SDG) 6.1 quality standards for absence of faecal contamination leads to improved growth. Growth outcomes (stunting, underweight, wasting, and their corresponding Z-scores) were assessed in children 12–23 months of age. For each outcome, we estimated the mean and 95% confidence interval of the absolute risk difference between treatment groups. Findings: Of 1088 households, 442 (40.62%) received drinking water meeting SDG 6.1 standards. The adjusted risk of child underweight was 7.4% (1.3% to 13.4%) lower among those drinking water satisfying SDG 6.1 norms than among controls. Evidence concerning the relationship of drinking water meeting SDG 6.1 norms to length-for-age and weight-for-age was inconclusive, and there was no apparent relationship with stunting or wasting. Conclusions: In contexts characterised by high pathogen transmission, water quality improvements have the potential to reduce the proportion of underweight children, but are unlikely to impact stunting or wasting. Further research is required to assess how these modelled benefits can best be achieved in real world settings. [ABSTRACT FROM AUTHOR]

In a recent global survey commissioned for the Millennium Summit of the United Nations, people around the world consistently mentioned good health as what they most desired. This preeminent concern [...]

Background: Decreasing trends in measles mortality have been reported in recent years. However, such estimates of measles mortality have depended heavily on assumed regional measles case fatality risks (CFRs) and made little use of mortality data from low- and middle-income countries in general and India, the country with the highest measles burden globally, in particular.Methods: We constructed a dynamic model of measles transmission in India with parameters that were empirically inferred using spectral analysis from a time series of measles mortality extracted from the Million Death Study, an ongoing longitudinal study recording deaths across 2.4 million Indian households and attributing causes of death using verbal autopsy. The model was then used to estimate the measles CFR, the number of measles deaths, and the impact of vaccination in 2000-2015 among under-five children in India and in the states of Bihar and Uttar Pradesh (UP), two states with large populations and the highest numbers of measles deaths in India.Results: We obtained the following estimated CFRs among under-five children for the year 2005: 0.63% (95% confidence interval (CI): 0.40-1.00%) for India as a whole, 0.62% (0.38-1.00%) for Bihar, and 1.19% (0.80-1.75%) for UP. During 2000-2015, we estimated that 607,000 (95% CI: 383,000-958,000) under-five deaths attributed to measles occurred in India as a whole. If no routine vaccination or supplemental immunization activities had occurred from 2000 to 2015, an additional 1.6 (1.0-2.6) million deaths for under-five children would have occurred across India.Conclusions: We developed a data- and model-driven estimation of the historical measles dynamics, CFR, and vaccination impact in India, extracting the periodicity of epidemics using spectral and coherence analysis, which allowed us to infer key parameters driving measles transmission dynamics and mortality. [ABSTRACT FROM AUTHOR]

Background: Widespread increases in caesarean section (CS) rates have sparked concerns about risks to mothers and infants and rising healthcare costs. A multicentre, two-arm, cluster-randomized trial in Quebec, Canada assessed whether an audit and feedback intervention targeting health professionals would reduce CS rates for pregnant women compared to usual care, and concluded that it reduced CS rates without adverse effects on maternal or neonatal health. The effect was statistically significant but clinically small. We assessed cost-effectiveness to inform scale-up decisions.Methods: A prospective economic evaluation was undertaken using individual patient data from the Quality of Care, Obstetrics Risk Management, and Mode of Delivery (QUARISMA) trial (April 2008 to October 2011). Analyses took a healthcare payer perspective. The time horizon captured hospital-based costs and clinical events for mothers and neonates from labour onset to 3 months postpartum. Resource use was identified and measured from patient charts and valued using standardized government sources. We estimated the changes in CS rates and costs for the intervention group (versus controls) between the baseline and post-intervention periods. We examined heterogeneity between clinical subgroups of high-risk versus low-risk pregnancies and estimated the joint uncertainty in cost-effectiveness over 20,000 trial simulations. We decomposed costs to identify drivers of change.Results: The intervention group experienced per-patient reductions of 0.005 CS (95% confidence interval (CI): -0.015 to 0.004, P = 0.09) and $180 (95% CI: -$277 to - $83, P < 0.001). Women with low-risk pregnancies experienced statistically significant reductions in CS rates and costs; changes for the high-risk subgroup were not significant. The intervention was "dominant" (effective in reducing CS and less costly than usual care) in 86.08% of simulations. It reduced costs in 99.99% of simulations. Cost reductions were driven by lower rates of neonatal complications in the intervention group (-$190, 95% CI: -$255 to - $125, P < 0.001). Given 88,000 annual provincial births, a similar intervention could save $15.8 million (range: $7.3 to $24.4 million) in Quebec annually.Conclusions: From a healthcare payer perspective, a multifaceted intervention involving audits and feedback resulted in a small reduction in caesarean deliveries and important cost savings. Cost reductions are consistent with improved quality of care in intervention group hospitals.Trial Registration: International Clinical Trials Registry Platform, ISRCTN95086407 . Registered on 23 October 2007. [ABSTRACT FROM AUTHOR]

Background: Diabetes mellitus (DM) is one of the most burdensome chronic diseases and is associated with shorter lifetime, diminished quality of life and economic burdens on the patient and society as a result of healthcare, medication, and reduced labor market participation. We aimed to estimate the direct (medical and non-medical) and indirect costs of DM and compare them with those of people without DM (ND), as well as the cost predictors. Methods and findings: Observational retrospective case–control study performed in Mali. Participants were identified and randomly selected from diabetes registries. We recruited 500 subjects with DM and 500 subjects without DM, matched by sex and age. We conducted structured, personal interviews. Costs were expressed for a 90-day period. Direct medical costs comprised: inpatient stays, ICU, laboratory tests and other hospital visits, specialist and primary care doctor visits, others, traditional practitioners, and medication. Direct non-medical costs comprised travel for treatment and paid caregivers. The indirect costs include the productivity losses by patients and caregivers, and absenteeism. We estimate a two-part model by type of service and a linear multiple regression model for the total cost. We found that total costs of persons with DM were almost 4 times higher than total cost of people without DM. Total costs were $77.08 and $281.92 for ND and DM, respectively, with a difference of $204.84. Conclusions: Healthcare use and costs were dramatically higher for people with DM than for people with normal glucose tolerance and, in relative terms, much higher than in developed countries. [ABSTRACT FROM AUTHOR]

Background: Cluster randomised trials (CRTs) are a key instrument to evaluate public health interventions, particularly in low- and middle-income countries (LMICs). Fidelity assessment examines study processes to gauge whether an intervention was delivered as initially planned. Evaluation of implementation fidelity (IF) is required to establish whether the measured effects of a trial are due to the intervention itself and may be particularly important for CRTs of complex interventions. Current CRT reporting guidelines offer no guidance on IF assessment. We will systematically review the scientific literature to study current practices concerning the assessment of IF in CRTs of public health interventions in LMICs. Methods: We will include CRTs of public health interventions in LMICs that planned or assessed IF in either the trial protocol or the main trial report (or an associated document). Search strategies use Medical Subject Headings (MESH) and text words related to CRTs, developing countries, and public health interventions. The electronic database search was developed first for MEDLINE and adapted for the following databases: EMBASE, CINAHL, PubMed, and EMB Reviews, to identify CRT reports in English, Spanish, or French published on or after January 1, 2012. To ensure availability of a study protocol, we will include CRTs reporting a registration number in the abstract. For each included study, we will compare planned versus reported assessment of IF, and consider the dimensions of IF studied, and data collection methods used to evaluate each dimension. Data will be synthesised using quantitative and narrative techniques. Risk of bias for individual studies will be assessed using the Cochrane Collaboration Risk of Bias Tool criteria and additional criteria related to CRT methods. We will investigate possible sources of heterogeneity by performing subgroup analysis. This review was not eligible for inclusion in the PROSPERO registry. Discussion: Fidelity assessment may be a key tool for making studies more reliable, internally valid, and externally generalizable. This review will provide a portrait of current practices related to the assessment of intervention fidelity in CRTs and offer suggestions for improvement. Results will be relevant to researchers, those who finance health interventions, and for decision-makers who seek the best evidence on public health interventions. [ABSTRACT FROM AUTHOR]

Background: The global burden of child undernutrition is concentrated in South Asia, where gender inequality and female educational disadvantage are important factors. Maternal health literacy is linked to women's education and empowerment, can influence multiple malnutrition determinants, and is rapidly modifiable.Objective: This study investigated whether maternal health literacy is associated with child undernutrition in 2 resource-poor Indian populations.Methods: We conducted cross-sectional surveys in an urban and a rural site, interviewing 1 woman with a child aged 12-23 mo/household. Multivariate logistic regression analyses were conducted independently for each site. The main exposure was maternal health literacy. We assessed respondents' ability to understand, appraise, and apply health-related information with the use of Indian health promotion materials. The main outcomes were severe stunting, severe underweight, and severe wasting. We classified children as having a severe nutritional deficiency if their z score was <-3 SDs from the WHO reference population for children of the same age and sex. Analyses controlled for potential confounding factors including parental education and household wealth.Results: Rural and urban analyses included 1116 and 657 mother-child pairs, respectively. In each site, fully adjusted models showed that children of mothers with high health literacy had approximately half the likelihood of being severely stunted (rural adjusted OR: 0.50; 95% CI: 0.33, 0.74; P = 0.001; urban adjusted OR: 0.58; 95% CI: 0.35, 0.94; P = 0.028) or severely underweight (rural adjusted OR: 0.57; 95% CI: 0.38, 0.87; P = 0.009; urban adjusted OR: 0.48; 95% CI: 0.25, 0.91; P = 0.025) than children of mothers with low health literacy. Health literacy was not associated with severe wasting.Conclusions: In resource-poor rural and urban settings in India, maternal health literacy is associated with child nutritional status. Programs targeting health literacy may offer effective entry points for intervention. [ABSTRACT FROM AUTHOR]

Objective. To summarize key findings of economic evaluations of lifestyle interventions for the primary prevention of type 2 diabetes (T2D) in high-risk subjects. Methods. We conducted a systematic review of peer-reviewed original studies published since January 2009 in English, French, and Spanish. Eligible studies were identified through relevant databases including PubMed, Medline, National Health Services Economic Evaluation, CINHAL, EconLit, Web of sciences, EMBASE, and the Latin American and Caribbean Health Sciences Literature. Studies targeting obesity were also included. Data were extracted using a standardized method. The BMJ checklist was used to assess study quality. The heterogeneity of lifestyle interventions precluded a meta-analysis. Results. Overall, 20 studies were retained, including six focusing on obesity control. Seven were conducted within trials and 13 using modeling techniques. T2D prevention by physical activity or diet or both proved cost-effective according to accepted thresholds, except for five inconclusive studies, three on diabetes prevention and two on obesity control. Most studies exhibited limitations in reporting results, primarily with regard to generalizability and justification of selected sensitivity parameters. Conclusion. This confirms that lifestyle interventions for the primary prevention of diabetes are cost-effective. Such interventions should be further promoted as sound investment in the fight against diabetes. [ABSTRACT FROM AUTHOR]

Introduction: Accurate measurement of health inequities is indispensable to track progress or to identify needs for health equity policy interventions. A key empirical task is to measure the extent to which observed inequality in health -- a difference in health -- is inequitable. Empirically operationalizing definitions of health inequity has generated an important question not considered in the conceptual literature on health inequity. Empirical analysis can explain only a portion of observed health inequality. This paper demonstrates that the treatment of unexplained inequality is not only a methodological but ethical question and that the answer to the ethical question -- whether unexplained health inequality is unfair -- determines the appropriate standardization method for health inequity analysis and can lead to potentially divergent estimates of health inequity. Methods: We use the American sample of the 2002-03 Joint Canada/United States Survey of Health and measure health by the Health Utilities Index (HUI). We model variation in the observed HUI by demographic, socioeconomic, health behaviour, and health care variables using Ordinary Least Squares. We estimate unfair HUI by standardizing fairness, removing the fair component from the observed HUI. We consider health inequality due to factors amenable to policy intervention as unfair. We contrast estimates of inequity using two fairness-standardization methods: direct (considering unexplained inequality as ethically acceptable) and indirect (considering unexplained inequality as unfair). We use the Gini coefficient to quantify inequity. Results: Our analysis shows that about 75% of the variation in the observed HUI is unexplained by the model. The direct standardization results in a smaller inequity estimate (about 60% of health inequality is inequitable) than the indirect standardization (almost all inequality is inequitable). Conclusions: The choice of the fairness-standardization method is ethical and influences the empirical health inequity results considerably. More debate and analysis is necessary regarding which treatment of the unexplained inequality has the stronger foundation in equity considerations. [ABSTRACT FROM AUTHOR]

Background The rate of avoidable caesarean sections (CS) could be reduced through multifaceted strategies focusing on the involvement of health professionals and compliance with clinical practice guidelines (CPGs). Quality improvements for CS (QICS) programmes (QICS) based on this approach, have been implemented in Canada and Spain. Objectives Their objectives are as follows: 1) Toto identify clusters in each setting with similar results in terms of costconsequences, 2) Toto investigate whether demographic, clinical or context characteristics can distinguish these clusters, and 3) Toto explore the implementation of QICS in the 2 regions, in order to identify factors that have been facilitators in changing practices and reducing the use of obstetric intervention, as well as the challenges faced by hospitals in implementing the recommendations. Methods Descriptive study with a quantitative and qualitative approach. 1) Cluster analysis at patient level with data from 16 hospitals in Quebec (Canada) (n = 105,348) and 15 hospitals in Andalusia (Spain) (n = 64,760). The outcome measures are CS and costs. For the cost, we will consider the intervention, delivery and complications in mother and baby, from the hospital perspective. Cluster analysis will be used to identify participants with similar patterns of CS and costs based, and t tests will be used to evaluate if the clusters differed in terms of characteristics: Hospital level (academic status of hospital, level of care, supply and demand factors), patient level (mother age, parity, gestational age, previous CS, previous pathology, presentation of the baby, baby birth weight). 2) Analysis of in-depth interviews with obstetricians and midwives in hospitals where the QICS were implemented, to explore the differences in delivery-related practices, and the importance of the different constructs for positive or negative adherence to CPGs. Dimensions: political/management level, hospital level, health professionals, mothers and their birth partner. Discussion This work sets out a new approach for programme evaluation, using different techniques to make it possible to take into account the specific context where the programmes were implemented. [ABSTRACT FROM AUTHOR]

Introduction Measurement of health inequities is fundamental to all health equity initiatives. It is complex because it requires considerations of ethics, methods, and policy. Drawing upon the recent developments in related specialized fields, in this paper we incorporate alternative definitions of health inequity explicitly and transparently in its measurement. We propose a three-stage approach to measuring health inequities that assembles univariate health inequality, univariate health inequity, and bivariate health inequities in a systematic and comparative manner. Methods We illustrate the application of the three-stage approach using the Joint Canada/United States Survey of Health, measuring health by the Health Utilities Index (HUI). Univariate health inequality is the distribution of the observed HUI across individuals. Univariate health inequity is the distribution of unfair HUI -- components of HUI associated with ethically unacceptable factors -- across individuals. To estimate the unfair HUI, we apply two popular definitions of inequity: "equal opportunity for health" (health outcomes due to factors beyond individual control are unfair), and "policy amenability" (health outcomes due to factors amenable to policy interventions are unfair). We quantify univariate health inequality and inequity using the Gini coefficient. We assess bivariate inequities using a regression-based decomposition method. Results Our analysis reveals that, empirically, different definitions of health inequity do not yield statistically significant differences in the estimated amount of univariate inequity. This derives from the relatively small explanatory power common in regression models describing variations in health. As is typical, our model explains about 20% of the variation in the observed HUI. With regard to bivariate inequities, income and health care show strong associations with the unfair HUI. Conclusions The measurement of health inequities is an excitingly multidisciplinary endeavour. Its development requires interdisciplinary integration of advances from relevant disciplines. The proposed three- stage approach is one such effort and stimulates cross-disciplinary dialogues, specifically, about conceptual and empirical significance of definitions of health inequities. [ABSTRACT FROM AUTHOR]

Objective To estimate the impact on maternal and child mortality after eliminating user fees for pregnant women and for children less than five years of age in Burkina Faso. Methods Two health districts in the Sahel region eliminated user fees for facility deliveries and curative consultations for children in September 2008. To compare health-care coverage before and after this change, we used interrupted time series, propensity scores and three independent data sources. Coverage changes were assessed for four variables: women giving birth at a health facility, and children aged 1 to 59 months receiving oral rehydration salts for diarrhoea, antibiotics for pneumonia and artemesinin for malaria. We modelled the mortality impact of coverage changes in the Lives Saved Tool using several scenarios. Findings Coverage increased for all variables, however, the increase was not statistically significant for antibiotics for pneumonia. For estimated mortality impact, the intervention saved approximately 593 (estimate range 168-1060) children’s lives in both districts during the first year. This lowered the estimated under-five mortality rate from 235 deaths per 1000 live births in 2008 to 210 (estimate range 189-228) in 2009. If a similar intervention were to be introduced nationwide, 14 000 to 19 000 (estimate range 4000-28 000) children’s lives could be saved annually. Maternal mortality showed a modest decrease in all scenarios. Conclusion In this setting, eliminating user fees increased use of health services and may have contributed to reduced child mortality. [ABSTRACT FROM AUTHOR]