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Objective: To obtain the perspectives of health professionals and community health workers on factors that determine health service coverage and maternal health outcomes so as to understand variations between districts. Methods: 16 Focus group discussions involving four different groups of participants were conducted in May 2015 in four purposively selected districts, complemented by three key informant interviews in one of the districts. Results: The solidarity support for poor people and the interconnectedness between local leaders and heads of health facilities were identified as enablers of health service utilization. Geographical factors, in particular location close to borders with mobile populations and migrants, and large populations with sparsely distributed health infrastructure, exacerbated by hilly topography and muddy roads were identified as barriers. Shortages of skilled health providers at the level of district hospitals were cited as contributing to poor maternal health outcomes. Conclusion: There is a need to take into account disparities between districts when allocating staff and financial resources in order to achieve universal coverage for high-quality maternal health services and better outcomes. Local innovations such as the use of SMS and WhatsApp text messages by health workers and financial protection schemes for poor patients improve solidarity and are worth to be scaled up. [ABSTRACT FROM AUTHOR]

Background: In Equatorial Guinea, malaria continues to be one of the main causes of morbidity and mortality among children. The National Therapeutic Guide established artesunate-amodiaquine (ASAQ) as first-line treatment for uncomplicated malaria, but compliance with this treatment is low. The aim of this study was to assess, for the first time, the performance of public healthcare workers in the diagnosis and treatment of uncomplicated malaria, their compliance with first-line Malaria National Therapeutic Guide and the associated factors. Methods: A cross-sectional survey was conducted at the nine public health facilities in the Bata District of Equatorial Guinea to assess the management of uncomplicated malaria in children < 15 years of age. Bivariate and multivariate statistical analyses were used to determine the recommended treatment compliance and related factors. Results: A total of 227 children with uncomplicated malaria were recorded from 9 public health facilities. Most of the treatments prescribed (83.3%) did not follow the first-line treatment recommended for uncomplicated malaria. The diagnosis was established with parasite confirmation in 182 cases (80.2%). After adjustment for other variables, children under 2 months of age, the use of parasite confirmation to the diagnosis of malaria and being familiar with the national therapeutic guide were significantly associated with the prescription of the first-line recommended treatment. Cases attended at the hospital or in a health facility with ASAQ in the pharmacy at the time of the study were also more likely to be prescribed with the recommended treatment, but with non-significant association after adjustment for other variables. Conclusions: This study identified the factors associated with the low compliance with the first-line treatment by the public healthcare facilities of Bata District of Equatorial Guinea. It seems necessary to improve case management of children with uncomplicated malaria; to reinforce the use of Malaria National Therapeutic Guide and to inform about the danger of using artemisinin monotherapy. Furthermore, it is crucial to provide recommended first-line treatment to the pharmacies of all public health facilities to ensure access to this treatment. [ABSTRACT FROM AUTHOR]

Background: A knowledge brokering (KB) intervention was implemented in Burkina Faso. By creating partnerships with health system actors in one district, the broker was expected to assess their knowledge needs, survey the literature to provide the most recent research evidence, produce various knowledge translation tools, and support them in using research to improve their actions. The purpose of this study was to analyze the key factors that influenced the KB project and to make recommendations for future initiatives. Methods: The qualitative design involved a single case study in which the KB intervention implementation was evaluated retrospectively. Data came from interviews with the intervention team (n = 4) and with various actors involved in the intervention (n = 16). Data from formative evaluations conducted during the KB implementation and observation data from a two-month field mission were also used. Two conceptual frameworks were combined to guide the analysis: the Consolidated Framework for Implementation Research (Damschroder et al., 2009) and the Ecological Framework (Durlak & DuPre, 2008). Results: Various KB activities were conducted during the first two years of implementation at the local level. The project came to an early end following vain efforts to relocate the intervention at the central level in order to further influence the policy process. Certain shortcomings in the implementation team negatively influenced the implementation: inadequate leadership, no shared vision regarding the reorientation of the intervention, challenges related to the KB role, and lack of frank communications internally. Other impediments to the intervention’s deployment included local actors' lack of decision-making authority, the unavailability of resources and of organizational incentives for involvement in the KB intervention, and contextual challenges in accessing the central level. However, the KB strategy presented several strengths: collaborative development, support provided to local partners by the broker, and training opportunities and support provided to the broker. Conclusions: More attention must be paid to intervention planning, partners’ engagement, human, financial and technical resources availability, continuous development of skills and of communications within the KB team, and periodic assessment of potential obstacles related to the complexity of the system within which the intervention has been implemented. Using implementation science frameworks when developing KB strategies in the West African context should be promoted. [ABSTRACT FROM AUTHOR]

Background: In 2016 the first African emergency care clinical practice guideline (CPG) was developed for national uptake in the prehospital sector in South Africa, with implementation starting in 2018. Comprehensive uptake of CPGs post development is not a given, as this requires effective and efficient dissemination and implementation strategies that take into account the perceptions, barriers and facilitators of the local end-users. This study aimed to identify prehospital end-users’ perceptions of the emergency care guidelines, including barriers and facilitators for national decision makers, to strengthen CPG uptake in South Africa. Methods: Our study employed a descriptive qualitative research design, including nine focus groups with 56 operational emergency care providers across four major provinces in South Africa. Data was analysed using thematic analysis in ATLAS.ti. Ethics approval was provided by Stellenbosch University. Results: Themes related to provider perceptions, expectations and guideline uptake emerging from the data was unofficial and unclear communication, broadening versus limiting guideline expectations, conflicted personal reactions and spreading the word. Challenges to dissemination and implementation included poor communication, changes to scope of practice, and limited capacity to upskill existing providers. Facilitators included using technology for end-user documents, local champions to support change, establishing online and modular training, and implementation by independent decision makers. Conclusion: This study provides an overview of the perceptions of operational emergency care providers and how their experiences of hearing about and engaging with the guidelines, in their industry, can contribute to the dissemination, implementation and uptake of emergency care guidelines. In order to disseminate and implement an emergency care CPG, decision makers must take into account the perceptions, barriers, and facilitators of local end-users. [ABSTRACT FROM AUTHOR]

In December 2016, the Nigerian Federal Ministry of Health updated its HIV guidelines to a Treat All approach, expanding antiretroviral therapy (ART) eligibility to all individuals with HIV infection, regardless of CD4+ cell count, and recommending ART be initiated within two weeks of HIV diagnosis (i.e., the Test and Treat strategy). The Test and Treat policy was first piloted in 32 local government areas (LGAs). The primary objective of this study was to evaluate the clinical outcomes of adult patients initiated on ART within two weeks of HIV diagnosis during this pilot. We conducted a retrospective cohort analysis of patients who initiated ART within two weeks of new HIV diagnosis between October 2015 and September 2016 in eight randomly selected LGAs participating in the Test and Treat pilot study. 2,652 adults were newly diagnosed and initiated on ART within two weeks of HIV diagnosis. Of these patients, 8% had documentation of a 12-month viral load measurement, and 13% had documentation of a six-month viral load measurement. Among Test and Treat patients with a documented viral load, 79% were suppressed (≤400 copies/ml) at six months and 78% were suppressed at 12 months. By 12 months post-ART initiation, 34% of the patients who initiated ART under the Test and Treat strategy were lost to follow-up. The median CD4 cell count among patients initiating ART within two weeks of HIV diagnosis was 323 cells/mm3 (interquartile range, 161–518). While randomized controlled trials have demonstrated that Test and Treat strategies can improve patient retention and increase viral suppression compared to standard of care, these findings indicate that the effectiveness of Test and Treat in some settings may be far lower than the efficacy demonstrated in randomized controlled trials. Significant attention to the way Test and Treat strategies are implemented, monitored, and improved particularly related to early retention, can help expand access to ART for all patients. [ABSTRACT FROM AUTHOR]

Introduction: HIV misdiagnosis leads to severe individual and public health consequences. Retesting for verification of all HIV-positive cases prior to antiretroviral therapy initiation can reduce HIV misdiagnosis, yet this practice has not been not widely implemented. Methods: We evaluated and compared the cost of retesting for verification of HIV seropositivity (retesting) to the cost of antiretroviral treatment (ART) for misdiagnosed cases in the absence of retesting (no retesting), from the perspective of the health care system. We estimated the number of misdiagnosed cases based on a review of misdiagnosis rates, and the number of positives persons needing ART initiation by 2020. We presented the total and per person costs of retesting as compared to no retesting, over a ten-year horizon, across 50 countries in Africa grouped by income level. We conducted univariate sensitivity analysis on all model input parameters, and threshold analysis to evaluate the parameter values where the total costs of retesting and the costs no retesting are equivalent. Cost data were adjusted to 2017 United States Dollars. Results and discussion: The estimated number of misdiagnoses, in the absence of retesting was 156,117, 52,720 and 29,884 for lower-income countries (LICs), lower-middle income countries (LMICs), and upper middle-income countries (UMICs), respectively, totaling 240,463 for Africa. Under the retesting scenario, costs per person initially diagnosed were: $40, $21, and $42, for LICs, LMICs, and UMICs, respectively. When retesting for verification is implemented, the savings in unnecessary ART were $125, $43, and $75 per person initially diagnosed, for LICs, LMICs, and UMICs, respectively. Over the ten-year horizon, the total costs under the retesting scenario, over all country income levels, was $475 million, and was $1.192 billion under the no retesting scenario, representing total estimated savings of $717 million in HIV treatment costs averted. Conclusions: Results show that to reduce HIV misdiagnosis, countries in Africa should implement the WHO’s recommendation of retesting for verification prior to ART initiation, as part of a comprehensive quality assurance program for HIV testing services. [ABSTRACT FROM AUTHOR]

The scale-up of antiretroviral therapy (ART) in South Africa substantially reduced AIDS-related deaths and new HIV infections. However, its success is threatened by the emergence of resistance to non-nucleoside reverse-transcriptase inhibitors (NNRTI). The MARISA (Modelling Antiretroviral drug Resistance In South Africa) model presented here aims at investigating the time trends and factors driving NNRTI resistance in South Africa. MARISA is a compartmental model that includes the key aspects of the local HIV epidemic: continuum of care, disease progression, and gender. The dynamics of NNRTI resistance emergence and transmission are then added to this framework. Model parameters are informed using data from HIV cohorts participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) and literature estimates, or fitted to UNAIDS estimates. Using this novel approach of triangulating clinical and resistance data from various sources, MARISA reproduces the time trends of HIV in South Africa in 2005–2016, with a decrease in new infections, undiagnosed individuals, and AIDS-related deaths. MARISA captures the dynamics of the spread of NNRTI resistance: high levels of acquired drug resistance (ADR, in 83% of first-line treatment failures in 2016), and increasing transmitted drug resistance (TDR, in 8.1% of ART initiators in 2016). Simulation of counter-factual scenarios reflecting alternative public health policies shows that increasing treatment coverage would have resulted in fewer new infections and deaths, at the cost of higher TDR (11.6% in 2016 for doubling the treatment rate). Conversely, improving switching to second-line treatment would have led to lower TDR (6.5% in 2016 for doubling the switching rate) and fewer new infections and deaths. Implementing drug resistance testing would have had little impact. The rapid ART scale-up and inadequate switching to second-line treatment were the key drivers of the spread of NNRTI resistance in South Africa. However, even though some interventions could have substantially reduced the level of NNRTI resistance, no policy including NNRTI-based first line regimens could have prevented this spread. Thus, by combining epidemiological data on HIV in South Africa with biological data on resistance evolution, our modelling approach identified key factors driving NNRTI resistance, highlighting the need of alternative first-line regimens. [ABSTRACT FROM AUTHOR]

Poor reproductive health among youth and adolescents threatens their future health and economic wellbeing in Zimbabwe amidst a high HIV/AIDS prevalence. This study evaluates the impact of a multi-pronged adolescent sexual and reproductive health (ASRH) strategy implemented by government of Zimbabwe between 2010 and 2015 to improve ASRH in terms of the uptake of condoms and HIV testing as well as outcomes in terms of sexually transmitted infection (STI) prevalence and HIV prevalence. We combine the difference in difference and propensity score matching methods to analyse repeated Zimbabwe demographic health survey cross-sectional datasets. Young people aged 15–19 years at baseline in 2010, who were exposed for the entire five-year strategy are designated as the treatment group and young adults aged 25–29 at baseline as the control. We find that the ASRH strategy increased HIV testing amongst youth by 36.6 percent, whilst treatment of STIs also increased by 30.4 percent. We also find that the HIV prevalence trajectory was reduced by 0.7 percent. We do not find evidence of impact on condom use and STI prevalence. The findings also suggest that although HIV testing increased for all socio-economic groups that were investigated, the effect was not the same. Lastly, we do not find evidence supporting that more resources translate to better ASRH outcomes. We recommend designing future ASRH strategies in a way that differentiates service delivery for youths in HIV hotspots, rural areas and out of school. We also recommend improving the strategy’s coordination and monitoring, as well as aligning and enforcing government policies that promote sexual and reproductive health rights. [ABSTRACT FROM AUTHOR]

Background: Globally, 37 million people are in need of lifelong antiretroviral treatment (ART). With the continual increase in the number of people living with HIV starting ART and the need for life-long retention and adherence, increasing attention is being paid to differentiated service delivery (DSD), such as adherence clubs. Adherence clubs are groups of 25–30 stable ART patients who meet five times per year at their clinic or a community location and are facilitated by a lay health-care worker who distributes pre-packed ART. This qualitative study explores patient experiences of clubs in two sites in Cape Town, South Africa. Methods: A total of 144 participants took part in 11 focus group discussions (FGDs) and 56 in-depth interviews in the informal settlements of Khayelitsha and Gugulethu in Cape Town, South Africa. Participants included current club members, stable patients who had never joined a club and club members referred back to clinician-led facility-based standard care. FGDs and interviews were conducted in isiXhosa, translated and transcribed into English, entered into NVivo, coded and thematically analysed. Results: The main themes were 1) understanding and knowledge of clubs; 2) understanding of and barriers to enrolment; 3) perceived benefits and 4) perceived disadvantages of the clubs. Participants viewed membership as an achievement and considered returning to clinician-led care a ‘failure’. Moving between clubs and the clinic created frustration and broke down trust in the health-care system. Conclusions: Adherence clubs were appreciated by patients, particularly time-saving in relation to flexible ART collection. Improved patient understanding of enrolment processes, eligibility and referral criteria and the role of clinical oversight is essential for building relationships with health-care workers and trust in the health-care system. [ABSTRACT FROM AUTHOR]

Background: The Ghana Health Service in collaboration with partner institutions implemented a five-year primary health systems strengthening program known as the Ghana Essential Health Intervention Program (GEHIP). GEHIP was a plausibility trial implemented in an impoverished region of northern Ghana around the World Health Organizations (WHO) six pillars combined with community engagement, leadership development and grassroots political support, the program organized a program of training and action focused on strategies for saving newborn lives and community-engaged emergency referral services. This paper analyzes the effect of the GEHIP program on child survival. Methods: Birth history data assembled from baseline and endline surveys are used to assess the hazard of child mortality in GEHIP treatment and comparison areas prior to and after the start of treatment. Difference-in-differences (DiD) methods are used to compare mortality change over time among children exposed to GEHIP relative to children in the comparison area over the same time period. Models test the hypothesis that a package of systems strengthening activities improved childhood survival. Models adjusted for the potentially confounding effects of baseline differentials, secular mortality trends, household characteristics such as relative wealth and parental educational attainment, and geographic accessibility of clinical care. Results: The GEHIP combination of health systems strengthening activities reduced neonatal mortality by approximately one half (HR = 0.52, 95% CI = 0.28,0.98, p = 0.045). There was a null incremental effect of GEHIP on mortality of post-neonate infants (from 1 to 12 months old) (HR = 0.72; 95% CI = 0.30,1.79; p = 0.480) and post-infants (from 1 year to 5 years old) -(HR = 1.02; 95% CI = 0.55–1.90; p = 0.940). Age-specific analyses show that impact was concentrated among neonates. However, effect ratios for post-infancy were inefficiently assessed owing to extensive survival history censoring for the later months of childhood. Children were observed only rarely for periods over 40 months of age. Conclusion: GEHIP results show that a comprehensive approach to newborn care is feasible, if care is augmented by community-based nurses. It supports the assertion that if appropriate mechanisms are put in place to enable the various pillars of the health system as espoused by WHO in rural impoverished settings where childhood mortality is high, it could lead to accelerated reductions in mortality thereby increasing survival of children. Policy implications of the pronounced neonatal effect of GEHIP merit national review for possible scale-up. [ABSTRACT FROM AUTHOR]

Background: Drug resistant-tuberculosis is a growing burden on the South African health care budget. In response the National Department of Health implemented two important strategies in 2011; universal access to drug-sensitivity testing for rifampicin with Xpert MTB/RIF as the first-line diagnostic test for TB; and decentralization of treatment for RR/MDR-TB to improve access and reduce costs of treatment. Objective: Estimate the costs by treatment outcome of decentralized care for rifampicin and multi-drug resistant tuberculosis under routine conditions. The study was set at an outpatient drug resistant-tuberculosis treatment facility at a public academic hospital in Johannesburg, South Africa. During the study period 18–24 month long course treatment was offered for rifampicin-resistant and multi-drug-resistant tuberculosis. Methods: Data are from a prospective observational cohort study. Costs of treatment were estimated from the provider perspective using bottom-up micro-costing. Costs were estimated as patient-level resource use multiplied by the unit cost of the resource. Clinic visits, drugs, laboratory tests, and total days hospitalized were collected from patients' medical records. Staff time was estimated through a time and motion study. A successful treatment outcome was defined as cure or completion of the regimen. Results: We enrolled 124 patients with 52% having a successful outcome. The average total cost/patient for all patients was $3,430 and $4,530 for successfully treated patients. The largest contributors to total cost across all outcomes were drugs (43%) and staff (28%). The average cost to achieve a successful outcome including all patients who started treatment ("production cost") in the cohort is $6,684. Conclusions: Decentralized, outpatient RR/MDR-TB care under South Africa's 2011 strategy costs 74% less per patient than the previous strategy of inpatient care. The treatment cost of RR/MDR-TB is primarily driven by drug and staff costs, which are in turn dependant on treatment length. [ABSTRACT FROM AUTHOR]

Ghana has made significant stride towards universal health coverage (UHC) by implementing the National Health Insurance Scheme (NHIS) in 2003. This paper investigates the progress of UHC indicators in Ghana from 1995 to 2015 and makes future predictions up to 2030 to assess the probability of achieving UHC targets. National representative surveys of Ghana were used to assess health service coverage and financial risk protection. The analyses estimated the coverage of 13 prevention and four treatment service indicators at the national level and across wealth quintiles. In addition, we calculated catastrophic health payments and impoverishment to assess financial hardship and used a Bayesian regression model to estimate trends and future projections as well as the probabilities of achieving UHC targets by 2030. Wealth-based inequalities and regional disparities were also assessed. At the national level, 14 out of the 17 health service indicators are projected to reach the target of 80% coverage by 2030. Across wealth quintiles, inequalities were observed amongst most indicators with richer groups obtaining more coverage than their poorer counterparts. Subnational analysis revealed while all regions will achieve the 80% coverage target with high probabilities for the prevention services, the same cannot be applied to the treatment services. In 2015, the proportion of households that suffered catastrophic health payments and impoverishment at a threshold of 25% non-food expenditure were 1.9% (95%CrI: 0.9–3.5) and 0.4% (95%CrI: 0.2–0.8), respectively. These are projected to reduce to 0.4% (95% CrI: 0.1–1.3) and 0.2% (0.0–0.5) respectively by 2030. Inequality measures and subnational assessment revealed that catastrophic expenditure experienced by wealth quintiles and regions are not equal. Significant improvements were seen in both health service coverage and financial risk protection over the years. However, inequalities across wealth quintiles and regions continue to be cause of concerns. Further efforts are needed to narrow these gaps. [ABSTRACT FROM AUTHOR]

Introduction: Despite the government’s efforts to decentralize and expand health institutions to promote facility-based child delivery, home delivery and maternal mortality are still widespread problems in Ethiopia. Most mothers continue to give birth at home. This study aims at identifying the socio-cultural practices, perceived benefit or need, and accessibility factors influencing women’s choice of health facilities for delivery services in Gida Ayana Woreda, western Ethiopia. Methods: We conducted a cross-sectional survey to assess women’s use of delivery care services in Gida Ayana Woreda, from November 2016 to January 2017; 459 women who were selected randomly participated in the study. We evaluated the socio-cultural, perceived benefit or need, and economic and physical accessibility factors in women’s choice of delivery care and used adjusted logistic regression analysis to examine significant predictors of delivery site use decisions. Results: Over half (56.6%) of the women self-reported using institutional delivery care; 80.9% gave birth at a health center. A socio-cultural variable, maternal education, significantly influenced women’s choice of health facility for delivery care services (AOR 3.4; 95% CI 2.0–5.9). Mothers’ knowledge level of obstetric complications and experience of complications during the last birth were the two perceived benefits or need factors associated with higher odds of receiving delivery care from decentralized local facilities. Utilization of health centers for maternal delivery care was significantly higher than of health posts (AOR 5.0; 95% CI 2.4–10.2). Availability of motorized transportation during labor to nearby delivery site was a significant predictor of institutional delivery. Conclusion: This study demonstrates the under-utilization of decentralized health facilities for maternal delivery care services in Gida Ayana Woreda, which was significantly influenced by socio-cultural, perceived need, and accessibility factors of women during childbirth. This suggests the need for tailored intervention to improve childbirth services use for mothers in this kind of rural settings. [ABSTRACT FROM AUTHOR]

Background: Jhpiego implemented a 5-year project to strengthen the Community-Based Health Planning and Services (CHPS) model in six coastal districts of Ghana’s Western Region. The project utilized a quality improvement approach (Standards-Based Management and Recognition [SBM-R]) to strengthen implementation fidelity of the CHPS model. This article presents findings from an end-of-project evaluation comparing quality, access to care, and experience of care in intervention and comparison CHPS zones. Methods: A non-equivalent, posttest–only, end-of-project evaluation compared 12 randomly selected intervention zones with 12 matched comparison zones. Data from standards-based assessments measured provision of care in three categories: community engagement, clinical services, and facility readiness and management. Access to and experience of care were assessed using a household survey of 426 randomly selected community members from the selected CHPS zones. Bivariate and multivariate analyses were conducted to compare performance on these measures between intervention and comparison CHPS zones. Results: Overall, intervention zones outperformed comparison zones on achievement of standards (83.6% vs 58.8%) across all three assessment categories, with strongest results in community engagement (85.7% vs. 41.4%). Respondents in intervention zones were more than twice as likely to have received a home visit from a community health officer, three times as likely to have a home visit from a community health volunteer, and more likely to have attended a health talk (41.9% vs. 27.0%). Client experiences of care were reported as positive in both study arms. Conclusions: The evaluation demonstrated improved access to quality care; however, there were very few differences in client experience of care between intervention and comparison zones. As Ghana and other countries are committed to scaling up universal health care, a pragmatic approach such as SBM-R could prove useful to engage both facility- and community-based service providers, as well as community members, to improve provision of care. [ABSTRACT FROM AUTHOR]

Background: Patients experiencing adverse drug events (ADE) in many developing countries are in the best position to report these events to the authorities but need to be empowered to do so. Systematic evaluation of community engagement and patient support especially in rural areas would provide evidence for a program to monitor potential harm from medicines. The aim of this study was to assess the effects of a community dialogue and sensitization (CDS) program on the knowledge, attitude and practises of community members for reporting ADE. Methods: This an uncontrolled before-after study was conducted in two eastern Ugandan districts between September 2016 and August 2017 Results: After implementation of the community dialogue and sensitization (CDS) program, there was an overall 20% (95% CI:16% to 25%) increase in knowledge about ADE in the community compared to before the program began. Awareness levels increased by 50% (95% CI: 37% to 63%) among those with little or no education and by41% (95% CI: 31% to 52%) among young people (15–24 years). Furthermore, 5% (95% CI: 3% to 7%) more respondents recognized the need for reporting ADEs compared to before the program. Finally, there was a significant increase of 115% (95% CI:137% to 217%) in respondent recognition and reporting of ADEs compared to the beginning of the CDS program. Overall, this community found the CDS program acceptable and proposed aspects that could be improved for future use. Conclusion: Our evaluation showed that the CDS program increased knowledge and improved attitudes by catalyzing discussions among community members and healthcare professionals on health issues and monitoring safety of medicines compared to before the program. Successful implementation of the program depends on holistic health systems strengthening and adaptation to the community’s way of life. [ABSTRACT FROM AUTHOR]

Introduction: The Government of Kenya instituted the free maternity services (FMS) policy to improve utilization of maternal healthcare services and thus improve maternal health. The aim of this study was to evaluate the effect of the FMS policy on the uptake of maternal health services in Nyamira County in western Kenya. Methods: An interrupted time series study design was used to design the study and to analyze the collected data. Forty-two data sets were collected for each outcome variable i.e. 24 pre- and 18 post-intervention. Monthly data was abstracted from the District Health Information System-2 (DHIS-2) and verified using facility data. The collected data was then keyed into SPSS-17, cleaned and analyzed. Results: During the study period, there was a significant increase in births attended by skilled attendants up to the 12th month (p<0.05) and caesarean section up to the ninth month (p<0.05). There was a decrease in obstetric complications up to the 12 month (p<0.05). In addition there was a significant increase in institutional maternal mortality ratio (iMMR) in the 12th and 18th months (p<0.05) following the implementation of free maternity service policy. There was a significant increase in deliveries in hospitals from the 1st to the 18th month (p<0.05) whereas in primary health care facilities the increase in deliveries was only significant up to the 6th month (p<0.05). Conclusions: The FMS policy led to progress towards improving maternal health by improving access to maternal health services. The improved utilization of maternal health services was more marked in hospitals. There was a worsening of institutional maternal mortality ratio. [ABSTRACT FROM AUTHOR]

Using data from the UN World Population Prospects, we document global trends in lifespan inequality from 1950 until 2015. Our findings indicate that (i) there has been a sustained decline in overall lifespan inequality, (ii) adult lifespan variability has also declined, but some plateaus and trend reversals have been identified, (iii) lifespan inequality among the elderly has increased virtually everywhere, and (iv) most of the world variability in age-at-death can be attributed to within-country variability. Such changes have occurred against a backdrop of generalized longevity increases. Our analyses suggest that the world is facing a new challenge: the emergence of diverging trends in longevity and age-at-death inequality among the elderly around the globe—particularly in high-income areas. As larger fractions of the world population survive to more advanced ages, it will be necessary for national and international health planners to recognize the growing heterogeneity that characterizes older populations. [ABSTRACT FROM AUTHOR]

Despite the removal of user fees on public primary healthcare in Zambia, prior studies suggest that out-of-pocket payments are still significant. However, we have little understanding of the extent to which out-of-pocket payments lead patients to hardship methods of financing out-of-pocket costs. This study analyses the prevalence and determinants of hardship financing arising from out-of-pocket payments in healthcare, using data from a nationally-representative household health expenditure survey conducted in 2014. We employ a sequential logistic regression model to examine the factors associated with the risk of hardship financing conditional on reporting an illness and an out-of-pocket expenditure. The results show that up to 11% of households who reported an illness had borrowed money, or sold items or asked a friend for help, or displaced other household consumption in order to pay for health care. The risk of hardship financing was higher among the poorest households, female headed-households and households who reside further from health facilities. Improvements in physical access and quality of public health services have the potential to reduce the incidence of hardship financing especially among the poorest. [ABSTRACT FROM AUTHOR]

Objective: To assess the existing knowledge and skills relating to Emergency Obstetrics Care (EMOC) among health providers in eight referral maternity hospitals in Nigeria. Study design: A cross-sectional study of skilled health providers (doctors, nurses and midwives) working in the hospitals during the period. Setting: Six general hospitals (4 in the south and 2 in the north), and two teaching hospitals (both in the Northern part) of the country. Population: All skilled providers offering EMOC services in the hospitals during the study. Methods: A pre-tested self-administered questionnaire was used to obtain information relating to socio-demographic characteristics, the respondents’ knowledge and skills in offering specific EMOC services (as compared to standard World Health Organization recommendations), and their confidence in transferring the skills to mid-level providers. Data were analyzed with univariate, bivariate, binary and multinomial logistic regression analyses. Main outcome measures: knowledge and skills in EMOC services by hospital and overall. Results: A total of 341 health providers (148 doctors and 193 nurses/midwives) participated in the study. Averagely, the providers scored less than 46% in a composite EMOC knowledge score, with doctors scoring considerable higher than the nurses/midwives. Similarly, doctors scored higher than nurses/midwives in the self-reporting of confidence in carrying out specific EMOC functions. Health providers that scored higher in knowledge were significantly more likely to report confidence in performing specific EMOC functions as compared to those with lower scores. The self-reporting of confidence in transferring clinical skills was also higher in those with higher EMOC knowledge scores. Conclusion: The knowledge and reported skills on EMOC by health providers in referral facilities in Nigeria was lower than average. We conclude that the in-service training and re-training of health providers should be included in national policy and programs that address maternal mortality prevention in referral facilities in the country. Trial registration: Nigeria Clinical Trials Registry . [ABSTRACT FROM AUTHOR]

Background: Modeling contributes to health program planning by allowing users to estimate future outcomes that are otherwise difficult to evaluate. However, modeling results are often not easily translated into practical policies. This paper examines the barriers and enabling factors that can allow models to better inform health decision-making. Description: The Decision Makers’ Program Planning Tool (DMPPT) and its successor, DMPPT 2, are illustrative examples of modeling tools that have been used to inform health policy. Their use underpinned Voluntary Medical Male Circumcision (VMMC) scale-up for HIV prevention in southern and eastern Africa. Both examine the impact and cost-effectiveness of VMMC scale-up, with DMPPT used initially in global advocacy and DMPPT 2 then providing VMMC coverage estimates by client age and subnational region for use in country-specific program planning. Their application involved three essential steps: identifying and engaging a wide array of stakeholders from the outset, reaching consensus on key assumptions and analysis plans, and convening data validation meetings with critical stakeholders. The subsequent DMPPT 2 Online is a user-friendly tool for in-country modeling analyses and continuous program planning and monitoring. Lessons learned: Through three iterations of the DMPPT applied to VMMC, a comprehensive framework with six steps was identified: (1) identify a champion, (2) engage stakeholders early and often, (3) encourage consensus, (4) customize analyses, (5), build capacity, and (6) establish a plan for sustainability. This framework could be successfully adapted to other HIV prevention programs to translate modeling results to policy and programming. Conclusions: Models can be used to mobilize support, strategically plan, and monitor key programmatic elements, but they can also help inform policy environments in which programs are conceptualized and implemented to achieve results. The ways in which modeling has informed VMMC programs and policy may be applicable to an array of other health interventions. [ABSTRACT FROM AUTHOR]

Background: Incidence and mortality of cervical cancer is the leading cancer among women in Ethiopia. Absence of effective detection methods and treatment strategies is a major reason for the sharply rising cervical cancer rates in developing countries. Objective: To determine factors affecting utilization of cervical cancer screening services among women attending public hospitals in Tigray region in 2018. Methods: Hospital based unmatched case control study was applied with sample size of 312 cases and 312 controls. Data was entered to Epi data version 3.1 and exported to SPSS version 20. The odds ratio with their 95% confidence interval, two-tailed P value was calculated. Variables with P value ≤ 0.05 in the bivariate analysis were included in the multivariate logistic regression model. Results: Being in the age group of 30–39 and 40–49 years were two and four times more likely to utilize cervical cancer screening than those who were 21–29 years (AOR = 2.15 95%CI:1.11, 4.17 and AOR = 3.86 95%CI:1.48, 10.06) respectively. Current occupation with governmental and private employee were four and three times more likely to utilize the screening service than those housewife respectively (AOR = 3.85 95%CI: 1.87, 7.92 and AOR = 3.17 95%CI: 1.31, 7.66). Having ever given birth and history of multiple sexual partners were more likely to utilize the screening service (AOR = 2.57 95%CI: 1.02, 6.50) and (AOR = 2.65 95%CI: 1.10, 6.40) respectively. Conclusions: There is a need to strengthen policy and guidelines on cervical cancer screening among women particularly with regarding age group of 21–29, current occupation with housewife, single sexual partner and null parity. All stakeholders should give priority on the promotion and initiation of women to acquired good knowledge and attitude on cervical cancer screening. [ABSTRACT FROM AUTHOR]

Background: Adherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies. Methods: We used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains. Results: We included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism—these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a “tipping point”, a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time. Conclusion: This analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead ‘normal’ lives. [ABSTRACT FROM AUTHOR]

Introduction: Sub-Saharan Africa is experiencing an epidemiological transition as the burden of NCDs overtake communicable diseases. However, it is unknown what capacity and gaps exist at primary care level to address the growing burden of NCDs. This study aimed to assess the Zambian health system’s capacity to address in NCDs, using an adapted WHO Essential Non Communicable Disease Interventions (WHO PEN) tool. Methodology: This was a cross-sectional facility survey in the three districts conducted from September 2017 to October 2017. We defined facility readiness along five domains: basic equipment, essential services, diagnostic capacity, counseling services, and essential medicines. For each domain, we calculated an index as the mean score of items expressed as percentage. These indices were compared to an agreed cutoff at 70%, meaning that a facility index or district index below 70% off was considered as ‘not ready’ to manage NCDs at that level. All analysis were performed using Stata 15 MP. Results: There appeared to be wide heterogeneity between facilities in respect of readiness to manage NCDs. Only 6 (including the three 1st level hospitals) out of the 46 facilities were deemed ready to manage NCDs. Only the first level hospitals scored a mean index higher than the 70% cut off; With regard to medications needed to manage NCDs, urban and rural health facilities were comparably equipped. However, there was evidence that calcium channel blockers (p = 0.013) and insulin (p = 0.022) were more likely to be available in urban and semi-urban health facilities compared to rural facilities. Conclusion: Our study revealed gaps in primary health care capacity to manage NCDs in Zambia, with almost all health facilities failing to reach the minimum threshold. These results could be generalized to other similar districts in Zambia and the sub-region, where health systems remain focused on infectious rather than non-communicable Disease. These results should attract policy attention and potentially form the basis to review current approach to NCD care at the primary care level in Zambia and Sub-Saharan Africa. [ABSTRACT FROM AUTHOR]

Background: The population of Ghana is increasingly becoming urbanized with about 70% of the estimated 27 million people living in urban and peri-urban areas. Nonetheless, eight out of the ten regions in Ghana remain predominantly rural where only 32% of the national health sector workforce works. Moreover, the rural-urban disparities in the density of health tutors (staff responsible for pre-service training of health professionals) are enormous. This paper explores perceived needs of health tutors in rural and urban health training institutions in Ghana. Methods: This is a descriptive qualitative study conducted in the Greater Accra and Northern regions of Ghana. The Study used the deductive thematic and sub-thematic analysis approaches. Five health training institutions were randomly sampled, and 72 tutors engaged in separate focus group discussions with an average size of 14 participants per group in each training institution. Results: Perceived rural-urban disparities among health tutors were found in the payment of extra duty allowances; school infrastructure including libraries and internet connectivity; staff accommodation; and opportunities for scholarships and higher education. Health tutors in rural areas generally expressed more frustration with these work conditions than those in urban areas. Conclusions: There is the need to initiate and sustain work incentives that promote motivation of rural health tutors to control ongoing rural-urban migration of qualified staff. It is recommended the following incentives be prioritized to promote retention of qualified health tutors in rural health training schools: payment of research, book and rural allowances; early promotion of rural staff; prioritizing rural tutors for scholarships, and introduction of national best health tutor awards. [ABSTRACT FROM AUTHOR]

Background and methods: Knowledge of utilization of health services and associated factors is important in planning and delivery of interventions to improve health services coverage. We determined the prevalence and factors associated with health services utilization in a rural area of Kenya. Our findings inform the local health management in development of appropriately targeted interventions. We used a cluster sample survey design and interviewed household key informants on history of illness for household members and health services utilization in the preceding month. We estimated prevalence and performed random effects logistic regression to determine the influence of individual and household level factors on decisions to utilize health services. Results and conclusions: 1230/6,440 (19.1%, 95% CI: 18.3%-20.2%) household members reported an illness. Of these, 76.7% (95% CI: 74.2%-79.0%) sought healthcare in a health facility. The majority (94%) of the respondents visited dispensary-level facilities and only 60.1% attended facilities within the study sub-counties. Of those that did not seek health services, 43% self-medicated by buying non-prescription drugs, 20% thought health services were too costly, and 10% indicated that the sickness was not serious enough to necessitate visiting a health facility. In the multivariate analyses, relationship to head of household was associated with utilization of health services. Relatives other than the nuclear family of the head of household were five times less likely to seek medical help (Odds Ratio 0.21 (95% CI: 0.05–0.87)). Dispensary level health facilities are the most commonly used by members of this community, and relations at the level of the household influence utilization of health services during an illness. These data enrich the perspective of the local health management to better plan the allocation of healthcare resources according to need and demand. The findings will also contribute in the development of community-level health coverage interventions that target the disadvantaged household groups. [ABSTRACT FROM AUTHOR]

Robert W. Snow discusses the importance of empirical evidence, such as that provided in the trial published this week by Milligan and colleagues, in guiding malaria control in Africa. [ABSTRACT FROM AUTHOR]

The provision of healthcare in rural African communities is a highly complex and largely unsolved problem. Two main difficulties are the identification of individuals that are most likely affected by disease and the prediction of responses to health interventions. Social networks have been shown to capture health outcomes in a variety of contexts. Yet, it is an open question as to what extent social network analysis can identify and distinguish among households that are most likely to report poor health and those most likely to respond to positive behavioural influences. We use data from seven highly remote, post-conflict villages in Liberia and compare two prominent network measures: in-degree and betweenness. We define in-degree as the frequency in which members from one household are named by another household as a friends. Betweenness is defined as the proportion of shortest friendship paths between any two households in a network that traverses a particular household. We find that in-degree explains the number of ill family members, whereas betweenness explains engagement in preventative health. In-degree and betweenness independently explained self-reported health and behaviour, respectively. Further, we find that betweenness predicts susceptibility to, instead of influence over, good health behaviours. The results suggest that targeting households based on network measures rather than health status may be effective for promoting the uptake of health interventions in rural poor villages. [ABSTRACT FROM AUTHOR]

Background: Pharmacovigilance programmes monitor and help ensuring the safe use of medicines which is critical to the success of public health programmes. The commonest method used for discovering previously unknown safety risks is spontaneous notifications. In this study we examine the use of data mining algorithms to identify signals from adverse events reported in a phase IIIb/IV clinical trial evaluating the efficacy and safety of several Artemisinin-based combination therapies (ACTs) for treatment of uncomplicated malaria in African children. Methods: We used paediatric safety data from a multi-site, multi-country clinical study conducted in seven African countries (Burkina Faso, Gabon, Nigeria, Rwanda, Uganda, Zambia, and Mozambique). Each site compared three out of four ACTs, namely amodiaquine-artesunate (ASAQ), dihydroartemisinin-piperaquine (DHAPQ), artemether-lumefantrine (AL) or chlorproguanil/dapsone and artesunate (CD+A). We examine two pharmacovigilance signal detection methods, namely proportional reporting ratio and Bayesian Confidence Propagation Neural Network on the clinical safety dataset. Results: Among the 4,116 children (6–59 months old) enrolled and followed up for 28 days post treatment, a total of 6,238 adverse events were reported resulting into 346 drug-event combinations. Nine signals were generated both by proportional reporting ratio and Bayesian Confidence Propagation Neural Network. A review of the manufacturer package leaflets, an online Multi-Drug Symptom/Interaction Checker (DoubleCheckMD) and further by therapeutic area experts reduced the number of signals to five. The ranking of some drug-adverse reaction pairs on the basis of their signal index differed between the two methods. Conclusions: Our two data mining methods were equally able to generate suspected signals using the pooled safety data from a phase IIIb/IV clinical trial. This analysis demonstrated the possibility of utilising clinical studies safety data for key pharmacovigilance activities like signal detection and evaluation. This approach can be applied to complement the spontaneous reporting systems which are limited by under reporting. [ABSTRACT FROM AUTHOR]

Objective: To compare the population-level impact of two World Health Organization-endorsed strategies for improving the diagnosis of tuberculosis (TB): same-day microscopy and Xpert MTB/RIF (Cepheid, USA). Methods: We created a compartmental transmission model of TB in a representative African community, fit to the regional incidence and mortality of TB and HIV. We compared the population-level reduction in TB burden over ten years achievable with implementation over two years of same-day microscopy, Xpert MTB/RIF testing, and the combination of both approaches. Findings: Same-day microscopy averted an estimated 11.0% of TB incidence over ten years (95% uncertainty range, UR: 3.3%–22.5%), and prevented 11.8% of all TB deaths (95% UR: 7.7%–27.1%). Scaling up Xpert MTB/RIF to all centralized laboratories to achieve 75% population coverage had similar impact on incidence (9.3% reduction, 95% UR: 1.9%–21.5%) and greater effect on mortality (23.8% reduction, 95% UR: 8.6%–33.4%). Combining the two strategies (i.e., same-day microscopy plus Xpert MTB/RIF) generated synergistic effects: an 18.7% reduction in incidence (95% UR: 5.6%–39.2%) and 33.1% reduction in TB mortality (95% UR: 18.1%–50.2%). By the end of year ten, combining same-day microscopy and Xpert MTB/RIF could reduce annual TB mortality by 44% relative to the current standard of care. Conclusion: Scaling up novel diagnostic tests for TB and optimizing existing ones are complementary strategies that, when combined, may have substantial impact on TB epidemics in Africa. [ABSTRACT FROM AUTHOR]

Background: Labour induction should be performed where benefit outweighs potential harm, however epidemiology of induction in lower-income countries is not well described. We used the WHO Global Survey dataset to describe the epidemiology and outcomes of labour induction in 192,538 deliveries in 253 facilities across 16 countries in Africa and Asia. Methods: Data was analyzed separately for Africa and Asia. Prevalence of indications, methods, success and characteristics associated with labour induction were determined. Multilevel logistic regression was used to determine the relationship between induction (with medical indication and elective) and maternal/perinatal outcomes. Results: Induction accounted for 4.4% (Africa) and 12.1% (Asia) of deliveries. Oxytocin alone was the most common method (45.9% and 37.5%) and success rates were generally over 80%. Medically indicated inductions were associated with increased adjusted odds of Apgar <7 at 5 minutes, low birthweight, NICU admission and fresh stillbirth in both regions. The odds of caesarean section in Africa were reduced (Adj OR 0.61, 95%CI 0.42–0.88). Elective induction was associated with increased adjusted odds of NICU (Africa) and ICU (Asia) admissions. Discussion: Induction was generally less common than in higher-income countries. Prostaglandin use was uncommon despite evidence supporting use. Induction for medical indications may be associated with poorer outcomes due to maternal baseline risks. Despite one-third of elective inductions occurring at <39 weeks, the risk of maternal, fetal and neonatal mortality was not elevated following elective inductions. [ABSTRACT FROM AUTHOR]

Quantitative estimates for the global impact of COVID-19 on the diagnosis and management of patients with inborn errors of metabolism (IEM) are lacking. We collected relevant data from 16 specialized medical centers treating IEM patients in Europe, Asia and Africa. The median decline of reported IEM related services in March 1st-May 31st 2020 compared to the same period in 2019 were as high as 60-80% with a profound impact on patient management and care for this vulnerable patient group. More representative data along with outcome data and guidelines for managing IEM disorders under such extraordinary circumstances are needed., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest regarding the current study., (Copyright © 2020 Elsevier Inc. All rights reserved.)