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Background Many priority countries in the countdown to the millennium development goals deadline are lagging in progress towards maternal and child health (MCH) targets. Papua New Guinea (PNG) is one such country beset by challenges of geographical inaccessibility, inequity and health system weakness. Several countries, however, have made progress through focused initiatives which align with the burden of disease and overcome specific inequities. This study identifies the potential impact on maternal and child mortality through increased coverage of prioritised interventions within the PNG health system. Methods The burden of disease and health system environment of PNG was documented to inform prioritised MCH interventions at community, outreach, and clinical levels. Potential reductions in maternal and child mortality through increased intervention coverage to close the geographical equity gap were estimated with the lives saved tool. Results A set community-level interventions, with highest feasibility, would yield significant reductions in newborn and child mortality. Adding the outreach group delivers gains for maternal mortality, particularly through family planning. The clinical services group of interventions demands greater investment but are essential to reach MCH targets. Cumulatively, the increased coverage is estimated to reduce the rates of under-five mortality by 19 %, neonatal mortality by 26 %, maternal mortality ratio by 10 % and maternal mortality by 33 %. Conclusions Modest investments in health systems focused on disadvantaged populations can accelerate progress in maternal and child survival even in fragile health systems like PNG. The critical approach may be to target interventions and implementation appropriately to the sensitive context of lagging countries. Electronic supplementary material The online version of this article (doi:10.1007/s10995-015-1762-6) contains supplementary material, which is available to authorized users., Author(s): Abbey Byrne[sup.1] [sup.2] , Andrew Hodge[sup.2] , Eliana Jimenez-Soto[sup.2] Author Affiliations: (1) The Nossal Institute for Global Health, The University of Melbourne, Alan Gilbert Building, 161 Barry Street, 3010, [...]

A rapid reduction in under-five mortality has put Bangladesh on-track to reach Millennium Development Goal 4. Little research, however, has been conducted into neonatal reductions and sub-national rates in the country, with considerable disparities potentially masked by national reductions. The aim of this paper is to estimate national and sub-national rates of neonatal mortality to compute relative and absolute inequalities between sub-national groups and draw comparisons with rates of under-five mortality. Mortality rates for under-five children and neonates were estimated directly for 1980-1981 to 2010-2011 using data from six waves of the Demographic and Health Survey. Rates were stratified by levels of rural/urban location, household wealth and maternal education. Absolute and relative inequalities within these groups were measured by rate differences and ratios, and where possible, slope and relative indices of inequality. National mortality was shown to have decreased dramatically although at differential rates for under-fives and neonates. Across all equity markers, a general pattern of declining absolute but constant relative inequalities was found. For mortality rates stratified by education and wealth mixed evidence suggests that relative inequalities may have also fallen. Although disparities remain, Bangladesh has achieved a rare combination of substantive reductions in mortality levels without increases in relative inequalities. A coalescence of substantial increases in coverage and equitable distribution of key child and neonatal interventions with widespread health sectoral and policy changes over the last 30 years may in part explain this exceptional pattern. Electronic supplementary material The online version of this article (doi:10.1007/s10995-015-1716-z) contains supplementary material, which is available to authorized users., Author(s): Mark Minnery[sup.1] , Sonja Firth[sup.1] , Andrew Hodge[sup.1] , Eliana Jimenez-Soto[sup.1] Author Affiliations: (1) Investment Case, School of Population Health, The University of Queensland, Public Health Building, Herston Road, [...]

While established that geographical inaccessibility is a key barrier to the utilisation of health services, it remains unknown whether disparities are driven only by limited access to these services, or are also attributable to health behaviour. Significant disparities exist in health outcomes and the coverage of many critical health services between the mountains region of Nepal and the rest of the country, yet the principal factors driving these regional disparities are not well understood. Using national representative data from the 2011 Nepal Demographic and Health Survey, we examine the extent to which observable factors explain the overall differences in the utilisation of maternal health services. We apply nonlinear Blinder--Oaxaca-type decomposition methods to quantify the effect that differences in measurable characteristics have on the regional coverage gap in facility-based delivery. The mean coverage of facility-based deliveries was 18.6 and 36.3% in the mountains region and the rest of Nepal, respectively. Between 54.8 and 74.1% of the regional coverage gap was explained by differences in observed characteristics. Factors influencing health behaviours (proxied by mothers' education, TV viewership and tobacco use, and household wealth) and subjective distance to the health facility were the major factors, contributing between 52.9 and 62.5% of the disparity. Mothers' birth history was also noteworthy. Policies simultaneously addressing access and health behaviours appear necessary to achieve greater coverage and better health outcomes for women and children in isolated areas. Keywords Facility-based delivery care * Regional coverage gaps * Geographic inaccessibility * Decomposition * Nepal, Introduction In order to achieve universal coverage, the so-called third global health transition [1], policy and program responses must address the major barriers to the use of essential health services. [...]

As a part of the Millennium Development Goals, India seeks to substantially reduce its burden of childhood mortality. The success or failure of this goal may depend on outcomes within India's most populous state, Uttar Pradesh. This study examines the level of disparities in under-five and neonatal mortality across a range of equity markers within the state. Estimates of under-five and neonatal mortality rates were computed using five datasets, from three available sources: sample registration system, summary birth histories in surveys, and complete birth histories. Disparities were evaluated via comparisons of mortality rates by rural-urban location, ethnicity, wealth, and districts. While Uttar Pradesh has experienced declines in both rates of under-five (162-108 per 1,000 live births) and neonatal (76-49 per 1,000 live births) mortality, the rate of decline has been slow (averaging 2% per annum). Mortality trends in rural and urban areas are showing signs of convergence, largely due to the much slower rate of change in urban areas. While the gap between rich and poor households has decreased in both urban and rural areas, trends suggest that differences in mortality will remain. Caste-related disparities remain high and show no signs of diminishing. Of concern are also the signs of stagnation in mortality amongst groups with greater ability to access services, such as the urban middle class. Not-withstanding the slow but steady reduction of absolute levels of childhood mortality within Uttar Pradesh, the distribution of the mortality by sub-state populations remains unequal. Future progress may require significant investment in quality of care provided to all sections of the community. Keywords Childhood mortality * Under-five mortality * Health disparities * Uttar Pradesh * India, Introduction In 2007 an estimated 1.84 million deaths under the age of five occurred in India, with over a quarter of these deaths occurring within the country's most populous state, [...]

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

Public Engagement in Public Sector Activities Democratization, rising literacy, the advent of the information age, and increasing connectedness are resulting in unprecedented opportunities for public participation in public affairs. In [...]

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

ABSTRACT Small island states are increasingly characterised by the growing role of international migration and remittances as components of national and household incomes. Recent household-level survey data on migration and remittances in two Pacific island states, Fiji and Tonga, demonstrate that where formal social protection systems are largely absent, migration and remittances can perform a similar function informally, contributing significantly to development objectives. Remittances also have a positive effect on poverty alleviation and wealth creation, although the impacts on income distribution are mixed. From a policy perspective, these informal social protection and poverty alleviation mechanisms may be more effective in promoting development than policies designed to incorporate remittances into the formal financial systems. Migration and remittances play an increasingly valuable role in small states where domestic development opportunities are limited. Copyright © 2013 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

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

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

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

Significant disparities in reproductive, maternal, newborn, and child health (RMNCH) outcomes and intervention coverage exist between the Mountains and other ecoregions of Nepal. Delivery of essential health services to remote mountainous areas is challenging and access is a known barrier to utilization. However, the contribution of demand-side barriers is poorly understood. Consequently, policies and programs cannot strategically target constraints to increase coverage. This systematic review identifies demand-side barriers to utilization of RMNCH services in the Mountain districts of Nepal. Research was drawn from MEDLINE, Web of Science, Scopus, Google Scholar, Eldis, and unpublished literature. Beyond inaccessibility, utilization is undermined by costs of care-seeking, traditional attitudes and practices, low status of women, limited health knowledge, dissatisfaction with service quality, and low and inequitable care by community health workers. The intensity and repercussions of these barriers are of greater magnitude in the Mountains where delayed care-seeking combines with long distances for critical health consequences.