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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.

Objective To quantify the impact of the change in definition of severe pneumonia on documented pneumonia burden. Methods We reviewed existing data acquired during observational hospitalized pneumonia studies, before the introduction of the pneumococcal conjugate vaccine, in infants aged 2-23 months from Fiji, Gambia, Lao People's Democratic Republic, Malawi, Mongolia and Viet Nam. We used clinical data to calculate the percentage of all-cause pneumonia hospitalizations with severe pneumonia, and with primary end-point consolidation, according to both the 2005 or 2013 World Health Organization (WHO) definitions. Where population data were available, we also calculated the incidence of severe pneumonia hospitalizations according to the different definitions. Findings At six of the seven sites, the percentages of all-cause pneumonia hospitalizations due to severe pneumonia were significantly less (P < 0.001) according to the 2013 WHO definition compared with the 2005 definition. However, the percentage of severe pneumonia hospitalizations, according to the two definitions of severe pneumonia, with primary end-point consolidation varied little within each site. The annual incidences of severe pneumonia hospitalizations per 100 000 infants were significantly less (all P < 0.001) according to the 2013 definition compared with the 2005 definition, ranging from a difference of -301.0 (95% confidence interval, CI: -405.2 to -196.8) in Fiji to -3242.6 (95% CI: -3695.2 to -2789.9) in the Gambia. Conclusion The revision of WHO's definition of severe pneumonia affects pneumonia epidemiology, and hence the interpretation of any pneumonia intervention impact evaluation. Objectif Quantifier l'impact de la modification de la definition de pneumonie severe sur le fardeau documente de la pneumonie. Methodes Nous avons examine les donnees existantes obtenues dans le cadre d'etudes d'observation de la pneumonie hospitaliere, avant l'introduction du vaccin antipneumococcique conjugue, chez des nourrissons ages de 2 a 23 mois aux Fidji, en Gambie, au Malawi, en Mongolie, en Republique democratique populaire lao et au Viet Nam. Nous avons utilise des donnees cliniques pour calculer le pourcentage d'hospitalisations pour une pneumonie toutes causes confondues avec une pneumonie severe, et avec une consolidation des criteres d'evaluation primaire, selon les definitions de l'Organisation mondiale de la Sante (OMS) de 2005 et 2013. Lorsque des donnees demographiques etaient disponibles, nous avons egalement calcule l'incidence des hospitalisations pour une pneumonie severe selon les differentes definitions. Resultats Dans six des sept sites, les pourcentages d'hospitalisations pour une pneumonie toutes causes confondues en raison d'une pneumonie severe etaient nettement plus faibles (P < 0,001) selon la definition de l'OMS de 2013 en comparaison avec la definition de 2005. Neanmoins, le pourcentage d'hospitalisations pour une pneumonie severe, selon les deux definitions de la pneumonie severe, avec une consolidation des criteres d'evaluation primaire variait peu dans chaque site. Les incidences annuelles d'hospitalisations pour une pneumonie severe pour 100 000 nourrissons etaient nettement plus faibles (total P < 0,001) selon la definition de 2013 en comparaison avec la definition de 2005, la difference allant de -301,0 (intervalle de confiance, IC, a 95%: de -405,2 a -196,8) aux Fidji a -3242,6 (IC a 95%I: -de 3695,2 a -2789,9) en Gambie. Conclusion La revision de la definition de l'OMS de la pneumonie severe affecte l'epidemiologie de la pneumonie et, par consequent, l'interpretation de toute evaluation de l'impact d'une intervention contre la pneumonie. Objetivo Cuantificar el impacto del cambio en la definicion de neumonia grave sobre la carga de neumonia documentada. Metodos Se revisaron los datos existentes adquiridos durante los estudios observacionales de neumonia hospitalizada, antes de la introduccion de la vacuna antineumococica conjugada, en lactantes de 2 a 23 meses de edad procedentes de Fiji, Gambia, Malawi, Mongolia, la Republica Democratica Popular Lao y Vietnam. Se utilizaron datos clinicos para calcular el porcentaje de hospitalizaciones por neumonia de cualquier causa con neumonia grave, y con consolidacion del punto final primario, de acuerdo con las definiciones de la Organizacion Mundial de la Salud (OMS) de 2005 o 2013. Cuando se dispuso de datos demograficos, tambien se calculo la incidencia de las hospitalizaciones por neumonia grave de acuerdo con las diferentes definiciones. Resultados En seis de los siete sitios, los porcentajes de hospitalizaciones por neumonia de cualquier causa con neumonia grave fueron significativamente menores (p < 0,001) segun la definicion de la OMS de 2013 en comparacion con la de 2005. Sin embargo, el porcentaje de hospitalizaciones por neumonia grave, segun las dos definiciones de neumonia grave, con consolidacion del punto final primario vario poco dentro de cada sitio. La incidencia anual de hospitalizaciones por neumonia grave por cada 100.000 lactantes fue significativamente menor (total p < 0,001) segun la definicion de 2013 en comparacion con la de 2005 y oscilo entre una diferencia de -301,0 (intervalo de confianza, IC, del 95%: -405,2 a -196,8) en Fiji y -3242,6 (IC del 95%: -3695,2 a -2789,9) en Gambia. Conclusion La revision de la definicion de neumonia grave de la OMS afecta a la epidemiologia de la neumonia y, por tanto, a la interpretacion de cualquier evaluacion del impacto de una intervencion para la neumonia., Introduction Pneumonia is the leading cause of post-neonatal deaths in children younger than 5 years, with many of the deaths occurring in low- and middle-income countries. (1,2) Several interventions exist [...]

Background Technically feasible and cost-effective interventions exist to reduce maternal, newborn, and child mortality [1,2]. This potential has not been fully realised due to the failure of health systems to [...]

Rheumatic heart disease (RHD) is an avoidable disease of poverty that persists predominantly in low resource settings and among Indigenous and other high-risk populations in some high-income nations. Following a period of relative global policy inertia on RHD, recent years have seen a resurgence of research, policy and civil society activity to tackle RHD; this has culminated in growing momentum at the highest levels of global health diplomacy to definitively address this disease of disadvantage. RHD is inextricably entangled with the global development agenda, and effective RHD action requires concerted efforts both within and beyond the health policy sphere. This report provides an update on the contemporary global and regional policy landscapes relevant to RHD, and highlights the fundamental importance of good data to inform these policy dialogues, monitor systems responses and ensure that no one is left behind. [ABSTRACT FROM AUTHOR]

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Background: Without addressing the constraints specific to disadvantaged populations, national health policies such as universal health coverage risk increasing equity gaps. Health system constraints often have the greatest impact on disadvantaged populations, resulting in poor access to quality health services among vulnerable groups. Methods: The Investment Cases in Indonesia, Nepal, Philippines, and the state of Orissa in India were implemented to support evidence-based sub-national planning and budgeting for equitable scale-up of quality MNCH services. The Investment Case framework combines the basic setup of strategic problem solving with a decision-support model. The analysis and identification of strategies to scale-up priority MNCH interventions is conducted by in-country planners and policymakers with facilitation from local and international research partners. Results: Significant variation in scaling-up constraints, strategies, and associated costs were identified between countries and across urban and rural typologies. Community-based strategies have been considered for rural populations served predominantly by public providers, but this analysis suggests that the scaling-up of maternal, newborn, and child health services requires health system interventions focused on 'getting the basics right'. These include upgrading or building facilities, training and redistribution of staff, better supervision, and strengthening the procurement of essential commodities. Some of these strategies involve substantial early capital expenditure in remote and sparsely populated districts. These supply-side strategies are not only the 'best buys', but also the 'required buys' to ensure the quality of health services as coverage increases. By contrast, such public supply strategies may not be the 'best buys' in densely populated urbanised settings, served by a mix of public and private providers. Instead, robust regulatory and supervisory mechanisms are required to improve the accessibility and quality of services delivered by the private sector. They can lead to important maternal mortality reductions at relatively low costs. Conclusions: National strategies that do not take into consideration the special circumstances of disadvantaged areas risk disempowering local managers and may lead to a "business-as-usual" acceptance of unreachable goals. To effectively guide health service delivery at a local level, national plans should adopt typologies that reflect the different problems and strategies to scale up key MNCH interventions. [ABSTRACT FROM AUTHOR]

Background: Nasopharyngeal carriage of Streptococcus pneumoniae precedes disease, is the source of pneumococcal community spread, and the mechanism for herd protection provided by pneumococcal conjugate vaccines (PCVs). There are few PCV impact studies in low- and middle-income countries, particularly in Asia. In 2016, Mongolia introduced the 13-valent PCV (PCV13) in a phased manner using a 2 + 1 schedule, with catch-up. We aimed to assess the impact of PCV13 introduction on nasopharyngeal pneumococcal carriage and density in children in Mongolia., Methods: We conducted two cross-sectional carriage surveys (pre- and one year post-PCV) at community health clinics in two districts of the capital city, Ulaanbaatar in both May-July 2015 and 2017. The study analysis included 961 children too young to be vaccinated (5-8 weeks old) and 989 children eligible for vaccination (12-23 months old). Pneumococci were detected by quantitative real-time PCR and molecular serotyping performed using DNA microarray., Findings: One year post-PCV introduction, PCV13 serotype carriage reduced by 52% in 12-23 month olds (adjusted prevalence ratio [aPR] 0.48 [95% confidence interval [CI] 0.39-0.59]), with evidence of non-PCV13 serotype replacement (aPR 1.55 [95% CI 1.30-1.85]), compared with the pre-PCV period. In 5-8 week olds, PCV13 serotype carriage reduced by 51% (aPR 0.49 [95% CI 0.33-0.73]) with no significant change in non-PCV13 serotype carriage (aPR 1.10 [95% CI 0.83-1.46]). An increase was observed in both PCV13 and non-PCV13 pneumococcal density post-PCV introduction. Antimicrobial resistance (AMR) genes were common, with 82.3% of samples containing at least one of the 10 AMR genes assessed., Conclusion: This study demonstrates substantive PCV13 impact on pneumococcal carriage one year post-vaccine introduction in Mongolia. The reductions in PCV13 serotype carriage are likely to result in reductions in pneumococcal disease including indirect effects. Increases in non-PCV13 serotypes require further monitoring., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Without addressing the constraints specific to disadvantaged populations, national health policies such as universal health coverage risk increasing equity gaps. Health system constraints often have the greatest impact on disadvantaged populations, resulting in poor access to quality health services among vulnerable groups., Methods: The Investment Cases in Indonesia, Nepal, Philippines, and the state of Orissa in India were implemented to support evidence-based sub-national planning and budgeting for equitable scale-up of quality MNCH services. The Investment Case framework combines the basic setup of strategic problem solving with a decision-support model. The analysis and identification of strategies to scale-up priority MNCH interventions is conducted by in-country planners and policymakers with facilitation from local and international research partners., Results: Significant variation in scaling-up constraints, strategies, and associated costs were identified between countries and across urban and rural typologies. Community-based strategies have been considered for rural populations served predominantly by public providers, but this analysis suggests that the scaling-up of maternal, newborn, and child health services requires health system interventions focused on 'getting the basics right'. These include upgrading or building facilities, training and redistribution of staff, better supervision, and strengthening the procurement of essential commodities. Some of these strategies involve substantial early capital expenditure in remote and sparsely populated districts. These supply-side strategies are not only the 'best buys', but also the 'required buys' to ensure the quality of health services as coverage increases. By contrast, such public supply strategies may not be the 'best buys' in densely populated urbanised settings, served by a mix of public and private providers. Instead, robust regulatory and supervisory mechanisms are required to improve the accessibility and quality of services delivered by the private sector. They can lead to important maternal mortality reductions at relatively low costs., Conclusions: National strategies that do not take into consideration the special circumstances of disadvantaged areas risk disempowering local managers and may lead to a "business-as-usual" acceptance of unreachable goals. To effectively guide health service delivery at a local level, national plans should adopt typologies that reflect the different problems and strategies to scale up key MNCH interventions.

Problem: Hypoxaemia in children with severe or very severe pneumonia is a reliable predictor of mortality, yet oxygen was not available in most paediatric wards in Malawi., Approach: The Child Lung Health Programme in Malawi made oxygen available by supplying oxygen concentrators and essential supplies to 22 district and 3 regional hospitals' paediatric wards. Five key steps were taken to introduce concentrators: (1) develop a curriculum and training materials; (2) train staff on use and maintenance; (3) retrain electromedical departments on maintenance and repair; (4) conduct training once concentrators arrived in the country; and (5) distribute concentrators once staff had been trained., Local Setting: The paediatric wards in 3 regional and 22 government district hospitals and 3 regional electromedical engineering departments in Malawi., Relevant Changes: Main changes were: (1) provision of a source of oxygen in every paediatric ward in all district hospitals; (2) training of electrical engineering and health personnel in the use, maintenance and repair of oxygen concentrators; and (3) setting-up of high-dependency rooms or areas for severely ill children where oxygen is administered., Lessons Learned: It is feasible to implement an oxygen system using concentrators throughout a low-income country. Oxygen delivery requires trained staff with necessary equipment and supplies. Regular maintenance and supervision are essential to ensure optimal utilization.