292 results on '"Margaret E. Kruk"'
Search Results
2. Antenatal care quality and detection of risk among pregnant women: An observational study in Ethiopia, India, Kenya, and South Africa
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Catherine Arsenault, Nompumelelo Gloria Mfeka-Nkabinde, Monica Chaudhry, Prashant Jarhyan, Tefera Taddele, Irene Mugenya, Shalom Sabwa, Katherine Wright, Beatrice Amboko, Laura Baensch, Gebeyaw Molla Wondim, Londiwe Mthethwa, Emma Clarke-Deelder, Wen-Chien Yang, Rose J. Kosgei, Priyanka Purohit, Nokuzola Cynthia Mzolo, Anagaw Derseh Mebratie, Subhojit Shaw, Adiam Nega, Boikhutso Tlou, Günther Fink, Mosa Moshabela, Dorairaj Prabhakaran, Sailesh Mohan, Damen Haile Mariam, Jacinta Nzinga, Theodros Getachew, and Margaret E. Kruk
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Medicine - Published
- 2024
3. The maternal and newborn health eCohort to track longitudinal care quality: study protocol and survey development
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Catherine Arsenault, Katherine Wright, Tefera Taddele, Ashenif Tadele, Anagaw Derseh Mebratie, Firew Tiruneh Tiyare, Rose J. Kosgei, Jacinta Nzinga, Bethany Holt, Irene Mugenya, Emma Clarke-Deelder, Adiam Nega, Dorairaj Prabhakaran, Sailesh Mohan, Nompumelelo Gloria Mfeka-Nkabinde, Londiwe Mthethwa, Damen Haile Mariam, Gebeyaw Molla, Theodros Getachew, Prashant Jarhyan, Monica Chaudhry, Munir Kassa, and Margaret E. Kruk
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health system quality ,maternal and newborn health ,implementation science ,evidence-based care ,quality of care ,Public aspects of medicine ,RA1-1270 - Abstract
The MNH eCohort was developed to fill gaps in maternal and newborn health (MNH) care quality measurement. In this paper, we describe the survey development process, recruitment strategy, data collection procedures, survey content and plans for analysis of the data generated by the study. We also compare the survey content to that of existing multi-country tools on MNH care quality. The eCohort is a longitudinal mixed-mode (in-person and phone) survey that will recruit women in health facilities at their first antenatal care (ANC) visit. Women will be followed via phone survey until 10-12 weeks postpartum. User-reported information will be complemented with data from physical health assessments at baseline and endline, extraction from MNH cards, and a brief facility survey. The final MNH eCohort instrument is centered around six key domains of high-quality health systems including competent care (content of ANC, delivery, and postnatal care for the mother and newborn), competent systems (prevention and detection, timely care, continuity, integration), user experience, health outcomes, confidence in the health system, and economic outcomes. The eCohort combines the maternal and newborn experience and, due to its longitudinal nature, will allow for quality assessment according to specific risks that evolve throughout the pregnancy and postpartum period. Detailed information on medical and obstetric history and current health status of respondents and newborns will allow us to determine whether women and newborns at risk are receiving needed care. The MNH eCohort will answer novel questions to guide health system improvements and to fill data gaps in implementing countries.
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- 2024
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4. Users’ perception of quality as a driver of private healthcare use in Mexico: Insights from the People’s Voice Survey
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Svetlana V. Doubova, Hannah H. Leslie, Ricardo Pérez-Cuevas, Margaret E. Kruk, and Catherine Arsenault
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Medicine ,Science - Published
- 2024
5. Associations between the stringency of COVID-19 containment policies and health service disruptions in 10 countries
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Tarylee Reddy, Neena R. Kapoor, Shogo Kubota, Svetlana V Doubova, Daisuke Asai, Damen Haile Mariam, Wondimu Ayele, Anagaw Derseh Mebratie, Roody Thermidor, Jaime C. Sapag, Paula Bedregal, Álvaro Passi-Solar, Georgiana Gordon-Strachan, Mahesh Dulal, Dominic Dormenyo Gadeka, Suresh Mehata, Paula Margozzini, Borwornsom Leerapan, Thanitsara Rittiphairoj, Phanuwich Kaewkamjornchai, Adiam Nega, John Koku Awoonor-Williams, Margaret E. Kruk, and Catherine Arsenault
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COVID-19 restrictions ,Health systems ,Health services ,Pandemic response ,Health system resilience ,Health care disruptions ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Background Disruptions in essential health services during the COVID-19 pandemic have been reported in several countries. Yet, patterns in health service disruption according to country responses remain unclear. In this paper, we investigate associations between the stringency of COVID-19 containment policies and disruptions in 31 health services in 10 low- middle- and high-income countries in 2020. Methods Using routine health information systems and administrative data from 10 countries (Chile, Ethiopia, Ghana, Haiti, Lao People’s Democratic Republic, Mexico, Nepal, South Africa, South Korea, and Thailand) we estimated health service disruptions for the period of April to December 2020 by dividing monthly service provision at national levels by the average service provision in the 15 months pre-COVID (January 2019-March 2020). We used the Oxford COVID-19 Government Response Tracker (OxCGRT) index and multi-level linear regression analyses to assess associations between the stringency of restrictions and health service disruptions over nine months. We extended the analysis by examining associations between 11 individual containment or closure policies and health service disruptions. Models were adjusted for COVID caseload, health service category and country GDP and included robust standard errors. Findings Chronic disease care was among the most affected services. Regression analyses revealed that a 10% increase in the mean stringency index was associated with a 3.3 percentage-point (95% CI -3.9, -2.7) reduction in relative service volumes. Among individual policies, curfews, and the presence of a state of emergency, had the largest coefficients and were associated with 14.1 (95% CI -19.6, 8.7) and 10.7 (95% CI -12.7, -8.7) percentage-point lower relative service volumes, respectively. In contrast, number of COVID-19 cases in 2020 was not associated with health service disruptions in any model. Conclusions Although containment policies were crucial in reducing COVID-19 mortality in many contexts, it is important to consider the indirect effects of these restrictions. Strategies to improve the resilience of health systems should be designed to ensure that populations can continue accessing essential health care despite the presence of containment policies during future infectious disease outbreaks.
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- 2023
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6. Tracking health system performance in times of crisis using routine health data: lessons learned from a multicountry consortium
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Anne-Marie Turcotte-Tremblay, Borwornsom Leerapan, Patricia Akweongo, Freddie Amponsah, Amit Aryal, Daisuke Asai, John Koku Awoonor-Williams, Wondimu Ayele, Sebastian Bauhoff, Svetlana V. Doubova, Dominic Dormenyo Gadeka, Mahesh Dulal, Anna Gage, Georgiana Gordon-Strachan, Damen Haile-Mariam, Jean Paul Joseph, Phanuwich Kaewkamjornchai, Neena R. Kapoor, Solomon Kassahun Gelaw, Min Kyung Kim, Margaret E. Kruk, Shogo Kubota, Paula Margozzini, Suresh Mehata, Londiwe Mthethwa, Adiam Nega, Juhwan Oh, Soo Kyung Park, Alvaro Passi-Solar, Ricardo Enrique Perez Cuevas, Tarylee Reddy, Thanitsara Rittiphairoj, Jaime C. Sapag, Roody Thermidor, Boikhutso Tlou, and Catherine Arsenault
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Routine health information systems ,Health systems ,Quality of care ,COVID-19 ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract COVID-19 has prompted the use of readily available administrative data to track health system performance in times of crisis and to monitor disruptions in essential healthcare services. In this commentary we describe our experience working with these data and lessons learned across countries. Since April 2020, the Quality Evidence for Health System Transformation (QuEST) network has used administrative data and routine health information systems (RHIS) to assess health system performance during COVID-19 in Chile, Ethiopia, Ghana, Haiti, Lao People’s Democratic Republic, Mexico, Nepal, South Africa, Republic of Korea and Thailand. We compiled a large set of indicators related to common health conditions for the purpose of multicountry comparisons. The study compiled 73 indicators. A total of 43% of the indicators compiled pertained to reproductive, maternal, newborn and child health (RMNCH). Only 12% of the indicators were related to hypertension, diabetes or cancer care. We also found few indicators related to mental health services and outcomes within these data systems. Moreover, 72% of the indicators compiled were related to volume of services delivered, 18% to health outcomes and only 10% to the quality of processes of care. While several datasets were complete or near-complete censuses of all health facilities in the country, others excluded some facility types or population groups. In some countries, RHIS did not capture services delivered through non-visit or nonconventional care during COVID-19, such as telemedicine. We propose the following recommendations to improve the analysis of administrative and RHIS data to track health system performance in times of crisis: ensure the scope of health conditions covered is aligned with the burden of disease, increase the number of indicators related to quality of care and health outcomes; incorporate data on nonconventional care such as telehealth; continue improving data quality and expand reporting from private sector facilities; move towards collecting patient-level data through electronic health records to facilitate quality-of-care assessment and equity analyses; implement more resilient and standardized health information technologies; reduce delays and loosen restrictions for researchers to access the data; complement routine data with patient-reported data; and employ mixed methods to better understand the underlying causes of service disruptions.
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- 2023
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7. Adverse birth outcomes among women with ‘low-risk’ pregnancies in India: findings from the Fifth National Family Health Survey, 2019–21Research in context
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Ajay Tandon, Sanam Roder-DeWan, Mickey Chopra, Sheena Chhabra, Kevin Croke, Marion Cros, Rifat Hasan, Guru Rajesh Jammy, Navneet Manchanda, Amith Nagaraj, Rahul Pandey, Elina Pradhan, Andrew Sunil Rajkumar, Michael A. Peters, and Margaret E. Kruk
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Newborn mortality ,Health system quality ,Risk stratification ,Pregnancy risk ,Health system ,India ,Public aspects of medicine ,RA1-1270 - Abstract
Summary: Background: Despite substantial progress in improving maternal and newborn health, India continues to experience high rates of newborn mortality and stillbirths. One reason may be that many births happen in health facilities that lack advanced services—such as Caesarean section, blood transfusion, or newborn intensive care. Stratification based on pregnancy risk factors is used to guide ‘high-risk’ women to advanced facilities. To assess the utility of risk stratification for guiding the choice of facility, we estimated the frequency of adverse newborn outcomes among women classified as ‘low risk’ in India. Methods: We used the 2019–21 Fifth National Family Health Survey (NFHS-5)—India’s Demographic and Health Survey—which includes modules administered to women aged 15–49 years. In addition to pregnancy history and outcomes, the survey collected a range of risk factors, including biomarkers. We used national obstetric risk guidelines to classify women as ‘high risk’ versus ‘low risk’ and assessed the frequency of stillbirths, newborn deaths, and unplanned Caesarean sections for the respondent’s last pregnancy lasting 7 or more months in the past five years. We calculated the proportion of deliveries occurring at non-hospital facilities in all the Indian states. Findings: Using data from nearly 176,699 recent pregnancies, we found that 46.6% of India’s newborn deaths and 56.3% of stillbirths were among women who were ‘low risk’ according to national guidelines. Women classified as ‘low risk’ had a Caesarean section rate of 8.4% (95% CI 8.1–8.7%), marginally lower than the national average of 10.0% (95% CI 9.8–10.3%). In India as a whole, 32.0% (95% CI 31.5–32.5%) of deliveries occurred in facilities that were likely to lack advanced services. There was substantial variation across the country, with less than 5% non-hospital public facility deliveries in Punjab, Kerala, and Delhi compared to more than 40% in Odisha, Madhya Pradesh, and Rajasthan. Newborn mortality tended to be lower in states with highest hospital delivery rates. Interpretation: Individual risk stratification based on factors identified in pregnancy fails to accurately predict which women will have delivery complications and experience stillbirth and newborn death in India. Thus a determination of ‘low risk’ should not be used to guide women to health facilities lacking key life saving services, including Caesarean section, blood transfusion, and advanced newborn resuscitation and care. Funding: Bill and Melinda Gates Foundation and the World Bank. The findings, interpretations and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the Gates Foundation or of the World Bank, its Executive Directors, or the countries they represent.
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- 2023
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8. The association between institutional delivery and neonatal mortality based on the quality of maternal and newborn health system in India
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Hwa-Young Lee, Hannah H. Leslie, Juhwan Oh, Rockli Kim, Alok Kumar, S. V. Subramanian, and Margaret E. Kruk
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Medicine ,Science - Abstract
Abstract Over 600,000 newborns in India died in their first month of life in 2017 despite large increases in access to maternal health services. We assess whether maternal and newborn health system quality in India is adequate for institutional delivery to reduce neonatal mortality. We identified recent births from the cross-sectional 2015–2016 National Family Health Survey and used reported content of antenatal care and immediate postpartum care averaged at the district level to characterize health system quality for maternity and newborn services. We used random effect logistic models to assess the relationship between institutional delivery and neonatal (death within the first 28 days of life) and early neonatal (death within 7 days of live births) mortality by quintile of district maternal and newborn health system quality. Three quarters of 191,963 births were in health facilities; 2% of newborns died within 28 days. District-level quality scores ranged from 40 to 90% of expected interventions. Institutional delivery was not protective against newborn mortality in the districts with poorest health system quality, but was associated with decreased mortality in districts with higher quality. Predicted neonatal mortality in the highest quintile of quality would be 0.018 (95% CI 0.010, 0.026) for home delivery and 0.010 (0.007, 0.013) for institutional delivery. Measurement of quality is limited by lack of data on quality of acute and referral care. Institutional delivery is associated with meaningful survival gains where quality of maternity services is higher. Addressing health system quality is an essential element of achieving the promise of increased access to maternal health services.
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- 2022
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9. What is the impact of removing performance-based financial incentives on community health worker motivation? A qualitative study from an infant and young child feeding program in Bangladesh
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Jeffrey Glenn, Corrina Moucheraud, Denise Diaz Payán, Allison Crook, James Stagg, Haribondhu Sarma, Tahmeed Ahmed, Adrienne Epstein, Sharmin Khan Luies, Mahfuzur Rahman, Margaret E. Kruk, and Thomas J. Bossert
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Community health worker ,Financial incentives ,Motivation ,Health workforce ,Health systems ,Child health ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Background Community health worker (CHW) motivation is an important factor related to health service quality and CHW program sustainability in low- and middle-income countries. Financial and non-financial motivators may influence CHW behavior through two dimensions of motivation: desire to perform and effort expended. The aim of this study was to explore how the removal of performance-based financial incentives impacted CHW motivation after formal funding ceased for Alive and Thrive (A&T), an infant and young child feeding (IYCF) program in Bangladesh. Methods This qualitative study included seven focus groups (n = 43 respondents) with paid supervisors of volunteer CHWs tasked with delivering interpersonal IYCF counseling services. Data were transcribed, translated into English, and then analyzed using both a priori themes and a grounded theory approach. Results Results suggest the removal of financial incentives was perceived to have negatively impacted CHWs’ desire to perform in three primary ways: 1) a decreased desire to work without financial compensation, 2) changes in pre- and post-intervention motivation, and 3) household income challenges due to dependence on incentives. Removal of financial incentives was perceived to have negatively impacted CHWs’ level of effort expended in four primary ways: 1) a reduction in CHW visits, 2) a reduction in quality of care, 3) CHW attrition, and 4) substitution of other income-generating activities. Conclusions This study provides new evidence regarding how removing performance-based financial incentives from a CHW program can negatively impact CHW motivation. The findings suggest that program decision makers should consider how to construct community health work programs such that CHWs may continue to receive performance-based compensation after the original funding ceases.
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- 2021
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10. Patient volume and quality of primary care in Ethiopia: findings from the routine health information system and the 2014 Service Provision Assessment survey
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Catherine Arsenault, Bereket Yakob, Tizta Tilahun, Tsinuel Girma Nigatu, Girmaye Dinsa, Mirkuzie Woldie, Munir Kassa, Peter Berman, and Margaret E. Kruk
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Public aspects of medicine ,RA1-1270 - Abstract
Abstract Background Several studies have reported inadequate levels of quality of care in the Ethiopian health system. Facility characteristics associated with better quality remain unclear. Understanding associations between patient volumes and quality of care could help organize service delivery and potentially improve patient outcomes. Methods Using data from the routine health management information system (HMIS) and the 2014 Ethiopian Service Provision Assessment survey + we assessed associations between daily total outpatient volumes and quality of services. Quality of care at the facility level was estimated as the average of five measures of provider knowledge (clinical vignettes on malaria and tuberculosis) and competence (observations of family planning, antenatal care and sick child care consultations). We used linear regression models adjusted for several facility-level confounders and region fixed effects with log-transformed patient volume fitted as a linear spline. We repeated analyses for the association between volume of antenatal care visits and quality. Results Our analysis included 424 facilities including 270 health centers, 45 primary hospitals and 109 general hospitals in Ethiopia. Quality was low across all facilities ranging from only 18 to 56% with a mean score of 38%. Outpatient volume varied from less than one patient per day to 581. We found a small but statistically significant association between volume and quality which appeared non-linear, with an inverted U-shape. Among facilities seeing less than 90.6 outpatients per day, quality increased with greater patient volumes. Among facilities seeing 90.6 or more outpatients per day, quality decreased with greater patient volumes. We found a similar association between volume and quality of antenatal care visits. Conclusions Health care utilization and quality must be improved throughout the health system in Ethiopia. Our results are suggestive of a potential U-shape association between volume and quality of primary care services. Understanding the links between volume of patients and quality of care may provide insights for organizing service delivery in Ethiopia and similar contexts.
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- 2021
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11. Equitable Distribution of Poor Quality of Care? Equity in Quality of Reproductive Health Services in Ethiopia
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Girmaye D Dinsa, Ermias Dessie, Sarah Hurlburt, Yosef Gebreyohannes, Catherine Arsenault, Bereket Yakob, Tsinuel Girma, Peter Berman, and Margaret E. Kruk
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ANC ,equity ,Ethiopia ,FP ,multidimensional poverty ,quality ,Medicine (General) ,R5-920 ,Public aspects of medicine ,RA1-1270 - Abstract
AbstractThe Ethiopian health system faces persistent inequities in health-care utilization and outcomes, despite continued efforts to expand health service coverage. There is little evidence in the literature describing the status of equity in the quality of healthcare. This paper aims to understand the disparities in quality of antenatal care (ANC) and family planning (FP) among the poor and non-poor communities. We used the 2016 Ethiopia Demographic and Health Survey (DHS) data to compute a Multidimensional Poverty Index (MPI), and the 2014 Service Provision Assessment (SPA) data to assess quality of ANC and FP services—defined as the level of adherence to World Health Organization (WHO) clinical and service guidelines. We merged the two datasets using geographical coordinates, and aggregated service users into facility catchment area clusters using a 2-km radius for urban and 10-km radius for rural facilities. We computed ANC and FP quality and MPI indices for each facility and assigned these to catchment areas. Using the international cutoff point for deprivation (MPI = 33.3%), we evaluated whether the quality of ANC and FP services varies by poor and non-poor catchment areas. We found that most of catchment areas (75.7%) were deprived. While the overall quality of ANC and FP services are low (33% and 34% respectively), we found little variation in the distribution of the quality of these services between poor and non-poor areas, urban and rural settings, or regionally. The short-term focus needs to be on improving the overall quality of services rather than on its distribution.
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- 2022
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12. Can complex programs be sustained? A mixed methods sustainability evaluation of a national infant and young child feeding program in Bangladesh and Vietnam
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Corrina Moucheraud, Haribondhu Sarma, Tran Thi Thu Ha, Tahmeed Ahmed, Adrienne Epstein, Jeffrey Glenn, Hoang Hong Hanh, Tran Thi Thu Huong, Sharmin Khan Luies, Aninda Nishat Moitry, Doan Phuong Nhung, Denise Diaz Payán, Mahfuzur Rahman, Md Tariqujjaman, Tran Thi Thuy, Tran Tuan, Thomas J. Bossert, and Margaret E. Kruk
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Sustainability ,Mixed methods ,Global health ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Background Poor early-life nutrition is a major barrier to good health and cognitive development, and is a global health priority. Alive & Thrive (A&T) was a multi-pronged initiative to improve infant and young child feeding behaviors. It aimed to achieve at-scale child health and nutrition improvements via a comprehensive approach that included nutrition counseling by health workers, policy change, social mobilization and mass media activities. This study evaluated the sustainability of activities introduced during A&T implementation (2009–2014) in Bangladesh and Vietnam. Methods This was a mixed methods study that used a quasi-experimental design. Quantitative data (surveys with 668 health workers, and 269 service observations) were collected in 2017; and analysis compared outcomes (primarily dose and fidelity of activities, and capacity) in former A&T intervention areas versus areas that did not receive the full A&T intervention. Additionally, we conducted interviews and focus groups with 218 stakeholders to explore their impressions about the determinants of sustainability, based on a multi-level conceptual framework. Results After program conclusion, stakeholders perceive declines in mass media campaigns, policy and advocacy activities, and social mobilization activities – but counseling activities were institutionalized and continued in both countries. Quantitative data show a persisting modest intervention effect: health workers in intervention areas had significantly higher child feeding knowledge, and in Bangladesh greater self-efficacy and job satisfaction, compared to their counterparts who did not receive the full package of A&T activities. While elements of the program were integrated into routine services, stakeholders noted dilution of the program focus due to competing priorities. Qualitative data suggest that some elements, such as training, monitoring, and evaluation, which were seen as essential to A&T’s success, have declined in frequency, quality, coverage, or were eliminated altogether. Conclusions The inclusion of multiple activities in A&T and efforts to integrate the program into existing institutions were seen as crucial to its success but also made it difficult to sustain, particularly given unstable financial support and human resource constraints. Future complex programs should carefully plan for institutionalization in advance of the program by cultivating champions across the health system, and designing unique and complementary roles for all stakeholders including donors.
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- 2020
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13. Determinants of healthcare providers’ confidence in their clinical skills to deliver quality obstetric and newborn care in Uganda and Zambia
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Min Kyung Kim, Catherine Arsenault, Lynn M. Atuyambe, Mubiana Macwan’gi, and Margaret E. Kruk
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Confidence ,Healthcare provider ,Knowledge ,Newborn care ,Obstetric care ,Quality of care ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Background Poor quality obstetric and newborn care persists in sub-Saharan Africa and weak provider competence is an important contributor. To be competent, providers need to be both knowledgeable and confident in their ability to perform necessary clinical actions. Confidence or self-efficacy has not been extensively studied but may be related to individuals’ knowledge, ability to practice their skills, and other modifiable factors. In this study, we investigated how knowledge and scope of practice are associated with provider confidence in delivering obstetric and newborn health services in Uganda and Zambia. Methods This study was a secondary analysis of data from an obstetric and newborn care program implementation evaluation. Provider knowledge, scope of practice (completion of a series of obstetric tasks in the past 3 months) and confidence in delivering obstetric and newborn care were measured post intervention in intervention and comparison districts in Uganda and Zambia. We used multiple linear regression models to investigate the extent to which exposure to a wider range of clinical tasks associated with confidence, adjusting for facility and provider characteristics. Results Of the 574 providers included in the study, 69% were female, 24% were nurses, and 6% were doctors. The mean confidence score was 71%. Providers’ mean knowledge score was 56% and they reported performing 57% of basic obstetric tasks in the past 3 months. In the adjusted model, providers who completed more than 69% of the obstetric tasks reported a 13-percentage point (95% CI 0.08, 0.17) higher confidence than providers who performed less than 50% of the tasks. Female providers and nurses were considerably less confident than males and doctors. Provider knowledge was moderately associated with provider confidence. Conclusions Our study showed that scope of practice (the range of clinical tasks routinely performed by providers) is an important determinant of confidence. Ensuring that providers are exposed to a variety of services is crucial to support improvement in provider confidence and competence. Policies to improve provider confidence and pre-service training should also address differences by gender and by cadres.
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- 2020
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14. A synthesis of implementation science frameworks and application to global health gaps
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Pablo Villalobos Dintrans, Thomas J. Bossert, Jim Sherry, and Margaret E. Kruk
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Implementation science frameworks ,Global health gaps ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Background Implementation science has been growing as discipline in the past decades, producing an increasing number of models in the area. On the other hand, most frameworks are intended to guide the implementation of programs, focusing on identifying elements and stages that increase their success. This article aims to structure this discussion, proposing a simplified tool that synthesizes common elements of other frameworks, and highlight the usefulness to use implementation science not only in identifying successful implementation strategies but as a tool to assess gaps in global health initiatives. Methods The study was carried out through a combined methodology that included an initial search of implementation science frameworks, experts’ opinions, and the use of references in frameworks to elaborate a list of articles to be reviewed. A total of 52 articles were analyzed, identifying their definitions of implementation science and the elements of different frameworks. Results The analysis of articles allowed identifying the main goals and definitions of implementation science. In a second stage, frameworks were classified into “time-based”, “component-based” and “mixed”, and common elements of each type of model were used to propose a synthetic framework with six elements: Diagnosis, Intervention provider/ system, Intervention, Recipient, Environment, and Evaluation. Finally, this simplified framework was used to identify gaps in global health was using The Lancet Global Health Series. Potential areas of intervention arise for five different global health issues: malaria, non-communicable diseases, maternal and child health, HIV/AIDS, and tuberculosis. Prioritization strategies differ for the different health issues, and the proposed framework can help identify and classify all these different proposals. Conclusions There is a huge variety of definitions and models in implementation science. The analysis showed the usefulness of applying an implementation science approach to identify and prioritize gaps in implementation strategies in global health.
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- 2019
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15. Does health worker performance affect clients’ health behaviors? A multilevel analysis from Bangladesh
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Adrienne Epstein, Corrina Moucheraud, Haribondhu Sarma, Mahfuzur Rahman, Md. Tariqujjaman, Tahmeed Ahmed, Jeffrey Glenn, Thomas Bossert, and Margaret E. Kruk
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health behavior ,counseling ,evidence-based practice ,nutrition ,Bangladesh ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Background Suboptimal healthcare quality may be a barrier to achieving child health improvements, yet little is known about the relationship between provider compliance with evidence-based practices and client behavior change. We assess provider compliance in the context of infant and young child feeding (IYCF) counseling, its relationship with client IYCF behaviors in Bangladesh, and explore its potential determinants. Methods We use data from a 2017 evaluation of an IYCF program that includes a health worker survey (n = 74), caregiver survey (n = 232), and direct service observation checklists of counseling sessions (n = 232 observations of 74 health workers). We assess the relationship between provider compliance with recommended IYCF counseling topics and behaviors (standardized to a 100-point scale) and three reported IYCF behaviors among clients using multi-level models with random effects at the health worker and sub-district (sampling) levels. We also evaluate whether health worker self-efficacy, satisfaction, and technical knowledge are associated with provider compliance. Results Health worker compliance was significantly associated with reported exclusive breastfeeding for children under 6 months of age (adjusted odds ratio per 1 percentage point increase in counseling compliance score = 1.06, 95% CI 1.01, 1.12) and marginally associated with minimum dietary diversity (adjusted odds ratio per 1 percentage point increase in counseling compliance score = 1.05, 95% CI 1.00, 1.11). Counseling compliance was significantly and positively associated with both health worker self-efficacy and technical knowledge. Conclusions We find evidence for an association between health worker compliance and client health behaviors; however, small effect sizes suggest that behavior change is multifactorial and affected by factors beyond care quality. Improvements to technical quality of care may contribute to desired health outcomes; but policies and programs seeking to change health behaviors through counseling may also wish to target upstream factors such as self-efficacy, alongside technical skill-building and knowledge, for maximum impact.
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- 2019
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16. Does quality influence utilization of primary health care? Evidence from Haiti
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Anna D. Gage, Hannah H. Leslie, Asaf Bitton, J. Gregory Jerome, Jean Paul Joseph, Roody Thermidor, and Margaret E. Kruk
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Health systems ,primary health care ,quality of care ,service readiness ,utilization ,patient perception ,Haiti ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Background Expanding coverage of primary healthcare services such as antenatal care and vaccinations is a global health priority; however, many Haitians do not utilize these services. One reason may be that the population avoids low quality health facilities. We examined how facility infrastructure and the quality of primary health care service delivery were associated with community utilization of primary health care services in Haiti. Methods We constructed two composite measures of quality for all Haitian facilities using the 2013 Service Provision Assessment survey. We geographically linked population clusters from the Demographic and Health Surveys to nearby facilities offering primary health care services. We assessed the cross-sectional association between quality and utilization of four primary care services: antenatal care, postnatal care, vaccinations and sick child care, as well as one more complex service: facility delivery. Results Facilities performed poorly on both measures of quality, scoring 0.55 and 0.58 out of 1 on infrastructure and service delivery quality respectively. In rural areas, utilization of several primary cares services (antenatal care, postnatal care, and vaccination) was associated with both infrastructure and quality of service delivery, with stronger associations for service delivery. Facility delivery was associated with infrastructure quality, and there was no association for sick child care. In urban areas, care utilization was not associated with either quality measure. Conclusions Poor quality of care may deter utilization of beneficial primary health care services in rural areas of Haiti. Improving health service quality may offer an opportunity not only to improve health outcomes for patients, but also to expand coverage of key primary health care services.
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- 2018
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17. Measuring and improving the quality of tuberculosis care: A framework and implications from the Lancet Global Health Commission
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Catherine Arsenault, Sanam Roder-DeWan, and Margaret E. Kruk
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Diseases of the respiratory system ,RC705-779 ,Infectious and parasitic diseases ,RC109-216 - Abstract
In this article, we describe the framework of the Lancet Global Health Commission on High Quality Health Systems, propose new and undermeasured indicators of TB care quality, and discuss implications of the Commission's key conclusions for measuring and improving the quality of TB care services. The Commission contends that measurement of quality should focus on the processes of care and their impacts. In addition to monitoring treatment coverage and the availability of tools, governments should consider indicators of clinical competence (for e.g. ability of providers to correctly diagnose TB and adhere to treatment guidelines), of timely, continuous and integrated care and of respectful and patient-centered care. Indicators of impact include TB mortality and treatment success rates, but also quality of life and daily functioning among TB patients, public trust in TB services, and bypassing of the formal health system for TB care. Cascades of care, from initial care seeking to recurrence-free survival, should be built in every high-burden country to monitor quality longitudinally. In turn, improvement efforts should target the foundations of health systems and consider the Commission's four universal actions: governing for quality, redesigning service delivery, transforming the health workforce and igniting demand for quality TB services. Important work remains to validate new indicators of TB care quality, develop data collection systems for new measures, and to test new strategies for improving the delivery of competent and respectful TB care. Keywords: Developing countries, Health systems, Quality, Measurement, Monitoring, Improvement
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- 2019
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18. When Waiting to See a Doctor Is Less Irritating: Understanding Patient Preferences and Choice Behavior in Appointment Scheduling.
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Nan Liu, Stacey R. Finkelstein, Margaret E. Kruk, and David Rosenthal
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- 2018
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19. Resilience learning from the COVID-19 pandemic and its relevance for routine immunization programs
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Oluyemisi Falope, Mawuli K. Nyaku, Ciara O’Rourke, Lindsay V. Hermany, Brittany Plavchak, Josephine Mauskopf, Louise Hartley, and Margaret E. Kruk
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Pharmacology ,Drug Discovery ,Immunology ,Molecular Medicine - Published
- 2022
20. Improving health and social systems for all children in LMICs: structural innovations to deliver high-quality services
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Margaret E, Kruk, Todd P, Lewis, Catherine, Arsenault, Zulfiqar A, Bhutta, Grace, Irimu, Joshua, Jeong, Zohra S, Lassi, Susan M, Sawyer, Tyler, Vaivada, Peter, Waiswa, and Aisha K, Yousafzai
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Social Work ,Mental Health ,Adolescent ,Humans ,Health Promotion ,General Medicine ,Child ,Developing Countries ,Poverty ,Series - Abstract
Despite health gains over the past 30 years, children and adolescents are not reaching their health potential in many low-income and middle-income countries (LMICs). In addition to health systems, social systems, such as schools, communities, families, and digital platforms, can be used to promote health. We did a targeted literature review of how well health and social systems are meeting the needs of children in LMICs using the framework of The Lancet Global Health Commission on high-quality health systems and we reviewed evidence for structural reforms in health and social sectors. We found that quality of services for children is substandard across both health and social systems. Health systems have deficits in care competence (eg, diagnosis and management), system competence (eg, timeliness, continuity, and referral), user experience (eg, respect and usability), service provision for common and serious conditions (eg, cancer, trauma, and mental health), and service offerings for adolescents. Education and social services for child health are limited by low funding and poor coordination with other sectors. Structural reforms are more likely to improve service quality substantially and at scale than are micro-level efforts. Promising approaches include governing for quality (eg, leadership, expert management, and learning systems), redesigning service delivery to maximise outcomes, and empowering families to better care for children and to demand quality care from health and social systems. Additional research is needed on health needs across the life course, health system performance for children and families, and large-scale evaluation of promising health and social programmes.
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- 2022
21. High-Quality Health Systems for an Aging Population: Primary Care Models with Users at the Center
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Todd P. Lewis, Margaret E. Kruk, Jigyasa Sharma, and Xiaohui Hou
- Published
- 2023
22. Evaluating patient-reported outcome measures in Peru: a cross-sectional study of satisfaction and net promoter score using the 2016 EnSuSalud survey
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Hannah H Leslie, Hwa-Young Lee, Brittany Blouin, Margaret E Kruk, and Patricia J García
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net promoter score ,Cross-Sectional Studies ,Patient Satisfaction ,Surveys and Questionnaires ,Health Policy ,Peru ,satisfaction ,cross-sectional study ,Humans ,Reproducibility of Results ,Patient Reported Outcome Measures ,Personal Satisfaction ,EnSuSalud survey - Abstract
BackgroundPatient-reported measures attempt to quantify the value health services provide to users. Satisfaction is a common summative measure, but often has limited utility in identifying poor quality care. We compared satisfaction and the net promoter score (NPS), which was developed to help businesses quantify consumer sentiment, in a nationally representative survey in Peru. We aimed to compare NPS and satisfaction as individual ratings of care, assess the relationship of patient-reported experience ratings to these outcome measures and consider the utility of these measures as indicators of facility performance based on reliability within facilities and capacity to discriminate between facilities.MethodsWe analysed the 2016 National Survey on User Satisfaction of Health Services, a cross-sectional outpatient exit survey. We assessed ratings by patient characteristics and compared the distributions of satisfaction and NPS categories. We tested the association of patient-reported experience measures with each outcome using multilevel ordinal logistic regression. We used intraclass correlation (ICC) from these models to predict minimum sample for reliable assessment and compared patient-reported experience measures in facilities with average satisfaction but below or above average NPS.Results13 434 individuals rated services at 184 facilities. Satisfaction (74% satisfied) and NPS (17% reported at least 9 out of 10) were largely concordant within individuals but weakly correlated (0.37). Ratings varied by individual factors such as age and visit purpose. Most domains of patient-reported experience were associated with both outcomes. Adjusted ICC was higher for NPS (0.26 vs 0.11), requiring a minimum of 7 (vs 20) respondents for adequate reliability. Within the 70% of facilities classified as average based on satisfaction, NPS-based classification revealed systematic differences in patient-reported experience measures.ConclusionWhile satisfaction and NPS were broadly similar at an individual level, this evidence suggests NPS may be useful for benchmarking facility performance as part of national efforts in Peru and throughout Latin America to identify deficits in health service quality.
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- 2022
23. Seizing the moment to rethink health systems
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Kojo Nimako and Margaret E Kruk
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Quality management ,business.industry ,Energy (esotericism) ,Psychological intervention ,COVID-19 ,General Medicine ,Public relations ,Purchasing ,Politics ,Viewpoint ,Incentive ,Pandemic ,Humans ,Data system ,Business ,Public aspects of medicine ,RA1-1270 ,Delivery of Health Care ,Forecasting - Abstract
Summary: The COVID-19 pandemic has made vivid the need for resilient, high-quality health systems and presents an opportunity to reconsider how to build such systems. Although even well resourced, well performing health systems have struggled at various points to cope with surges of COVID-19, experience suggests that establishing health system foundations based on clear aims, adequate resources, and effective constraints and incentives is crucial for consistent provision of high-quality care, and that these cannot be replaced by piecemeal quality improvement interventions. We identify four mutually reinforcing structural investments that could transform health system performance in resource-constrained countries: revamping health provider education, redesigning platforms for care delivery, instituting strategic purchasing and management strategies, and developing patient-level data systems. Countries should seize the political and moral energy provided by the COVID-19 pandemic to build health systems fit for the future.
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- 2021
24. Effect of lifting COVID-19 restrictions on utilisation of primary care services in Nepal: a difference-in-differences analysis
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Neena R Kapoor, Amit Aryal, Suresh Mehata, Mahesh Dulal, Margaret E Kruk, Sebastian Bauhoff, and Catherine Arsenault
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Contraceptive Agents ,Nepal ,Primary Health Care ,Pregnancy ,Communicable Disease Control ,Humans ,COVID-19 ,Female ,General Medicine ,Child ,Pandemics - Abstract
IntroductionAn increasing number of studies have reported disruptions in health service utilisation due to the COVID-19 pandemic and its associated restrictions. However, little is known about the effect of lifting COVID-19 restrictions on health service utilisation. The objective of this study was to estimate the effect of lifting COVID-19 restrictions on primary care service utilisation in Nepal.MethodsData on utilisation of 10 primary care services were extracted from the Health Management Information System across all health facilities in Nepal. We used a difference-in-differences design and linear fixed effects regressions to estimate the effect of lifting COVID-19 restrictions. The treatment group included palikas that had lifted restrictions in place from 17 August 2020 to 16 September 2020 (Bhadra 2077) and the control group included palikas that had maintained restrictions during that period. The pre-period included the 4 months of national lockdown from 24 March 2020 to 22 July 2020 (Chaitra 2076 to Ashar 2077). Models included month and palika fixed effects and controlled for COVID-19 incidence.ResultsWe found that lifting COVID-19 restrictions was associated with an average increase per palika of 57.5 contraceptive users (95% CI 14.6 to 100.5), 15.6 antenatal care visits (95% CI 5.3 to 25.9) and 1.6 child pneumonia visits (95% CI 0.2 to 2.9). This corresponded to a 9.4% increase in contraceptive users, 34.2% increase in antenatal care visits and 15.6% increase in child pneumonia visits. Utilisation of most other primary care services also increased after lifting restrictions, but coefficients were not statistically significant.ConclusionsDespite the ongoing pandemic, lifting restrictions can lead to an increase in some primary care services. Our results point to a causal link between restrictions and health service utilisation and call for policy makers in low- and middle-income countries to carefully consider the trade-offs of strict lockdowns during future COVID-19 waves or future pandemics.
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- 2022
25. Universal Health Coverage for Better Cardiovascular Disease Outcomes in LMICs
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Giridhara R. Babu, Yamuna Ana, Min Kyung Kim, Margaret E. Kruk, and Hannah H. Leslie
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- 2022
26. The role of teams in shaping quality of obstetrical care: a cross-sectional study in Dire Dawa, Ethiopia
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Anna D Gage, Bereket Yakob, Margaret McConnell, Tsinuel Girma, Brook Damtachew, Sebastian Bauhoff, and Margaret E Kruk
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Obstetrics ,Cross-Sectional Studies ,Labor, Obstetric ,Pregnancy ,Infant, Newborn ,Parturition ,Humans ,Female ,General Medicine ,Ethiopia ,Quality of Health Care - Abstract
ObjectivesTo examine how characteristics of clinical colleagues influence quality of care.DesignWe conducted a cross-sectional observational study examining the associations between quality of care and a provider’s coworkers, controlling for individual provider’s characteristics and contextual factors.SettingNine health facilities in Dire Dawa Administration, Ethiopia, from December 2020 to February 2021.Participants824 clients and 95 unique providers were observed across the 9 health facilities.Outcome measuresWe examine the quality of processes of intrapartum and immediate postpartum care during five phases of the delivery (first examination, first stage of labour, third stage of labour, immediate newborn care and immediate maternal postpartum care).ResultsFor the average client, 50% of the recommended routine clinical actions were completed during the delivery overall, with immediate maternal postpartum care being the least well performed (17% of recommended actions). Multiple healthcare providers were involved in 55% of deliveries. The number of providers contributing to a delivery was unassociated with the quality of care, but a one standard deviation increase in the coworker’s performance was associated with a 2% point increase in quality of care (pConclusionsA provider’s typical performance had a modest positive association with quality of delivery care given by their coworker. As delivery care is often provided by multiple healthcare providers, examining the dynamics of how they influence one another can provide important insights for quality improvement.
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- 2022
27. Disease Control Priorities, Third Edition: Volume 1. Essential Surgery
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Haile T. Debas, Peter Donkor, Atul Gawande, Dean T. Jamison, Margaret E. Kruk, Charles N. Mock and Haile T. Debas, Peter Donkor, Atul Gawande, Dean T. Jamison, Margaret E. Kruk, Charles N. Mock
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- 2015
28. Context Matters: Strategies to Improve Maternal and Newborn Health Services in Sub-Saharan Africa
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Florina Serbanescu, Margaret E. Kruk, Sunday Dominico, and Kojo Nimako
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Health Policy ,Public Health, Environmental and Occupational Health ,Infant, Newborn ,Humans ,Infant Health ,Health Services ,Africa South of the Sahara - Published
- 2022
29. Population Preferences for Primary Care Models for Hypertension in Karnataka, India
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Hannah H. Leslie, Giridhara R. Babu, Nolita Dolcy Saldanha, Anne-Marie Turcotte-Tremblay, Deepa Ravi, Neena R. Kapoor, Suresh S. Shapeti, Dorairaj Prabhakaran, and Margaret E. Kruk
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General Medicine - Abstract
ImportanceHypertension contributes to more than 1.6 million deaths annually in India, with many individuals being unaware they have the condition or receiving inadequate treatment. Policy initiatives to strengthen disease detection and management through primary care services in India are not currently informed by population preferences.ObjectiveTo quantify population preferences for attributes of public primary care services for hypertension.Design, Setting, and ParticipantsThis cross-sectional study involved administration of a household survey to a population-based sample of adults with hypertension in the Bengaluru Nagara district (Bengaluru City; urban setting) and the Kolar district (rural setting) in the state of Karnataka, India, from June 22 to July 27, 2021. A discrete choice experiment was designed in which participants selected preferred primary care clinic attributes from hypothetical alternatives. Eligible participants were 30 years or older with a previous diagnosis of hypertension or with measured diastolic blood pressure of 90 mm Hg or higher or systolic blood pressure of 140 mm Hg or higher. A total of 1422 of 1927 individuals (73.8%) consented to receive initial screening, and 1150 (80.9%) were eligible for participation, with 1085 (94.3%) of those eligible completing the survey.Main Outcomes and MeasuresRelative preference for health care service attributes and preference class derived from respondents selecting a preferred clinic scenario from 8 sets of hypothetical comparisons based on wait time, staff courtesy, clinician type, carefulness of clinical assessment, and availability of free medication.ResultsAmong 1085 adult respondents with hypertension, the mean (SD) age was 54.4 (11.2) years; 573 participants (52.8%) identified as female, and 918 (84.6%) had a previous diagnosis of hypertension. Overall preferences were for careful clinical assessment and consistent availability of free medication; 3 of 5 latent classes prioritized 1 or both of these attributes, accounting for 85.1% of all respondents. However, the largest class (52.4% of respondents) had weak preferences distributed across all attributes (largest relative utility for careful clinical assessment: β = 0.13; 95% CI, 0.06-0.20; 36.4% preference share). Two small classes had strong preferences; 1 class (5.4% of respondents) prioritized shorter wait time (85.1% preference share; utility, β = −3.04; 95% CI, −4.94 to −1.14); the posterior probability of membership in this class was higher among urban vs rural respondents (mean [SD], 0.09 [0.26] vs 0.02 [0.13]). The other class (9.5% of respondents) prioritized seeing a physician (the term doctor was used in the survey) rather than a nurse (66.2% preference share; utility, β = 4.01; 95% CI, 2.76-5.25); the posterior probability of membership in this class was greater among rural vs urban respondents (mean [SD], 0.17 [0.35] vs 0.02 [0.10]).Conclusions and RelevanceIn this study, stated population preferences suggested that consistent medication availability and quality of clinical assessment should be prioritized in primary care services in Karnataka, India. The heterogeneity observed in population preferences supports considering additional models of care, such as fast-track medication dispensing to reduce wait times in urban settings and physician-led services in rural areas.
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- 2023
30. Associations between women’s empowerment, care seeking, and quality of malaria care for children: A cross-sectional analysis of demographic and health surveys in 16 sub-Saharan African countries
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Todd P Lewis, Youssoupha Ndiaye, Fatuma Manzi, and Margaret E Kruk
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Cross-Sectional Studies ,Health Policy ,Public Health, Environmental and Occupational Health ,Humans ,Female ,Patient Acceptance of Health Care ,Power, Psychological ,Child ,Demography ,Malaria - Abstract
Fever and malaria are highly prevalent among children under five across sub-Saharan Africa, but utilization and quality of care for febrile illness remain insufficient. Many studies examine socioeconomic and demographic determinants of care seeking; however, few assess how women's empowerment influences care seeking and quality. We examine associations of women's empowerment with: a) care utilization for children with fever and malaria and b) the quality of that care in 16 sub-Saharan African countries.This cross-sectional study used data from Demographic and Health Surveys conducted between 2010 and 2018. We constructed indices for economic, educational, sociocultural, and health-related empowerment and calculated the proportion of children with fever and malaria who sought care and received a range of recommended clinical actions. We used multivariable Poisson hurdle models to assess associations between empowerment, utilization, and number of components of quality care, controlling for socioeconomic and demographic factors.Our sample consisted of 25 871 febrile children, 4731 of whom had malaria diagnosed by rapid diagnostic test. Empowerment among mothers of children with fever was 0.50 (interquartile range, 0.38-0.63). In both the fever and malaria groups, over 30% of children were not taken for care. Among care seekers, febrile children received on average 0.47 (SD = 0.37) of components of quality care, and children with malaria received 0.38 (SD = 0.34). Multidimensional women's empowerment was significantly associated with care seeking and quality among febrile children, and with quality among children with malaria. Associations persisted after adjustment for socioeconomic and demographic characteristics.Results demonstrate substantial gaps in women's empowerment and poor utilization and quality of care for fever and malaria among children. Increased women's empowerment is associated with seeking care and, separately, obtaining high-quality care. To improve health outcomes, consideration of how empowering women can promote care seeking and extract quality from the health system is warranted.
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- 2022
31. Community engagement for health system resilience: evidence from Liberia’s Ebola epidemic
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Brian VanDeBogert, Emilia J. Ling, Margaret E Kruk, Kathryn M. Barker, Kasisomayajula Viswanath, Yvonne Kodl, Mosoka Fallah, and Rose Macauley
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media_common.quotation_subject ,Interviews as Topic ,03 medical and health sciences ,0302 clinical medicine ,Political science ,Humans ,030212 general & internal medicine ,Epidemics ,Empirical evidence ,Poverty ,Qualitative Research ,media_common ,030505 public health ,Operationalization ,Community engagement ,business.industry ,Communication ,Health Policy ,Community Participation ,International health ,Focus Groups ,Hemorrhagic Fever, Ebola ,Resilience, Psychological ,Public relations ,Liberia ,Focus group ,Local government ,Health Resources ,Psychological resilience ,0305 other medical science ,business ,Delivery of Health Care ,Qualitative research - Abstract
The importance of community engagement (CE) for health system resilience is established in theoretical and empirical literature. The practical dimensions of how to operationalize theory and implement its principles have been less explored, especially within low-resource crisis settings. It is therefore unclear how CE is drawn upon and how, if at all, it facilitates health system resilience in times of health system crises. To address this critical gap, we adapt and apply existing theoretical CE frameworks to analyse qualitative data from 92 in-depth interviews and 16 focus group discussions collected with health system stakeholders in Liberia in the aftermath of the 2014–15 Ebola outbreak. Health system stakeholders indicated that CE was a crucial contributing factor in addressing the Ebola epidemic in Liberia. Multiple forms of CE were used during the outbreak; however, only some forms were perceived as meaningful, such as the formation of community-based surveillance teams. To achieve meaningful CE, participants recommended that communities be treated as active participants in—as opposed to passive recipients of—health response efforts and that communication platforms for CE be established ahead of a crisis. Participant responses highlight that meaningful CE led to improved communication with and increased trust in health authorities and programming. This facilitated health system response efforts, leading to a fortuitous cycle of increased trust, improved communication and continued meaningful CE—all necessary conditions for health system resilience. This study refines our understanding of CE and demonstrates the ways in which meaningful CE and trust work together in mutually reinforcing and beneficial ways. These findings provide empirical evidence on which to base policies and programmes aimed at improving health system resilience in low-resource settings to more effectively respond to health system crises.
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- 2020
32. Variation in competent and respectful delivery care in Kenya and Malawi: a retrospective analysis of national facility surveys
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David Gathara, Address Malata, Margaret E Kruk, Catherine Arsenault, Mike English, and Wilson Mandala
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Adult ,Malawi ,Adolescent ,recherche sur les systèmes de santé ,media_common.quotation_subject ,medicine.medical_treatment ,030231 tropical medicine ,Staffing ,childbirth ,Afrique subsaharienne ,labour ,Young Adult ,03 medical and health sciences ,accouchement ,0302 clinical medicine ,Promotion (rank) ,Health facility ,Pregnancy ,Surveys and Questionnaires ,Environmental health ,Humans ,Medicine ,Childbirth ,Quality (business) ,Caesarean section ,Quality Indicators, Health Care ,Retrospective Studies ,media_common ,health systems research ,Descriptive statistics ,qualité ,business.industry ,Infant, Newborn ,Public Health, Environmental and Occupational Health ,Prenatal Care ,Delivery, Obstetric ,Explained variation ,Kenya ,Infectious Diseases ,travail ,quality ,Female ,Original Article ,Parasitology ,Health Facilities ,business ,Original Research Papers ,sub‐Saharan Africa - Abstract
Although substantial progress has been made in increasing access to care during childbirth, reductions in maternal and neonatal mortality have been slower. Poor-quality care may be to blame. In this study, we measure the quality of labour and delivery services in Kenya and Malawi using data from observations of deliveries and explore factors associated with levels of competent and respectful care.We used data from nationally representative health facility assessment surveys. A total of 1100 deliveries in 392 facilities across Kenya and Malawi were observed and quality was assessed using two indices: the quality of the process of intrapartum and immediate postpartum care (QoPIIPC) index and a previously validated index of respectful maternity care. Data from standardised observations of care were analysed using descriptive statistics and multivariable random-intercept regression models to examine factors associated with variation in quality of care. We also quantified the variance in quality explained by each domain of covariates (patient-, provider- and facility-level and subnational divisions).Only 61-66% of basic elements of competent and respectful care were performed. In adjusted models, better-staffed facilities, private hospitals and morning deliveries were associated with higher levels of competent and respectful care. In Malawi, younger, primipara and HIV-positive women received higher-quality care. Quality also differed substantially across regions in Kenya, with a 25 percentage-point gap between Nairobi and the Coast region. Quality was also higher in higher-volume facilities and those with caesarean section capacity. Most of the explained variance in quality was due to regions in Kenya and to facility, and patient-level characteristics in Malawi.Our findings suggest considerable scope for improvement in quality. Increasing staffing and shifting births to higher-volume facilities - along with promotion of respectful care in these facilities - should be considered in sub-Saharan Africa to improve outcomes for mothers and newborns.Bien que des progrès substantiels aient été accomplis dans l'amélioration de l'accès aux soins pendant l'accouchement, les réductions de la mortalité maternelle et néonatale ont été plus lentes. Des soins de mauvaise qualité peuvent être à blâmer. Dans cette étude, nous mesurons la qualité de la main-d'œuvre et des services d'accouchement au Kenya et au Malawi en utilisant les données des observations des accouchements et explorons les facteurs associés aux niveaux de la compétence et du respect dans les soins. MÉTHODES: Nous avons utilisé les données d'enquêtes d'évaluation des établissements de santé représentatives au niveau national. 1100 accouchements dans 392 établissements au Kenya et au Malawi ont été observés et la qualité a été évaluée à l'aide de deux indices: l'indice de qualité du processus de soins intra-partum et postpartum immédiat (QoPIIPC) et un indice précédemment validé de soins maternels respectueux. Les données des observations normalisées des soins ont été analysées à l'aide de statistiques descriptives et de modèles de régression à interceptions aléatoires multivariables pour examiner les facteurs associés à la variation de la qualité des soins. Nous avons également quantifié la variance de la qualité expliquée par chaque domaine de covariables (divisions au niveau des patients, des prestataires et des établissements, et infranationales). RÉSULTATS: Seuls 61% à 66% des éléments de base de soins compétents et respectueux ont été réalisés. Dans les modèles ajustés, des établissements mieux dotés en personnel, des hôpitaux privés et des accouchements le matin étaient associés à des niveaux plus élevés de soins compétents et respectueux. Au Malawi, les femmes plus jeunes, primipares et VIH positives ont reçu des soins de meilleure qualité. La qualité différait également considérablement d'une région à l'autre au Kenya, avec un écart de 25 points de pourcentage entre Nairobi et la région côtière. La qualité était également plus élevée dans les établissements avec un volume plus élevé et ceux ayant une capacité de césarienne. La majeure partie des raisons de la variance dans la qualité était liée aux régions du Kenya et à l'établissement et aux caractéristiques des patients au Malawi.Nos résultats suggèrent une marge considérable pour l'amélioration de la qualité. L'augmentation du personnel et le déplacement des naissances vers des établissements de plus grand volume - ainsi que la promotion de soins respectueux dans ces établissements - devraient être envisagés en Afrique subsaharienne pour améliorer les résultats pour les mères et les nouveau-nés.
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- 2020
33. Implementation research on noncommunicable disease prevention and control interventions in low- and middle-income countries: A systematic review
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Celestin Hategeka, Prince Adu, Allissa Desloge, Robert Marten, Ruitai Shao, Maoyi Tian, Ting Wei, and Margaret E. Kruk
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Income ,Humans ,General Medicine ,Health Services ,Noncommunicable Diseases ,Developing Countries ,Poverty - Abstract
Background While the evidence for the clinical effectiveness of most noncommunicable disease (NCD) prevention and treatment interventions is well established, care delivery models and means of scaling these up in a variety of resource-constrained health systems are not. The objective of this review was to synthesize evidence on the current state of implementation research on priority NCD prevention and control interventions provided by health systems in low- and middle-income countries (LMICs). Methods and findings On January 20, 2021, we searched MEDLINE and EMBASE databases from 1990 through 2020 to identify implementation research studies that focused on the World Health Organization (WHO) priority NCD prevention and control interventions targeting cardiovascular disease, cancer, diabetes, and chronic respiratory disease and provided within health systems in LMICs. Any empirical and peer-reviewed studies that focused on these interventions and reported implementation outcomes were eligible for inclusion. Given the focus on this review and the heterogeneity in aims and methodologies of included studies, risk of bias assessment to understand how effect size may have been compromised by bias is not applicable. We instead commented on the distribution of research designs and discussed about stronger/weaker designs. We synthesized extracted data using descriptive statistics and following the review protocol registered in PROSPERO (CRD42021252969). Of 9,683 potential studies and 7,419 unique records screened for inclusion, 222 eligible studies evaluated 265 priority NCD prevention and control interventions implemented in 62 countries (6% in low-income countries and 90% in middle-income countries). The number of studies published has been increasing over time. Nearly 40% of all the studies were on cervical cancer. With regards to intervention type, screening accounted for 49%, treatment for 39%, while prevention for 12% (with 80% of the latter focusing on prevention of the NCD behavior risk factors). Feasibility (38%) was the most studied implementation outcome followed by adoption (23%); few studies addressed sustainability. The implementation strategies were not specified well enough. Most studies used quantitative methods (86%). The weakest study design, preexperimental, and the strongest study design, experimental, were respectively employed in 25% and 24% of included studies. Approximately 72% of studies reported funding, with international funding being the predominant source. The majority of studies were proof of concept or pilot (88%) and targeted the micro level of health system (79%). Less than 5% of studies report using implementation research framework. Conclusions Despite growth in implementation research on NCDs in LMICs, we found major gaps in the science. Future studies should prioritize implementation at scale, target higher levels health systems (meso and macro levels), and test sustainability of NCD programs. They should employ designs with stronger internal validity, be more conceptually driven, and use mixed methods to understand mechanisms. To maximize impact of the research under limited resources, adding implementation science outcomes to effectiveness research and regional collaborations are promising.
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- 2021
34. Optimising child and adolescent health and development in the post-pandemic world
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Zulfiqar A Bhutta, Ties Boerma, Maureen M Black, Cesar G Victora, Margaret E Kruk, and Robert E Black
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Adolescent ,SARS-CoV-2 ,Influenza, Human ,Adolescent Health ,COVID-19 ,Humans ,Family ,General Medicine ,Child ,Pandemics - Published
- 2021
35. The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion
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Andrea B. Feigl, Stéphane Verguet, Rachel Nugent, Christopher Noble, Julie Makani, Kafui Adjaye-Gbewonyo, Maia Olsen, Alma J Adler, Fred Amegashie, Akshar Saxena, Annie Haakenstad, Nobhojit Roy, Katie Dain, Neil Gupta, Gisela Robles Aguilar, Anne E. Becker, Kibachio Joseph Muiruri Mwangi, Andrew P. Sumner, Nicole Bassoff, Solomon Tessema Memirie, Ole Frithjof Norheim, Zulfiqar A Bhutta, Adnan A. Hyder, Alexander Kintu, Peter Byass, Jean Roland Cadet, Abraham Haileamlak, Zoe Taylor Doe, Yogesh Jain, Majid Ezzati, Bashir Noormal, Lee A. Wallis, Jones Masiye, Amy McLaughlin, Andrew Marx, Jason Beste, Senendra Raj Upreti, Noel Kasomekera, Bhagawan Koirala, Indrani Gupta, Mamusu Kamanda, Humberto Nelson Muquingue, Ana Olga Mocumbi, Emily B Wroe, Dan Schwarz, Margaret E Kruk, Cristina Stefan, Gilles Francois Ndayisaba, Chelsea Clinton, Sarah Maongezi, Agnes Binagwaho, Kjell Arne Johansson, Leah N. Schwartz, Gladwell Gathecha, Wubaye Walelgne Dagnaw, Jonathan D. Shaffer, David A Watkins, Bongani M. Mayosi, Paul H. Park, Gary L. Gottlieb, Arielle Wilder Eagan, J. Jaime Miranda, Osman Sankoh, Mary Amuyunzu-Nyamongo, Nancy Charles Larco, Said Habib Arwal, Matthew M Coates, Rifat Atun, Chantelle Boudreaux, Mary T Mayige, Gene F. Kwan, Biraj Man Karmacharya, Gene Bukhman, Robles Aguilar, G, and Group, Lancet NCDI Poverty Commission Study
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education.field_of_study ,Economic growth ,Extreme poverty ,medicine.medical_specialty ,Poverty ,business.industry ,Public health ,Population ,The Lancet Commissions ,General Medicine ,Health Services Accessibility ,Sierra leone ,Epidemiological transition ,HV ,Social protection ,RA0421 ,Universal Health Insurance ,Political science ,Health care ,medicine ,Humans ,Noncommunicable Diseases ,business ,education - Abstract
On March 2–3, 2011—ahead of the first UN High-Level Meeting on NCDs—a conference hosted in Boston (MA, USA) focused on the NCDs of the world's poorest billion, whose poverty was embodied in young average age, low energy intake, and subsistence through physical labour.30 Participants at the Boston event argued that global thinking about NCDs had been too focused on a theory of epidemiological transition, which projected epidemics of chronic disease associated with development.31 This theory created a blind spot regarding the existence and pattern of non-infectious conditions before declines in infectious mortality (pre-transitional NCDIs). The poorest populations were still experiencing NCDIs as part of a nexus of hunger, toxic environments, infectious diseases, and lack of health care. The NCDIs that emerged under these circumstances were both more severe and more varied than could be captured by frameworks developed for other populations. In April, 2011, the WHO African Regional Office held a consultation of health ministers in Congo (Brazzaville).32 The Brazzaville Declaration on NCDs called for an expanded NCDI agenda addressing haemoglobinopathies (sickle cell disease), mental disorders, and violence and injury.32 Other prominent African health experts called for a 5 × 5 strategy inclusive of neuropsychiatric disorders and infectious risks.33, 34 In July, 2013, at a meeting in Rwanda, a group of NCD unit leaders from ten African ministries of health called for a complementary strategy for NCDIs.35 This NCDI equity agenda focused on policies and integrated health-sector interventions to eliminate deaths among the poorest children and young adults (aged
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- 2021
36. COVID-19 and resilience of healthcare systems in ten countries
- Author
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Catherine Arsenault, Anna Gage, Min Kyung Kim, Neena R. Kapoor, Patricia Akweongo, Freddie Amponsah, Amit Aryal, Daisuke Asai, John Koku Awoonor-Williams, Wondimu Ayele, Paula Bedregal, Svetlana V. Doubova, Mahesh Dulal, Dominic Dormenyo Gadeka, Georgiana Gordon-Strachan, Damen Haile Mariam, Dilipkumar Hensman, Jean Paul Joseph, Phanuwich Kaewkamjornchai, Munir Kassa Eshetu, Solomon Kassahun Gelaw, Shogo Kubota, Borwornsom Leerapan, Paula Margozzini, Anagaw Derseh Mebratie, Suresh Mehata, Mosa Moshabela, Londiwe Mthethwa, Adiam Nega, Juhwan Oh, Sookyung Park, Álvaro Passi-Solar, Ricardo Pérez-Cuevas, Alongkhone Phengsavanh, Tarylee Reddy, Thanitsara Rittiphairoj, Jaime C. Sapag, Roody Thermidor, Boikhutso Tlou, Francisco Valenzuela Guiñez, Sebastian Bauhoff, and Margaret E. Kruk
- Subjects
Communicable Disease Control ,Income ,COVID-19 ,Humans ,General Medicine ,Child ,Delivery of Health Care ,Pandemics ,General Biochemistry, Genetics and Molecular Biology - Abstract
Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People’s Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26–96% declines). Total outpatient visits declined by 9–40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.
- Published
- 2021
37. What is the impact of removing performance-based financial incentives on community health worker motivation? A qualitative study from an infant and young child feeding program in Bangladesh
- Author
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Denise Diaz Payan, Mahfuzur Rahman, Adrienne Epstein, James Stagg, Corrina Moucheraud, Allison Crook, Tahmeed Ahmed, Haribondhu Sarma, Sharmin Khan Luies, Jeffrey Glenn, Margaret E Kruk, and Thomas J. Bossert
- Subjects
Volunteers ,Community health worker ,Grounded theory ,Health administration ,Health systems ,Nursing ,Medicine ,Humans ,Financial compensation ,Child ,Qualitative Research ,Child health ,Community Health Workers ,Motivation ,Bangladesh ,business.industry ,Health Policy ,Nursing research ,Infant ,Health workforce ,Focus group ,Incentive ,Community health ,Financial incentives ,Public aspects of medicine ,RA1-1270 ,business ,Qualitative research ,Research Article - Abstract
Background Community health worker (CHW) motivation is an important factor related to health service quality and CHW program sustainability in low- and middle-income countries. Financial and non-financial motivators may influence CHW behavior through two dimensions of motivation: desire to perform and effort expended. The aim of this study was to explore how the removal of performance-based financial incentives impacted CHW motivation after formal funding ceased for Alive and Thrive (A&T), an infant and young child feeding (IYCF) program in Bangladesh. Methods This qualitative study included seven focus groups (n = 43 respondents) with paid supervisors of volunteer CHWs tasked with delivering interpersonal IYCF counseling services. Data were transcribed, translated into English, and then analyzed using both a priori themes and a grounded theory approach. Results Results suggest the removal of financial incentives was perceived to have negatively impacted CHWs’ desire to perform in three primary ways: 1) a decreased desire to work without financial compensation, 2) changes in pre- and post-intervention motivation, and 3) household income challenges due to dependence on incentives. Removal of financial incentives was perceived to have negatively impacted CHWs’ level of effort expended in four primary ways: 1) a reduction in CHW visits, 2) a reduction in quality of care, 3) CHW attrition, and 4) substitution of other income-generating activities. Conclusions This study provides new evidence regarding how removing performance-based financial incentives from a CHW program can negatively impact CHW motivation. The findings suggest that program decision makers should consider how to construct community health work programs such that CHWs may continue to receive performance-based compensation after the original funding ceases.
- Published
- 2021
38. Best and worst performing health facilities: A positive deviance analysis of perceived drivers of primary care performance in Nepal
- Author
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Todd P. Lewis, Amit Aryal, Suresh Mehata, Astha Thapa, Aisha K. Yousafzai, and Margaret E. Kruk
- Subjects
Leadership ,Social Responsibility ,Health (social science) ,Nepal ,Primary Health Care ,History and Philosophy of Science ,Humans ,Health Facilities - Abstract
Primary care services are on average of low quality in Nepal. However, there is marked variation in performance of basic clinical and managerial functions between primary health care centers. The determinants of variation in primary care performance in low- and middle-income countries have been understudied relative to the prominence of primary care in national health plans. We used the positive deviance approach to identify best and worst performing primary health care centers in Nepal and investigated perceived drivers of best performance. We selected eight primary health care centers in Province 1, Nepal, using an index of basic clinical and operational activities to identify four best and four worst performing primary health care centers. We conducted semi-structured, in-depth interviews with managers and clinical staff from each of the eight primary health care centers for a total of 32 interviews. We identified the following factors that distinguished best from worst performers: 1) Managing the facility effectively, 2) engaging local leadership, 3) building active community accountability, 4) assessing and responding to facility performance, 5) developing sources of funding, 6) compensating staff fairly, 7) managing clinical staff performance, and 8) promoting uninterrupted availability of supplies and equipment. These findings can be used to inform quality improvement efforts and health system reforms in Nepal and other similarly under-resourced health systems.
- Published
- 2022
39. Predictors of job satisfaction and intention to stay in the job among health-care providers in Uganda and Zambia
- Author
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Margaret E Kruk, Lynn Atuyambe, Min Kyung Kim, and Catherine Arsenault
- Subjects
health-care provider ,Zambia ,Intention ,Job Satisfaction ,Likert scale ,Facility management ,Nursing ,Pregnancy ,Surveys and Questionnaires ,Health care ,Humans ,Uganda ,AcademicSubjects/MED00860 ,Original Research Article ,Health management system ,business.industry ,Health Policy ,Public sector ,Public Health, Environmental and Occupational Health ,Infant, Newborn ,intention to stay ,General Medicine ,Explained variation ,Cross-Sectional Studies ,Work (electrical) ,Job satisfaction ,Female ,business ,Psychology - Abstract
Background A shortage of competent health-care providers is a major contributor to poor quality health care in sub-Saharan Africa. To increase the retention of skilled health-care providers, we need to understand which factors make them feel satisfied with their work and want to stay in their job. This study investigates the relative contribution of provider, facility and contextual factors to job satisfaction and intention to stay on the job among health-care providers who performed obstetric care in Uganda and Zambia. Methods This study was a secondary analysis of data from a maternal and newborn health program implementation evaluation in Uganda and Zambia. Using a Likert scale, providers rated their job satisfaction and intention to stay in their job. Predictors included gender, cadre, satisfaction with various facility resources and country. We used the Shapley and Owen decomposition of R2 method to estimate the variance explained by individual factors and groups of factors, adjusting for covariates at the facility and provider levels. Results Of the 1134 providers included in the study, 68.3% were female, 32.4% were nurses and 77.1% worked in the public sector. Slightly more than half (52.3%) of providers were strongly satisfied with their job and 42.8% strongly agreed that they would continue to work at their facility for some time. A group of variables related to facility management explained most of the variance in both job satisfaction (37.6%) and intention to stay (43.1%). Among these, the most important individual variables were satisfaction with pay (20.57%) for job satisfaction and opinions being respected in the workplace (17.52%) for intention to stay. Doctors reported lower intention to stay than nurses. Provider demographics and facility level and ownership (public/private) were not associated with either outcome. There were also differences in job satisfaction and intention to stay between Ugandan and Zambian health-care providers. Conclusion Our study suggests that managers play a crucial role in retaining a sufficient number of satisfied health-care providers providing obstetric care in two sub-Saharan African countries, Uganda and Zambia. Prioritizing and investing in health management systems and health managers are essential foundations for high-quality health systems.
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- 2021
40. In Low- And Middle-Income Countries, Is Delivery In High-Quality Obstetric Facilities Geographically Feasible?
- Author
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Address Malata, Jeff Blossom, Sanam Roder-DeWan, Nana A Y Twum-Danso, Kishori Mahat, Anna D. Gage, Fei Carnes, Talhiya Yahya, Jalemba Aluvaala, Margaret E Kruk, and Archana Amatya
- Subjects
Neonatal mortality ,030503 health policy & services ,Health Policy ,media_common.quotation_subject ,03 medical and health sciences ,0302 clinical medicine ,Health facility ,Low and middle income countries ,Environmental health ,Maternal health ,Quality (business) ,030212 general & internal medicine ,Business ,Quality of care ,0305 other medical science ,Healthcare system ,media_common - Abstract
Delivery in a health facility is a key strategy for reducing maternal and neonatal mortality, yet increasing use of facilities has not consistently translated into reduced mortality in low- and mid...
- Published
- 2019
41. Disrespectful treatment in primary care in rural Tanzania: beyond any single health issue
- Author
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Elysia Larson, Godfrey Mbaruku, Stephanie A Kujawski, Irene Mashasi, and Margaret E Kruk
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Adult ,Rural Population ,medicine.medical_specialty ,Adolescent ,Attitude of Health Personnel ,education ,Psychological intervention ,Primary care ,Tanzania ,primary care ,03 medical and health sciences ,0302 clinical medicine ,Patient satisfaction ,women’s health ,Surveys and Questionnaires ,Outpatients ,Patient experience ,Humans ,Medicine ,030212 general & internal medicine ,10. No inequality ,Quality of Health Care ,030219 obstetrics & reproductive medicine ,Primary Health Care ,biology ,patient experience ,Rural tanzania ,business.industry ,Health Policy ,1. No poverty ,Professional-Patient Relations ,Original Articles ,biology.organism_classification ,3. Good health ,Cross-Sectional Studies ,Outpatient visits ,Patient Satisfaction ,Relative risk ,Family medicine ,Female ,business ,Disrespect - Abstract
Knowing how patients are treated in care is foundational for creating patient-centred, high-quality health systems and identifying areas where policies and practices need to adapt to improve patient care. However, little is known about the prevalence of disrespectful treatment of patients in sub-Saharan Africa outside of maternity care. We used data from a household survey of 2002 women living in rural Tanzania to describe the extent of disrespectful care during outpatient visits, who receive disrespectful care, and determine the association with patient satisfaction, rating of quality and recommendation of the facility to others. We asked about women’s most recent outpatient visit to the local clinic, including if they were made to feel disrespected, if a provider shouted at or scolded them, and if providers made negative or disparaging comments about them. Women who answered yes to any of these questions were considered to have experienced disrespectful care. We report risk ratios with standard errors clustered at the facility level. The most common reasons for seeking care were fever or malaria (33.9%), vaccination (33.6%) and non-emergent check-up (13.4%). Disrespectful care was reported by 14.3% of women and was more likely if the visit was for sickness compared to a routine check-up [risk ratio (RR): 1.6, 95% confidence interval (CI): 1.1–2.2]. Women who did not report disrespectful care were 2.1 times as likely to recommend the clinic (95% CI: 1.6–2.7). While there is currently a lot of attention on disrespectful maternity care, our results suggest that this is a problem that goes beyond this single health issue and should be addressed by more horizontal health system interventions and policies.
- Published
- 2019
42. A synthesis of implementation science frameworks and application to global health gaps
- Author
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Margaret E Kruk, Pablo Villalobos Dintrans, Jim Sherry, and Thomas J. Bossert
- Subjects
Prioritization ,medicine.medical_specialty ,Health (social science) ,Epidemiology ,Computer science ,Human immunodeficiency virus (HIV) ,medicine.disease_cause ,03 medical and health sciences ,0302 clinical medicine ,Global health ,medicine ,030212 general & internal medicine ,Structure (mathematical logic) ,Implementation science frameworks ,Management science ,030503 health policy & services ,Health Policy ,Public health ,Research ,lcsh:Public aspects of medicine ,Public Health, Environmental and Occupational Health ,Global health gaps ,lcsh:RA1-1270 ,Variety (cybernetics) ,Intervention (law) ,Global Health Initiatives ,0305 other medical science - Abstract
Background Implementation science has been growing as discipline in the past decades, producing an increasing number of models in the area. On the other hand, most frameworks are intended to guide the implementation of programs, focusing on identifying elements and stages that increase their success. This article aims to structure this discussion, proposing a simplified tool that synthesizes common elements of other frameworks, and highlight the usefulness to use implementation science not only in identifying successful implementation strategies but as a tool to assess gaps in global health initiatives. Methods The study was carried out through a combined methodology that included an initial search of implementation science frameworks, experts’ opinions, and the use of references in frameworks to elaborate a list of articles to be reviewed. A total of 52 articles were analyzed, identifying their definitions of implementation science and the elements of different frameworks. Results The analysis of articles allowed identifying the main goals and definitions of implementation science. In a second stage, frameworks were classified into “time-based”, “component-based” and “mixed”, and common elements of each type of model were used to propose a synthetic framework with six elements: Diagnosis, Intervention provider/ system, Intervention, Recipient, Environment, and Evaluation. Finally, this simplified framework was used to identify gaps in global health was using The Lancet Global Health Series. Potential areas of intervention arise for five different global health issues: malaria, non-communicable diseases, maternal and child health, HIV/AIDS, and tuberculosis. Prioritization strategies differ for the different health issues, and the proposed framework can help identify and classify all these different proposals. Conclusions There is a huge variety of definitions and models in implementation science. The analysis showed the usefulness of applying an implementation science approach to identify and prioritize gaps in implementation strategies in global health. Electronic supplementary material The online version of this article (10.1186/s41256-019-0115-1) contains supplementary material, which is available to authorized users.
- Published
- 2019
43. Forty Years After Alma‐Ata: At the Intersection of Primary Care and Population Health
- Author
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Margaret E Kruk and Sandro Galea
- Subjects
medicine.medical_specialty ,Population Health ,Primary Health Care ,Health Policy ,Public Health, Environmental and Occupational Health ,Population health ,Primary care ,Congresses as Topic ,Global Health ,Opinions ,Kazakhstan ,Intersection ,Universal Health Insurance ,Family medicine ,Political science ,medicine ,Humans ,Alma ata - Published
- 2019
44. Neighbour home gardening predicts dietary diversity among rural Tanzanian women
- Author
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Joyce Kinabo, Honorati Masanja, Chelsey R Canavan, Dominic Mosha, Alexandra L. Bellows, Mia M. Blakstad, Wafaie W. Fawzi, Killian Mlalama, and Margaret E Kruk
- Subjects
Adult ,Rural Population ,Psychological intervention ,Nutritional Status ,Medicine (miscellaneous) ,Tanzania ,Article ,Food Supply ,Food group ,Young Adult ,Intervention (counseling) ,Humans ,Forest gardening ,Risk factor ,Family Characteristics ,Nutrition and Dietetics ,biology ,business.industry ,Public Health, Environmental and Occupational Health ,Gardening ,biology.organism_classification ,Diet ,Geography ,Agriculture ,Respondent ,Female ,business ,Nutritive Value ,Demography - Abstract
ObjectiveThe present study’s aim was to assess the impact of a nutrition-sensitive intervention on dietary diversity and home gardening among non-participants residing within intervention communities.DesignThe study was a cross-sectional risk factor analysis using linear and logistic multivariate models.SettingIn Tanzania, women and children often consume monotonous diets of poor nutritional value primarily because of physical or financial inaccessibility or low awareness of healthy foods.ParticipantsParticipants were women of reproductive age (18–49 years) in rural Tanzania.ResultsMean dietary diversity was low with women consuming three out of ten possible food groups. Only 23·4 % of respondents achieved the recommended minimum dietary diversity of five or more food groups out of ten per day. Compared with those who did not, respondents who had a neighbour who grew crops in their home garden were 2·71 times more likely to achieve minimum dietary diversity (95 % CI 1·60, 4·59; P=0·0004) and 1·91 times more likely to grow a home garden themselves (95 % CI 1·10, 3·33; P=0·02). Other significant predictors of higher dietary diversity were respondent age, education and wealth, and number of crops grown.ConclusionsThese results suggest that there are substantial positive externalities of home garden interventions beyond those attained by the people who own and grow the vegetables. Cost-effectiveness assessments of nutrition-sensitive agriculture, including home garden interventions, should factor in the effects on the community, and not just on the individual households receiving the intervention.
- Published
- 2019
45. Where is quality in health systems policy? An analysis of global policy documents
- Author
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Bernadette Daelmans, Keely Jordan, Margaret E Kruk, Robert Marten, and Oye Gureje
- Subjects
030505 public health ,media_common.quotation_subject ,Comment ,General Medicine ,Environmental economics ,03 medical and health sciences ,0302 clinical medicine ,Political science ,Global policy ,Quality (business) ,030212 general & internal medicine ,0305 other medical science ,media_common ,Healthcare system - Published
- 2018
46. What can work and how? An overview of evidence-based interventions and delivery strategies to support health and human development from before conception to 20 years
- Author
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Tyler Vaivada, Zohra S Lassi, Omar Irfan, Rehana A Salam, Jai K Das, Christina Oh, Bianca Carducci, Reena P Jain, Daina Als, Naeha Sharma, Emily C Keats, George C Patton, Margaret E Kruk, Robert E Black, and Zulfiqar A Bhutta
- Subjects
Adult ,Young Adult ,Evidence-Based Medicine ,Adolescent ,Child, Preschool ,Child Mortality ,Infant, Newborn ,Humans ,General Medicine ,Morbidity ,Child ,Delivery of Health Care ,Poverty - Abstract
Progress has been made globally in improving the coverage of key maternal, newborn, and early childhood interventions in low-income and middle-income countries, which has contributed to a decrease in child mortality and morbidity. However, inequities remain, and many children and adolescents are still not covered by life-saving and nurturing care interventions, despite their relatively low costs and high cost-effectiveness. This Series paper builds on a large body of work from the past two decades on evidence-based interventions and packages of care for survival, strategies for delivery, and platforms to reach the most vulnerable. We review the current evidence base on the effectiveness of a variety of essential and emerging interventions that can be delivered from before conception until age 20 years to help children and adolescents not only survive into adulthood, but also to grow and develop optimally, support their wellbeing, and help them reach their full developmental potential. Although scaling up evidence-based interventions in children younger than 5 years might have the greatest effect on reducing child mortality rates, we highlight interventions and evidence gaps for school-age children (5-9 years) and the transition from childhood to adolescence (10-19 years), including interventions to support mental health and positive development, and address unintentional injuries, neglected tropical diseases, and non-communicable diseases.
- Published
- 2021
47. Conducting a household survey in poor urban settlements in Ghana: challenges and strategic adaptations for fieldwork
- Author
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Patrick O. Asuming, Margaret E Kruk, Ayaga A. Bawah, Navdep Kaur, Iqbal Shah, Elizabeth G. Henry, and Caesar Agula
- Subjects
Household survey ,Geography ,business.industry ,Human settlement ,Socioeconomics ,business ,Reproductive health ,Urban health - Published
- 2021
48. Considerations for a sustainability framework for neglected tropical diseases programming
- Author
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Emily Wainwright, Madame Cisse Mariama Mohamed, Marcos A. Espinal, and Margaret E Kruk
- Subjects
health financing ,Service delivery framework ,030231 tropical medicine ,Global Health ,World Health Organization ,03 medical and health sciences ,0302 clinical medicine ,Tropical Medicine ,Health care ,Humans ,AcademicSubjects/MED00860 ,030212 general & internal medicine ,Disease Eradication ,neglected tropical diseases ,Health policy ,Sustainable development ,Government ,business.industry ,Corporate governance ,Public Health, Environmental and Occupational Health ,Neglected Diseases ,health policy ,General Medicine ,sustainability ,Infectious Diseases ,AcademicSubjects/MED00290 ,Risk analysis (engineering) ,Sustainability ,Neglected tropical diseases ,Commentary ,Parasitology ,business ,health systems - Abstract
Addressing neglected tropical diseases (NTDs) is critical to achieving universal healthcare and the Sustainable Development Goals. Significant strides are being made to expand NTD programs, but these programs still need to be fully incorporated into national governance, financing, planning and service delivery structures. The World Health Organization has developed a sustainability framework that calls for governments to create a vision and a multisector plan to achieving sustainability. Several critical factors need to be considered to avoid undermining progress toward disease elimination and control targets, while merging program components into national systems.
- Published
- 2020
49. Patient volume and quality of primary care in Ethiopia: findings from the routine health information system and the 2014 Service Provision Assessment survey
- Author
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Catherine Arsenault, Tsinuel Girma Nigatu, Bereket Yakob, Mirkuzie Woldie, Margaret E Kruk, Girmaye Dinsa, Munir Kassa, Tizta Tilahun, and Peter Berman
- Subjects
medicine.medical_specialty ,Service delivery framework ,media_common.quotation_subject ,030231 tropical medicine ,Health informatics ,Health administration ,03 medical and health sciences ,Health Information Systems ,0302 clinical medicine ,Pregnancy ,Surveys and Questionnaires ,Health care ,medicine ,Humans ,Quality (business) ,030212 general & internal medicine ,Child ,media_common ,Quality of Health Care ,Primary Health Care ,business.industry ,Health Policy ,Public health ,Nursing research ,Prenatal Care ,Cross-Sectional Studies ,Family planning ,Family medicine ,Female ,Ethiopia ,Public aspects of medicine ,RA1-1270 ,business ,Research Article - Abstract
Background Several studies have reported inadequate levels of quality of care in the Ethiopian health system. Facility characteristics associated with better quality remain unclear. Understanding associations between patient volumes and quality of care could help organize service delivery and potentially improve patient outcomes. Methods Using data from the routine health management information system (HMIS) and the 2014 Ethiopian Service Provision Assessment survey + we assessed associations between daily total outpatient volumes and quality of services. Quality of care at the facility level was estimated as the average of five measures of provider knowledge (clinical vignettes on malaria and tuberculosis) and competence (observations of family planning, antenatal care and sick child care consultations). We used linear regression models adjusted for several facility-level confounders and region fixed effects with log-transformed patient volume fitted as a linear spline. We repeated analyses for the association between volume of antenatal care visits and quality. Results Our analysis included 424 facilities including 270 health centers, 45 primary hospitals and 109 general hospitals in Ethiopia. Quality was low across all facilities ranging from only 18 to 56% with a mean score of 38%. Outpatient volume varied from less than one patient per day to 581. We found a small but statistically significant association between volume and quality which appeared non-linear, with an inverted U-shape. Among facilities seeing less than 90.6 outpatients per day, quality increased with greater patient volumes. Among facilities seeing 90.6 or more outpatients per day, quality decreased with greater patient volumes. We found a similar association between volume and quality of antenatal care visits. Conclusions Health care utilization and quality must be improved throughout the health system in Ethiopia. Our results are suggestive of a potential U-shape association between volume and quality of primary care services. Understanding the links between volume of patients and quality of care may provide insights for organizing service delivery in Ethiopia and similar contexts.
- Published
- 2020
50. Temporal trends in coverage, quality and equity of maternal and child health services in Rwanda, 2000–2015
- Author
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Margaret E Kruk, Celestin Hategeka, and Catherine Arsenault
- Subjects
Inequality ,descriptive study ,Maternal-Child Health Services ,media_common.quotation_subject ,Psychological intervention ,maternal health ,lcsh:Infectious and parasitic diseases ,Policy decision ,Pregnancy ,Environmental health ,Medicine ,Area of residence ,Humans ,Maternal health ,Maternal Health Services ,lcsh:RC109-216 ,Child ,media_common ,Original Research ,lcsh:R5-920 ,Equity (economics) ,Maternal and child health ,business.industry ,Health Policy ,Public Health, Environmental and Occupational Health ,Rwanda ,Prenatal Care ,Sick child ,Socioeconomic Factors ,Child, Preschool ,child health ,Female ,business ,lcsh:Medicine (General) - Abstract
IntroductionAchieving the maternal and child health (MCH)-related Sustainable Development Goals (SDG) will require equitable and effective (quality-adjusted) coverage of recommended health interventions in low- and middle-income countries. We assessed effective coverage and equity of MCH services in Rwanda in the Millennium Development Goal (MDG) era to help guide policy decisions to improve equitable health gains in the SDG era and beyond.MethodsUsing four rounds of Rwanda demographic and health surveys conducted from 2000 to 2015, we identified coverage and quality indicators for five MCH services: antenatal care (ANC), delivery care, and care for child diarrhoea, suspected pneumonia and fever. We calculated crude coverage and quality in each survey and used these to estimate effective coverage. The effective coverage should be regarded as an upper bound because there were few available quality measures. We also described equity in effective coverage of these five MCH services over time across the wealth index, area of residence and maternal education using equiplots.ResultsA total of 48 910 women aged 15–49 years and 33 429 children under 5 years were included across the four survey rounds. In 2015, average effective coverage was 33.2% (range 19.9%–44.2%) across all five MCH services, 30.1% (range 19.9%–40.2%) for maternal health services (average of ANC and delivery) and 35.3% (range 27.3%–44.2%) for sick child care (diarrhoea, pneumonia and fever). This is in contrast to crude coverage which averaged 56.5% (range 43.6%–90.7%) across all five MCH services, 67.3% (range 43.9%–90.7%) for maternal health services and 49.2% (range 43.6%–53.9%) for sick child care. Between 2010 and 2015 effective coverage increased by 154.2% (range 127.3%–170.0%) for maternal health services and by 27.4% (range 4.2%–79.6%) for sick child care. These increases were associated with widening socioeconomic inequalities in effective coverage for maternal health services, and narrowing inequalities in effective coverage for sick child care.ConclusionWhile effective coverage of common MCH services generally improved in the MDG era, it still lagged substantially behind crude coverage for the same services due to low-quality care. Overall, effective coverage of MCH services remained suboptimal and inequitable. Policies should focus on improving effective coverage of these services and reducing inequities.
- Published
- 2020
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