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IntroductionThere is limited guidance on strategies for delivering complex global health programs. We synthesized available evidence on implementation strategies and outcomes utilized in the global polio eradication initiative (GPEI) across low and middle-income country (LMIC) settings.MethodsWe nested our scoping review into a literature review conducted as part of a parent study, STRIPE. This review systematically searched PubMed for articles between 1 January 1988 and 25 April 2018 using polio search terms. Strategies from included studies were organized according to the Expert Recommendations for Implementing Change (ERIC) framework, specified using Proctor's framework, and linked to various outcomes (implementation, services delivery, impact).Results152 unique articles fulfilled our inclusion criteria (from 1,885 articles included in the parent study). Only 43 out of the 152 articles described a suitable quantitative study design for evaluating outcomes. We extracted 66 outcomes from the 43 unique studies. Study publication dates ranged from 1989 to 2018 and represented diverse country settings. The most common implementation strategies were developing mechanisms for feedback, monitoring, and evaluation (n = 69); increasing awareness among the population (n = 58); involving stakeholders, workers, and consumers in the implementation efforts (n = 46); conducting workshops (n = 33); using mass media (n = 31); and building robust record systems to capture outcomes (n = 31). Coverage (n = 13) and morbidity (n = 12) were the most frequently identified outcomes, followed by effectiveness (n = 9) and fidelity (n = 6). Feasibility and sustainability were rarely evaluated.ConclusionsThis review provides a catalogue of implementation strategies and outcomes relevant for advancing global health services delivery in LMICs drawing from the GPEI. Implementation strategies reviewed were poorly described and not adequately linked to outcomes. It calls for additional implementation research to unravel the mechanisms of implementation strategies and their effectiveness, and adaptation of the ERIC framework in LMICs.

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.

Abstract Background With nearly 90% of annual hypertension-related deaths occurring in low- and middle-income countries (LMICs), there is an urgent need to measure the coverage of health services that effectively manage hypertension. However, there is little agreement on how to define effective coverage and the existing hypertension care cascade (hypertension prevalence, percent aware, percent treated, and percent controlled) does not account for the quality of care received by patients. This study reviews definitions of effective coverage and service quality for hypertension management services and proposes an expanded hypertension care cascade to improve measurement of health systems performance. Methods A systematic scoping review of literature published in six electronic databases between January 2000 and October 2020 identified studies that defined effective coverage of hypertension management services or integrated dimensions of service quality into population-based estimates of hypertension management in LMICs. Findings informed an expanded hypertension care cascade from which quality-adjusted service coverage can be calculated to approximate effective coverage. Results The review identified 18 relevant studies, including 6 that defined effective coverage for hypertension management services and 12 that reported a measure of service quality in a population-based study. Based on commonly reported barriers to hypertension management, new steps on the proposed expanded care cascade include (i) population screened, (ii) population linked to quality care, and (iii) population adhering to prescribed treatment. Conclusion There is little consensus on the definition of effective coverage of hypertension management services, and most studies do not describe the quality of hypertension management services provided to populations. Incorporating aspects of service quality to the hypertension care cascade allows for the calculation of quality-adjusted coverage of relevant services, enabling an appropriate measurement of health systems performance through effective coverage.

Abstract Background Improving service delivery is a key strategy for achieving service coverage, one of the two components of universal health coverage (UHC). As one of the largest global public health initiatives, individuals involved with the Global Polio Eradication Initiative (GPEI) have learned many important lessons about service delivery. We identified contributors and challenges to delivering health services at national and subnational levels using experiences from the GPEI. We described strategies used to strengthen service delivery and draw lessons that could be applicable to achieving UHC. Methods Online cross-sectional surveys based on the Consolidated Framework for Implementation Research (CFIR) domains and socioecological model were conducted from 2018–2019. Data were analyzed using an embedded mixed methods approach. Frequencies of the contributors and challenges to service delivery by levels of involvement were estimated. Chi-square tests of independence were used to assess unadjusted associations among categorical outcome variables. Logistic regressions were used to examine the association between respondent characteristics and contributors to successful implementation or implementation challenges. Horizontal analysis of free text responses by CFIR domain was done to contextualize the quantitative results. Results Three thousand nine hundred fifty-five people responded to the online survey which generated 3,659 valid responses. Among these, 887 (24.2%) reported involvement in service delivery at the global, national, or subnational level with more than 90% involved at subnational levels. The main internal contributor of strengthened service delivery was the process of conducting activities (48%); working in frontline role had higher odds of identifying the process of conducting activities as the main internal contributor (AOR: 1.22, p = 0.687). The main external contributor was the social environment (42.5%); having 10–14 years of polio program implementation was significantly associated with identifying the social environment as the main external contributor to strengthened service delivery (AOR: 1.61, p = 0.038). The most frequent implementation challenge was the external environment (56%); working in Eastern Mediterranean region was almost 4 times more likely to identify the external environment as the major challenge in service delivery strengthening (AOR:3.59, p

Background: During and after the SARS-CoV-2 (COVID-19) pandemic, many countries experienced declines in immunization that have not fully recovered to pre-pandemic levels. This study uses routine health facility immunization data to estimate variability between and within countries in post-pandemic immunization service recovery for BCG, DPT1, and DPT3. Methods: After adjusting for data reporting completeness and outliers, interrupted time series regression was used to estimate the expected immunization service volume for each subnational unit, using an interruption point of March 2020. We assessed and compared the percent deviation of observed immunizations from the expected service volume for March 2020 between and within countries. Results: Six countries experienced significant service volume declines for at least one vaccine as of October 2022. The shortfall in BCG service volume was ~6% (95% CI −1.2%, −9.8%) in Guinea and ~19% (95% CI −16%, 22%) in Liberia. Significant cumulative shortfalls in DPT1 service volume are observed in Afghanistan (−4%, 95% CI −1%, −7%), Ghana (−3%, 95% CI −1%, −5%), Haiti (−7%, 95% CI −1%, −12%), and Kenya (−3%, 95% CI −1%, −4%). Afghanistan has the highest percentage of subnational units reporting a shortfall of 5% or higher in DPT1 service volume (85% in 2021 Q1 and 79% in 2020 Q4), followed by Bangladesh (2020 Q1, 83%), Haiti (80% in 2020 Q2), and Ghana (2022 Q2, 75%). All subnational units in Bangladesh experienced a 5% or higher shortfall in DPT3 service volume in the second quarter of 2020. In Haiti, 80% of the subnational units experienced a 5% or higher reduction in DPT3 service volume in the second quarter of 2020 and the third quarter of 2022. Conclusions: At least one region in every country has a significantly lower-than-expected post-pandemic cumulative volume for at least one of the three vaccines. Subnational monitoring of immunization service volumes using disaggregated routine health facility information data should be conducted routinely to target the limited vaccination resources to subnational units with the highest inequities.

Abstract Background Linking facility and household surveys through geographic methods is a popular technique to draw conclusions about the relationship between health services and population health outcomes at local levels. These methods are useful tools for measuring effective coverage and tracking progress towards Universal Health Coverage, but are understudied. This paper compares the appropriateness of several geospatial methods used for linking individuals (within displaced survey cluster locations) to their source of family planning (at undisplaced health facilities) at a national level. Methods In Malawi, geographic methods linked a population health survey, rural clusters from the Woman’s Questionnaire of the 2015 Malawi Demographic and Health Survey (MDHS 2015), to Malawi’s national health facility census to understand the service environment where women receive family planning services. Individuals from MDHS 2015 clusters were linked to health facilities through four geographic methods: (i) closest facility, (ii) buffer (5 km), (iii) administrative boundary, and (iv) a newly described theoretical catchment area method. Results were compared across metrics to assess the number of unlinked clusters (data lost), the number of linkages per cluster (precision of linkage), and the number of women linked to their last source of modern contraceptive (appropriateness of linkage). Results The closest facility and administrative boundary methods linked every cluster to at least one facility, while the 5-km buffer method left 288 clusters (35.3%) unlinked. The theoretical catchment area method linked all but one cluster to at least one facility (99.9% linked). Closest facility, 5-km buffer, administrative boundary, and catchment methods linked clusters to 1.0, 1.4, 21.1, and 3.3 facilities on average, respectively. Overall, the closest facility, 5-km buffer, administrative boundary, and catchment methods appropriately linked 64.8%, 51.9%, 97.5%, and 88.9% of women to their last source of modern contraceptive, respectively. Conclusions Of the methods studied, the theoretical catchment area linking method loses a marginal amount of population data, links clusters to a relatively low number of facilities, and maintains a high level of appropriate linkages. This linking method is demonstrated at scale and can be used to link individuals to qualities of their service environments and better understand the pathways through which interventions impact health.

Abstract Background Afghanistan and Nigeria are two of the three remaining polio endemic countries. While these two countries have unique sociocultural characteristics, they share major polio risk factors. This paper describes the countries’ shared contexts and highlights important lessons on implementing polio eradication activities among hard-to-reach populations relevant for future global health programs. Methods A grey literature review of the Global Polio Eradication Initiative (GPEI) followed by an online survey was conducted in both countries. The survey was targeted to individuals who have been involved continuously in polio eradication activities for 12 months or more since 1988. A sub-set of respondents from the survey was recruited for key-informant interviews (KII). The survey and KIIs were conducted between September 2018–April 2019. A cross-case comparison analysis was conducted to describe shared implementation challenges, strategies, and unintended consequences of polio eradication activities across these contexts. Results Five hundred thirteen and nine hundred twenty-one surveys were completed in Afghanistan and Nigeria respectively; 28 KIIs were conducted in Afghanistan and 29 in Nigeria. Major polio eradication activities in both countries include house-to-house campaigns, cross-border stations, outreach to mobile populations, and surveillance. Common barriers to these activities in both countries include civil unrest and conflict; competing political agendas; and vaccine refusal, fatigue, and mistrust, all of which are all bases for describing hard-to-reach populations. Both countries employed strategies to engage community leadership, political and religious groups through advocacy visits, and recruited community members to participate in program activities to address misconceptions and distrust. Recruitment of female workers has been necessary for accessing women and children in conservative communities. Synergy with other health programs has been valuable; health workers have improved knowledge of the communities they serve which is applicable to other initiatives. Conclusions The power of community engagement at all levels (from leadership to membership) cannot be overstated, particularly in countries facing civil unrest and insecurity. Workforce motivation, community fatigue and mistrust, political priorities, and conflict are intricately interrelated. Community needs should be holistically assessed and addressed;programs must invest in the needs of health workers who engage in these long-term health programs, particularly in unsafe areas, to alleviate demotivation and fatigue.

Abstract Background Previous initiatives have aimed to document the history and legacy of the Smallpox Eradication Program (SEP) and the Global Polio Eradication Initiative (GPEI). In this multi-pronged scoping review, we explored the evolution and learning from SEP and GPEI implementation over time at global and country levels to inform other global health programs. Methods Three related reviews of literature were conducted; we searched for documents on 1) the SEP and 2) GPEI via online database searches and also conducted global and national-level grey literature searches for documents related to the GPEI in seven purposively selected countries under the Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) project. We included documents relevant to GPEI implementation. We conducted full text data analysis and captured data on Expert Recommendations for Implementing Change (ERIC) implementation strategies and principles, tools, outcomes, target audiences, and relevance to global health knowledge areas. Results 200 articles were included in the SEP scoping review, 1885 articles in the GPEI scoping review, and 963 documents in the grey literature review. M&E and engagement strategies were consistently translated from the SEP to GPEI; these evolved into newer approaches under the GPEI. Management strategies including setting up robust record systems also carried forward from SEP to GPEI; however, lessons around the need for operational flexibility in applying these strategies at national and sub-national levels did not. Similarly, strategies and lessons around conducting health systems readiness assessments prior to implementation were not carried forward from SEP to GPEI. Differences in the planning and communication strategies between the two programs included fidelity to implementation blueprints appeared to be higher under SEP, and independent monitoring boards and communication and media strategies were more prominent under GPEI. Conclusions Linear learning did not always occur between SEP and GPEI; several lessons were lost and had to be re-learned. Implementation and adaptation of strategies in global health programs should be well codified, including information on the contextual, time and stakeholders’ issues that elicit adaptations. Such description can improve the systematic translation of knowledge, and gains in efficiency and effectiveness of future global health programs.

Abstract Background Lessons from polio eradication efforts and the Global Polio Eradication Initiative (GPEI) are useful for improving health service delivery and outcomes globally. The Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) is a multi-phase project which aims to map, package and disseminate knowledge from polio eradication initiatives as academic and training programs. This paper discusses initial findings from the knowledge mapping around polio eradication activities across a multi-country context. Methods The knowledge mapping phase (January 2018 – December 2019) encompassed four research activities (scoping review, survey, key informant interviews (KIIs), health system analyses). This paper utilized a sequential mixed method design combining data from the survey and KIIs. The survey included individuals involved in polio eradication between 1988 and 2019, and described the contexts, implementation strategies, intended and unintended outcomes of polio eradication activities across levels. KIIs were conducted among a nested sample in seven countries (Afghanistan, Bangladesh, the Democratic Republic of Congo, Ethiopia, India, Indonesia, Nigeria) and at the global level to further explore these domains. Results The survey generated 3955 unique responses, mainly sub-national actors representing experience in over 74 countries; 194 KIIs were conducted. External factors including social, political, and economic factors were the most frequently cited barriers to eradication, followed by the process of implementing activities, including program execution, planning, monitoring, and stakeholder engagement. Key informants described common strategies for addressing these barriers, e.g. generating political will, engaging communities, capacity-building in planning and measurement, and adapting delivery strategies. The polio program positively affected health systems by investing in system structures and governance, however, long-term effects have been mixed as some countries have struggled to institutionalize program assets. Conclusion Understanding the implementing context is critical for identifying threats and opportunities to global health programs. Common implementation strategies emerged across countries; however, these strategies were only effective where organizational and individual capacity were sufficient, and where strategies were appropriately tailored to the sociopolitical context. To maximize gains, readiness assessments at different levels should predate future global health programs and initiatives should consider system integration earlier to ensure program institutionalization and minimize system distortions.

Abstract Background Complex global initiatives, like the Global Polio Eradication Initiative (GPEI), have prevented millions of paralyses and improved the health status of diverse populations. Despite the logistical challenges these initiatives must overcome at several levels, scant methods exist for systematically identifying and reaching a range of actors involved in their implementation. As a result, efforts to document the lessons learned from such initiatives are often incomplete. This paper describes the development and application of the Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) systematic approach for identifying a comprehensive sample of actors involved in the GPEI. Results The survey for collecting lessons learned from the GPEI was conducted at the global level and within seven countries that represented GPEI operational contexts. Standard organizational and operational levels, as well as goals of program activities, were defined across contexts. Each survey iteration followed similar methodologies to theorize a target population or “universe” of all polio-related actors in the study area, enumerate a source population of specific individuals within the target population, and administer the survey to individuals within the source population. Based on the systematic approach used to obtain a comprehensive sample for lessons learned in GPEI, steps for obtaining a comprehensive sample for studying complex initiatives can be summarized as follows: (i) State research goal(s); (ii) Describe the program of interest; (iii) Define a sampling universe to meet these criteria; (iv) Estimate the size of the sampling universe; (v) Enumerate a source population within the universe that can be feasibly reached for sampling; (vi) Sample from the source population; and (vii) Reflect on the process to determine strength of inferences drawn. Conclusions The application of these methods can inform future evaluations of complex public health initiatives, resulting in better adoption of lessons learned, ultimately improving efficacy and efficiency, and resulting in significant health gains. Their use to administer the STRIPE lessons learned survey reflects experiences related to implementation challenges and strategies used to overcome barriers from actors across an extensive range of organizational, programming, and contextual settings.

Effective management of hypertension in low- and middle-income settings is a persistent public health challenge. This study examined supply- and demand-side barriers to receiving quality care and achieving effective hypertension management in rural Bihar, India. A state-representative household survey collected information from adults over 30 years of age on characteristics of the hypertension screening, diagnosis, and management services they received. A linked provider assessment determined the percent of providers who provided quality hypertension care (i.e., had a functioning BP measurement device, measured a patient’s BP, could correctly diagnose hypertension, had at least one first-line antihypertension medication, and could prescribe correctly based on standard guidelines). Patients were linked with their provider to determine the quality-adjusted coverage of hypertension management and logistic regression analysis was conducted to determine characteristics associated with receiving quality care. A total of 14,386 patients and 390 providers were studied. Nearly a quarter (22.5%) of adults had never had their BP measured before and 8.1% of adults reported a previous hypertension diagnosis. Less than one third (31.0%) of all interviewed providers demonstrated ability to provide quality hypertension care, and quality varied between provider types (14.8% of private homeopathic, 25.2% of informal, 40.0% of private modern medicine, and 60.0% of public providers gave quality care). While 95.8% of diagnosed individuals received some treatment, only 10.9% of patients received care from quality local providers. Nearly 45% of individuals with hypertension received care from non-local providers. Individuals from the general caste with comorbidities living in villages with more high-quality providers were most likely to receive quality care from a local provider. Whereas the coverage of services for individuals diagnosed with hypertension is high, the quality of these services is suboptimal for economically and socially vulnerable populations, which limits effective management and control of hypertension in rural Bihar. Efforts should be targeted towards providers to initiate quality treatment upon diagnosis, including correct prescription of antihypertensives.

In this brief autobiographical excursus, Professor Michael Peters not only presents us with the most fundamental aspects of his thinking in philosophy of education, but reveals how, in the midst of some specific concerns, his encounter with Wittgenstein and post-structuralist philosophers ended up shaping the way that he traveled in his intellectual path.

This paper investigates the trope of the zombie and the recent upsurge in popular culture surrounding the figure of the zombie described as the “walking dead”. We investigate this trope and figure as a means of analyzing the “pedagogy of the walking dead” with particular attention to the crisis of education in the era of neoliberal capitalism. In particular we examine the professionalization and responsibilization of teachers in the new regulative environment and ask whether there is any room left for the project of critical education.

Purpose —This paper aims at exploring politics of contemporary knowledge cultures and possible directions for responding to the postdigital challenge. Design/Approach/Methods —This paper researches history and present of several prominent strands and readings of the knowledge economy. Following Caruso's work (2016), it examines more closely the differences between the managerial paradigm and the cognitive capitalism paradigm. Recognizing the postdigital nature of contemporary knowledge cultures, it points towards a postdigital merger between the managerial paradigm and the cognitive capitalism paradigm. Findings —The paper identifies individual and social tensions between industrial and post-industrial modes of production and rapidly changing dynamic of social development. It examines the relationships between knowledge cultures and digital technologies. Based on recent insights by the father of the World Wide Web Tim Berners-Lee and his non-determinist views to digital technologies, it identifies knowledge cultures as sites of political struggle against various (material and non-material, technological and non-technological) closures over access to information and knowledge. Finally, it briefly outlines possible directions for responding to the postdigital challenge of knowledge cultures. Originality/Value —The paper provides an original contribution to theory of knowledge cultures and its relationships to the postdigital condition.