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Responsive primary health-care facilities are the foundation of resilient health systems, yet little is known about facility-level processes that contribute to the continuity of essential services during a crisis. This paper describes the aspects of primary health-care facility resilience to coronavirus disease 2019 (COVID-19) in eight countries. Rapid-cycle phone surveys were conducted with health facility managers in Bangladesh, Burkina Faso, Chad, Guatemala, Guinea, Liberia, Malawi and Nigeria between August 2020 and December 2021. Responses were mapped to a validated health facility resilience framework and coded as binary variables for whether a facility demonstrated capacity in eight areas: removing barriers to accessing services, infection control, workforce, surge capacity, financing, critical infrastructure, risk communications, and medical supplies and equipment. These self-reported capacities were summarized nationally and validated with the ministries of health. The analysis of service volume data determined the outcome: maintenance of essential health services. Of primary health-care facilities, 1,453 were surveyed. Facilities maintained between 84% and 97% of the expected outpatient services, except for Bangladesh, where 69% of the expected outpatient consultations were conducted between March 2020 and December 2021. For Burkina Faso, Chad, Guatemala, Guinea and Nigeria, critical infrastructure was the largest constraint in resilience capabilities (47%, 14%, 51%, 9% and 29% of facilities demonstrated capacity, respectively). Medical supplies and equipment were the largest constraints for Liberia and Malawi (15% and 48% of facilities demonstrating capacity, respectively). In Bangladesh, the largest constraint was workforce and staffing, where 44% of facilities experienced moderate to severe challenges with human resources during the pandemic. The largest constraints in facility resilience during COVID-19 were related to health systems building blocks. These challenges likely existed before the pandemic, suggesting the need for strategic investments and reforms in core capacities of comprehensive primary health-care systems to improve resilience to future shocks.

Background Important inequalities in childhood vaccination coverage persist between countries and population groups. Understanding why some countries achieve higher and more equitable levels of coverage is crucial to redress these inequalities. In this study, we explored the country-level determinants of (1) coverage of the third dose of diphtheria-tetanus-pertussis- (DTP3) containing vaccine and (2) within-country inequalities in DTP3 coverage in 45 countries supported by Gavi, the Vaccine Alliance. Methods We used data from the most recent Demographic and Health Surveys (DHS) conducted between 2005 and 2014. We measured national DTP3 coverage and the slope index of inequality in DTP3 coverage with respect to household wealth, maternal education, and multidimensional poverty. We collated data on country health systems, health financing, governance and geographic and sociocultural contexts from published sources. We used meta-regressions to assess the relationship between these country-level factors and variations in DTP3 coverage and inequalities. To validate our findings, we repeated these analyses for coverage with measles-containing vaccine (MCV). Results We found considerable heterogeneity in DTP3 coverage and in the magnitude of inequalities across countries. Results for MCV were consistent with those from DTP3. Political stability, gender equality and smaller land surface were important predictors of higher and more equitable levels of DTP3 coverage. Inequalities in DTP3 coverage were also lower in countries receiving more external resources for health, with lower rates of out-of-pocket spending and with higher national coverage. Greater government spending on heath and lower linguistic fractionalization were also consistent with better vaccination outcomes. Conclusion Improving vaccination coverage and reducing inequalities requires that policies and programs address critical social determinants of health including geographic and social exclusion, gender inequality and the availability of financial protection for health. Further research should investigate the mechanisms contributing to these associations.

Objectives (1) To conduct a systematic analysis of inequalities in childhood vaccination coverage in Gavi-supported countries; (2) to comparatively assess alternative measurement approaches and how they may affect cross-country comparisons of the level of inequalities. Methods Using the most recent Demographic and Health Surveys (2005–2014) in 45 Gavi-supported countries, we measured inequalities in vaccination coverage across seven dimensions of social stratification and of vulnerability to poor health outcomes. We quantified inequalities using pairwise comparisons (risk differences and ratios) and whole spectrum measures (slope and relative indices of inequality). To contrast measurement approaches, we pooled the estimates using random-effects meta-analyses, ranked countries by the magnitude of inequality and compared agreement in country ranks. Results At the aggregate level, maternal education, multidimensional poverty, and wealth index poverty were the dimensions associated with the largest inequalities. In 36 out of 45 countries, inequalities were substantial, with a difference in coverage of 10 percentage points or more between the top and bottom of at least one of these social dimensions. Important inequalities by child sex, child malnutrition and urban/rural residence were also found in a smaller set of countries. The magnitude of inequality and ranking of countries differed across dimension and depending on the measure used. Pairwise comparisons could not be estimated in certain countries. The slope and relative indices of inequality were estimated in all countries and produced more stable country rankings, and should thus facilitate more reliable international comparisons. Conclusions Inequalities in vaccination coverage persist in a large majority of Gavi-supported countries. Inequalities should be monitored across multiple dimensions of vulnerability. Using whole spectrum measures to quantify inequality across multiple ordered social groups has important advantages. We illustrate these findings using an equity dashboard designed to support decision-making in the Sustainable Development Goals period.

There was no global guidance or agreement regarding when a country has an adequate system to report on the service packages among human immunodeficiency virus (HIV) key populations. This article describes an approach to categorizing the system in a country for reporting the service package among HIV key populations. The approach consists of four dimensions, namely the epidemiological significance, comprehensiveness of the service packages, geographic coverage of services, and adequacy of the monitoring system. The proposed categorization approach utilizes available information and can inform the improvement of the service delivery and monitoring systems among HIV key populations. Electronic supplementary material The online version of this article (10.1186/s40249-019-0570-4) contains supplementary material, which is available to authorized users.

A new Global Investment Framework for Women's and Children's Health demonstrates how investment in women's and children's health will secure high health, social, and economic returns. We costed health systems strengthening and six investment packages for: maternal and newborn health, child health, immunisation, family planning, HIV/AIDS, and malaria. Nutrition is a cross-cutting theme. We then used simulation modelling to estimate the health and socioeconomic returns of these investments. Increasing health expenditure by just $5 per person per year up to 2035 in 74 high-burden countries could yield up to nine times that value in economic and social benefits. These returns include greater gross domestic product (GDP) growth through improved productivity, and prevention of the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. These gains could be achieved by an additional investment of $30 billion per year, equivalent to a 2% increase above current spending.

SUMMARY Background After the fall of the Taliban regime, most clinics in Afghanistan were charging fees to patients. The government invested in monitoring and evaluation systems for its newly rebuilt primary care system, but little was known about the effects of user fees. This study was undertaken to provide evidence on user fees' effects on quality and service utilization and to help inform development of health financing policy and strategy. Methods A quasi-experimental health financing pilot study was implemented in 2005. Forty-seven facilities were randomized to implement a standardized user fee intervention, offer free services, or serve as controls, continuing current cost-sharing systems. Revenues were co-managed by staff and community leaders for facility improvement. Baseline and follow-up facility assessments, exit interviews, and household surveys, as well as routine data were used to evaluate user fee effects over 2 years. Results Observed and perceived quality improved at most facilities but did not differ by study group. Utilization increased in all groups, but the increase was 682 to 748 visits per month larger in facilities randomized to free services compared with those randomized to fees or controls (p

To estimate the economic impact likely to be achieved by efforts to vaccinate against 10 vaccine-preventable diseases between 2001 and 2020 in 73 low- and middle-income countries largely supported by Gavi, the Vaccine Alliance.We used health impact models to estimate the economic impact of achieving forecasted coverages for vaccination againstWe estimated that, in the 73 countries, vaccinations given between 2001 and 2020 will avert over 20 million deaths and save US$ 350 billion in cost of illness. The deaths and disability prevented by vaccinations given during the two decades will result in estimated lifelong productivity gains totalling US$ 330 billion and US$ 9 billion, respectively. Over the lifetimes of the vaccinated cohorts, the same vaccinations will save an estimated US$ 5 billion in treatment costs. The broader economic and social value of these vaccinations is estimated at US$ 820 billion.By preventing significant costs and potentially increasing economic productivity among some of the world's poorest countries, the impact of immunization goes well beyond health.Estimer l'impact économique qui pourrait découler des efforts de vaccination contre 10 maladies à prévention vaccinale déployés entre 2001 et 2020 dans 73 pays à revenu faible et intermédiaire, et largement soutenus par Gavi, l'Alliance du Vaccin.Nous avons utilisé des modèles d'évaluation de l'impact sur la santé pour estimer l'impact économique qui découlerait, si le taux de couverture prévu est atteint, des vaccinations contreD'après nos estimations, les vaccinations pratiquées entre 2001 et 2020 dans les 73 pays permettront d'éviter plus de 20 millions de décès et d'économiser 350 milliards de dollars des États-Unis en coûts sanitaires. Les cas de décès et d'invalidité évités grâce à la vaccination pratiquée au cours de ces deux décennies entraîneront des gains de productivité permanents respectivement estimés à 330 milliards de dollars des États-Unis et 9 milliards de dollars des États-Unis. On estime qu'au cours de la vie des cohortes vaccinées, les mêmes vaccinations permettront d'économiser 5 milliards de dollars des États-Unis en coûts de traitement. La valeur économique et sociale au sens large de ces vaccinations est estimée à 820 milliards de dollars des États-Unis.L'impact de la vaccination dépasse le domaine de la santé, car il permet d'éviter d'importants coûts et une augmentation potentielle de la productivité économique de certains des pays les plus pauvres du monde.Estimar el impacto económico que probablemente se logaría con los esfuerzos de vacunar frente a 10 enfermedades evitables mediante la vacunación entre 2001 y 2020 en 73 países con ingresos bajos y medios ampliamente respaldados por la Gavi, la Vaccine Alliance.Se utilizaron modelos de impacto sanitario para estimar el impacto económico de lograr las coberturas previstas de vacunación frente aSe estimó que, en los 73 países, las vacunas suministradas entre 2001 y 2020 evitarán más de 20 millones de muertes y ahorrarán 350 000 millones de USD en costes de enfermedades. Las muertes y las discapacidades evitadas gracias a las vacunas suministradas durante las dos décadas tendrán como resultado unas ganancias permanentes estimadas en la productividad de un total de 330 000 millones de USD y 9 000 millones de USD, respectivamente. Durante la vida de las cohortes vacunadas, se estima que las mismas vacunaciones ahorrarán 5 000 millones de USD en costes de tratamientos. El valor económico y social más amplio de estas vacunas se estima en 820 000 millones de USD.El impacto de las vacunas es positivo más allá de la salud, ya que se evitan costes significativos y se aumenta potencialmente la productividad económica entre algunos de los países más pobres.الغرض تقدير الأثر الاقتصادي المحتمل من خلال الجهود المبذولة للتمنيع ضد 10 أمراض يمكن الوقاية منها باللقاحات في الفترة ما بين عامي 2001 و2020 في 73 بلدًا من البلدان منخفضة ومتوسطة الدخل التي تتلقى دعمًا واسع النطاق من جانب التحالف العالمي للقاحات والتحصين (Gavi) لإنتاج الأمصال. الطريقة استخدمنا نماذج الأثر الصحي لتقدير الأثر الاقتصادي لتحقيق التغطية المتوقعة للتمنيع ضد المستدمية النزلية من النوع (ب)، وفيروس التهاب الكبد (ب)، وفيروس الورم الحليمي البشري، والتهاب الدماغ الياباني، والحصبة، والزمرة المصلية النيسرية السحائية (أ)، والفيروس العجلي، والحصبة الألمانية، والعقدية الرئوية، والحمى الصفراء. وبالمقارنة مع عدم التمنيع، قمنا بوضع نموذج للتكاليف – المحتسبة في عام 2010 بالدولار الأمريكي – للمعالجة التي تم تفاديها وتكاليف النقل وخسائر الإنتاجية لدى مقدمي الرعاية وخسائر الإنتاجية بسبب العجز والوفاة. وقد استخدمنا طريقة التقييم على أساس العمر لتقدير القيمة الاقتصادية والاجتماعية الأوسع للعيش لفترة أطول، في صحة أفضل، نتيجة للحصول على التمنيع. النتائج تشير تقديراتنا إلى أن اللقاحات الممنوحة في الفترة ما بين عامي 2001 و2020 ستؤدي في 73 بلدًا إلى تفادي أكثر من 20 مليون حالة وفاة وتوفير 350 مليار دولار من تكاليف المرض. وستؤدي حالات الوفيات والعجز التي تم تمنيعها باللقاحات خلال العقدين إلى تحقيق مكاسب إنتاجية تستمر مدى الحياة بإجمالي 330 مليار دولار أمريكي و9 مليارات دولار أمريكي على التوالي. وعلى مدى عمر المجموعات الملقحة، فإن نفس عمليات التمنيع ستوفر ما يقدر بـ 5 مليارات دولار في تكاليف العلاج. وتُقدر القيمة الاقتصادية والاجتماعية الأوسع لهذه اللقاحات بمبلغ 820 مليار دولار أمريكي. الاستنتاج من خلال منع التكاليف الباهظة واحتمال زيادة الإنتاجية الاقتصادية بين بعض أفقر بلدان العالم، فإن أثر التمنيع يتخطى مجرد تحقيق منافع صحية.评估 2001 到 2020 年间 73 个中低收入国家通过针对 10 种疫苗可预防疾病进行疫苗接种可能实现的经济影响。评估主要由全球疫苗联盟 (Gavi) 提供支持。.我们使用健康影响模型评估了实现预期的我们估计 2001 年到 2020 年间,73 个国家的疫苗接种将避免超过 2000 万人的死亡数和节省 3500 亿美元的疾病成本。 二十年间通过疫苗接种避免的死亡和残疾数预计将分别带来总额为 3300 亿美元和 90 亿美元的终身生产力收益。 在接种疫苗人群的一生中接种同种疫苗预计会节省 50 亿的治疗成本。 预计此类疫苗接种的更广泛经济和社会价值达 8200 亿美元。.通过减少世界上一些最贫穷国家的重大开支和提高潜在的经济生产力,免疫接种的影响远不止在卫生领域。.Оценить экономические последствия, которые могут быть достигнуты благодаря усилиям в области вакцинации против 10 предупреждаемых вакцинацией болезней, в период с 2001 по 2020 г. в 73 странах с низким и средним уровнем дохода, которые в значительной степени поддерживаются ГАВИ (Глобальным альянсом по вакцинам и иммунизации).Мы использовали модели воздействия на здоровье для оценки экономических последствий достижения прогнозируемых покрытий вакцинацией против таких возбудителей инфекций, как Haemophilus influenzae типа b, вирус гепатита B, вирус папилломы человека, вирус японского энцефалита, вирус кори, Neisseria meningitidis серогруппы A, ротавирус, вирус краснухи, Streptococcus pneumoniae и вирус желтой лихорадки. При сравнении с отсутствием вакцинации мы моделировали затраты, выраженные в долларах США (US $) по курсу 2010 года: предотвращение расходов на лечение, транспортных расходов, нетрудоспособности лиц, ухаживающих за детьми, и нетрудоспособности из-за инвалидности и смерти. Мы использовали метод, основанный на ценности одного года жизни, чтобы оценить более широкую экономическую и социальную ценность более долгой жизни и лучшего состояния здоровья, достигнутых в результате иммунизации.Мы подсчитали, что в 73 странах вакцинации, проведенные в период с 2001 по 2020 г., предотвратят более 20 миллионов смертей и позволят сэкономить 350 миллиардов долларов США на затратах, связанных с болезнями. Смертность и инвалидность, предотвращенные с помощью вакцинации, проведенной в течение двух десятилетий, приведут к ожидаемому росту производительности труда на протяжении всей жизни на общую сумму 330 миллиардов долларов США и 9 миллиардов долларов США соответственно. В течение жизни вакцинированных когорт те же вакцинации позволят сэкономить приблизительно 5 миллиардов долларов США на расходах на лечение. Более широкая экономическая и социальная ценность этих вакцинаций оценивается в 820 миллиардов долларов США.Предотвращая значительные издержки и потенциально увеличивая экономическую производительность среди некоторых беднейших стран мира, влияние иммунизации выходит далеко за пределы здоровья.

Equity monitoring is a priority for Gavi, the Vaccine Alliance, and for those implementingLe suivi de l'équité est une priorité pour Gavi, l'Alliance du Vaccin et pour ceux qui mettent en œuvre leLa supervisión de la equidad es una prioridad para la Gavi, la Vaccine Alliance y para los que implementan la Agenda 2030 para el Desarrollo Sostenible. Para su nueva fase de operaciones, la Gavi reevaluó su enfoque para supervisar la equidad en la cobertura de vacunación. Para ayudar a informar este esfuerzo, se realizó un análisis sistemático de desigualdades en la cobertura de vacunación en 45 países apoyados por la Gavi y se compararon los resultados desde distintos enfoques de medición. En base a los resultados, se formularon recomendaciones para el enfoque de supervisión de equidad de la Gavi. El enfoque implicó la definición de las poblaciones vulnerables, la selección de las medidas adecuadas para cuantificar las desigualdades y la definición de las referencias de equidad que reflejan las ambiciones de la agencia de desarrollo sostenible. En este artículo, se explican los motivos de las recomendaciones y el desarrollo de una herramienta mejorada de supervisión de la equidad. El anterior enfoque de la Gavi para la medición de la equidad era la diferencia de la cobertura de vacunación entre los sectores demográficos más ricos y más pobres de un país. Además del índice patrimonial, se recomienda supervisar otras dimensiones de vulnerabilidad (educación de la madre, lugar de residencia, sexo de los niños y el índice de pobreza multidimensional). Para las dimensiones con múltiples subgrupos, deberían utilizarse medidas de desigualdad que tienen en cuenta información acerca de todos los subgrupos. También se recomienda que, con el paso del tiempo, se haga un seguimiento tanto de la medida de desigualdad absoluta como relativa. Por último, se propone que las referencias de equidad tengan como objetivo la eliminación completa de la desigualdad. Para facilitar la supervisión de la equidad, se recomienda utilizar una herramienta de indicación de datos (el tablero de equidad) para apoyar la toma de decisiones durante el periodo de desarrollo sostenible. Se destacan sus ventajas básicas utilizando datos de Côte d’Ivoire y de Haití.تعد عملية رصد تحقيق المساواة في التغطية التطعيمية من أهم أولويات التحالف العالمي للقاحات والتحصين (Gavi) لإنتاج الأمصال والقائمين على تطبيق جدول أعمال التنمية المستدامة لعام 2030. وقام التحالف العالمي للقاحات والتحصين بإعادة تقييم استراتيجيته للمرحلة الجديدة لضمان تحقيق المساواة في التغطية التطعيمية. وللمساعدة في تحقيق تلك المهمة قمنا بإجراء تحليل منهجي للفروقات في التغطية التطعيمية بين 45 دولة تدعم الاتحاد ومقارنة نتائج القياس المختلفة. كما قمنا بصياغة توصيات لاستراتيجية الاتحاد المتعلقة برصد عملية المساواة في التغطية التطعيمية من واقع النتائج التي توصلنا إليها. وتشمل تلك الاستراتيجية تحديد الشرائح الاجتماعية الهشة واتخاذ الإجراءات المناسبة وقياس الفروقات في التغطية التطعيمية وتحديد معايير المساواة التي تعكس طموحات جدول أعمال التنمية المستدامة. وسوف نقوم ضمن هذا المقال بشرح الأساس المنطقي لتلك التوصيات وتطوير أداة رصد تحقيق المساواة في التغطية التطعيمية. كانت الاستراتيجية السابقة التي كان الاتحاد ينتهجها تقوم على أساس الاختلافات في التغطية التطعيمية بين الفئات الخمسية السكانية الغنية والفقيرة داخل الدولة الواحدة. ونوصي برصد الزوايا الأخرى الهشة والضعيفة (تعليم الأمهات ومكان الإقامة وجنس الطفل ومؤشر الفقر متعدد الجوانب) إلى جانب مؤشر الثروة. وينبغي الاعتماد على مؤشرات قياس عدم المساواة التي تراعي المعلومات المتعلقة بجميع الفئات الفرعية وذلك لمتابعة الجوانب التي تضم مجموعات ثانوية متعددة. كما نوصي أيضًا برصد مؤشرات قياس عدم المساواة المطلقة والنسبية بمرور الوقت. وأخيرًا نقترح أن تهدف معايير المساواة إلى إنهاء الفروقات في التغطية التطعيمية بشكل تام. ولتسهيل عملية رصد تحقيق المساواة في التغطية التطعيمية، فإننا نوصي باستخدام أداة عرض البيانات المعروفة باسم "لوحة متابعة الاستفادة من الحقوق" لدعم اتخاذ القرارات خلال فترة التنمية المستدامة. ونقوم بتسليط الضوء على مزاياها الرئيسية باستخدام البيانات المأخوذة من كوت ديفوار وهايتي.公平性监测是全球疫苗免疫联盟 (Gavi) 以及实施Контролирование равномерности вакцинации — это приоритет для GAVI (Global Alliance for Vaccines and Immunisation — Глобальный альянс по вакцинам и иммунизации) и для всех, кто участвует в реализации

Vaccination is the centerpiece of preventive care of the well child. Vaccination has been one of the singular public health successes of the past half century, and its full potential remains unrealized. Pneumonia and diarrhea, two of the leading causes of child mortality, account for approximately 1.4 million deaths annually (Liu and others 2016); vaccination with currently available vaccines has the potential to prevent 59 percent of pneumonia-related deaths and 29 percent of diarrhea-related deaths (Fischer Walker, Munos, and Black 2013). Other leading causes of childhood deaths are already preventable through available and effective vaccines, such as measles and meningitis, and other diseases, such as malaria, may become vaccine preventable in the near future (Agnandji and others 2011; Liu and others 2012). Forecasts for vaccine use in the 73 countries supported by Gavi, the Vaccine Alliance, project that 17.7 million deaths will be averted in children under age five years as a result of vaccinations administered from 2011 to 2020 (Lee and others 2013). Childhood vaccination contributed greatly to progress made toward achieving the fourth United Nations Millennium Development Goal, a two-thirds reduction in childhood mortality between 1990 and 2015 (UN 2015), and the centerpiece of several other major global initiatives (PHR 2014; WHO 2012a). Vaccination is central to the health goal included in the post-2015 Sustainable Development Goals, which is on a critical pathway to delivering on its targets.In addition to the clear health benefits, vaccination has been one of the most cost-effective public health interventions (Brenzel and others 2006; WHO, UNICEF, and World Bank 2002). Based on 2001 data, the cost per death averted through routine vaccination with the six original antigens in the Expanded Program on Immunization (EPI) was US$205 in South Asia and Sub-Saharan Africa; estimated cost per disability-adjusted life year (DALY) averted was US$7 to US$16 (Brenzel and others 2006). New vaccines, although more expensive, have also been determined to be cost-effective in Gavi-eligible countries (Atherly and others 2012; Sinha and others 2007) (see box 10.1).This chapter describes the epidemiology and burden of vaccine-preventable diseases and provides estimates of the value of vaccines in health impact as well as broader economic benefits. The focus is on vaccination of infants during routine well-child visits and not on other important vaccines for older children and young adults, such as human papillomavirus vaccine, typhoid vaccine, and dengue vaccines.

A randomized controlled trial of four interventions was conducted using tubewells (n=2,486), liquid sodium hypochlorite (‘Clorin’) distributed with an improved water vessel (n=2,305), hygiene promotion (n=1,877), and a combination of the three (n=2,040) to create an evidence-base for water policy in Afghanistan. A fifth group served as a control (n=2,377). Interventions were randomized across 32 villages in Wardak province. Outcomes were measured through two household surveys separated by one year and twice-weekly household surveillance conducted over 16 months. The households receiving all three interventions showed reduction in diarrhoea compared with the control group, through both longitudinal surveillance data (IRR [95% CI]=0.61 [0.47–0.81]) and cross-sectional survey data (AOR [95% CI]=0.53 [0.30–0.93]). This reduction was significant when all household members were included, but did not reach significance when only children under five were considered. These results suggest multi-barrier methods are necessary where there are many opportunities for water contamination. Surveillance data suggested a greater impact of interventions on reducing diarrhoeal diseases than data from the surveys. Higher economic status as measured through household assets was associated with lower rates of diarrhoea and greater intervention uptake, excepting Clorin. Use of soap was also associated with lower prevalence of diarrhoea.

Objectives: An assessment of provincial hospitals in Afghanistan was carried out in 2007 to measure performance against the national standards and guidelines in the Essential Package of Hospital Services. Methods: Assessment instruments were developed through consultation with the Ministry of Public Health and key stakeholders. Teams of six persons spent three days at each of the 30 provincial hospitals. Results are displayed using a balanced score card approach. Results: Considerable variation exists across hospitals. Administrative management domains, patient satisfaction and community involvement tended to be higher scoring. Financial systems, quality and safety, and ethics and value domains and indicators were lower. Discussion: This assessment demonstrates a wide range of performance of provincial hospitals nationally. This may reflect the diversity of funding, funding levels, and characteristics of facilities. Despite these challenges the level of performance in many hospitals is surprisingly good. Conclusion: Assessment of hospital performance when displayed using the balanced score card approach can provide meaningful information for policy formulation and assist hospital management in improvement of services.

As Afghanistan rebuilds its health system, it faces key challenges in financing health services. To reduce dependence on donor funds, it is important to develop sustainable local financing mechanisms. A second challenge is to reduce high levels of out-of-pocket payments. Community-based health insurance (CBHI) schemes offer the possibility of raising revenues from communities and at the same time providing financial protection. This paper describes the performance of one type of CBHI scheme, the Community Health Fund (CHF), which was piloted for the first time in five provinces of Afghanistan between June 2005 and October 2006. The performance of the CHF programme demonstrates that complex community-based health financing schemes can be implemented in post-conflict settings like Afghanistan, except in areas of high insecurity. The funds raised from the community, via premiums and user fees, enabled the pilot facilities to overcome temporary shortages of drugs and supplies, and to conduct outreach services via mobile clinics. However, enrolment and cost-recovery were modest. The median enrolment rate for premium-paying households was 6% of eligible households in the catchment areas of the clinics. Cost recovery rates ranged up to 16% of total operating costs and 32% of non-salary operating costs. No evidence of reduced out-of-pocket health expenditures was observed at the community level, though CHF members had markedly higher utilization of health services. The main reasons among non-members for not enrolling were being unaware of the programme; high premiums; and perceived low quality of services at the CHF clinics. The performance of Afghanistan's CHF was similar to other CHF-type programmes operating at the primary care level internationally. The solution to building local capacity to finance health services lies in a combination of financing sources rather than any single mechanism. In this context, it is critical that international assistance for Afghanistan's health sector continues.

This paper analyses the effect of wealth status on care-seeking patterns and health expenditures in Afghanistan, based on a national household survey conducted within public health facility catchment areas. We found high rates of reported care-seeking, with more than 90% of those ill seeking care. Sick individuals from all wealth quintiles had high rates of care-seeking, although those in the wealthiest quintile were more likely to seek care than those from the poorest (odds ratio 2.2; 95% CI 1.6, 3.0). The nearest clinic providing the government's Basic Package of Health Services (BPHS) was the most commonly sought first provider (53% overall), especially for relatively poor households (62% in poorest vs. 42% in least poor quintile, P < 0.0001). Sick individuals from wealthier quintiles used hospitals and for-profit private providers more than those in poorer quintiles. Multivariate analysis showed that wealth quintile was the strongest predictor of seeking care, and of going first to private providers. More than 90% of those seeking care paid money out-of-pocket. Mean (median) expenditures among those paying for care in the previous month were 873 Afghanis (200 Afghanis), equivalent to US$17.5 (US$4). Expenditures were lowest at BPHS clinics and highest at private providers. Financing care through borrowing money or selling assets/land ('any distress' financing) was reported in nearly 30% of cases and was almost twice as high among households in the poorest versus the least poor quintile (P < 0.0001). Financing care through selling assets/land ('severe distress' financing) was less common (10% overall) and did not differ by wealth status. These findings indicate that BPHS facilities are being used by the poor who live close to them, but further research is needed to assess utilization among populations in more remote areas. The high out-of-pocket health expenditures, particularly for private sector services, highlight the need to develop financial protection mechanisms in Afghanistan.

Objective. To identify factors associated with service quality provided by agencies implementing a basic package of health services in Afghanistan. Design. Cross-sectional survey of outpatient health facilities, health workers, patients and caretakers. Setting. Primary health care facilities in every province of Afghanistan. Main outcome measures. Composite scale measuring the quality of clinical processes in four areas: patient histories, physical examinations, communication and time spent with patient. Results. No difference in service quality was observed between male and female providers or between male and female patients, but when both the provider and patient were female quality was much higher. Overall, the quality of care at nongovernmental organization and government-managed health facilities did not differ, but the poor received higher quality care at non-governmental facilities than at government facilities. Doctors provided higher quality care than lower level providers. Provision of six or more supervisory visits in the last 6 months was associated with higher service quality. Training doctors in integrated management of childhood illness was not associated with quality, but when lower level health workers received such training the quality of patient – provider communication was higher. Other recurrent inputs and geographic remoteness are not associated with the quality of care provided. Conclusions. The government’s strategy to form partnerships with non-governmental organizations has led to higher quality of care provided to the poor. This represents a promising start in the reconstruction of Afghanistan’s health system and provides useful evidence to other countries striving to increase access to quality care for the poor.

Objective. To identify factors associated with client perceptions of the quality of primary care services in Afghanistan. Design. Cross-sectional survey of outpatient health facilities, health workers, patients and caretakers. Setting. Primary health care facilities in every province of Afghanistan. Main outcome measure. Numerical scale of client perceptions of service quality. Results. Clients report relatively high levels of perceived quality in Afghanistan. Most of the variation that is explained relates specifically to the patient’s interaction with the health worker and not to other health facility characteristics, such as cleanliness, infrastructure, service capacity and the presence of equipment or drugs. The strongest determinants of client-perceived quality identified are health worker thoroughness in taking patient histories, conducting physical examinations and communicating with patients. Being seen by a doctor and being from a household in the poorest quintile are also associated with higher perceived quality. For female patients, being seen by a female provider is associated with higher perceived quality, while for male patients time and money spent for travel to the health facility are negatively associated with perceived quality. Conclusions. Clinical quality and client perceived quality appear to be mutually reinforcing, and efforts to improve health worker performance in taking histories, conducting exams and communicating with patients are likely to increase client perceived quality in this setting. Client perceptions of service quality assume additional importance in Afghanistan, where the perceived legitimacy of the government may depend partially on its ability to convince the population that it can deliver essential health services.

SUMMARY The Ministry of Public Health (MOPH) of Afghanistan has adopted the Balanced Scorecard (BSC) as a tool to measure and manage performance in delivery of a Basic Package of Health Services. Based on results from the 2004 baseline round, the MOPH identified eight of the 29 indicators on the BSC as priority areas for improvement. Like the 2004 round, the 2005 and 2006 BSCs involved a random selection of more than 600 health facilities, 1700 health workers and 5800 patient-provider interactions. The 2005 and 2006 BSCs demonstrated substantial improvements in all eight of the priority areas compared to 2004 baseline levels, with increases in median provincial scores for presence of active village health councils, availability of essential drugs, functional laboratories, provider knowledge, health worker training, use of clinical guidelines, monitoring of tuberculosis treatment, and provision of delivery care. For three of the priority indicators—drug availability, health worker training and provider knowledge—scores remained unchanged or decreased between 2005 and 2006. This highlights the need to ensure that early gains achieved in establishment of health services in Afghanistan are maintained over time. The use of a coherent and balanced monitoring framework to identify priority areas for improvement and measure performance over time reflects an objectives-based approach to management of health services that is proving to be effective in a difficult environment. Copyright # 2008 John Wiley & Sons, Ltd.

Summary Background Immunisation programmes have made substantial contributions to lowering the burden of disease in children, but there is a growing need to ensure that programmes are equity-oriented. We aimed to provide a detailed update about the state of between-country inequality and within-country economic-related inequality in the delivery of three doses of the combined diphtheria, tetanus toxoid, and pertussis-containing vaccine (DTP3), with a special focus on inequalities in high-priority countries. Methods We used data from the latest available Demographic and Health Surveys and Multiple Indicator Cluster Surveys done in 51 low-income and middle-income countries. Data for DTP3 coverage were disaggregated by wealth quintile, and inequality was calculated as difference and ratio measures based on coverage in richest (quintile 5) and poorest (quintile 1) household wealth quintiles. Excess change was calculated for 21 countries with data available at two timepoints spanning a 10 year period. Further analyses were done for six high-priority countries—ie, those with low national immunisation coverage and/or high absolute numbers of unvaccinated children. Significance was determined using 95% CIs. Findings National DTP3 immunisation coverage across the 51 study countries ranged from 32% in Central African Republic to 98% in Jordan. Within countries, the gap in DTP3 immunisation coverage suggested pro-rich inequality, with a difference of 20 percentage points or more between quintiles 1 and 5 for 20 of 51 countries. In Nigeria, Pakistan, Laos, Cameroon, and Central African Republic, the difference between quintiles 1 and 5 exceeded 40 percentage points. In 15 of 21 study countries, an increase over time in national coverage of DTP3 immunisation was realised alongside faster improvements in the poorest quintile than the richest. For example, in Burkina Faso, Cambodia, Gabon, Mali, and Nepal, the absolute increase in coverage was at least 2·0 percentage points per year, with faster improvement in the poorest quintile. Substantial economic-related inequality in DTP3 immunisation coverage was reported in five high-priority study countries (DR Congo, Ethiopia, Indonesia, Nigeria, and Pakistan), but not Uganda. Interpretation Overall, within-country inequalities in DTP3 immunisation persist, but seem to have narrowed over the past 10 years. Monitoring economic-related inequalities in immunisation coverage is warranted to reveal where gaps exist and inform appropriate approaches to reach disadvantaged populations. Funding None.

The large observed redshift of quasars has suggested large cosmological distances and a corresponding enormous energy output to explain the brightness or luminosity as seen at earth. Alternative or complementary sources of redshift have not been identified by the astronomical community. This study examines one possible source of additional redshift: an intrinsic component based on the plasma characteristics of high temperature and high electron density which are believed to be present., 11 pages; 9 figures

Astronomical or cosmological redshifts are an observable property of extragalactic objects and have historically been wholly attributed to the recessional velocity of that object. The question of other, or intrinsic, components of the redshift has been highly controversial since it was first proposed. This paper investigates one theoretical source of intrinsic redshift that has been identified. The highly ionized regions of Active Galactic Nuclei (AGN) and Quasi-Stellar Objects (QSO) are, by definition, plasmas. All plasmas have electromagnetic scattering characteristics that could contribute to the observed redshift. To investigate this possibility, one region of a generalized AGN was selected, the so called Broad Line Region (BLR). Even though unresolvable with current instrumentation, physical estimates of this region have been published for years in the astronomical literature. These data, selected and then averaged, are used to construct an overall model that is consistent with the published data to within an order of magnitude. The model is then subjected to a theoretical scattering investigation. The results suggest that intrinsic redshifts, derivable from the characteristics of the ambient plasma, may indeed contribute to the overall observed redshift of these objects., Comment: 24 pages; 8 figures

Introduction From August to December 2011, a multidisciplinary group with expertise in mathematical modeling was constituted by the GAVI Alliance and the Bill & Melinda Gates Foundation to estimate the impact of vaccination in 73 countries supported by the GAVI Alliance. Methods The number of deaths averted in persons projected to be vaccinated during 2011–2020 was estimated for ten antigens: hepatitis B, yellow fever, Haemophilus influenzae type B (Hib), Streptococcus pneumoniae , rotavirus, Neisseria meningitidis serogroup A, Japanese encephalitis, human papillomavirus, measles, and rubella. Impact was calculated as the difference in the number of deaths expected over the lifetime of vaccinated cohorts compared to the number of deaths expected in those cohorts with no vaccination. Numbers of persons vaccinated were based on 2011 GAVI Strategic Demand Forecasts with projected dates of vaccine introductions, vaccination coverage, and target population size in each country. Results By 2020, nearly all GAVI-supported countries with endemic disease are projected to have introduced hepatitis B, Hib, pneumococcal, rotavirus, rubella, yellow fever, N. meningitidis serogroup A, and Japanese encephalitis-containing vaccines; 55 (75 percent) countries are projected to have introduced human papillomavirus vaccine. Projected use of these vaccines during 2011–2020 is expected to avert an estimated 9.9 million deaths. Routine and supplementary immunization activities with measles vaccine are expected to avert an additional 13.4 million deaths. Estimated numbers of deaths averted per 1000 persons vaccinated were highest for first-dose measles (16.5), human papillomavirus (15.1), and hepatitis B (8.3) vaccination. Approximately 52 percent of the expected deaths averted will be in Africa, 27 percent in Southeast Asia, and 13 percent in the Eastern Mediterranean. Conclusion Vaccination of persons during 2011–2020 in 73 GAVI-eligible countries is expected to have substantial public health impact, particularly in Africa and Southeast Asia, two regions with high mortality. The actual impact of vaccination in these countries may be higher than our estimates because several widely used antigens were not included in the analysis. The quality of our estimates is limited by lack of data on underlying disease burden and vaccine effectiveness against fatal disease outcomes in developing countries. We plan to update the estimates annually to reflect updated demand forecasts, to refine model assumptions based on results of new information, and to extend the analysis to include morbidity and economic benefits.

After the fall of the Taliban regime, most clinics in Afghanistan were charging fees to patients. The government invested in monitoring and evaluation systems for its newly rebuilt primary care system, but little was known about the effects of user fees. This study was undertaken to provide evidence on user fees' effects on quality and service utilization and to help inform development of health financing policy and strategy.A quasi-experimental health financing pilot study was implemented in 2005. Forty-seven facilities were randomized to implement a standardized user fee intervention, offer free services, or serve as controls, continuing current cost-sharing systems. Revenues were co-managed by staff and community leaders for facility improvement. Baseline and follow-up facility assessments, exit interviews, and household surveys, as well as routine data were used to evaluate user fee effects over 2 years.Observed and perceived quality improved at most facilities but did not differ by study group. Utilization increased in all groups, but the increase was 682 to 748 visits per month larger in facilities randomized to free services compared with those randomized to fees or controls (p 0.01).User fees demonstrated few beneficial effects and slowed the rate of increase of service utilization in Afghanistan. In 2008, the government abolished primary care fees, citing results of this study.

BackgroundHealth services were severely affected during the many years of instability and conflict in Afghanistan. In recent years, substantial increases in the coverage of reproductive health services have been achieved, yet absolute levels of coverage remain very low, especially in rural areas. One strategy for increasing use of reproductive health services is deploying community health workers (CHWs) to promote the use of services within the community and at health facilities.MethodsUsing a multilevel model employing data from a cross-sectional survey of 8320 households in 29 provinces of Afghanistan conducted in 2006, this study determines whether presence of a CHW in the community leads to an increase in use of modern contraceptives, skilled antenatal care and skilled birth attendance. This study further examines whether the effect varies by the sex of the CHW.ResultsResults show that presence of a female CHW in the community is associated with higher use of modern contraception, antenatal care services and skilled birth attendants but presence of a male CHW is not. Community-level random effects were also significant.ConclusionsThis study provides evidence that indicates that CHWs can contribute to increased use of reproductive health services and that context and CHW sex are important factors that need to be addressed in programme design.

Objective. To determine the quality of outpatient hospital care for children under 5 years in Afghanistan. Design. Case management observations were conducted on 10 – 12 children under five selected by systematic random sampling in 31 outpatient hospital clinics across the country, followed by interviews with caretakers and providers. Main Outcome Measures. Quality of care defined as adherence to the clinical standards described in the Integrated Management of Childhood Illness. Results. Overall quality of outpatient care for children was suboptimal based on patient examination and caretaker counseling (median score: 27.5 on a 100 point scale). Children receiving care from female providers had better care than those seen by male providers (OR: 6.6, 95% CI: 2.0 – 21.9, P ¼ 0.002), and doctors provided better quality of care than other providers (OR: 2.7, 95% CI: 1.1 – 6.4, P ¼ 0.02). The poor were more likely to receive better care in hospitals managed by non-governmental organizations than those managed by other mechanisms (OR: 15.2, 95% CI: 1.2 –200.1, P ¼ 0.04). Conclusions. Efforts to strengthen optimal care provision at peripheral health clinics must be complemented with investments at the referral and tertiary care facilities to ensure care continuity. The findings of improved care by female providers, doctors and NGO’s for poor patients, warrant further empirical evidence on care determinants. Optimizing care quality at referral hospitals is one of the prerequisites to ensure service utilization and outcomes for the achievement of the Child health Millennium Development Goals for Afghanistan.

OBJECTIVE: To examine historical estimates of infant and under-five mortality in Afghanistan, provide estimates for rural areas from current population-based data, and discuss the methodological challenges that undermine data quality and hinder retrospective estimations of mortality. METHODS: Indirect methods of estimation were used to calculate infant and under-five mortality from a household survey conducted in 2006. Sex-specific differences in underreporting of births and deaths were examined and sensitivity analyses were conducted to assess the effect of underreporting on infant and under-five mortality. FINDINGS: For 2004, rural unadjusted infant and under-five mortality rates were estimated to be 129 and 191 deaths per 1000 live births, respectively, with some evidence indicating underreporting of female deaths. If adjustment for underreporting is made (i.e. by assuming 50% of the unreported girls are dead), mortality estimates go up to 140 and 209, respectively. CONCLUSION: Commonly used estimates of infant and under-five mortality in Afghanistan are outdated; they do not reflect changes that have occurred in the past 15 years or recent intensive investments in health services development, such as the implementation of the Basic Package of Health Services. The sociocultural aspects of mortality and their effect on the reporting of births and deaths in Afghanistan need to be investigated further.

Afghanistan has used several approaches to contracting as part of its national strategy to increase access to basic health services. This study compares changes in the utilization of outpatient curative services from 2004 to 2005 between the different approaches for contracting-out services to non-governmental service providers, contracting-in technical assistance at public sector facilities, and public sector facilities that did not use contracting. We find that both contracting-in and contracting-out approaches are associated with substantial double difference increases in service use from 2004 to 2005 compared with non-contracted facilities. The double difference increase in contracting-out facilities for outpatient visits is 29% (P < 0.01), while outpatient visits from female patients increased 41% (P < 0.01), use by the poorest quintile increased 68% (P < 0.01) and use by children aged under 5 years increased 27% (P < 0.05). Comparing the individual contracting-out approaches, we find similar increases in outpatient visits when contracts are managed directly by the Ministry of Public Health compared with when contracts are managed by an experienced international non-profit organization. Finally, contracting-in facilities show even larger increases in all the measures of utilization other than visits from children under 5. Although there are minor differences in the results between contracting-out approaches, these differences cannot be attributed to a specific contracting-out approach because of factors limiting the comparability of the groups. It is nonetheless clear that the government was able to manage contracts effectively despite early concerns about their lack of experience, and that contracting has helped to improve utilization of basic health services.

The Ministry of Public Health (MOPH) in Afghanistan has developed a balanced scorecard (BSC) to regularly monitor the progress of its strategy to deliver a basic package of health services. Although frequently used in other health-care settings, this represents the first time that the BSC has been employed in a developing country. The BSC was designed via a collaborative process focusing on translating the vision and mission of the MOPH into 29 core indicators and benchmarks representing six different domains of health services, together with two composite measures of performance. In the absence of a routine health information system, the 2004 BSC for Afghanistan was derived from a stratified random sample of 617 health facilities, 5719 observations of patient-provider interactions, and interviews with 5597 patients, 1553 health workers, and 13 843 households. Nationally, health services were found to be reaching more of the poor than the less-poor population, and providing for more women than men, both key concerns of the government. However, serious deficiencies were found in five domains, and particularly in counselling patients, providing delivery care during childbirth, monitoring tuberculosis treatment, placing staff and equipment, and establishing functional village health councils. The BSC also identified wide variations in performance across provinces; no province performed better than the others across all domains. The innovative adaptation of the BSC in Afghanistan has provided a useful tool to summarize the multidimensional nature of health-services performance, and is enabling managers to benchmark performance and identify strengths and weaknesses in the Afghan context.

The private health sector provides a significant portion of sexual and reproductive health (SRH) services in developing countries. Yet little is known about which strategies for intervening with private providers can improve quality or coverage of services. We conducted a systematic review of the literature through PubMed from 1980 to 2003 to assess the effectiveness of private sector strategies for SRH services in developing countries. The strategies examined were regulating, contracting, financing, franchising, social marketing, training and collaborating. Over 700 studies were examined, though most were descriptive papers, with only 71 meeting our inclusion criteria of having a private sector strategy for one or more SRH services and the measurement of an outcome in the provider or the beneficiary. Nearly all studies (96%) had at least one positive association between SRH and the private sector strategy. About three-quarters of the studies involved training private providers, though combinations of strategies tended to give better results. Maternity services were most commonly addressed (55% of studies), followed by prevention and treatment of sexually transmitted diseases (32%). Using study design to rate the strength of evidence, we found that the evidence about effectiveness of private sector strategies on SRH services is weak. Most studies did not use comparison groups, or they relied on cross-sectional designs. Nearly all studies examined short-term effects, largely measuring changes in providers rather than changes in health status or other effects on beneficiaries. Five studies with more robust designs (randomized controlled trials) demonstrated that contraceptive use could be increased through supporting private providers, and showed cases where the knowledge and practices of private providers could be improved through training, regulation and incentives. Although tools to work with the private sector offer considerable promise, without stronger research designs, key questions regarding their feasibility and impact remain unanswered.

This paper presents the findings of a study to assess the effectiveness and sustainability of a GAVI (Global Alliance of Vaccines and Immunization) sponsored, time-limited Injection Safety (INS) support. The support came in two forms: 1) in-kind, in the form of AD syringes and safety boxes, and 2) in cash, for those countries that already had a secure, multi-year source of AD syringes and safety boxes, but proposed to use INS support to strengthen their injection safety activities. In total, GAVI gave INS support for a three-year period to 58 countries: 46 with commodities and 12 with cash support. To identify variables that might be associated with financial sustainability, frequencies and cross-tabulations were run against various programmatic and socio-economic variables in the 58 countries. All but two of the 46 commodity-recipient countries were able to replace and sustain the use of AD syringes and safety boxes after the end of their GAVI INS support despite the fact that standard disposable syringes are less costly than ADs (10-15 percent differential). In addition, all 12 cash-recipient countries continued to use AD syringes and safety boxes in their immunization programs in the years following GAVI INS assistance. At the same time, countries were often not prepared for the increased waste management requirements associated with the use of the syringes, suggesting the importance of anticipating challenges with the introduction of new technologies. The sustained use of AD syringes in countries receiving injection safety support from GAVI, in a majority of cases through government financing, following the completion of three years of time-limited support, represents an early indication of how GHPs can contribute to improved health outcomes in immunization safety in the world's poorest countries in a sustainable way.