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In 2016, the Gavi Cold Chain Equipment Optimization Platform (CCEOP) was approved and launched in recognition of the fact that functional cold chain equipment (CCE) is essential to strengthening vaccine supply chains and ultimately achieving Gavi's immunization equity and coverage goals. Through CCEOP, Gavi committed to investing US$250 million between 2016 and 2021 to commission CCE in more than 63,000 facilities to upgrade and expand their CCE footprint while stimulating the market to provide affordable, technologically advanced, and accessible equipment. We present case studies from Guinea and Kenya, both of which received CCEOP support, that highlight 2 ways for countries to prioritize investments and implement activities through a large funding and support mechanism. The studies explore the different ways that each country implemented CCEOP and consider how aspects of leadership and technical capacity influence country priorities and results. They also uncover key lessons on sustainability of a large immunization supply chain effort. The experiences of Guinea and Kenya can help other countries embarking on similarly large health system interventions, especially related to supply chain strengthening and immunization programs. In particular, these experiences offer important lessons in leadership, processes and systems, country ownership, technical capacity, and sustainability.

Background In 2014, Gavi and partners developed a global Immunization Supply Chain (iSC) Strategy, 2015–2020, which prioritized functioning cold chain equipment (CCE) and additional storage capacity. In 2016, Gavi launched the Cold Chain Equipment Optimization Platform (CCEOP) as a funding mechanism to improve CCE availability. In 2018, Gavi commissioned an evaluation of CCEOP in Guinea, Kenya and Pakistan. The global iSC Strategy has recently been revised, drawing on findings from effective vaccine management assessments and practical experiences. This case study presents the CCEOP evaluation and how its findings reinforced the revision of the iSC strategy. Methods The CCEOP evaluation used a prospective mixed-methods research design in all three countries involving key informant interviews at multiple levels of the health system, document reviews, direct observation (as and when possible), and a health facility assessment. Results Results show that CCEOP was effective at increasing the number of available and reliable CCE, and establishing improved management processes using the project management team (PMT) approach for country management systems and the service bundle provider approach for installation and maintenance. CCEOP also extended the iSC and immunization services in countries. The evaluation results also show gaps in the overall supply chain system, including CCE maintenance. Discussion Gavi has recently revised its iSC strategy, which has addressed gaps identified through assessments and practical experiences from stakeholders. Results of the CCEOP evaluation reinforce many of these findings. The strategy now provides more emphasis on supporting the fundamental infrastructure and establishing strong processes for maintenance. It also emphasizes strategic planning and forward thinking for iSC decisions, building on the processes established for the PMT through CCEOP. The original iSC strategy was an impetus for the establishment of CCEOP. The new strategy reflects shifting trends and priorities to fill gaps identified through practical experience, advocated for by stakeholders and thought leaders engaged in the iSC, and validated by the evaluation. It demonstrates the importance of aligning stakeholders with clear objectives and a sound strategy.

Career advancement and continued education are critical components of health worker motivation and retention. Continuous advancement also builds health system capacity by ensuring that leaders are those with experience and strong performance records. To understand more about the satisfaction, desires, and career opportunities available to community health nurses (CHNs) in Ghana, we conducted 29 in-depth interviews and four focus group discussions across five predominantly rural districts. Interview transcripts and summary notes were coded in NVivo based on pre-defined and emergent codes using thematic content analysis. Frustration with existing opportunities for career advancement and continued education emerged as key themes. Overall, the CHNs desired greater opportunities for career development, as most aspired to return to school to pursue higher-level health positions. While workshops were available to improve CHNs knowledge and skills, they were infrequent and irregular. CHNs wanted greater recognition for their work experience in the form of respect from leaders within the Ghana Health System and credit towards future degree programs. CHNs are part of a rapidly expanding cadre of salaried community-based workers in sub-Saharan Africa, and information about their experiences and needs can be used to shape future health policy and program planning.

ObjectivesTo describe the prevalence and correlates of depression and anxiety among adult Ebola virus disease (EVD) survivors in Liberia, Sierra Leone and Guinea.DesignCross-sectional.SettingOne-on-one surveys were conducted in EVD-affected communities in Liberia, Sierra Leone and Guinea in early 2018.Participants1495 adult EVD survivors (726 male, 769 female).Primary and secondary outcome measuresPatient Health Questionnaire-9 (PHQ-9) depression scores and Generalised Anxiety Disorder-7 (GAD-7) scores.ResultsPrevalence and severity of depression and anxiety varied across the three countries. Sierra Leone had the highest prevalence of depression, with 22.0% of participants meeting the criteria for a tentative diagnosis of depression, compared with 20.2% in Liberia and 13.0% in Guinea. Sierra Leone also showed the highest prevalence of anxiety, with 10.7% of participants meeting criteria for generalized anxiety disorder (GAD-7 score ≥10), compared with 9.9% in Liberia and 4.2% in Guinea. Between one-third and one-half of respondents reported little interest or pleasure in doing things in the previous 2 weeks (range: 47.0% in Liberia to 37.6% in Sierra Leone), and more than 1 in 10 respondents reported ideation of self-harm or suicide (range: 19.4% in Sierra Leone to 10.4% in Guinea). Higher depression and anxiety scores were statistically significantly associated with each other and with experiences of health facility-based stigma in all three countries. Other associations between mental health scores and respondent characteristics varied across countries.ConclusionsOur results indicate that both depression and anxiety are common among EVD survivors in Liberia, Sierra Leone and Guinea, but that there is country-level heterogeneity in prevalence, severity and correlates of these conditions. All three countries should work to make mental health services available for survivors, and governments and organisations should consider the intersection between EVD-related stigma and mental health when designing programmes and training healthcare providers.

Ambitious efforts to detect and treat tuberculosis (TB) are required to reduce the burden of disease in low resource settings, and the provision of high quality TB services is critical to reaching global TB targets. The quality of TB services assessment (QTSA) is a facility-based approach aimed at identifying gaps in TB services and prioritizing interventions to improve care across multiple countries with high TB burden. Randomly sampled facilities are assessed with standardized instruments to collect data on structures, processes, and outcomes of TB care, with adaption for local diagnostic and treatment algorithms. The sampling strategy is modified to ensure representation of all levels of the health system where TB services are provided, as well as inclusion of private sector or other facility types relevant to the context. Instruments include a facility audit, provider and patient interviews, and a review of TB registers. A recent QTSA in the Philippines generated important data on provider and patient perspectives on quality of care, showing that providers are more likely to report that they counseled current TB patients on key aspects of TB diagnosis and treatment than patients are to report having received the information. These comparisons highlight areas where refresher training or interpersonal communication and counseling skills may be needed. Keywords: Tuberculosis, Quality, Facility, Patient, Provider, Knowledge

Fish living around the coral reefs in the Philippines provide livelihoods for more than a million local fishers and are an important source of protein for coastal communities. However, this rich resource is at risk from myriad threats, which consequently threaten human livelihoods, nutrition, and health. In this paper, we examine the degree to which marine protected areas (MPAs), which aim to conserve marine biodiversity, are associated with improved nutritional outcomes in children under age 5. This analysis, which uses data from the 2008 Philippines Demographic and Health Survey and MPA data from the Coastal Conservation and Education Fund, found a positive association between MPAs and children’s dietary diversity when the MPAs were located closer than 2 km to a child’s community. MPA characteristics such as age or type of management were not consistently associated with dietary diversity. These results suggest a positive association of proximity to MPAs with certain aspects of children’s diet. Electronic supplementary material The online version of this article (doi:10.1007/s11111-015-0240-9) contains supplementary material, which is available to authorized users.

Over the past two decades, multilateral organizations have encouraged increased engagement with private healthcare providers in developing countries. As these efforts progress, there are concerns regarding how private delivery care may effect maternal health outcomes. Currently available data do not allow for an in-depth study of the direct effect of increasing private sector use on maternal health across countries. As a first step, however, we use demographic and health surveys (DHS) data to (1) examine trends in growth of delivery care provided by private facilities and (2) describe who is using the private sector within the healthcare system. As Asia has shown strong increases in institutional coverage of delivery care in the last decade, we will examine trends in six Asian countries. We hypothesize that if the private sector competes for clients based on perceived quality, their clientele will be wealthier, more educated and live in an area where there are enough health facilities to allow for competition. We test this hypothesis by examining factors of socio-demographic, economic and physical access and actual/perceived need related to a mother’s choice to deliver in a health facility and then, among women delivering in a facility, their use of a private provider. Results show a significant trend towards greater use of private sector delivery care over the last decade. Wealth and education are related to private sector delivery care in about half of our countries, but are not as universally related to use as we would expect. A previous private facility birth predicted repeat private facility use across nearly all countries. In two countries (Cambodia and India), primiparity also predicted private facility use. More in-depth work is needed to truly understand the behaviour of the private sector in these countries; these results warn against making generalizations about private sector delivery care.

Using data from the nationally representative Head Start Family and Child Experiences Survey (FACES), the relationships between living in a household where a household member had been arrested or incarcerated and conduct problems of preschool children enrolled in Head Start were examined. Children who lived in such households showed more aggressive, hyperactive, and withdrawn behaviors than children who lived in households with no such exposure. These associations remained statistically significant after controlling for other family background characteristics. Parental involvement in Head Start, less use of spanking, and more time spent by the child in Head Start were associated with less problem behaviors.

In an effort to provide high-quality preschool education, policymakers are increasingly requiring public preschool teachers to have at least a Bachelor's degree, preferably in early childhood education. Seven major studies of early care and education were used to predict classroom quality and children's academic outcomes from the educational attainment and major of teachers of 4-year-olds. The findings indicate largely null or contradictory associations, indicating that policies focused solely on increasing teachers' education will not suffice for improving classroom quality or maximizing children's academic gains. Instead, raising the effectiveness of early childhood education likely will require a broad range of professional development activities and supports targeted toward teachers' interactions with children.

In 2010, 7.6 million children under five died globally – largely due to preventable diseases including pneumonia (14%), diarrhea (10%), and malaria (7%) [1]. Ninety–nine percent of these deaths occurred in low–resource settings and nearly half (47%) in Sub–Saharan Africa in communities where people have limited or no access to life saving interventions and medical supplies. Integrated Community Case Management (iCCM) is a strategy designed to bring care and treatment for childhood pneumonia, diarrhea, and malaria closer home by training community health workers (CHW) in the identification and treatment of common childhood illnesses [2,3]. iCCM involves training CHWs on essential health packages and ensuring that they have the medicines needed to manage and treat illnesses among children under five years of age. Continuous access to these medicines by CHWs requires a well–functioning supply chain across all levels of the health care system. However, the supply chain systems of many resource–constrained countries function poorly and face a myriad of challenges [4], including but not limited to shortage of human resources, weak inventory management, low supply chain skills among health workers, and a lack of data visibility and utilization for sound decision making. In 2008, the Government of Malawi (GoM) initiated iCCM as a strategy to reduce child mortality. The program entailed training an existing cadre of CHWs, known as Health Surveillance Assistants (HSAs) to treat children in the community. HSAs are posted nationwide to serve communities at a ratio of 1:1000 population. By September 2011, 3296 HSAs had been trained in integrated management of childhood illness (IMCI) [5]. With the implementation of the iCCM strategy in Malawi, mortality among children under five years decreased from 225 deaths per 1000 live births in 1990 to 71 per 1000 live births in 2012 [6], and the country is considered on track to achieve Millennium Development Goal (MDG) 4, to reduce child–mortality by two–thirds, by 2015. Despite the gains made towards MDG 4, the health care infrastructure in Malawi still faces challenges, among them weak supply chain systems. This affects continuous health product availability at the community level, consequently undermining the full effectiveness of the iCCM strategy. In order to identify the constraints associated with maintaining regular product availability, Supply Chains for Community Case Management (SC4CCM) in collaboration with the Ministry of Health (MOH), conducted a formative assessment across 10 districts in Malawi (Nkhatabay, Nkhotakota, Mulanje, Kasungu, Nsanje, Machinga, Mzimba North, Zomba, Nchitsi, and Salima) in 2010 [7]. The assessment identified poor availability and limited use of logistics data (ie, low data visibility) across all levels of the health system, low motivation among HSAs and transport challenges such as difficult terrain and long travel time for HSAs to collect products as key barriers to continuous product availability. This assessment identified additional opportunities of using mobile phones to promote data visibility as 89% of the HSAs surveyed had mobile phones, 80% of HSAs and health facility (HF) staff had continuous network coverage at their place of work and all districts surveyed had computers and access to the Internet. The survey also found high levels (80%) of bicycle ownership among the HSAs [7]. To address the identified constraints related to data visibility, motivation and transport, SC4CCM designed and piloted cStock, a mHealth tool for community–level reporting of stock on hand data and resupply of 19 health products managed by HSAs. cStock was nested within two broader interventions, namely, Enhanced Management (EM) and Efficient Product Transport (EPT), to address challenges in motivation of HSAs and transport to the health facilities, respectively. The primary objective of this paper is to assess the feasibility, acceptability, and effectiveness of cStock as a mHealth strategy for improving data visibility and reducing stockouts of health products used at the community level. Additionally, the study will explore the added effects of the team approach deployed through EM in improving supply chain performance. Program description cStock is an SMS and web–based reporting and resupply system that is used by HSAs to report stock data via SMS through their personal mobile phones. cStock calculates HSA resupply quantities and sends this information to HF staff to use to pick and pack products for HSAs and notify them about a collection time. cStock was designed using a consultative, user–centered and iterative process. Potential users at all levels of the health system provided inputs based on their experience with the existing manual reporting and resupply system. Information on the existing flow of data across levels of the health system was combined with inputs from supply chain specialists to ensure the system was based on supply chain best practices. In designing the workflows and dashboard for cStock, an important criterion was to ensure the health care workers and managers at each level would have access to data most relevant to them, at the right time and in a format that could be easily accessed, interpreted and used for decision making. HSAs and HF staff would interact with cStock using SMS messages on their own phones, while district and central level staff would receive alert messages from cStock on their own phones. District and central level staff would use computers to access the web–based dashboard for reports. The dashboard was redesigned six months after implementation so that district and central level users could incorporate their experience interacting with the system into the redesign and prioritize metrics and visuals most useful for their day–to–day operations. cStock is a key component of both the EM and EPT intervention packages. The EM intervention addresses challenges related to data availability and visibility, as well as low motivation among HSAs while the EPT intervention addresses challenges of transport in addition to data visibility. The additional component of the EM intervention was District Product Availability Teams (DPATs). These are multilevel quality improvement teams that use data supplied by cStock to monitor performance of the supply chain and make informed supply chain decisions. In contrast, the additional component of the EPT intervention consisted of training all HSAs on bicycle maintenance, provision of a basic tool kit, and the use of a continuous review inventory control system. HSAs and HF staff in six districts where the project was piloted were trained on the use of cStock for reporting and resupply and used their own phones to register with cStock. Training was conducted using a cascade approach. The project trained a group of trainers consisting of central and district level staff from pilot districts as TOTs and they in turn trained the HSAs, HF and district staff. Both intervention groups were trained over a 2–day period, with one day dedicated to training users on how to register and use cStock. HSAs in the EM group were trained to send reports to cStock using a fixed monthly reporting schedule between the last day of the month and second day of the next month, while those in the EPT group were trained to send reports to cStock at any time during the month when they planned to travel to the HF giving them the flexibility to report and receive product. Once trained, HSAs were provided with job aids to carry back to their facilities and expected to start using cStock immediately. Implementation support for cStock was provided through group messages sent by the system administrator to users to correct common errors, automated messages sent directly by the system to users in response to formatting errors, and field visits made by Ministry and project staff to monitor and reinforce good practices. In designing the interventions, the project identified feasibility and acceptability of cStock as critical components to enhancing uptake and laying the foundation for country ownership and scalability. See Figure 1 for a visual representation of the intervention design. Figure 1 Components of the two intervention groups (EM – Enhanced Management and EPT – Efficient Product Transport). DPAT – district product availability teams.

Alva, Murrugarra, and Paci examine the impact of ethnic segmentation in education on educational outcomes. Between 1991 and the late 1990s, the Albanian Kosovar population received education services in an informal system parallel to the official one. Using the 2000 Kosovo LSMS Survey data, the authors exploit cohort differences in exposure to the parallel system to estimate its effects among Albanian youth. The first (untreated) cohort includes individuals who entered secondary education before 1991 when the "parallel" education system was initiated. The second (treated) cohort includes individuals who entered secondary school in the last ten years under the ethnically segmented education system. To disentangle the effects of the changing system and economic environment, and the changes in the characteristics of the population, a Oaxaca-type decomposition is used. The results suggest that the past decade of ethnic tension has claimed a substantial toll on the educational outcomes of young male Albanian Kosovars. In addition to declines in enrollment rates in secondary education, those who are enrolled are expected to complete one less year of education. However, secondary school enrollment for girls increased during the parallel system, but with a sharp decline in the expected number of years completed. This paper - a product of the Human Development Sector Unit, Europe and Central Asia Region - is part of a larger effort in the region to examine poverty and social service delivery issues.

Background A strong health system requires a competent and caring workforce. A more satisfied and motivated health workforce should be more willing to serve in difficult areas, have lower turnover, and theoretically provide better care to patients. This paper examines the motivation, satisfaction, and correlation with clinical knowledge, of community health nurses (CHNs), a cadre of provider focused on maternal, newborn and child health in rural Ghana. Methods This study employed three methods of evaluation. Two quantitative measurements were used: (1) a survey of health worker satisfaction and motivation and (2) a clinical knowledge assessment focusing on maternal, newborn and child health. Both were administered to all rostered CHNs working in the five sampled districts in the Greater Accra and Volta regions in Eastern Ghana (N = 205). Qualitative interviews (N = 29) and focus group discussions (N = 4) were held with selected CHNs in the same districts. These data were analysed using NVivo (Version 10) and Stata (Version 13.0) based on domains of extrinsic and intrinsic motivation including general satisfaction, work environment and access to resources, respect and recognition received and opportunities for advancement. Results CHNs desired more training, especially those who were posted at the community level (a Community-based Health Planning and Services post or “CHPS”) versus at a health facility. CHNs working at CHPS believed their work to be more difficult than those posted at health facilities, due to challenges associated with foot travel to visit patients at home, and they were more likely to report having insufficient resources to do their jobs (48% vs 36%). However, CHNs posted at health facilities were more likely to report insufficient opportunities for career advancement than the CHPS nurses (49% vs 33%). CHNs generally reported good relationships with colleagues and being respected by patients but desired more respect from supervisors. The median score on the knowledge assessment was 78%. On average, subgroups of CHNs with different reported levels of satisfaction did not perform differently on the knowledge assessment. Conclusions CHNs in Ghana were satisfied overall but desired more training, more guidance and supervision, fair pay and opportunities to advance in their career. Improving health worker satisfaction and morale may be important for health worker retention and certain aspects of care but may not have a significant influence on clinical knowledge or performance.

Using data from the first round of Demographic and Health Surveys for 22 developing countries, we examine the effect of maternal education on three markers of child health: infant mortality, children s height-for-age, and immunization status. In contrast to other studies, we argue that although there is a strong correlation between maternal education and markers of child health, a causal relationship is far from established. Education acts as a proxy for the socioeconomic status of the family and geographic area of residence. Introducing controls for husband’s education and access to piped water and toilet attenuate the impact of maternal education on infant mortality and children’s height-for-age. This effect is further reduced by controlling for area of residence through the use of fixed-effects models. In the final model. maternal education has a statistically significant impact on infant mortality and height-forage in only a handful of countries. In contrast. maternal education remains statistically significant for chidren’s immunization status in about one-half of the countries even after individual-level and community-level controls are introduced.