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ObjectivesWomen in sub-Saharan Africa face well-documented barriers to facility-based deliveries. An improved maternity waiting homes (MWH) model was implemented in rural Zambia to bring pregnant women closer to facilities for delivery. We qualitatively assessed whether MWHs changed perceived barriers to facility delivery among remote-living women.DesignWe administered in-depth interviews (IDIs) to a randomly selected subsample of women in intervention (n=78) and control (n=80) groups who participated in the primary quasi-experimental evaluation of an improved MWH model. The IDIs explored perceptions and preferences of delivery location. We conducted content analysis to understand perceived barriers and facilitators to facility delivery.Setting and participantsParticipants lived in villages 10+ km from the health facility and had delivered a baby in the previous 12 months.InterventionThe improved MWH model was implemented at 20 rural health facilities.ResultsOver 96% of participants in the intervention arm and 90% in the control arm delivered their last baby at a health facility. Key barriers to facility delivery were distance and transportation, and costs associated with delivery. Facilitators included no user fees, penalties for home delivery, desire for safe delivery and availability of MWHs. Most themes were similar between study arms. Both discussed the role MWHs have in improving access to facility-based delivery. Intervention arm participants expressed that the improved MWH model encourages use and helps overcome the distance barrier. Control arm participants either expressed a desire for an improved MWH model or did not consider it in their decision making.ConclusionsEven in areas with high facility-based delivery rates in rural Zambia, barriers to access persist. MWHs may be useful to address the distance challenge, but no single intervention is likely to address all barriers experienced by rural, low-resourced populations. MWHs should be considered in a broader systems approach to improving access in remote areas.Trial registration numberNCT02620436.

Background In low-income countries such as Zambia, where maternal mortality rates are persistently high, maternity waiting homes (MWHs) represent one potential strategy to improve access to safe delivery, especially for women living in remote areas. The Maternity Homes Access in Zambia project (MAHMAZ) is evaluating the impact of a MWH model on women’s access to safe delivery in rural Zambia. There is a growing need to understand not only the effectiveness of interventions but also the effectiveness of their implementation in order to appropriately interpret outcomes. There is little evidence to guide effective implementation of MWH for both immediate uptake and to promote sustainability in this context. This protocol describes a study that aims to investigate the effectiveness of the implementation of MAHMAZ by not only documenting fidelity but also identifying factors that influence implementation success and affect longer-term sustainability. Methods This study will use mixed methods to evaluate the implementation effectiveness and sustainability of the MAHMAZ intervention. In our study, “implementation effectiveness” means to expand beyond measuring fidelity to the MWH model and includes assessing both the adoption and uptake of the model and identifying those factors that facilitate or inhibit uptake. Sustainability is defined as the routine implementation of an intervention after external support has ended. Quantitative methods include extracting data from existing records at the MWHs and health facilities to analyze patterns of utilization, and conducting a routine health facility assessment to determine facility-level factors that may influence MWH implementation and woman-level outcomes. We will also conduct an experience survey with MWH users and apply a checklist to assess fidelity to the MWH model. Qualitative methods include in-depth interviews and focus group discussions with MWH users, community members and other stakeholders. Qualitative data will be analyzed using an integrated framework drawing constructs from the Consolidated Framework for Implementation Research and the Conceptual Framework for Sustainability. Discussion The findings from this evaluation will be shared with policymakers formulating policy affecting the implementation of MWH and may be used as evidence for programmatic decisions by the government and supporting agencies in deciding to take this model to scale. Trial registration NCT02620436, Registered 3 December 2015, Prospectively registered (clinicaltrials.gov; for the overarching quasi-experimental impact study).

Objectives Corruption is a widely acknowledged problem in the health sector of low- and middle-income countries (LMICs). Yet, little is known about the types of corruption that affect the delivery of pathology and laboratory medicine (PALM) services. This review is a first step at examining corruption risks in PALM. Methods We performed a critical review of medical literature focused on health sector corruption in LMICs. To provide context, we categorized cases of laboratory-related fraud and abuse in the United States. Results Forms of corruption in LMICs that may affect the provision of PALM services include informal payments, absenteeism, theft and diversion, kickbacks, self-referral, and fraudulent billing. Conclusions Corruption represents a functional reality in many LMICs and hinders the delivery of services and distribution of resources to which individuals and entities are legally entitled. Further study is needed to estimate the extent of corruption in PALM and develop appropriate anticorruption strategies.

Objective To report on the effectiveness of a standardised core Maternity Waiting Home (MWH) model to increase facility deliveries among women living >10 km from a health facility. Design Quasi‐experimental design with partial randomisation at the cluster level. Setting Seven rural districts in Zambia. Population Women delivering at 40 health facilities between June 2016 and August 2018. Methods Twenty intervention and 20 comparison sites were used to test whether MWHs increased facility delivery for women living in rural Zambia. Difference‐in‐differences (DID) methodology was used to examine the effectiveness of the core MWH model on our identified outcomes. Main outcome measures Differences in the change from baseline to study period in the percentage of women living >10 km from a health facility who: (1) delivered at the health facility, (2) attended a postnatal care (PNC) visit and (3) were referred to a higher‐level health facility between intervention and comparison group. Results We detected a significant difference in the percentage of deliveries at intervention facilities with the core MWH model for all women living >10 km away (DID 4.2%, 95% CI 0.6–7.6, P = 0.03), adolescent women (10 km away (DID 18.1%, 95% CI 6.3–29.8, P = 0.002) and primigravida women living >10 km away (DID 9.3%, 95% CI 2.4–16.4, P = 0.01) and for women attending the first PNC visit (DID 17.8%, 95% CI 7.7–28, P 10 km from a healthcare facility, including adolescent women and primigravidas and attendance at the first PNC visit. Tweetable abstract A core MWH model increased facility delivery for women living >10 km from a health facility including adolescents and primigravidas in Zambia., Tweetable abstract A core MWH model increased facility delivery for women living >10 km from a health facility including adolescents and primigravidas in Zambia.

Purpose Out-of-pocket expenses associated with facility-based deliveries are a well-known barrier to health care access. However, there is extremely limited contemporary information on delivery-related household out-of-pocket expenditure in sub-Saharan Africa. We assess the financial burden of delivery for the most remote Zambian women and compare differences between delivery locations (primary health center, hospital, or home). Methods We conducted household surveys and in-depth interviews among randomly selected remote Zambian women who delivered a baby within the last 13 months. Women reported expenditures for their most-recent delivery for delivery supplies, transportation, and baby clothes, among others. Expenditures were converted to US dollars for analysis. Results Of 2280 women sampled, 2223 (97.5%) reported spending money on their delivery. Nearly all respondents in the sample (95.9%) spent money on baby clothes/blanket, while over 80% purchased delivery supplies such as disinfectant or cord clamps, and a third spent on transportation. Women reported spending a mean of USD28.76 on their delivery, with baby clothes/blanket (USD21.46) being the main expenditure and delivery supplies (USD3.81) making up much of the remainder. Compared to women who delivered at home, women who delivered at a primary health center spent nearly USD4 (p

Summary Background Building financial management capacity is increasingly important in low‐ and middle‐income countries to help communities take ownership of development activities. Yet, many community members lack financial knowledge and skills. Methods We designed and conducted financial management trainings for 83 members from 10 community groups in rural Zambia. We conducted pre‐training and post‐training tests and elicited participant feedback. We conducted 28 in‐depth interviews over 18 months and reviewed financial records to assess practical application of skills. Results The training significantly improved knowledge of financial concepts, especially among participants with secondary education. Participants appreciated exercises to contextualize financial concepts within daily life and liked opportunities to learn from peers in small groups. Language barriers were a particular challenge. After trainings, sites successfully adhered to the principles of financial management, discussing the benefits they experienced from practicing accountability, transparency, and accurate recordkeeping. Conclusion Financial management trainings need to be tailored to the background and education level of participants. Trainings should relate financial concepts to more tangible applications and provide time for active learning. On‐site mentorship should be considered for a considerable time. This training approach could be used in similar settings to improve community oversight of resources intended to strengthen developmental initiatives.

Objective: To report on the effectiveness of a standardized core Maternity Waiting Home (MWH) model to increase facility deliveries and access to reproductive health services among women living farthest from a health facility (>10km) using facility-based data. Design: Quasi-experimental design. Setting: Seven rural districts in Zambia. Population: Women delivering at 40 health facilities between June 2016 to August 2018. Methods: 20 intervention sites and 20 comparison sites were used to test if MWHs increased access to reproductive health services for women living in rural Zambia. The difference-in-differences (DID) methodology was used to examine the effectiveness of the core MWH model on our primary outcomes. Main Outcome Measures: Differences in the change from baseline to endline in the percentage of women who: 1) traveled greater than 10 km for delivery, (2) attended a postnatal visit at 6 days postpartum, and (3) were referred to a higher-level health facility between intervention and comparison group. Results: We detected a significant difference for the percentage of deliveries at intervention facilities with the core MWH model for all women living >10km away (p=0.03), adolescent women ( 10km away (p=0.002), and primigravida women living >10km away (p=0.01). There were no significant differences for women attending a postnatal care visit at 6 days postpartum (p=0.07) or for women referred to the next level of care (p=0.29). Conclusion: The core MWH model was successful in reaching women with historically low rates of facility delivery, those living >10km from a healthcare facility, including adolescent women and primigravidas.

Background: Community-led governance can ensure that leaders are accountable to the populations they serve and strengthen health systems for maternal care. A key aspect of democratic accountability is electing respective governance bodies, in this case community boards, and holding public meetings to inform community members about actions taken on their behalf. After helping build and open 10 maternity waiting homes (MWHs) in rural Zambia as part of a randomized controlled trial, we assisted community governance committees to plan and execute annual meetings to present performance results and, where needed, to elect new board members. Methods: We applied a principally qualitative design using observation and analysis of written documentation of public meetings to answer our research question: how do governance committees enact inward transparency and demonstrate accountability to their communities. The analysis measured participation and stakeholder representation at public meetings, the types and purposes of accountability sought by community members as evidenced by questions asked of the governance committee, and responsiveness of the governance committee to issues raised at public meetings. Results: Public meetings were attended by 6 out of 7 possible stakeholder groups, and reports were generally transparent. Stakeholders asked probing questions focused mainly on financial performance. Governance committee members were responsive to questions raised by participants, with 59% of answers rated as fully or mostly responsive (showing understanding of and answering the question). Six of the 10 sites held elections to re-elect or replace governance committee members. Only 2 sites reached the target set by local stakeholder committees of 50% female membership, down from 3 at formation. To further improve transparency and accountability, community governance committees need to engage in advance preparation of reports, and should consult with stakeholders on broader measures for performance assessment. Despite receiving training, community-level governance committees lacked understanding of the strategic purpose of open public meetings and elections, and how these relate to democratic accountability. They were therefore not motivated to engage in tactics to manage stakeholders effectively. Conclusion: While open meetings and elections have potential to enhance good governance at the community level, continuous training and mentoring are needed to build capacity and enhance sustainability.

Although enduringly intangible, community ownership is foundational to primary health care. This intangibility is a reminder of what programs can and should do (create space for dialogue, question their own choices, expand diversity in stakeholder voices making sense of program-induced changes, including through evaluation) and what they cannot do (manage someone else’s ownership)., Key Messages The concept of community ownership in primary health care has a long history but remains challenged in terms of definition, measurement, and differences of perspective from practitioners on a gradient between utilitarianism and empowerment. It continues to be somewhat intangible.Although a universal definition across time and contexts may be illusory, contextual appreciation of its dynamic evolution under programmatic influences—for different stakeholders with diverse agendas—is accessible to evaluation and learning.No one can “manage” someone else’s ownership, but programs can reject hubris and tokenism by intentionally questioning their unavoidable impact on community ownership and whether they foster it through meaningful dialogue and “sense-making” with local stakeholders.

Access to safe, effective, good-quality medicines can be compromised by poor pharmaceutical system governance. This system is particularly vulnerable to inefficiencies and to losses from corruption, because it involves a complex mix of actors with diverse responsibilities. A high level of transparency and accountability is critical for minimizing opportunities for fraud and leakage. In the past decade, the Good Governance for Medicines programme and the Medicines Transparency Alliance focused on improving accountability in the pharmaceutical system and on reducing its vulnerability to corruption by increasing transparency and encouraging participation by a range of stakeholders. Experience with these two programmes revealed that stakeholders interpreted transparency and accountability in a range of different ways. Moreover, programme implementation and progress assessments were complicated by a lack of clarity about what information should be disclosed by governments and about how greater transparency can strengthen accountability for access to medicines. This article provides a conceptual understanding of how transparency can facilitate accountability for better access to medicines. We identified three categories of information as prerequisites for accountability: (i) standards and commitments; (ii) decisions and results; and (iii) consequences and responsive actions. Examples are provided for each. Conceptual clarity and practical examples of the information needed to ensure accountability can help policy-makers identify the actions required to increase transparency and accountability in their pharmaceutical systems. We also discuss factors that can hinder or facilitate the use of information to hold to account those responsible for improving access to medicines.L'accès à des médicaments sûrs, efficaces et de bonne qualité peut être compromis par la mauvaise gouvernance du secteur pharmaceutique. Celui-ci est particulièrement exposé aux inefficacités et aux pertes dues à la corruption, du fait qu'il implique un ensemble complexe d'acteurs aux différentes responsabilités. Une grande transparence et l'obligation de rendre des comptes sont indispensables pour minimiser les possibilités de fraude et de fuite. Durant la dernière décennie, le programme de Bonne gouvernance dans le secteur pharmaceutique et l'initiative Medicines Transparency Alliance se sont attachés à améliorer la reddition de comptes dans le secteur pharmaceutique et à réduire la vulnérabilité de ce dernier face à la corruption, en augmentant la transparence et en encourageant la participation de nombreuses parties prenantes. L'expérience de ces deux programmes a révélé que les parties prenantes interprétaient la transparence et la reddition de comptes de différentes manières. En outre, la mise en œuvre des programmes et l'évaluation des progrès ont été compliquées par un manque de clarté quant aux informations que les gouvernements devaient communiquer et à la manière dont une plus grande transparence pouvait renforcer la reddition de comptes et l'accès aux médicaments. Cet article entend expliquer en quoi la transparence peut faciliter la reddition de comptes et améliorer l'accès aux médicaments. Nous avons identifié trois catégories d'informations nécessaires à la reddition de comptes: (i) normes et engagements; (ii) décisions et résultats; (iii) conséquences et mesures réactives. Des exemples sont présentés pour chaque catégorie. Un cadre théorique clair et des exemples pratiques d’informations nécessaires pour assurer la reddition de comptes peuvent aider les responsables politiques à déterminer les actions requises pour augmenter la transparence et la reddition de comptes dans leurs systèmes pharmaceutiques. Nous évoquons aussi les facteurs qui peuvent entraver ou faciliter l'utilisation des informations et engager la responsabilité des personnes chargées d'améliorer l'accès aux médicaments.El acceso a medicamentos seguros, eficaces y de buena calidad puede verse comprometido por una mala gestión del sistema farmacéutico. Este sistema es particularmente vulnerable a las ineficiencias y a las pérdidas derivadas de la corrupción porque implica una compleja mezcla de distintos participantes con diversas responsabilidades. Un alto nivel de transparencia y responsabilidad es fundamental para minimizar las oportunidades de fraude y filtraciones. En la última década, el programa de Buena Gestión de los Medicamentos y la Alianza para la Transparencia de los Medicamentos se han centrado en mejorar la responsabilidad del sistema farmacéutico y en reducir su vulnerabilidad a la corrupción mediante el aumento de la transparencia y el fomento de la participación de una serie de partes interesadas. La experiencia con estos dos programas reveló que las partes interesadas interpretaban la transparencia y la responsabilidad de diversas maneras. Además, la implementación de los programas y las evaluaciones de progreso se complicaron debido a la falta de claridad sobre la información que deben divulgar los gobiernos y sobre cómo una mayor transparencia puede fortalecer la responsabilidad en el acceso a los medicamentos. Este artículo ofrece una explicación conceptual de cómo la transparencia puede facilitar la responsabilidad para un mejor acceso a los medicamentos. Se han identificado tres categorías de información como requisitos previos a la responsabilidad: (i) normas y compromisos; (ii) decisiones y resultados; y (iii) consecuencias y medidas de respuesta. Se ofrecen ejemplos de todas. La claridad de conceptos y los ejemplos prácticos de la información necesaria para garantizar la responsabilidad pueden ayudar a los responsables políticos a identificar las medidas necesarias para aumentar la transparencia y la responsabilidad en sus sistemas farmacéuticos. También se analizan los factores que dificultan o facilitan el uso de la información para responsabilizar a las personas responsables de mejorar el acceso a los medicamentos.إن إمكانية الحصول على أدوية آمنة وفعالة وذات نوعية جيدة، يمكن أن تتأثر بسوء إدارة أنظمة الدوائية. يكون هذا النظام على وجه التحديد عرضة لعدم الكفاءة والخسائر الناجمة عن الفساد لأنه ينطوي على مزيج معقد من الجهات الفاعلة ذات المسؤوليات المتنوعة. ويُعد توافر مستوى عال من الشفافية والمساءلة أمراً بالغ الأهمية للحد من فرص الاحتيال والتسرب. في العقد الماضي، ركز كل من برنامج الحكم الرشيد للأدوية، وتحالف الشفافية في الأدوية، على تحسين المساءلة في النظام الدوائي، والحد من تعرضه للفساد من خلال زيادة الشفافية وتشجيع المشاركة بواسطة قطاع من الجهات المعنية. وكشفت التجربة مع خلال هذين البرنامجين أن الجهات المعنية قد فسرت الشفافية والمساءلة عبر عدة طرق مختلفة. وعلاوة على ذلك، فإن تنفيذ البرامج وكذلك عمليات تقييمات التقدم، كانت معقدة بسبب الافتقار إلى الوضوح بشأن المعلومات التي ينبغي أن تفصح عنها الحكومات، وعن كيف يمكن لزيادة الشفافية أن تعزز المساءلة فيما يتعلق بالحصول على الأدوية. تقدم هذه المقالة فهماً مفاهيمياً لقدرة الشفافية على تسهيل المساءلة فيما يتعلق بالحصول على الأدوية بشكل أفضل. لقد حددنا ثلاث فئات من المعلومات كمتطلبات مسبقة للمساءلة: (1) المعايير والالتزامات؛ و(2) القرارات والنتائج؛ و(3) النتائج وإجراءات الاستجابة. ويتم توفير أمثلة لكل منها. يمكن للوضوح المفاهيمي، والأمثلة العملية للمعلومات المطلوبة لضمان المساءلة، أن تساعد واضعي السياسات في تحديد الإجراءات المطلوبة لزيادة الشفافية والمساءلة في نظمهم الدوائية. كما أننا نناقش العوامل التي يمكن أن تؤدي إلى تعويق أو تسهيل استخدام المعلومات لمحاسبة المسؤولين بخصوص تحسين الحصول على الأدوية.药物系统治理不善会影响安全、有效、优质药品的获取得不到保障。由于其涉及承担不同责任行为者的复杂组合,该系统尤其容易受到效率低下、因腐败带来损失的影响。为了最大限度降低欺诈和腐败的几率,高水平的透明度和问责制至关重要。在过去十年中,药物良好管理规划 (Good Governance for Medicines Programme) 和药品透明度联盟 (Medicines Transparency Alliance) 的关注重点在于改善药物系统的问责制,并通过提升药物系统的透明度,鼓励一系列利益相关者的参与,从而降低药物系统的腐败程度。这两个项目的经验表明,利益相关者以各种不同的方式阐释透明度和问责制。此外,由于并未明确政府应披露哪些信息以及如何提升透明度来完善药品获取的问责制,项目实施和进展评估变得复杂。本文提供了一种概念性理解,阐明了透明度如何促进问责制,以更佳途径获取药品。我们确定了三类信息作为问责制的先决条件:(i) 标准与承诺;(ii) 决策与结果;(iii) 后果与应对措施。并为每项提供了示例。确保问责制所需信息的概念清晰、示例可行能帮助政策制定者确定所需行动,以提高其药物系统透明度、健全相关问责制。我们还讨论了可能阻碍或促进信息使用的因素,以便对改善药品获取途径的责任人进行问责。.Доступ к безопасным, эффективным, качественным лекарственным препаратам может быть сведен на нет плохой организацией управления в фармацевтическом секторе. Эта система особенно уязвима для неэффективности и потерь, связанных с коррупцией, так как ей присуща сложная структура участников с различными обязанностями. Для сведения к минимуму мошеннических сделок и утечек средств крайне важно обеспечить высокий уровень прозрачности и подотчетности системы. В последнее десятилетние программа «Надлежащее управление в области лекарственных средств» (Good Governance for Medicines) и Альянс за прозрачность лекарственного обеспечения (Medicines Transparency Alliance) уделяют основное внимание подотчетности фармацевтических систем и снижению их уязвимости для коррупции за счет повышения прозрачности и привлечения целого ряда партнеров к участию в их работе. Опыт этих двух программ показал, что партнеры весьма по-разному интерпретируют понятия прозрачности и подотчетности. Более того, выполнение программы и оценка хода ее осуществления осложнялись отсутствием ясности в вопросе того, какую информацию должны раскрывать правительства стран и как именно повышение прозрачности сделок может укрепить подотчетность для доступа к лекарственным препаратам. Данная статья обеспечивает концептуальное понимание того, каким образом прозрачность действий может способствовать подотчетности для упрощения доступа к лекарственным препаратам. Авторы выделили три категории информации в качестве необходимых условий подотчетности: (i) стандарты и обязательства; (ii) решения и результаты; (iii) последствия и ответные действия. Для каждой категории приводятся примеры. Концептуальная ясность и практические примеры информации, необходимой для обеспечения подотчетности, помогут лицам, принимающим стратегические решения, определиться с мерами, необходимыми для повышения прозрачности и подотчетности соответствующих фармацевтических систем. Авторы также обсуждают факторы, которые могут содействовать или препятствовать использованию информации для привлечения к ответственности лиц, в чьи обязанности входит улучшение доступа к лекарственным средствам.

Background:Few Antiretroviral Therapy (ART) adherence trials investigate the reasons for intervention success or failure among HIV-positive individuals.Objectives:To conduct qualitative research to explore the reasons for effectiveness of a 6-month mHealth (mobile health) trial that improved adherence among ART patients in China. The intervention utilized Wireless Pill Containers (WPCs) to provide, real-time SMS reminders, WPC-generated adherence reports, and report-informed counseling.Methods:We conducted in-depth interviews with 20 intervention-arm participants immediately following the trial. Sampling was purposeful to ensure inclusion of participants with varied adherence histories. Questions covered adherence barriers and facilitators, and intervention experiences. We analyzed data in nVivo using a thematic approach.Results:Of participants, 14 (70%) were male; 7 (35%) had used injectable drugs. Pre-intervention, 11 were optimal adherers and 9 were suboptimal adherers, using a 95% threshold. In the final intervention month, all but 3 (85%) attained optimal adherence. Participants identified a range of adherence barriers and facilitators, and described various mechanisms for intervention success. Optimal adherers at baseline were motivated by positive adherence reports at monthly clinic visits-similar to receiving A+ grades. For suboptimal adherers, reminders facilitated the establishment of adherence-promoting routines; data-guided counseling helped identify strategies to overcome specific barriers.Conclusion:Different behavioral mechanisms appear to explain the success of an mHealth adherence intervention among patients with varying adherence histories. Positive reinforcement was effective for optimal adherers, while struggling patients benefitted from reminders and data-informed counseling. These findings are relevant for the design and scalability of mHealth interventions and warrant further investigation.

Background: In 2016, an estimated 872,000 Kenyans were living with diabetes, a country average of 4%. The study objectives were (1) to describe the sociodemographic and geographic characteristics of the households with individuals diagnosed and on treatment for diabetes (2) to describe the medicines available at the household level, monthly household expenditure on medicines, location of diagnosis and treatment and the associated factors of medicines purchase location. Methods: A household survey in eight countries was conducted asking whether a household member had been diagnosed and treated for a non-communicable disease (NCD). Households with at least one member with diabetes were included in this study. Results: Out of the 142 individuals being diagnosed and treated for diabetes, 68 participants (47.9%) were prescribed single and 74 (52.1%) multiple treatments. While 54.9% of the participants were diagnosed at public hospitals, 50% of individuals purchased their medicines from a private pharmacy/chemist or private hospitals. Purchase of medicines in public facilities was associated with being less wealthy and having more than one NCD. Having medicines not available at home was reported by 26.1% of individuals, mostly because the medicines were too expensive to buy. Conclusions: Affordability of diabetes medicines remains an important barrier to access. In addition, essential medicine list restrictions to offer diabetes medicines at public primary care level limit access. Programs to increase access to NCD medicines need to consider that diagnosis and choice of treatment occurs largely in the public sector whereas medicines purchase most frequently takes place in the private sector.

IntroductionMaternity waiting homes (MWHs) aim to increase access to maternity and emergency obstetric care by allowing women to stay near a health centre before delivery. An improved MWH model was developed with community input and included infrastructure, policies and linkages to health centres. We hypothesised this MWH model would increase health facility delivery among remote-living women in Zambia.MethodsWe conducted a quasi-experimental study at 40 rural health centres (RHC) that offer basic emergency obstetric care and had no recent stockouts of oxytocin or magnesium sulfate, located within 2 hours of a referral hospital. Intervention clusters (n=20) received an improved MWH model. Control clusters (n=20) implemented standard of care. Clusters were assigned to study arm using a matched-pair randomisation procedure (n=20) or non-randomly with matching criteria (n=20). We interviewed repeated cross-sectional random samples of women in villages 10+ kilometres from their RHC. The primary outcome was facility delivery; secondary outcomes included postnatal care utilisation, counselling, services received and expenditures. Intention-to-treat analysis was conducted. Generalised estimating equations were used to estimate ORs.ResultsWe interviewed 2381 women at baseline (March 2016) and 2330 at endline (October 2018). The improved MWH model was associated with increased odds of facility delivery (OR 1.60 (95% CI: 1.13 to 2.27); pConclusionMWHs near well-equipped RHCs increased access to facility delivery, encouraged use of facilities with emergency care capacity, and improved exposure to counselling. MWHs can be useful in the effort to increase delivery at advanced facilities in areas where substantial numbers of women live remotely.Trial registration numberNCT02620436.

INTRODUCTION: Complications of pregnancy and childbirth can pose serious risks to the health of women especially in resource-poor settings. Zambia has been implementing a program to improve access to emergency obstetric and neonatal care including expansion of maternity waiting homes-residential facilities located near a qualified medical facility where a pregnant woman can wait to give birth. Yet it is unclear how much support communities and women would be willing to provide to help fund the homes and increase sustainability. METHODS: We conducted a mixed-methods study to estimate willingness to pay for maternity waiting home services based on a survey of 167 women men and community elders. We also collected qualitative data from 16 focus group discussions to help interpret our findings in context. RESULTS: The maximum willingness to pay was 5.0 Zambian kwacha or $0.92 US dollars per night of stay. Focus group discussions showed that willingness to pay is dependent on higher quality of services such as food service and suggested that the pricing policy (by stay or by night) could influence affordability and use. DISCUSSION: While Zambians seem to value and be willing to contribute a modest amount for maternity waiting home services planners must still address potential barriers that may prevent women from staying at the shelters. These include cash availability and affordability for the poorest households. (c) 2016 by the American College of Nurse-Midwives.

Public-private partnerships (PPPs) seek to expand access to quality health services in ways that best leverage the capacities and resources of both sectors. There are few examples of PPPs in the hospital sector in developing countries, and little is known about how the involvement of the private sector transforms the delivery of health services in this context. In 2006, the government of Lesotho adopted a PPP approach for the health sector, contracting out to design, build, and operate a hospital network in its capital district. This case study examines differences between a government-run hospital and the PPP-run hospital that replaced it, using in-depth interviews with key informants, observation of management systems, and document review. Key informants emphasized changes in infrastructure, communication, human resource management, and organizational culture that improved quality and demand for services. Important drivers of improved performance included better defined policies and procedures, empowerment and training of managers and staff, and increased accountability. Well-functioning support systems kept the hospital clean and equipment functioning, reduced stock-outs, and allowed staff to do the jobs they were trained to do. The Lesotho PPP model provides insight into the mechanisms by which public-private partnerships may increase access and quality of care.

Background In 2014, Vietnam was the first Southeast Asian country to commit to achieving the World Health Organization’s 90–90-90 global HIV targets (90% know their HIV status, 90% on sustained treatment, and 90% virally suppressed) by 2020. This pledge represented further confirmation of Vietnam’s efforts to respond to the HIV epidemic, one feature of which has been close collaboration with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Starting in 2004, PEPFAR supported community outreach programs targeting high-risk populations (people who inject drugs, men who have sex with men, and sex workers). To provide early evidence on program impact, in 2007–2008 we conducted a nationwide evaluation of PEPFAR-supported outreach programs in Vietnam. The evaluation focused on assessing program effect on HIV knowledge, high-risk behaviors, and HIV testing among high-risk populations—results relevant to Vietnam’s push to meet global HIV goals. Methods We used a mixed-methods cross-sectional evaluation design. Data collection encompassed a quantitative survey of 2199 individuals, supplemented by 125 in-depth interviews. Participants were members of high-risk populations who reported recent contact with an outreach worker (intervention group) or no recent contact (comparison group). We assessed differences in HIV knowledge, risky behaviors, and HIV testing between groups, and between high-risk populations. Results Intervention participants knew significantly more about transmission, prevention, and treatment than comparison participants. We found low levels of injection drug-use-related risk behaviors and little evidence of program impact on such behaviors. In contrast, a significantly smaller proportion of intervention than comparison participants reported risky sexual behaviors generally and within each high-risk population. Intervention participants were also more likely to have undergone HIV testing (76.1% vs. 47.0%, p

Patient motivation is important in managing medication regimens such as antiretroviral treatment for HIV/AIDS. We tested whether self-determination theory could predict adherence behavior among 115 HIV-positive patients in the China Adherence through Technology Study, a randomized controlled trial of an intervention using text reminders and supportive counseling to increase adherence. Being in the treatment group had a significant effect on improving adherence; however, we did not find evidence that self-determination theory predicts adherence in this population of HIV-positive patients. Autonomous motivation was strongly associated with perceived competence; among low adherers, external regulation was negatively correlated with adherence.

Anti-corruption, transparency and accountability measures are often missing from efforts to promote universal health coverage. Yet, if unchecked, corruption represents a significant drain on domest...

Introduction Maternity waiting homes (MWHs) aim to improve access to facility delivery in rural areas. However, there is limited rigorous evidence of their effectiveness. Using formative research, we developed an MWH intervention model with three components: infrastructure, management and linkage to services. This protocol describes a study to measure the impact of the MWH model on facility delivery among women living farthest (≥10 km) from their designated health facility in rural Zambia. This study will generate key new evidence to inform decision-making for MWH policy in Zambia and globally. Methods and analysis We are conducting a mixed-methods quasiexperimental impact evaluation of the MWH model using a controlled before-and-after design in 40 health facility clusters. Clusters were assigned to the intervention or control group using two methods: 20 clusters were randomly assigned using a matched-pair design; the other 20 were assigned without randomisation due to local political constraints. Overall, 20 study clusters receive the MWH model intervention while 20 control clusters continue to implement the ‘standard of care’ for waiting mothers. We recruit a repeated cross section of 2400 randomly sampled recently delivered women at baseline (2016) and endline (2018); all participants are administered a household survey and a 10% subsample also participates in an in-depth interview. We will calculate descriptive statistics and adjusted ORs; qualitative data will be analysed using content analysis. The primary outcome is the probability of delivery at a health facility; secondary outcomes include utilisation of MWHs and maternal and neonatal health outcomes. Ethics and dissemination Ethical approvals were obtained from the Boston University Institutional Review Board (IRB), University of Michigan IRB (deidentified data only) and the ERES Converge IRB in Zambia. Written informed consent is obtained prior to data collection. Results will be disseminated to key stakeholders in Zambia, then through open-access journals, websites and international conferences. Trial registration number NCT02620436; Pre-results.

We discuss how corruption affects access to antiretroviral therapies (ARVs) globally. Recent cases of theft of ARVs, collusion, and manipulation in procurement found in countries such as Central African Republic, Bangladesh, Malawi, and Guinea, show there is still much work to be done to reduce the risk of corruption. This includes addressing the structural weaknesses in procurement mechanisms and supply chain management systems of health commodities and medicines.

Background It is estimated that about 4 million Kenyans, i.e., 10% of the country's population, have asthma. We aimed to evaluate access to asthma medicines at the household level in eight counties of Kenya, including factors associated with location of purchase. Methods Individuals with a diagnosis and prescription of asthma medicines were asked about the location of diagnosis, purchase of medicines, availability of medicines at home and costs of medicines per month. A logistic regression model explored the relationship between patient characteristics and the probability that the patient purchased asthma medicines at a public facility. Results Of 128 (15.2%) individuals with a diagnosis of asthma who were receiving treatment, only 57.0% had asthma medicines at home. The most frequently purchased asthma medicine was salbutamol, with one third of individuals taking it orally instead of by inhalation. The majority (55.4%) purchased asthma medicines at private pharmacies. Female patients and lower socio-economic status were predictors of purchasing asthma medicines at public facilities. Conclusions The availability and affordability of asthma medicines remain significant barriers to access to care. Improving the availability and affordability of all asthma medicines in the public sector, including inhaled corticosteroids, offers the opportunity to reach vulnerable populations.

Corruption is diverse in its forms and embedded in health systems worldwide. Health-sector corruption directly impedes progress towards universal health coverage by inhibiting people's access to quality health services and to safe and effective medicines, and undermining systems for financial risk protection. Corruption is also a cross-cutting theme in the United Nations' sustainable development goals (SDGs) which aim to improve population health, promote justice and strong institutions and advance sustainable human development. To address health-sector corruption, we need to identify how it happens, collect evidence on its impact and develop frameworks to assess the potential risks and put in place protective measures. We propose that the SDGs can be leveraged to develop a new approach to anti-corruption governance in the health sector. The aim will be to address coordination across the jurisdictions of different countries and foster partnerships among stakeholders to adopt coherent policies and anti-corruption best practices at all levels. Combating corruption requires a focused and invigorated political will, better advocacy and stronger institutions. There is no single solution to the problem. Nevertheless, a commitment to controlling corruption via the SDGs will better ensure the integrity of global health and human development now and beyond 2030.La corruption revêt diverses formes et mine les systèmes de santé du monde entier. La corruption dans le secteur de santé entrave directement les progrès en faveur de la couverture sanitaire universelle en empêchant l'accès de la population à des services de santé de qualité et à des médicaments sûrs et efficaces, et en ébranlant les systèmes de protection contre le risque financier. La corruption est également une thématique transversale des objectifs de développement durable (ODD) des Nations Unies, qui visent à améliorer la santé de la population, à promouvoir la justice et des institutions efficaces, et à favoriser le développement humain durable. Pour combattre la corruption dans le secteur de la santé, il est nécessaire de déterminer comment elle se produit, de collecter des données sur son impact et d'élaborer des cadres pour évaluer les risques potentiels et mettre en place des mesures de protection. Nous suggérons de tirer parti des ODD pour développer un nouveau système de gouvernance anticorruption dans le secteur de la santé. L'objectif sera d'assurer la coordination entre les systèmes juridiques des différents pays et d'encourager les partenariats entre les parties prenantes en vue de l'adoption de politiques cohérentes et de pratiques anticorruption exemplaires à tous les niveaux. La lutte contre la corruption exige une volonté politique ciblée et dynamisée, une prise de position renforcée et des institutions plus efficaces. Il n'existe pas de solution unique à ce problème. Néanmoins, un engagement en faveur de la lutte contre la corruption par le biais des ODD permettra de mieux assurer l'intégrité de la santé mondiale et du développement humain jusqu'à 2030 et au-delà.La corrupción es diversa en sus formas y está incrustada en los sistemas de salud de todo el mundo. La corrupción en el sector de la salud impide directamente el progreso hacia la cobertura universal de la salud al cohibir el acceso de las personas a servicios de salud de calidad y a medicamentos seguros y eficaces, y debilitar los sistemas de protección contra los riesgos financieros. La corrupción es también un tema transversal en los objetivos de desarrollo sostenible (ODS) de las Naciones Unidas, cuyo objetivo es mejorar la salud de la población, promover la justicia y el fortalecimiento de las instituciones y promover el desarrollo humano sostenible. Para hacer frente a la corrupción en el sector de la salud, es necesario identificar cómo se produce, recopilar pruebas de su impacto y desarrollar marcos para evaluar los riesgos potenciales y establecer medidas de protección. Se propone aprovechar los ODS para desarrollar un nuevo enfoque de la gobernanza anticorrupción en el sector de la salud. El objetivo será coordinar las distintas jurisdicciones de los distintos países y fomentar las asociaciones entre las partes interesadas para adoptar políticas coherentes y prácticas óptimas de lucha contra la corrupción a todos los niveles. La lucha contra la corrupción requiere una voluntad política centrada y fortalecida, una mejor promoción y el fortalecimiento de las instituciones. No existe una única solución al problema. Sin embargo, el compromiso de controlar la corrupción a través de los ODS garantizará mejor la integridad de la salud mundial y el desarrollo humano actual y después de 2030.تتنوع أشكال الفساد ويتجسد في النظم الصحية في جميع أنحاء العالم. يعيق الفساد في قطاع الصحة بشكل مباشر التقدم نحو التغطية الصحية الشاملة عن طريق إعاقة حصول الأشخاص على الخدمات الصحية ذات الجودة العالية، وكذلك حصولهم على الأدوية الآمنة والفعالة، وتقويض نظم الحماية من المخاطر المالية. ويشكل الفساد أيضاً موضوعاً شاملاً في أهداف التنمية المستدامة للأمم المتحدة (SDG)، والتي تهدف إلى تحسين صحة السكان، وتعزيز العدالة والمؤسسات القوية والنهوض بالتنمية البشرية المستدامة. ولمعالجة الفساد في القطاع الصحي، فإننا بحاجة إلى تحديد كيفية حدوثه، وجمع الأدلة حول تأثيره، ووضع أطر لتقييم المخاطر المحتملة، ووضع تدابير وقائية قيد التنفيذ. ونحن نقترح أنه يمكن الاستفادة من أهداف التنمية المستدامة لوضع نهج جديد لحوكمة مكافحة الفساد في القطاع الصحي. وسيكون الهدف هو معالجة التنسيق عبر الولايات القضائية لمختلف البلدان، وتعزيز حالات الشراكة بين الجهات المعنية لاعتماد سياسات متماسكة، فضلاً عن أفضل ممارسات مكافحة الفساد على جميع المستويات. تتطلب مكافحة الفساد إرادة سياسية مركزة ونشطة، ودعم أفضل، ومؤسسات أقوى. لا يوجد حل واحد لهذه المشكلة. ومع ذلك، فإن الالتزام بالسيطرة على الفساد من خلال أهداف التنمية المستدامة، سيضمن على نحو أفضل الاتساق بين الصحة العالمية، والتنمية البشرية الآن وما بعد عام 2030.腐败的形式多种多样，并潜伏于世界各地的卫生系统内。卫生部门腐败阻碍人们获得高质量的卫生服务和安全有效的药物，破坏金融风险防范体系，直接阻碍全面卫生覆盖进程。在联合国的可持续发展目标 (SDG) 中，腐败也是一个跨领域主题，该主题旨在改善人口健康，促进公平和强有力的机构，推动人类可持续发展。为解决健康领域的腐败问题，我们需要确定其是如何发生的，收集有关其影响的证据，制定框架来评估其潜在风险并采取相关保护措施。我们建议，可以利用可持续发展目标为卫生部门的反腐败治理制定一种新的方法。其目的将是解决不同国家之间的协调问题，并促进利益攸关方之间的伙伴关系，以便在各级采取一致的政策和反腐败最佳做法。打击腐败需要集中精力和有活力的政治意愿、更好的宣传和更强有力的机构。这个问题没有单一解决方案。尽管如此，通过可持续发展目标来控制腐败的承诺，将更好地确保现在和 2030 年以后全球卫生和人类发展的完整性。.Коррупция имеет различные формы и внедрена в системы здравоохранения во всем мире. Коррупция в секторе здравоохранения напрямую препятствует прогрессу в обеспечении всеобщего охвата медико-санитарным обслуживанием, препятствуя доступу людей к качественным медицинским услугам и безопасным и эффективным лекарственным средствам, а также подрывает системы защиты от финансовых рисков. Коррупция также является сквозной темой в целях в области устойчивого развития (ЦУР) Организации Объединенных Наций, которые направлены на улучшение здоровья населения, содействие правосудию, укрепление институтов и обеспечение устойчивого развития человеческого потенциала. Для борьбы с коррупцией в секторе здравоохранения нам необходимо определить, как это происходит, собрать фактические данные о ее влиянии и разработать основы для оценки потенциальных рисков и принятия защитных мер. Мы предлагаем использовать ЦУР для разработки нового подхода к борьбе с коррупцией в секторе здравоохранения. Цель будет заключаться в обеспечении координации между юрисдикциями разных стран и укреплении партнерских отношений между заинтересованными сторонами для принятия согласованной политики и лучшей практики борьбы с коррупцией на всех уровнях. Борьба с коррупцией требует целенаправленной и активной политической воли, более эффективной пропаганды и укрепления институтов. Единого решения проблемы не существует. Тем не менее приверженность борьбе с коррупцией с помощью ЦУР будет лучше обеспечивать целостность глобального здравоохранения и развития человеческого потенциала в настоящее время и после 2030 года.

In Kenya, noncommunicable diseases (NCDs) account for 27% of all deaths. Adult Kenyans have an 18% chance of dying prematurely from cancers, diabetes, cardiovascular diseases or chronic respiratory diseases. A Novartis Access Initiative is making medicines available to treat cardiovascular diseases, diabetes, chronic respiratory diseases, and breast cancer in 30 countries, including Kenya. Little is known about patients' perceptions of access to medicines for NCDs in Kenya. The study objective was to understand patients' perceptions of access to medicines; as well as barriers and facilitators at the household, community, and healthcare system level. A baseline qualitative study was conducted in eight of 47 counties as part of an evaluation of the Novartis Access Initiative in Kenya. The 84 patients interviewed through a household survey had been diagnosed and treated for an NCD. Although medicines at government facilities were free or cheaper than those sold in private pharmacies, the availability of medicines presented a constant challenge. Patients often resorted to private pharmacies, where NCD medicines cost more than at public facilities. Participants with an NCD took their health seriously and strove to get the medicines, even under difficult circumstances. Buying NCD medicines put a strain on the household budget, especially for the lower-income participants. Some actions to overcome affordability barriers included: borrowing money, selling assets, seeking help from relatives, taking on extra work, buying partial dosages, leaving without the medicines, or resorting to non-medical alternatives. In conclusion, access to NCD medicines is a major challenge for most adults in Kenya. As a result, they engage in complex interactions between public, private facilities and pharmacies to overcome the barriers. The government should ensure well-stocked public sector pharmacies and subsidize prices of medicines for lower-income patients. Integration of industry-led access to medicine programs may help governments to obtain low cost supplies.

BACKGROUND: Real-time adherence monitoring is now possible through medication storage devices equipped with cellular technology. We assessed the effect of triggered cell phone reminders and counseling using objective adherence data on antiretroviral therapy (ART) adherence among Chinese HIV-infected patients. METHODS: We provided ART patients in Nanning China with a medication device (Wisepill) to monitor their ART adherence electronically. After 3 months we randomized subjects within optimal (>/=95%) and suboptimal (

Estimates of hypertension prevalence in Kenya range from 12.3% to 50.1% nationally. Of those diagnosed, only 1 in 5 were taking medication.This study aims to describe the access to antihypertensive medicines at the household level in 8 counties of Kenya, including factors associated with the location of purchase.A household survey was conducted asking individuals with a diagnosis and prescription of antihypertensive medicines about the location of diagnosis and purchase of medicines, the availability of medicines at home, and the costs of medicines per month. A logistic regression model explores the relationship between patient characteristics and the probability that patients bought medicines at a public facility.Of 445 individuals diagnosed and prescribed medicines for hypertension, 20.9% were also diagnosed with another noncommunicable disease, including diabetes or asthma. The majority of study subjects received their diagnosis at a public hospital (67.5%) but the most common place of medicine purchase was a retail pharmacy (33.6%). Some study subjects bought their medicines at a public hospital (21.1%). The most frequent answer for not having medicines at home was that they could not afford their medicines (50.0%). Purchase in the public sector was associated with being less wealthy, having1 noncommunicable disease, and living in urban areas.Affordability remains an important barrier to hypertension treatment access in Kenya. Programs to promote access to affordable treatment need to take into account that diagnosis of disease and choice of medicines takes place largely in the public sector, whereas the private sector is the gatekeeper for purchase of medicines.