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The sexual and reproductive health and rights (SRHR) of migrants and refugees present important public health challenges. Social and structural determinants affect both the general health and SRHR of migrants, but the drivers of SRHR among migrant and refugee populations remain understudied.To identify upstream social and structural determinants of SRHR health of migrants and refugees reported in systematic reviews.We conducted a systematic review of reviews. We studied 3 aspects of SRHR: sexually transmitted infections, sexual violence and unintended pregnancy in migrants and refugees. We used an inductive approach to synthesize emerging themes, summarized them in a narrative format and made an adapted version of Dahlgren and Whitehead's social determinants of health (SDH) model.We included 12 systematic reviews, of which 10 were related to sexually transmitted infections, 4 to sexual violence and 2 to unintended pregnancy. We identified 6 themes that operate at 4 different levels in an adapted version of the Dahlgren and Whitehead SDH model: economic crisis and hostile discourse on migration; limited legal entitlements, rights and administrative barriers; inadequate resources and financial constraints; poor living and working conditions; cultural and linguistic barriers; and stigma and discrimination based on migration status, gender, sex and ethnicity.This review provides evidence of how upstream social and structural determinants undermine the SRHR of refugees and migrants. Unless these are addressed in policy-making and planning, the health of migrants and refugees is at risk.المحددات الاجتماعية والهيكلية للصحة الجنسية والإنجابية للمهاجرين واللاجئين والحقوق المتعلقة بها: استعراض منهجي للاستعراضات.ديان إيجلي-جيني، وفاء أفتاب، سارة هوكس، ليث أبو رداد، كينت بوس، فوزيه رباني، نيكولا لو، كريستين أونارهايم.تُثل الصحة الجنسية والإنجابية للمهاجرين واللاجئين والحقوق المتعلقة بها تحديات مهمة في مجال الصحة العامة. وتؤثر المحددات الاجتماعية والهيكلية على كلٍ من الصحة العامة والصحة الجنسية والإنجابية للمهاجرين والحقوق المتعلقة بها، ولكن لا تزال العوامل المؤثرة على الصحة الجنسية والإنجابية والحقوق المتعلقة بها في صفوف المهاجرين واللاجئين غير مدروسة دراسةً وافية.هدفت هذه الدراسة إلى تحديد المحددات الاجتماعية والهيكلية الأولية للصحة الجنسية والإنجابية للمهاجرين واللاجئين والحقوق المتعلقة بها التي أفادت بها الاستعراضات المنهجية.طُرق البحث: أجرينا استعراضًا منهجيًا للاستعراضات. ودرسنا ثلاثة جوانب من جوانب الصحة الجنسية والإنجابية والحقوق المتعلقة بها: الأمراض المنقولة جنسيًا، والعنف الجنسي، والحمل غير المقصود لدى المهاجرين واللاجئين. واتبعنا نهجًا استقرائيًا لتوليف المواضيع المستجدة، ولخصناها في شكل سردي، وأعددنا نسخة معدَّلة من نموذج دالجرين ووايتهيد للمحددات الاجتماعية للصحة.استعرضنا 12 استعراضًا منهجيًا، منها 10 استعراضات تتعلق بالأمراض المنقولة جنسيًا، و4 استعراضات تتعلق بالعنف الجنسي، واستعراضان يتعلقان بالحمل غير المقصود. وحددنا 6 مواضيع في 4 مستويات مختلفة في نسخة معدَّلة من نموذج دالجرين ووايتهيد للمحددات الاجتماعية للصحة: الأزمة الاقتصادية والخطاب العدائي بشأن الهجرة؛ ومحدودية الاستحقاقات القانونية والحقوق والعوائق الإدارية؛ وعدم كفاية الموارد والقيود المالية؛ وسوء ظروف المعيشة والعمل؛ والحواجز الثقافية واللغوية؛ والوصم والتمييز على أساس وضع الهجرة والنوع الاجتماعي ونوع الجنس والعرق.يقدِّم هذا الاستعراض دلائل على أثر المحددات الاجتماعية والهيكلية الأولية في تقويض الصحة الجنسية والإنجابية للمهاجرين واللاجئين والحقوق المتعلقة بها. وما لم تُعالَج هذه الأمور في إطار عملية رسم السياسات والتخطيط، فإن صحة المهاجرين واللاجئين ستكون عُرضة للخطر.Déterminants sociaux et structurels de la santé sexuelle et reproductive et droits associés chez les migrants et les réfugiés : examen systématique d'analyses.La santé sexuelle et reproductive et les droits associés des migrants et des réfugiés présentent d'importants défis en matière de santé publique. Les déterminants sociaux et structurels ont une incidence à la fois sur la santé générale et sur la santé sexuelle et reproductive et les droits associés des populations de migrants et de réfugiés, mais les facteurs qui influencent ces derniers demeurent sous-étudiés.Identifier les déterminants sociaux et structurels intervenant en amont de la santé sexuelle et reproductive et des droits associés des migrants et des réfugiés, tels que décrits dans les examens systématiques.Nous avons procédé à un examen systématique d'analyses. Nous avons étudié trois aspects de la santé sexuelle et reproductive et des droits associés : les infections sexuellement transmissibles, les violences sexuelles et les grossesses non désirées chez les migrants et les réfugiés. Nous avons utilisé une approche inductive pour synthétiser les thèmes émergents, puis les avons résumés dans un format narratif et avons réalisé une version adaptée du modèle de Dahlgren et Whitehead sur les déterminants sociaux de la santé.Nous avons inclus 12 examens systématiques, dont 10 étaient liés aux infections sexuellement transmissibles, quatre aux violences sexuelles et deux aux grossesses non désirées. Nous avons identifié six thèmes qui interviennent à quatre niveaux différents dans une version adaptée du modèle sur les déterminants sociaux de la santé de Dahlgren et Whitehead : la crise économique et les discours hostiles à la migration ; les droits légaux limités, les obstacles juridiques et administratifs ; les ressources insuffisantes et les contraintes financières ; les mauvaises conditions de vie et de travail ; les barrières culturelles et linguistiques ; et la stigmatisation et la discrimination basées sur le statut migratoire, le genre, le sexe et l'ethnicité.La présente analyse montre comment les déterminants sociaux et structurels intervenant en amont nuisent à la santé sexuelle et reproductive et aux droits associés des réfugiés et des migrants. Tant que ces éléments ne sont pas pris en compte dans l'élaboration des politiques et la planification, la santé des migrants et des réfugiés est en danger.

Incentivisation of general practitioners (GPs) by pharmaceutical companies is thought to affect prescribing practices, often not in patients' interest. Using a Bourdieusian lens, we examine the socially structured conditions that underpin exchanges between pharmaceutical companies and GPs in Pakistan. The analysis of qualitative interviews with 28 GPs and 13 pharmaceutical sales representatives (PSRs) shows that GPs, through prescribing medicines, met pharmaceutical sales targets in exchange for various incentives. We argue that these practices can be given meaning through the concept of 'field' - a social space in which GPs, PSRs, and pharmacists were hierarchically positioned, with their unique capacities, to enable healthcare provision. However, structural forces like the intense competition between pharmaceutical companies, the presence of unqualified healthcare providers in the healthcare market, and a lack of regulation by the state institutions produced a context that enabled pharmaceutical companies and GPs to use the healthcare field, also, as space to maximise profits. GPs believed the effort to maximise incomes and meet socially desired standards were two key factors that encouraged profit-led prescribing. We conclude that understanding the healthcare field is an important step toward developing governance practices that can address profit-led prescribing.

We assessed the technical content of sugar, salt and trans-fats policies in six countries in relation to the World Health Organization ‘Best Buys’ guidelines for the prevention and control of non-communicable diseases (NCDs). National research teams identified policies and strategies related to promoting healthy diets and restricting unhealthy consumption, including national legislation, development plans and strategies and health sector-related policies and plans. We identified relevant text in relation to the issuing agency, overarching aims, goals, targets and timeframes, specific policy measures and actions, accountability systems, budgets, responsiveness to inequitable vulnerabilities across population groups (including gender) and human rights. We captured findings in a ‘policy cube’ incorporating three dimensions: policy comprehensiveness, political salience and effectiveness of means of implementation, and equity/rights. We compared diet-related NCD policies to human immunodeficiency virus policies in relation to rights, gender and health equity. All six countries have made high-level commitments to address NCDs, but dietary NCDs policies vary and tend to be underdeveloped in terms of the specificity of targets and means of achieving them. There is patchwork reference to internationally recognized, evidence-informed technical interventions and a tendency to focus on interventions that will encounter least resistance, e.g. behaviour change communication in contrast to addressing food reformulation, taxation, subsidies and promotion/marketing. Policies are frequently at the lower end of the authoritativeness spectrum and have few identified budgetary commitments or clear accountability mechanisms. Of concern is the limited recognition of equity and rights-based approaches. Healthy diet policies in these countries do not match the severity of the NCDs burden nor are they designed in such a way that government action will focus on the most critical dietary drivers and population groups at risk. We propose a series of recommendations to expand policy cubes in each of the countries by re-orienting diet-related policies so as to ensure healthy diets for all.

Background To strengthen health systems, the shortage of physicians globally needs to be addressed. However, efforts to increase the numbers of physicians must be balanced with controls on medical education imparted and the professionalism of doctors licensed to practise medicine. Methods We conducted a multi-country comparison of mandatory regulations and voluntary guidelines to control standards for medical education, clinical training, licensing and re-licensing of doctors. We purposively selected seven case-study countries with differing health systems and income levels: Canada, China, India, Iran, Pakistan, UK and USA. Using an analytical framework to assess regulations at four sequential stages of the medical education to relicensing pathway, we extracted information from: systematically collected scientific and grey literature and online news articles, websites of regulatory bodies in study countries, and standardised input from researchers and medical professionals familiar with rules in the study countries. Results The strictest controls we identified to reduce variations in medical training, licensing and re-licensing of doctors between different medical colleges, and across different regions within a country, include: medical education delivery restricted to public sector institutions; uniform, national examinations for medical college admission and licensing; and standardised national requirements for relicensing linked to demonstration of competence. However, countries analysed used different combinations of controls, balancing the strictness of controls across the four stages. Conclusions While there is no gold standard model for medical education and practise regulation, examining the combinations of controls used in different countries enables identification of innovations and regulatory approaches to address specific contextual challenges, such as decentralisation of regulations to sub-national bodies or privatisation of medical education. Looking at the full continuum from medical education to licensing is valuable to understand how countries balance the strictness of controls at different stages. Further research is needed to understand how regulating authorities, policy-makers and medical associations can find the right balance of standardisation and context-based flexibility to produce well-rounded physicians.

Background Postpartum sepsis is one of the leading causes of maternal mortality and morbidity in developing countries. This formative research elicits local terms used for postpartum illnesses and symptoms of postpartum sepsis with the aim of improving postpartum diagnosis and management in Pakistan. Methods We conducted 34 in-depth interviews with recently delivered women (RDW), traditional birth attendants (TBAs), healthcare providers and family members of RDW from rural Sindh to explore local Sindhi terms used to describe postpartum sepsis and related symptoms. During interviews, all participants were asked to orally free list common symptoms of postpartum illnesses; those who were aware of the concept were asked to free list possible symptoms of postpartum sepsis. The responses were recorded by the interviewer. Free listing data were analyzed for frequency and salience. Results Most participants, including TBAs, were not familiar with the concept of postpartum sepsis as a distinct disease or of a local term denoting the concept. Almost all could identify and report symptoms related to postpartum sepsis in the local language. Only physicians were able to recognize the term postpartum sepsis and related symptoms. Multiple local terms were used for a particular symptom; still others were used to denote gradations of severity. ‘Bukhar’ (fever) was the most commonly named symptom although it was often considered a normal part of puerperium. Many postpartum illnesses were related to the highly non-specific local term ‘kamzori’ (weakness). Conclusions Better awareness about local terminology used in rural areas related to postpartum sepsis could improve communication, care-seeking patterns, diagnosis and management.

Background Lack of programmatic support and supervision is one of the underlying reasons of the poor performance of Pakistan’s Lady Health Worker Program (LHWP). This study describes the findings and potential for scale-up of a supportive supervision intervention in two districts of Pakistan for improving LHWs skills for integrated community case management (iCCM) of childhood diarrhea and pneumonia. Methods The intervention comprised an enhanced supervision training to lady health supervisors (LHSs) and written feedback to LHWs by LHSs, implemented in Districts Badin and Mirpur Khas (MPK). Clinical skills of LHWs and LHSs and supervision skills of LHSs were assessed before, during, and after the intervention using structured tools. Results LHSs’ practice of providing written feedback improved between pre- and mid-intervention assessments in both trials (0% to 88% in Badin and 25% to 75% in MPK) in the study arm. Similarly, supervisory performance of study arm LHSs was better than that in the comparison arm in reviewing the treatment suggested by workers’ (94% vs 13% in MPK and 94% vs 69% in Badin) during endline skills assessment in both trials. There were improvements in LHWs’ skills for iCCM of childhood diarrhea and pneumonia in both districts. In intervention arm, LHWs’ performance for correctly assessing for dehydration (28% to 92% in Badin and 74% to 96% in MPK), and measuring the respiratory rate correctly (12% to 44% in Badin and 46% to 79% in MPK) improved between baseline and endline assessments in both trials. Furthermore, study arm LHWs performed better than those in comparison arm in classifying diarrhea correctly during post-intervention skills assessment (68% vs 40% in Badin and 96% vs 83% in MPK). Conclusion Supportive supervision including written feedback and frequent supervisor contact could improve the performance of community-based workers in managing diarrhea and pneumonia among children. Positive lessons for provincial scale-up can be drawn. Trial registration Both trials are registered with the ‘Australian New Zealand Clinical Trials Registry’. Registration numbers: Nigraan Trial: ACTRN1261300126170; Nigraan Plus: ACTRN12617000309381.

Background Access to health services is an important way to reduce child mortality and is influenced by health-seeking behaviors of caregivers. There are numerous contextual factors that affect health-seeking behaviors, such as distance to health services, transportation, treatment cost, caregiver access to household finances, perceived quality of available health providers, availability and comprehension of health information, social and religious norms (including gender-based mobility), and perceived severity of illness. Objective The objective of this study (embedded in a larger trial called Nigraan) was to gather caregiver narratives in order to develop a comprehensive understanding of the context and process of care giving for children under five with pneumonia and diarrhea, in order to highlight the complexities and dynamics of health seeking in rural Sindh, Pakistan. Methods This study used a narrative interview approach gathering information in the form of stories from care givers of children under five with pneumonia and diarrhea. Twenty caregivers from 11 households participated in this exercise. All data collection was conducted privately in participants’ homes.Results The role of joint family households is integral in health seeking for pneumonia and diarrhea in children under five. Elders and female relatives, especially the child’s paternal grandmother, are an important and trusted source of knowledge regarding child sickness in the household. Furthermore, practice of home remedies is inherited from mother-in-law and older sisters-in-law in the household, and oftentimes their recommendations are taken as authority. Caregivers were generally dissatisfied with doctors in public sector who provide free consultation and associated higher quality care with private doctors who charge more and had shorter waiting times. Joint family households were generally observed to increase the support available to address the financial and practical considerations of health seeking and implementing treatment plans for pneumonia and diarrhea. Conclusions Policy and research on community-based health programs and interventions would be more comprehensive if a health education intervention considered the context of decision making and social influences at the household level rather than focusing on individual caregivers.

Aim To assess the effect of enhanced supportive supervision of lady health workers (LHWs) by lady health supervisors on integrated community case management of childhood pneumonia and diarrhoea. Methods A total of thirty-four supervisors were randomly assigned to intervention and comparison arms. The intervention included enhanced training of supervisors on supervisory skills and written feedback to LHWs by supervisors. The performance of both cadres was assessed three times. Household surveys judged caregiver practices. Results Intervention arm LHWs performed better than those in the comparison arm in assessing dehydration (92% [n = 25] vs 64% [n = 25]) and in classifying diarrhoea correctly (68% [n = 25] vs 40% [n = 25]). The two arms differed little in correct disease classification for pneumonia (44% [n = 25] vs 40% [n = 25]). Supervisory performance of intervention arm supervisors was better than that in the comparison arm in correcting the workers' clinical examination skills (64% [n = 25] vs 40% [n = 25]) and more frequent feedback. In the household survey, only 18% (n = 2182) intervention and 23% (n = 2197) comparison arm caregivers considered LHWs capable of providing diarrhoea and pneumonia care. Commodities for integrated community case management were not regularly available to workers. Conclusion Supportive supervision can improve community case management performance. Support through refresher training, logistics and commodities is essential.

In the Foreword to Benjamin Mason Meier and Lawrence Gostin’s edited volume on human rights and international organisations, Mary Robinson, former United Nations High Commissioner for Human Rights, writes that she first recognised the potential for human rights to contribute to public health in the response to AIDS.1 People living with and affected by HIV, and their allies, initially campaigned for rights-based approaches to confront stigma and discrimination. The AIDS movement demanded that their experiences and expertise were at the forefront of the response. ‘Nothing about us without us’ was a rallying cry of activists as they used the Greater Involvement of People living with AIDS principles to champion other rights-based norms including equity, transparency and accountability. Rights-based approaches included investment in legal literacy to empower marginalised communities to address social exclusion, inequalities and injustice and the strategic use of law to pressure governments and corporations to act with urgency. Initially the movement campaigned for individual civil and political rights (eg, privacy, non-discrimination) and with time encompassed economic and social rights (eg, addressing the structural drivers of vulnerability). At its core, the rights-based approach was a political project to race AIDS up agendas as well as enable people to reclaim their humanity and agency.2 Importantly, in 2001, the language of human rights was reflected in the United Nations General Assembly Declaration of Commitment on HIV/AIDS : the monitoring framework, still implemented, includes rights. UNAIDS (The Joint United Nations Programme on HIV/AIDS) technical support for countries’ periodic reports has been crucial.3 Many commentators credit the human rights framework as the bedrock of AIDS progress over the past four decades. Rights-based approaches have been similarly effective in global efforts to curb tobacco consumption and realise reproductive and sexual health. Although demanded by activists, creating an enabling legal environment and …

The importance of health policy and systems research (HPSR) for strengthening health systems is widely recognized. However, availability and uptake of research evidence for health systems to formulate evidence informed policies is challenging. The transition from Millennium Development Goals to Sustainable Development Goals (SDG) represents a new global promise to health by encompassing a broader range of economic, environmental, and social pillars of sustainable development. The adoption of the 2030 agenda offers an exciting opportunity for strengthening health system governance. The integration of HPSR is essential for the fulfillment of SDGs through the collaboration of multiple sectors and policy coherence. Various innovative strategies have been recognized to build strong partnerships between researchers, policy-makers, and academicians to highlight the role of HPSR in realizing and achieving SDGs. Multilateral and bilateral organizations working in the field of HPSR can play a facilitatory role to inform the development of healthcare reforms through strategic engagement among a variety of stakeholders.

Evidence on early achievements, challenges and opportunities would help low-income and middle-income countries (LMICs) accelerate implementation of health and health-related sustainable development goals (HHSDGs). A series of country-specific and multicountry consultative meetings were conducted during 2018–2019 that involved 15 countries across five regions to determine the status of implementation of HHSDGs. Almost 120 representatives from health and non-health sectors participated. The assessment relied on a multidomain analytical framework drawing on existing public health policy frameworks. During the first 5 years of the sustainable development goals (SDGs) era, participating LMICs from South and Central Asia, East Africa and Latin America demonstrated growing political commitment to HHSDGs, with augmentation of multisectoral institutional arrangements, strengthening of monitoring systems and engagement of development partners. On the other hand, there has been limited involvement of civic society representatives and academia, relatively few capacity development initiatives were in place, a well-crafted communication strategy was missing, and there is limited evidence of additional domestic financing for implementing HHSDGs. While the momentum towards universal health coverage is notable, explicit linkages with non-health SDGs and integrated multisectoral implementation strategies are lacking. The study offers messages to LMICs that would allow for a full decade of accelerated implementation of HHSDGs, and points to the need for more implementation research in each domain and for testing interventions that are likely to work before scale-up.

Background From 1990 to 2015, the number of maternal deaths globally has dropped by 43%. Despite this, progress in attaining MDG 5 is not remarkable in LMICs. Only 52% of pregnant women in LMICs obtain WHO recommended minimum of four antenatal consultations and the coverage of postnatal care is relatively poor. In recent years, the increased cellphone penetration has brought the potential for mHealth to improve preventive maternal healthcare services. The objective of this review is to assess the effectiveness of mHealth solutions on a range of maternal health outcomes by categorizing the interventions according to the types of mHealth applications. Methods Three international online electronic databases were searched between January 1, 2000 and January 25, 2016 to identify studies exploring the role of mHealth solutions in improving preventive maternal healthcare services. Of 1262 titles screened after duplication, 69 potentially relevant abstracts were obtained. Out of 69 abstracts, 42 abstracts were shortlisted. Full text of 42 articles was reviewed using data extraction sheet. A total of 14 full text studies were included in the final analysis. Results The 14 final studies were categorized in to five mHealth applications defined in the conceptual framework. Based on our analysis, the most reported use of mHealth was for client education and behavior change communication, such as SMS and voice reminders [n = 9, 65%]. The categorization provided the understanding that much work have been done on client education and behavior change communication. Most of the studies showed that mHealth interventions have proven to be effective to improve antenatal care and postnatal care services, especially those that are aimed at changing behavior of pregnant women and women in postnatal period. However, little evidence exists on other type of mHealth applications. Conclusion This review suggests that mHealth solutions targeted at pregnant women and women in postnatal period can improve preventive maternal healthcare services. However, there is a need to conduct more controlled-trials and quasi-experimental studies to strengthen the literature in this research area. The review recommends that mHealth researchers, sponsors, and publishers should prioritize the transparent reporting of interventions to allow effective interpretation of extracted data. Electronic supplementary material The online version of this article (10.1186/s12913-017-2664-7) contains supplementary material, which is available to authorized users.

This retrospective study was conducted to find out the expected ages in the patients of hepatic cirrhosis, chronic renal failure and heart failure. This study thus covers most of the patients of out medical wards presenting with chronic illnesses. On comparison of these expected ages it is also found that the expected age in all these three groups is not much different. So, the disease process or the mechanism of the chronic disease in the body may be different, but somehow the final out come is not much different in terms of life span.

Background: Despite 60% coverage by Lady Health Worker (LHW) Program, 30% of child deaths in Pakistan are still due to diarrhea and pneumonia. Caregivers are an important stakeholder yet there is little information on their case management practices and utilization of LHW Program. This study explored caregivers’ knowledge and practices about childhood diarrhea and pneumonia and utility of LHW services before and after a supportive supervision intervention. Methods: Cross sectional surveys were conducted with caregivers’ (mothers) pre and post intervention in project NIGRAAN. The intervention aimed to improve LHSs clinical and supervisory skills of lady health supervisors in order to improve LHW performance and ultimately impact caregiver practices. 4250 households were surveyed. Questionnaire was adapted from PDHS 2012-13. Differences between intervention and control groups were assessed using chi square test. P-value of

Various models and strategies have been implemented over the years in different parts of the world to improve maternal and newborn health (MNH) in conflict affected areas. These strategies are based on specific needs and acceptability of local communities. This paper has undertaken a systematic review of global and local (Pakistan) information from conflict areas on platforms of health service provision in the last 10 years and information on acceptability from local stakeholders on effective models of service delivery; and drafted key recommendations for improving coverage of health services in conflict affected areas. The literature search revealed ten studies that described MNH service delivery platforms. The results from the systematic review showed that with utilisation of community outreach services, the greatest impacts were observed in skilled birth attendance and antenatal consultation rates. Facility level services, on the other hand, showed that labour room services for an internally displaced population (IDP) improved antenatal care coverage, contraceptive prevalence rate and maternal mortality. Consultative meetings and discussions conducted in Quetta and Peshawar (capitals of conflict affected provinces) with relevant stakeholders revealed that no systematic models of MNH service delivery, especially tailored for conflict areas, are available. During conflict, even previously available services and infrastructure suffered due to various barriers specific to times of conflict and unrest. A number of barriers that hinder MNH services were discussed. Suggestions for improving MNH services in conflict areas were also laid down by participants. The review identified some important steps that can be undertaken to mitigate the effects of conflict on MNH services, which include: improve provision and access to infrastructure and equipment; development and training of healthcare providers; and advocacy at different levels for free access to healthcare services and for the introduction of the programme model in existing healthcare system. The obligation is enormous, however, for a sustainable programme, it is important to work closely with both the IDP and host community, and collaborating with the government and non-government organisations.

Background Diarrhoea and pneumonia contribute 30% of deaths in children under 5 in Pakistan. Pakistan’s Lady Health Workers Programme (LHW-P) covers about 60% of the population but has had little impact in reducing morbidity and mortality related to these major childhood killers. An external evaluation of the LHW-P suggests that lack of supportive supervision of LHWs by lady health supervisors (LHSs) is a key determinant of this problem. Project NIGRAAN aims to improve knowledge and skills of LHWs and community caregivers through supervisory strategies employed by LHSs. Ultimately, community case management (CCM) of childhood pneumonia and diarrhoea will improve. Methods/Design NIGRAAN is a cluster-randomised trial in District Badin, Pakistan. There are approximately 1100 LHWs supervised by 36 LHSs in Badin. For this study, each LHS serves as a cluster. All LHSs working permanently in Badin who regularly conduct and report field visits are eligible. Thirty-four LHSs have been allocated to either intervention or control arms in a ratio of 1:1 through computer-generated simple randomisation technique. Five LHWs from each LHSs are also randomly picked. All 34 LHSs and 170 LHWs will be actively monitored. The intervention consists of training to build LHS knowledge and skills, clinical mentorship and written feedback to LHWs. Pre- and post-intervention assessments of LHSs, LHWs and community caregivers will be conducted via focus group discussions, in-depth interviews, knowledge assessment questionnaires, skill assessment scorecards and household surveys. Primary outcome is improvement in CCM practices of childhood diarrhoea and pneumonia and will be assessed at the cluster level. Discussion NIGRAAN takes a novel approach to implementation research and explores whether training of LHSs in supervisory skills results in improving the CCM practices of childhood diarrhoea and pneumonia. No significant harm to participants is anticipated. The enablers and barriers towards improved CCM would provide recommendations to policymakers for scale up of this intervention nationally and regionally. Trial registration NIGRAAN is registered with the ‘Australian New Zealand Clinical Trials Registry’. Registration Number: ACTRN12613001261707

Background Community health worker motivation is an important consideration for improving performance and addressing maternal, newborn, and child health in low and middle-income countries. Therefore, identifying health system interventions that address motivating factors in resource-strained settings is essential. This study is part of a larger implementation research project called Nigraan, which is intervening on supportive supervision in the Lady Health Worker Programme to improve community case management of pneumonia and diarrhea in rural Pakistan. This study explored the motivation of Lady Health Supervisors, a cadre of community health workers, with particular attention to their views on supportive supervision. Methods Twenty-nine lady health supervisors enrolled in Nigraan completed open-ended structured surveys with questions exploring factors that affect their motivation. Thematic analysis was conducted using a conceptual framework categorizing motivating factors at individual, community, and health system levels. Results Supportive supervision, recognition, training, logistics, and salaries are community and health system motivating factors for lady health supervisors. Lady health supervisors are motivated by both their role in providing supportive supervision to lady health workers and by the supervisory support received from their coordinators and managers. Family support, autonomy, and altruism are individual level motivating factors. Conclusions Health system factors, including supportive supervision, are crucial to improving lady health supervisor motivation. As health worker motivation influences their performance, evaluating the impact of health system interventions on community health worker motivation is important to improving the effectiveness of community health worker programs. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1641-x) contains supplementary material, which is available to authorized users.

Background Pakistan’s Lady Health Worker Programme aims to provide care to children sick with pneumonia and diarrhoea, which continues to cause 27 % under-five mortality in Pakistan. The quality of supervision received by Lady Health Workers (LHWs) in the programme influence their knowledge and skills, in turn impacting their ability to provide care. Methods This study is part of an implementation research project titled “Nigraan” (an Urdu word meaning supervisor), and explores LHW and Lady Health Supervisor (LHS) perspectives regarding the role of supervision in improving LHWs performance and motivation in district Badin, Sindh, Pakistan. Their knowledge and skills regarding integrated community case management (iCCM) of diarrhoea and pneumonia were also assessed. Fourteen focus group discussions and 20 in-depth interviews were conducted as part of this qualitative inquiry. Analysis was done using QSR NVivo version 10. Results Most LHWs and LHSs identified pneumonia and diarrhoea as two major causes of death among children under-five. Poverty, illiteracy, poor hygiene and lack of clean drinking water were mentioned as underlying causes of high mortality due to diarrhoea and pneumonia. LHWs and LHSs gaps in knowledge included classification of dehydration, correctly preparing ORS and prescribing correct antibiotics in pneumonia. Lack of training, delayed salaries and insufficient medicines and other supplies were identified as major factors impeding appropriate knowledge and skill development for iCCM of childhood diarrhoea and pneumonia. LHWs considered adequate supervision and the presence of LHSs during household visits as a factor facilitating their performance. LHWs did not have a preference for written or verbal feedback, but LHSs considered written individual feedback to LHWs to be more useful than group and verbal feedback. Conclusion LHWs have knowledge and skill gaps that prevent them from providing effective care for diarrhoea and pneumonia. Enhanced supportive feedback from LHSs could improve LHWs skills and performance.