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Owais A, Islam M, Ataullahjan A, Bhutta ZA. Understanding the Determinants of Anemia Reduction among Women of Reproductive Age: Exemplar Country Case-Studies' Methodology. Am J Clin Nutr 2024:S0002-9165(24)00518-5. [PMID: 38825186 DOI: 10.1016/j.ajcnut.2024.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 05/21/2024] [Accepted: 05/28/2024] [Indexed: 06/04/2024] Open
Abstract
BACKGROUND Since 2000, only a few countries have substantially reduced the burden of anemia among women 15-49 years of age. The Exemplars in Anemia Reduction among Women of Reproductive Age (WRA) studied the determinants of success among these countries. OBJECTIVE To describe the methodology used to determine the factors associated with anemia reduction in high-performing countries, with the aim to guide policy and programmatic decisions in other countries with similar sociodemographic and health indices. METHODS This paper describes the process used to identify countries with exemplary reduction in WRA anemia burden, compared to their peers. We describe the Exemplars in Global Health methodology, the mixed-methods approach used to identify and quantify the macro- and micro-level characteristics associated with anemia burden decline among WRA. Quantitative analyses include descriptive and equity analyses, multivariate linear regression, and Oaxaca-Blinder decomposition analysis (OBDA). Qualitative analyses include in-depth interviews (IDIs) and focus group discussions (FGDs) with national, subnational, and community stakeholders, as well as review of programs and policies with the potential to impact women's health and/or nutrition, enacted in the countries over the last 20 years. A technical advisory group (TAG) oversaw all research activities. RESULTS We identified five countries, namely Mexico, Pakistan, Philippines, Uganda, and Senegal, as Anemia Exemplars, after considering the magnitude of anemia decline between 2000 and 2018, availability of at least two nationally representative anemia surveys, geographical diversity to account for the complex etiology of anemia, regional representation, and logistics of in-country work. CONCLUSION Exemplars in Anemia Reduction among WRA seeks to create awareness of how little anemia prevalence has changed globally and aims to inform and spur global efforts for improving women's health and nutrition.
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Affiliation(s)
- Aatekah Owais
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Muhammad Islam
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | | | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Centre of Excellence in Women and Child Health, the Aga Khan University, Karachi, Pakistan; Institute for Global Health & Development, The Aga Khan University, South-Central Asia, East Africa and United Kingdom.
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Akseer N, Phillips DE. Drivers of success in global health outcomes: A content analysis of Exemplar studies. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003000. [PMID: 38722816 PMCID: PMC11081220 DOI: 10.1371/journal.pgph.0003000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 03/04/2024] [Indexed: 05/12/2024]
Abstract
Applying a positive outlier lens is one effective approach for generating evidence to inform global health policy, program, and funding decisions. Exemplars in Global Health (EGH) is a program that studies positive outlier countries that have made extraordinary progress in health outcomes (despite limited resources) and disseminates their successes through multiple types of outputs. To date, EGH has studied, or is studying, 14 global health topics in 28 countries. This paper aims to identify findings, summarized as themes and sub-themes, that appear among all completed EGH studies. We developed a conceptual framework and used a content analysis approach to identify the top thematic areas that appear as drivers for programmatic success across EGH studies that were completed between June 2020-May 2023. The EGH studies (N = 31) spanned six topics including under-five child mortality (n = 6), childhood stunting (n = 5), community health workers (CHW) (n = 4), vaccine delivery (n = 3), COVID-19 response (n = 6), and newborn and maternal mortality reduction (n = 7) across 19 countries in sub-Saharan Africa, Latin America, South and Central Asia, and the Caribbean regions. Top drivers of success were defined as those critical or catalytic in achieving the intended outcome. Eight key drivers were identified: (1) efficient data collection and use for decision-making, (2) strong political commitment and health leadership, (3) effective stakeholder coordination, (4) a local, connected, and capacitated workforce, (5) intentional women's empowerment and engagement, (6) effective adoption and implementation of national policies, (7) effective and sustainable financing, and (8) equitable, efficient outreach and targeting. These cross-cutting drivers span a broad range of development outcomes, sectors, and populations, and indicate a need to effectively integrate people, systems, and sectors to improve global health outcomes. Findings from this study aim to support peer learning among countries and support evidence-based decision-making for funders, policymakers, and other key stakeholders.
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Affiliation(s)
- Nadia Akseer
- Department of International Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Exemplars in Global Health, Gates Ventures, Seattle, Washington, United States of America
| | - David E. Phillips
- Exemplars in Global Health, Gates Ventures, Seattle, Washington, United States of America
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Binagwaho A, VanderZanden A, Garcia PJ, Huda FA, Maskey M, Sall M, Sayinzoga F, Subedi RK, Teklu AM, Donahoe K, Frisch M, Ntawukuriryayo JT, Udoh K, Hirschhorn LR. Cross-country analysis of contextual factors and implementation strategies in under-5 mortality reduction in six low- and middle-income countries 2000-2015. BMC Pediatr 2024; 23:652. [PMID: 38413879 PMCID: PMC10900537 DOI: 10.1186/s12887-023-03906-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 02/13/2023] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND The Exemplars in Under-5 Mortality (U5M) was a multiple cases study of how six low- and middle-income countries (LMICs), Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal, implemented health system-delivered evidence-based interventions (EBIs) to reduce U5M between 2000 and 2015 more effectively than others in their regions or with similar economic growth. Using implementation research, we conducted a cross-country analysis to compare decision-making pathways for how these countries chose, implemented, and adapted strategies for health system-delivered EBIs that mitigated or leveraged contextual factors to improve implementation outcomes in reducing amenable U5M. METHODS The cross-country analysis was based on the hybrid mixed methods implementation research framework used to inform the country case studies. The framework included a common pathway of Exploration, Preparation, Implementation, Adaptation, and Sustainment (EPIAS). From the existing case studies, we extracted contextual factors which were barriers, facilitators, or determinants of strategic decisions; strategies to implement EBIs; and implementation outcomes including acceptability and coverage. We identified common factors and strategies shared by countries, and individual approaches used by countries reflecting differences in contextual factors and goals. RESULTS We found the six countries implemented many of the same EBIs, often using similar strategies with adaptations to local context and disease burden. Common implementation strategies included use of data by decision-makers to identify problems and prioritize EBIs, determine implementation strategies and their adaptation, and measure outcomes; leveraging existing primary healthcare systems; and community and stakeholder engagement. We also found common facilitators included culture of donor and partner coordination and culture and capacity of data use, while common barriers included geography and culture and beliefs. We found evidence for achieving implementation outcomes in many countries and EBIs including acceptability, coverage, equity, and sustainability. DISCUSSION We found all six countries used a common pathway to implementation with a number of strategies common across EBIs and countries which contributed to progress, either despite contextual barriers or by leveraging facilitators. The transferable knowledge from this cross-country study can be used by other countries to more effectively implement EBIs known to reduce amenable U5M and contribute to strengthening health system delivery now and in the future.
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Affiliation(s)
| | | | - Patricia J Garcia
- School of Public Health at Cayetano Heredia University, Lima, Peru
- Global Health Department, University of Washington, Seattle, USA
| | | | | | | | | | | | | | | | | | | | - Kelechi Udoh
- University of Global Health Equity, Kigali, Rwanda
| | - Lisa R Hirschhorn
- University of Global Health Equity, Kigali, Rwanda
- Northwestern University, Chicago, USA
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Sakas Z, Hester KA, Ellis A, Ogutu EA, Rodriguez K, Bednarczyk R, Dixit S, Kilembe W, Sarr M, Freeman MC. Critical success factors for high routine immunisation performance: a qualitative analysis of interviews and focus groups from Nepal, Senegal, and Zambia. BMJ Open 2023; 13:e070541. [PMID: 37793916 PMCID: PMC10551940 DOI: 10.1136/bmjopen-2022-070541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 08/16/2023] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVES Vaccination averts an estimated 2-3 million deaths annually. Although vaccine coverage improvements across Africa and South Asia have remained below global targets, several countries have outperformed their peers with significant increases in coverage. The objective of this study was to examine these countries' vaccination programmes and to identify and describe critical success factors that may have supported these improvements. DESIGN Multiple case study design using qualitative research methods. SETTING Three countries with high routine immunisation rates: Nepal, Senegal, and Zambia. PARTICIPANTS We conducted 207 key informant interviews and 71 focus group discussions with a total of 678 participants. Participants were recruited from all levels, including government officials, health facility staff, frontline workers, community health workers, and parents. Participants were recruited from both urban and rural districts in Nepal, Senegal, and Zambia. RESULTS Our data revealed that the critical success factors for vaccination programmes relied on the cultural, historical, and statutory context in which the interventions were delivered. In Nepal, Senegal, and Zambia, high immunisation coverage was driven by (1) strong governance structures and healthy policy environments; (2) adjacent successes in health system strengthening; (3) government-led community engagement initiatives, and (4) adaptation considering contextual factors at all levels of the health system. CONCLUSIONS Throughout this project, our analysis returned to the importance of defining and understanding the context, governance, financing, and health systems within a country, rather than focusing on any one intervention. This paper augments findings from existing literature by highlighting how contextual factors impact implementation decisions that have led to improvements in childhood vaccine delivery. Findings from this research may help identify transferable lessons and support actionable recommendations to improve national immunisation coverage in other settings.
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Affiliation(s)
- Zoe Sakas
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Kyra A Hester
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Anna Ellis
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Emily A Ogutu
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Katie Rodriguez
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Robert Bednarczyk
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
| | - Sameer Dixit
- Center for Molecular Dynamics Nepal, Kathmandu, Nepal
| | - William Kilembe
- Rwanda Zambia HIV Research Group, Emory University, Lusaka, Zambia
| | - Moussa Sarr
- Institut de Recherche en Santé de Surveillance Epidémiologique et de Formations, Dakar, Senegal
| | - Matthew C Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Sakas Z, Hester KA, Rodriguez K, Amos Diatta S, Ellis AS, Malick Gueye D, Matapano D, Souleymane Mboup P, Awino Ogutu E, Yang C, Bednarczyk RA, Freeman MC, Sarr M, Castillo Zunino F, Darwar R, Dounebaine B, Dudgeon MR, Escoffery C, Isett KR, Jaishwal C, James H, Keskinocak P, Pablo Montagnes B, Nazzali D, Orenstein W, Rueda Robayo M, Rosenblum S, Smalley HK. Critical success factors for high routine immunization performance: A case study of Senegal. Vaccine X 2023; 14:100296. [PMID: 37113739 PMCID: PMC10126928 DOI: 10.1016/j.jvacx.2023.100296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/24/2023] [Accepted: 03/30/2023] [Indexed: 04/08/2023] Open
Abstract
Background The essential components of a vaccine delivery system are well-documented, but robust evidence is lacking on how policies and implementation strategies are operationalized to drive catalytic improvements in coverage. To address this gap, we identified success factors that supported improvements in routine immunization coverage in Senegal, especially from 2000 to 2019. Methods We identified Senegal as an exemplar in the delivery of childhood vaccines through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national, regional, district, health facility, and community-level, we investigated factors that contributed to high and sustained vaccination coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data. Results The following success factors emerged: 1) Strong political will and prioritization of resources for immunization programming supported urgent allocation of funding and supplies; 2) Collaboration between the Ministry of Health and Social Action and external partners fostered innovation, capacity building, and efficiency; 3) Improved surveillance, monitoring, and evaluation allowed for timely and evidence-based decision making; 4) Community ownership of vaccine service delivery supported tailored programming and response to local needs; and 5) Community health workers spearheaded vaccine promotion and demand generation for vaccines. Conclusion The vaccination program in Senegal was supported by evidence-based decision making at the national-level, alignment of priorities between governmental entities and external partners, and strong community engagement initiatives that fostered local ownership of vaccine delivery and uptake. High routine immunization coverage was likely driven by prioritization of immunization programming, improved surveillance systems, a mature and reliable community health worker program, and tailored strategies for addressing geographical, social, and cultural barriers.
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Fullman N, Correa GC, Ikilezi G, Phillips DE, Reynolds HW. Assessing Potential Exemplars in Reducing Zero-Dose Children: A Novel Approach for Identifying Positive Outliers in Decreasing National Levels and Geographic Inequalities in Unvaccinated Children. Vaccines (Basel) 2023; 11:vaccines11030647. [PMID: 36992231 DOI: 10.3390/vaccines11030647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 03/15/2023] Open
Abstract
Background: Understanding past successes in reaching unvaccinated or “zero-dose” children can help inform strategies for improving childhood immunization in other settings. Drawing from positive outlier methods, we developed a novel approach for identifying potential exemplars in reducing zero-dose children. Methods: Focusing on 2000–2019, we assessed changes in the percentage of under-one children with no doses of the diphtheria–tetanus–pertussis vaccine (no-DTP) across two geographic dimensions in 56 low- or lower-middle-income countries: (1) national levels; (2) subnational gaps, as defined as the difference between the 5th and 95th percentiles of no-DTP prevalence across second administrative units. Countries with the largest reductions for both metrics were considered positive outliers or potential ‘exemplars’, demonstrating exception progress in reducing national no-DTP prevalence and subnational inequalities. Last, so-called “neighborhood analyses” were conducted for the Gavi Learning Hub countries (Nigeria, Mali, Uganda, and Bangladesh), comparing them with countries that had similar no-DTP measures in 2000 but different trajectories through 2019. Results: From 2000 to 2019, the Democratic Republic of the Congo, Ethiopia, and India had the largest absolute decreases for the two no-DTP dimensions—national prevalence and subnational gaps—while Bangladesh and Burundi registered the largest relative reductions for each no-DTP metric. Neighborhood analyses highlighted possible opportunities for cross-country learning among Gavi Learning Hub countries and potential exemplars in reducing zero-dose children. Conclusions: Identifying where exceptional progress has occurred is the first step toward better understanding how such gains could be achieved elsewhere. Further examination of how countries have successfully reduced levels of zero-dose children—especially across variable contexts and different drivers of inequality—could support faster, sustainable advances toward greater vaccination equity worldwide.
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Affiliation(s)
- Nancy Fullman
- Exemplars in Global Health, Gates Ventures, 2401 Elliott Ave, Seattle, WA 98121, USA
| | - Gustavo C Correa
- Gavi, the Vaccine Alliance, Chemin du Pommier 40, Le Grand-Saconnex, 1218 Geneva, Switzerland
| | - Gloria Ikilezi
- Exemplars in Global Health, Gates Ventures, 2401 Elliott Ave, Seattle, WA 98121, USA
| | - David E Phillips
- Exemplars in Global Health, Gates Ventures, 2401 Elliott Ave, Seattle, WA 98121, USA
| | - Heidi W Reynolds
- Gavi, the Vaccine Alliance, Chemin du Pommier 40, Le Grand-Saconnex, 1218 Geneva, Switzerland
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Hester KA, Sakas Z, Ellis AS, Bose AS, Darwar R, Gautam J, Jaishwal C, James H, Keskinocak P, Nazzal D, Awino Ogutu E, Rodriguez K, Castillo Zunino F, Dixit S, Bednarczyk RA, Freeman MC. Critical success factors for high routine immunization performance: A case study of Nepal. Vaccine X 2022; 12:100214. [PMID: 36148265 PMCID: PMC9486040 DOI: 10.1016/j.jvacx.2022.100214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 07/14/2022] [Accepted: 08/31/2022] [Indexed: 12/04/2022] Open
Abstract
Nepal reported high and sustained immunization coverage compared to peers. National and multi-national partnerships supported information sharing, division of labor, and mutual capacity building. Pro-vaccine messaging through various mediums, including Female Community Health Volunteers, which was tailored to local needs, generated public awareness. Cultural values fostered collective responsibility and community ownership of vaccine coverage.
Introduction The essential components of a vaccine delivery system are well-documented, but robust evidence on how and why the related processes and implementation strategies drive catalytic improvements in vaccination coverage are not well established. To address this gap, we identified critical success factors that may have led to substantial improvements in routine childhood immunization coverage in Nepal from 2000 through 2019. Methods We identified Nepal as an exemplar in the delivery of early childhood immunization through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national, regional, district, health post, and community level, we investigated factors that contributed to high and sustained vaccine coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data. Results The following success factors emerged: 1) Codification of health as a human right, - along with other vaccine-specific legislation - ensured the stability of vaccination programming; 2) National and multi-national partnerships supported information sharing, division of labor, and mutual capacity building; 3) Pro-vaccine messaging through various mediums, which was tailored to local needs, generated public awareness; 4) Female Community Health Volunteers educated community members as trusted and compassionate neighbors; and 5) Cultural values fostered collective responsibility and community ownership of vaccine coverage. Conclusion This case study of Nepal suggests that the success of its national immunization program relied on the engagement and understanding of the beneficiaries. The immunization program was supported by consistent and reliable commitment, collaboration, awareness, and collective responsibility between the government, community, and partners. These networks are strengthened through a collective dedication to vaccination programming and a universal belief in health as a human right.
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Affiliation(s)
- Kyra A. Hester
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Zoe Sakas
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Anna S. Ellis
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Anindya S. Bose
- World Health Organization, Nepal-Immunization Prevention Division, Nepal
| | - Roopa Darwar
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jhalak Gautam
- Family Welfare Division, Department of Health Services, Ministry of Health and Population, Nepal
| | - Chandni Jaishwal
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Hanleigh James
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Pinar Keskinocak
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Dima Nazzal
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | | | - Katie Rodriguez
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Francisco Castillo Zunino
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | | | | | - Matthew C. Freeman
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Corresponding author at: 1518 Clifton Road NE, Atlanta, GA 30322, USA.
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Micek K, Hester KA, Chanda C, Darwar R, Dounebaine B, Ellis AS, Keskinocak P, Leslie A, Manyando M, Sililo Manyando M, Nazzal D, Awino Ogutu E, Sakas Z, Castillo-Zunino F, Kilembe W, Bednarczyk RA, Freeman MC. Critical success factors for routine immunization performance: A case study of Zambia 2000 to 2018. Vaccine X 2022; 11:100166. [PMID: 35707220 PMCID: PMC9189203 DOI: 10.1016/j.jvacx.2022.100166] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 02/01/2022] [Accepted: 04/25/2022] [Indexed: 11/19/2022] Open
Abstract
This paper describes how policies and programs contributed to improved vaccine coverage in Zambia. Communication, coordination, and collaboration between implementing levels were imperative. Adjacent successes in health systems strengthening and governance were leveraged. Policies in Zambia include flexibility in implementation for tailored approaches in each district.
Introduction The essential components of a vaccine delivery system are well-documented, but robust evidence on how and why the related processes and implementation strategies prove effective at driving coverage is not well-established. To address this gap, we identified critical success factors associated with advancing key policies and programs that may have led to the substantial changes in routine childhood immunization coverage in Zambia between 2000 and 2018. Methods We identified Zambia as an exemplar in the delivery of childhood vaccines through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national and subnational levels, we investigated factors that contributed to high and sustained vaccination coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data. Results The following success factors emerged: 1) the Inter-agency Coordinating Committee was strengthened for long-term engagement which, complemented by the Zambia Immunization Technical Advisory Group, is valued by the government and integrated into national-level decision-making; 2) the Ministry of Health improved the coordination of data collection and review for informed decision-making across all levels; 3) Regional multi-actor committees identified development priorities, strategies, and funding, and iteratively adjusted policies to account for facilitators, barriers, and lessons learned; 4) Vaccine messaging was disseminated through multiple channels, including the media and community leaders, increasing trust in the government by community members; 5) The Zambia Ministry of Health and Churches Health Association of Zambia formalized a long-term organizational relationship to leverage the strengths of faith-based organizations; and 6) Neighborhood Health Committees spearheaded community-driven strategies via community action planning and ultimately strengthened the link between communities and health facilities. Conclusion Broader health systems strengthening and strong partnerships between various levels of the government, communities, and external organizations were critical factors that accelerated vaccine coverage in Zambia. These partnerships were leveraged to strengthen the overall health system and healthcare governance.
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Affiliation(s)
- Katie Micek
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kyra A. Hester
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Chama Chanda
- Center for Family Health Research in Zambia, Lusaka, Zambia
| | - Roopa Darwar
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Anna S. Ellis
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Pinar Keskinocak
- College of Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | | | | | | | - Dima Nazzal
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | | | - Zoe Sakas
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Francisco Castillo-Zunino
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | | | | | - Matthew C. Freeman
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Corresponding author at: 404-712-8767; 1518 Clifton Road NE, Atlanta, GA, 30322
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Muriithi FG, Banke-Thomas A, Gakuo R, Pope K, Coomarasamy A, Gallos ID. Individual, health facility and wider health system factors contributing to maternal deaths in Africa: A scoping review. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000385. [PMID: 36962364 PMCID: PMC10021542 DOI: 10.1371/journal.pgph.0000385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/24/2022] [Indexed: 11/18/2022]
Abstract
The number of women dying during pregnancy and after childbirth remains unacceptably high, with African countries showing the slowest decline. The leading causes of maternal deaths in Africa are preventable direct obstetric causes such as haemorrhage, infection, hypertension, unsafe abortion, and obstructed labour. There is an information gap on factors contributing to maternal deaths in Africa. Our objective was to identify these contributing factors and assess the frequency of their reporting in published literature. We followed the Arksey and O'Malley methodological framework for scoping reviews. We searched six electronic bibliographic databases: MEDLINE, SCOPUS, African Index Medicus, African Journals Online (AJOL), French humanities and social sciences databases, and Web of Science. We included articles published between 1987 and 2021 without language restriction. Our conceptual framework was informed by a combination of the socio-ecological model, the three delays conceptual framework for analysing the determinants of maternal mortality and the signal functions of emergency obstetric care. We included 104 articles from 27 African countries. The most frequently reported contributory factors by level were: (1) Individual-level: Delay in deciding to seek help and in recognition of danger signs (37.5% of articles), (2) Health facility-level: Suboptimal service delivery relating to triage, monitoring, and referral (80.8% of articles) and (3) Wider health system-level: Transport to and between health facilities (84.6% of articles). Our findings indicate that health facility-level factors were the most frequently reported contributing factors to maternal deaths in Africa. There is a lack of data from some African countries, especially those countries with armed conflict currently or in the recent past. Information gaps exist in the following areas: Statistical significance of each contributing factor and whether contributing factors alone adequately explain the variations in maternal mortality ratios (MMR) seen between countries and at sub-national levels.
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Affiliation(s)
- Francis G Muriithi
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Aduragbemi Banke-Thomas
- School of Human Sciences, University of Greenwich, Old Royal Naval College, Park Row, Greenwich, London, United Kingdom
| | - Ruth Gakuo
- School of Nursing, University of Derby, Derby, United Kingdom
| | - Kia Pope
- Nottingham Medical School, Queen's Medical Centre, Nottingham, United Kingdom
| | - Arri Coomarasamy
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Ioannis D Gallos
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, United Kingdom
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Afzal MM, Pariyo GW, Lassi ZS, Perry HB. Community health workers at the dawn of a new era: 2. Planning, coordination, and partnerships. Health Res Policy Syst 2021; 19:103. [PMID: 34641912 PMCID: PMC8506104 DOI: 10.1186/s12961-021-00753-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Community health workers (CHWs) play a critical role in grassroots healthcare and are essential for achieving the health-related Sustainable Development Goals. While there is a critical shortage of essential health workers in low- and middle-income countries, WHO and international partners have reached a consensus on the need to expand and strengthen CHW programmes as a key element in achieving Universal Health Coverage (UHC). The COVID-19 pandemic has further revealed that emerging health challenges require quick local responses such as those utilizing CHWs. This is the second paper of our 11-paper supplement, "Community health workers at the dawn of a new era". Our objective here is to highlight questions, challenges, and strategies for stakeholders to consider while planning the introduction, expansion, or strengthening of a large-scale CHW programme and the complex array of coordination and partnerships that need to be considered. METHODS The authors draw on the outcomes of discussions during key consultations with various government leaders and experts from across policy, implementation, research, and development organizations in which the authors have engaged in the past decade. These include global consultations on CHWs and global forums on human resources for health (HRH) conferences between 2010 and 2014 (Montreux, Bangkok, Recife, Washington DC). They also build on the authors' direct involvement with the Global Health Workforce Alliance. RESULTS Weak health systems, poor planning, lack of coordination, and failed partnerships have produced lacklustre CHW programmes in countries. This paper highlights the three issues that are generally agreed as being critical to the long-term effectiveness of national CHW programmes-planning, coordination, and partnerships. Mechanisms are available in many countries such as the UHC2030 (formerly International Health Partnership), country coordinating mechanisms (CCMs), and those focusing on the health workforce such as the national Human Resources for Health Observatory and the Country Coordination and Facilitation (CCF) initiatives introduced by the Global Health Workforce Alliance. CONCLUSION It is imperative to integrate CHW initiatives into formal health systems. Multidimensional interventions and multisectoral partnerships are required to holistically address the challenges at national and local levels, thereby ensuring synergy among the actions of partners and stakeholders. In order to establish robust and institutionalized processes, coordination is required to provide a workable platform and conducive environment, engaging all partners and stakeholders to yield tangible results.
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Affiliation(s)
| | - George W Pariyo
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Zohra S Lassi
- Robinson Research Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
| | - Henry B Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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11
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Vonaesch P, Djorie SG, Kandou KJE, Rakotondrainipiana M, Schaeffer L, Andriatsalama PV, Randriamparany R, Gondje BP, Nigatoloum S, Vondo SS, Etienne A, Robinson A, Hunald FA, Raharimalala L, Giles-Vernick T, Tondeur L, Randrianirina F, Bastaraud A, Gody JC, Sansonetti PJ, Randremanana RV. Factors Associated with Stunted Growth in Children Under Five Years in Antananarivo, Madagascar and Bangui, Central African Republic. Matern Child Health J 2021; 25:1626-1637. [PMID: 34383227 PMCID: PMC8448698 DOI: 10.1007/s10995-021-03201-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2021] [Indexed: 11/29/2022]
Abstract
Objectives With a fourth of all under-five children affected, stunting remains one of the biggest health challenges worldwide. Even though the main underlying factors are known, the exact pathways to stunting varying in affected regions, and interventions thus need to be tailored to the local contexts. This study aimed assessing and comparing factors associated with stunting in two understudied sub-Saharan urban contexts with some of the highest stunting prevalence globally: Bangui, Central African Republic (~ 36%) and Antananarivo, Madagascar (42%). Methods We performed a case–control study on 175 + 194 stunted and 237 + 230 non-stunted control children aged 2–5 years and matched for age, gender and district of residency. Factors associated with stunting were identified using a standardized, paper questionnaire delivered by trained interviewers. Statistical analysis was done using logistic regression modelling. Results In both sites, formal maternal education lowered the risk of being stunted and restricted access to soap, suffering of anaemia and low birth weight were associated with higher risk of stunting. Short maternal stature, household head different from parents, diarrhoea and coughing were associated with an increased risk and continuing breastfeeding was associated with a lower risk of stunting in Antananarivo. Previous severe undernutrition and dermatitis/ fungal skin infections were associated with higher and changes in diet during pregnancy with lower risk of stunting in Bangui. Conclusions Our results suggest maternal education, antenatal care, iron supplementation and simple WASH interventions such as using soap and infection control as general and breastfeeding (Antananarivo) or better nutrition (Bangui) as area-specified interventions. Supplementary Information The online version contains supplementary material available at 10.1007/s10995-021-03201-8.
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Affiliation(s)
- Pascale Vonaesch
- Unité de Pathogénie Microbienne Moléculaire, Institut Pasteur, 25-28 Rue du Dr Roux, Paris, France. .,Human and Animal Health Unit, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland. .,University of Basel, 4051, Basel, Switzerland.
| | - Serge Ghislain Djorie
- Unité D'Epidémiologie, Institut Pasteur de Bangui, Avenue de l'Indépendance, Bangui, Central African Republic
| | - Kaleb Jephté Estimé Kandou
- Unité D'Epidémiologie, Institut Pasteur de Bangui, Avenue de l'Indépendance, Bangui, Central African Republic
| | - Maheninasy Rakotondrainipiana
- Unité Epidémiologie Et de Recherche Clinique, Institut Pasteur de Madagascar-Ambatofotsikely, BP 1274, 101, Antananarivo, Madagascar
| | - Laura Schaeffer
- Unité D'Epidémiologie Des Maladies Emergentes, Institut Pasteur, 28 Rue du Dr. Roux, 75015, Paris, France
| | - Prisca Vega Andriatsalama
- Unité Epidémiologie Et de Recherche Clinique, Institut Pasteur de Madagascar-Ambatofotsikely, BP 1274, 101, Antananarivo, Madagascar
| | - Ravaka Randriamparany
- Unité Epidémiologie Et de Recherche Clinique, Institut Pasteur de Madagascar-Ambatofotsikely, BP 1274, 101, Antananarivo, Madagascar
| | - Bolmbaye Privat Gondje
- Centre Pédiatrique de Bangui, Avenue de l'Indépendance, Bangui, Central African Republic
| | - Synthia Nigatoloum
- Centre Pédiatrique de Bangui, Avenue de l'Indépendance, Bangui, Central African Republic
| | - Sonia Sandrine Vondo
- Centre Pédiatrique de Bangui, Avenue de l'Indépendance, Bangui, Central African Republic
| | - Aurélie Etienne
- Unité Epidémiologie Et de Recherche Clinique, Institut Pasteur de Madagascar-Ambatofotsikely, BP 1274, 101, Antananarivo, Madagascar
| | - Annick Robinson
- Centre Hospitalier Universitaire Mère Enfant de Tsaralalana, Rue Patrice Lumumba, Rue Mabizo S, 101, Antananarivo, Madagascar
| | - Francis Allen Hunald
- Service de Chirurgie Pédiatrique, Centre Hospitalier Universitaire Joseph Ravoahangy Andrianavalona, Ampefiloha, BP 4150, 101, Antananarivo, Madagascar
| | - Lisette Raharimalala
- Centre de Santé Maternelle Et Infantile de Tsaralalana, Lalana Andriantsilavo, 101, Antananarivo, Madagascar
| | - Tamara Giles-Vernick
- Anthropology and Ecology of Disease Emergence Unit, Institut Pasteur, 28 Rue du Dr. Roux, 75015, Paris, France
| | - Laura Tondeur
- Unité D'Epidémiologie Des Maladies Emergentes, Institut Pasteur, 28 Rue du Dr. Roux, 75015, Paris, France
| | - Frédérique Randrianirina
- Centre de Biologie Clinique, Institut Pasteur de Madagascar, BP 1274, 101, Antananarivo, Madagascar
| | - Alexandra Bastaraud
- Laboratoire D'Hygiène Des Aliments Et de L'Environnement (LHAE), Institut Pasteur de Madagascar, BP 1274, 101, Antananarivo, Madagascar
| | - Jean-Chrysostome Gody
- Centre Pédiatrique de Bangui, Avenue de l'Indépendance, Bangui, Central African Republic
| | - Philippe Jean Sansonetti
- Unité de Pathogénie Microbienne Moléculaire, Institut Pasteur, 25-28 Rue du Dr Roux, Paris, France.,The Center for Microbes, Development and Health, Institut Pasteur of Shanghai and Chinese Academy of Sciences, 411 Hefei Rd, Huangpu, Shanghai, China
| | - Rindra Vatosoa Randremanana
- Unité Epidémiologie Et de Recherche Clinique, Institut Pasteur de Madagascar-Ambatofotsikely, BP 1274, 101, Antananarivo, Madagascar.
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Dixit SM, Sarr M, Gueye DM, Muther K, Yarnko TR, Bednarczyk RA, Clarke AT, Diakhite F, Diallo A, Dounebaine B, Duwadi SB, Ellis AS, Fullman N, Gerthe N, Gautam JS, Hester KA, Ikilezi G, Mbengue RS, Mboup S, Ndiaye BP, Rajbhandari RM, Phillips DE, Freeman MC. Addressing disruptions in childhood routine immunisation services during the COVID-19 pandemic: perspectives from Nepal, Senegal and Liberia. BMJ Glob Health 2021; 6:e005031. [PMID: 34230065 PMCID: PMC8264163 DOI: 10.1136/bmjgh-2021-005031] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/01/2021] [Indexed: 12/14/2022] Open
Affiliation(s)
| | - Moussa Sarr
- Institut de Recherche en Santé de Surveillance Epidémiologique et de Formations, Dakar, Senegal
| | - Daouda M Gueye
- Institut de Recherche en Santé de Surveillance Epidémiologique et de Formations, Dakar, Senegal
| | | | | | | | - Adolphus T Clarke
- Expanded Programme on Immunisation, Republic of Liberia Ministry of Health, Monrovia, Liberia
| | - Fatoumata Diakhite
- Focal Point for EPI and Surveillance Activities, Health Center of Rufisque, Dakar, Senegal
| | - Aliou Diallo
- Expanded Programme on Immunisation Unit, WHO Country Office Senegal, Dakar, Senegal
| | | | | | - Anna S Ellis
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | | | - Jhalak S Gautam
- Child Health and Immunization Section, Family Welfare Division, Department of Health Services, Ministry of Health and Population, Kathmandu, Nepal
| | - Kyra A Hester
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Rokhaya S Mbengue
- Focal Point for EPI and Surveillance Activities, Health Center, Philip Maguilene Senghor of Yoff, Dakar, Senegal
| | - Souleymane Mboup
- Institut de Recherche en Santé de Surveillance Epidémiologique et de Formations, Dakar, Senegal
| | - Birahim P Ndiaye
- Institut de Recherche en Santé de Surveillance Epidémiologique et de Formations, Dakar, Senegal
| | | | | | - Matthew C Freeman
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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13
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Chen N, Raghavan M, Albert J, McDaniel A, Otiso L, Kintu R, West M, Jacobstein D. The Community Health Systems Reform Cycle: Strengthening the Integration of Community Health Worker Programs Through an Institutional Reform Perspective. GLOBAL HEALTH: SCIENCE AND PRACTICE 2021; 9:S32-S46. [PMID: 33727319 PMCID: PMC7971380 DOI: 10.9745/ghsp-d-20-00429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 01/07/2021] [Indexed: 11/15/2022]
Abstract
To develop guidance for governments and partners seeking to scale community health worker programs, we developed a conceptual framework, collected observations from the scale-up efforts of 7 countries, workshopped the framework with technical groups and with country stakeholders, and reviewed literature in the areas of health and policy reform, change management, institutional development, health systems, and advocacy. We observed that successful scale-up is a complex process of institutional reform. Successful scale-up: (1) depends on a carefully choreographed, problem-driven political process; (2) requires that scaled program models are drawn from solutions that are available in a given health system context and aligned with the resources, capabilities, and commitments of key health sector stakeholders; and (3) emerges from iterative cycles of learning and improvement, rather than a single, linear scale-up effort. We identify stages of the reform process associated with each of these 3 findings: problem prioritization, coalition building, solution gathering, design, program readiness, launch, governance, and management and learning. The resulting Community Health Systems Reform Cycle can be used by government, donors, and nongovernmental partners to prioritize and design community health worker scale-up efforts, diagnose challenges or gaps in successful scale-up and integration, and coordinate the contributions of diverse stakeholders.
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Affiliation(s)
- Nan Chen
- Last Mile Health, Washington, DC, USA.
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