Can we have better equity and access across health systems for children with disabilities?

The increasing frequency and intensity of climate extremes, such as floods and heatwaves, pose significant challenges to Maternal and Child Health (MCH) systems, disrupting the delivery and access to essential health services. Mothers and children, due to their heightened health vulnerabilities, are disproportionately affected, particularly in accessing preventive care such as antenatal services and immunizations. Understanding the drivers of climate vulnerability within health systems and their evolution under future climate extremes is critical for designing effective adaptation strategies. However, existing research has predominantly focused on static or qualitative frameworks, leaving a notable gap in quantitative, dynamic, and integrative modeling approaches capable of analysing feedback mechanisms and cascading impacts over time. This research addresses this gap by developing a conceptual and theoretical System Dynamics Modeling (SDM) framework. Informed by evidence-based Causal Loop Diagrams (CLDs) and local stakeholder engagement, the framework highlights critical feedback loops and leverage points influencing MCH system resilience during climate events. Specifically, the study presents findings on how supply-side components – such as service delivery, workforce availability, infrastructure functionality, and resource flows – interact under climate stressors like floods and heatwaves. Designed using Stella Architect and calibrated with real-world data from the REACH project in Zambia, the SDM framework incorporates climate variables (e.g., flood intensity, duration, and frequency; heatwave patterns) and MCH performance metrics (e.g., household health surveys and service utilization records). Key findings reveal pathways through which climate extremes impact system performance, such as infrastructure disruptions caused by flooding that reduce service delivery or prolonged heatwaves that impair workforce productivity, creating cascading system-wide effects. Furthermore, stakeholder engagement identified critical vulnerabilities, including transportation challenges, supply chain delays, and power outages, which informed potential intervention strategies. These strategies include implementing early warning systems to improve preparedness, investing in climate-resilient infrastructure to protect health facilities and road networks, and adopting adaptive governance frameworks for effective resource allocation and coordination during crises. While this study presents a foundation by identifying critical system dynamics and exploring preliminary intervention strategies, the SDM framework is designed to support future applications. It can be used to simulate diverse scenarios, evaluate the long-term impacts of interventions, and guide adaptive strategies to enhance the sustainability and resilience of MCH systems. By advancing from a qualitative CLD to a robust SDM, this research equips policymakers and planners with a dynamic tool for evidence-based decision-making. Ultimately, it contributes to global efforts to build resilient health systems capable of adapting to the escalating challenges of climate change, laying the groundwork for applications across diverse contexts.  Keywords: Maternal and Child Health Systems, Climate Extremes, System Dynamics Modeling, Resilient Health Systems, Climate Change Adaptation  Acknowledgments  This work was conducted under the framework of the Economic and Social Research Council grant: Building Resilience to Floods and Heat in the Maternal and Child Health Systems in Brazil and Zambia (REACH), Grant Number: ES/Y00258X/1.  

Strengthening the maternal and child health system in remote and low-income areas through multilevel governmental collaboration: a case study from Nujiang Prefecture in China

Differentiating Our Brand Highlights Our Value

Extreme weather events (floods and heatwaves) are becoming more frequent and intense due to climate change, posing significant risks to maternal and child health (MCH). These events interact in complex ways, occurring as compounding hazards (simultaneous or overlapping events), multiple hazards (independent but co-occurring risks), or cascading hazards (where one event triggers or exacerbates another). Understanding these interactions is critical for assessing their full health impacts and improving health system resilience. To date, health-related research has primarily focused on the effects of each hazard individually. This study employs an integrated framework that combines copula models, Bayesian networks, and machine learning approaches to analyse multi-hazard interactions, focusing on Zambia as a case study. Data, including daily rainfall and temperature, MCH-related datasets, utilisation data, and health system performance metrics – such as antenatal care (ANC), postnatal care (PNC), childhood immunisation, place and mode of delivery, and health service utilisation records – were obtained from Zambia through the REACH project. Daily rainfall was merged with TAMSAT and ERA5 reanalysis data (weather station data) to identify flood and heatwave events across Zambia from 1981 to 2023. Copula models were used to capture non-linear dependencies between heatwaves and floods; Bayesian networks uncovered causal pathways linking hazards with MCH and utilisation outcomes; and machine learning models (e.g., random forests and neural networks) predicted health impacts and identified critical patterns of hazard-MCH interactions. Intermediate variables, such as demand-side factors (e.g., education, wealth, age, etc.) and supply-side factors (e.g., facility density, health worker density, and healthcare financing), were incorporated to improve causal inference and identify actionable pathways. Marginal distributions for temperature and precipitation extremes were modelled using extreme value theory, while copulas quantified the joint probabilities of simultaneous extremes. Bayesian networks provided insights into cascading effects, such as how flooding damages healthcare infrastructure and exacerbates the impact of heatwaves on MCH services. Machine learning models were then trained to predict MCH outcomes (utilisation rates and counts) based on these multi-hazard interactions, leveraging their capacity to handle complex, non-linear relationships. Key results focus on estimating the level of ANC and PNC service disruption caused by compounding hazards, such as simultaneous floods and heatwaves. There is an urgent need for climate-resilient healthcare systems and targeted interventions to mitigate the risks of interacting with climate extremes on MCH. Such disruptions are anticipated to highlight important predictive factors, including increased rates of preterm births and maternal complications. This integrated approach, combining statistical, causal, and predictive tools, offers a holistic framework for analysing multi-hazard interactions and their impact on maternal and child health outcomes. By focusing on Zambia as a case study, this research aims to generate insights that are both contextually relevant and scalable for global application.  Keywords: Multiple hazards, maternal and child health, machine learning, copula models, Bayesian networks   Acknowledgements  This work was conducted under the framework of the Economic and Social Research Council grant: Building Resilience to Floods and Heat in the Maternal and Child Health Systems in Brazil and Zambia (REACH), Grant Number: ES/Y00258X/1

Management of pediatric patients with ependymoma includes posttreatment surveillance imaging to identify asymptomatic recurrences. However, it is unclear whether early detection translates into improved survival. The objective was to determine whether detection of ependymoma relapses on surveillance imaging translates into a survival benefit. Patients with ependymoma aged<21 years at diagnosis treated in the Nemours' Children's Health System between January 2003 and October 2016 underwent chart review. Relapsed patients' charts were assessed for details of initial therapy, surveillance imaging regimen, details of relapse including detection and therapy, and outcome. Median follow up of the entire cohort was 6.5 years from diagnosis and 3.5 years from relapse. Ninety of 198 (45%) patients experienced relapse with 61 (68%) detected by surveillance imaging and 29 (32%) detected based on symptoms. Five-year OS in the surveillance group was 67% (confidence interval [CI] 55-82%, SE 0.1) versus 51% (CI 35-73%, SE 0.19) in the symptoms group (P=.073). From relapse, the 3-year OS in the surveillance group was 62% (CI 50-78%, SE 0.11) versus 55% (CI 39-76%, SE 0.17) in the symptoms group (P=.063) and the 3-year SPFS was 45% (CI 33-61%, SE 0.16) in the surveillance group versus 32% (CI 19-55%, SE 0.27) in the symptoms group (P=.028). Surveillance imaging may identify recurrences in patients when they are more amenable to salvage therapy, resulting in superior 3-year SPFS, but given limited salvage options for children with recurrent ependymoma, the survival advantage of frequent surveillance imaging in asymptomatic patients remains ambiguous.

Higher hospital readmission rates do not necessarily reflect worse care

From 2019 to 2022, the For Our Children project gathered a team of Chinese and American pediatricians to explore the readiness of the pediatric workforce in each country to address pressing child health concerns. The teams compared existing data on child health outcomes, the pediatric workforce, and education and combined qualitative and quantitative comparisons centered on themes of effective health care delivery outlined in the World Health Organization Workforce 2030 Report. This article describes key findings about pediatric workload, career satisfaction, and systems to assure competency. We discuss pediatrician accessibility, including geographic distribution, practice locations, trends in pediatric hospitalizations, and payment mechanisms. Pediatric roles differed in the context of each country's child health systems and varied teams. We identified strengths we could learn from one another, such as the US Medical Home Model with continuity of care and robust numbers of skilled clinicians working alongside pediatricians, as well as China's Maternal Child Health system with broad community accessibility and health workers who provide preventive care.In both countries, notable inequities in child health outcomes, evolving epidemiology, and increasing complexity of care require new approaches to the pediatric workforce and education. Although child health systems in the United States and China have significant differences, in both countries, a way forward is to develop a more inclusive and broad view of the child health team to provide truly integrated care that reaches every child. Training competencies must evolve with changing epidemiology as well as changing health system structures and pediatrician roles.

This paper presents a vision and rationale for reform of the U.S. child health system based on paradigmatic changes in the conceptualization of child health development. Reviewing well-known and well-documented accounts of how this system is under-performing, we suggest that a bold, well-defined, transformative, and long-term reform strategy is needed to address intractable problems in the underlying operating logic, organization, and financing of the current child health system. We conclude by considering an optimistic, long-term policy transformation agenda, building up emerging opportunities and changing realities in the United States and abroad.

Guidance documents on post-newborn hearing surveillance and screen (Sutton et al.2006; Bamford et al. 2007) indicated the need for a wider system to identify children with hearing loss after neonatal hearing screening. Recommendations were made for systems to be in place for recording screening activity and audit of the school entry hearing screen to provide information on coverage, referral and yield. This project has two phases: * development of the data collection system for audit; * assess local service performance.The focus of the work was on data entered into the child health system from children eligible for universal infant and school entry hearing screen. Linking information from a paediatric register of hearing impaired children allowed analysis of birth cohort data related to new diagnoses of sensorineural hearing loss. Available guidelines have not specified gold standards for coverage rates and locally endorsed benchmarks were set at 80% as minimum standards. Analysis of data was carried out on 2003, 2004, 2005, 1998, 1999 and 2000 birth cohorts. The child health system and the paediatric register were the main data sources for the audit exercises. Data extracted were computed for coverage, referral and yield. Factors and situations contributing to difficulties in establishing a robust system were identified and addressed. Usable information could be obtained to influence current practice.Coverage rates for 2003, 2004 and 2005 cohort were 64.7%, 78.1% and 73.1%. Their respective referral rates were 1.4%, 1.2% and 2.6%. Coverage rates for 1998, 1999 and 2000 cohort were 74.9%,75.6% and 71.4%. Their respective referral rates were 5.2%, 4.2% and 6.6%. The overall yield from universal screens was low. Our study showed that it was achievable to collect and analyse data on childhood hearing loss in the context of routine surveillance. There were, however, limitations to analysis of data and findings have to be interpreted with this in mind.

Low immunisation rates: Fact or fiction?

National Research Agenda on Health Systems for Children and Youth With Special Health Care Needs.

When the Government of Ontario launched a comprehensive mental health and addictions strategy, the Institute for Clinical Evaluative Sciences (ICES) was tasked with developing a scorecard for ongoing monitoring of the child and youth mental health system. Using existing administrative and survey-based healthcare and education data, researchers at ICES developed a scorecard consisting of 25 indicators that described at-risk populations, child and youth mental healthcare and relevant outcomes. This scorecard is the first in Canada to report on performance indicators for the child and youth mental health system and provides a model for monitoring child and youth mental health using routinely collected administrative data.

IntroductionIn Ethiopia, country-wide community-based primary health programs have been in effect for about two decades. Despite the program’s significant contribution to advancing Maternal Newborn and Child Health (MNCH), Ethiopia’s maternal and child mortality is still one of the highest in the world. The aim of this manuscript is to critically examine the multifaceted fragmentation challenges of Ethiopia’s Community Health Workers (CHWs) program to deliver optimum MNCH and build a resilient community health system.MethodsWe conducted a qualitative case study in West Shewa Zone, rural Ethiopia. A purposive sampling technique was used to recruit participants. Data sources were two focus group discussions with sixteen CHWs, twelve key informant interviews with multilevel public health policy actors, and a policy document review related to the CHW program to triangulate the findings. Thematic analysis of the qualitative data was conducted. The World Health Organization’s health systems framework and socio-ecological model guided the data collection, analysis, and interpretation.ResultsThe CHWs program has been an extended arm of Ethiopia’s primary health system and has contributed to improved health outcomes. However, the program has been facing unique systemic challenges that stem from the fragmentation of health finance; medical and equipment supply; working and living infrastructures; CHWs empowerment and motivation, monitoring, supervision, and information; coordination and governance; and community and stakeholder engagement. The ongoing COVID-19 and volatile political and security issues are exacerbating these fragmentation challenges.ConclusionThis study emphasized the gap between the macro (national) level policy and the challenge during implementation at the micro (district)level. Fragmentation is a blind spot for the community-based health system in rural Ethiopia. We argue that the fragmentation challenges of the community health program are exacerbating the fragility of the health system and fragmentation of MNCH health outcomes. This is a threat to sustain the MNCH outcome gains, the realization of national health goals, and the resilience of the primary health system in rural Ethiopia. We recommend that beyond the current business-as-usual approach, it is important to emphasize an evidence-based and systemic fragmentation monitoring and responsive approach and to better understand the complexity of the community-based health system fragmentation challenges to sustain and achieve better health outcomes. The challenges can be addressed through the adoption of transformative and innovative approaches including capitalizing on multi-stakeholder engagement and health in all policies in the framework of co-production.

BackgroundDespite improvements over time, West Africa lags behind global as well as sub-Saharan averages in its maternal, newborn and child health (MNCH) outcomes. This is despite the availability of an increasing body of knowledge on interventions that improve such outcomes. Beyond our knowledge of what interventions work, insights are needed on others factors that facilitate or inhibit MNCH outcome improvement. This study aimed to explore health system factors conducive or limiting to MNCH policy and programme implementation and outcomes in West Africa, and how and why they work in context.MethodsWe conducted a mixed methods multi-country case study focusing predominantly, but not exclusively, on the six West African countries (Burkina Faso, Benin, Mali, Senegal, Nigeria and Ghana) of the Innovating for Maternal and Child Health in Africa initiative. Data collection involved non-exhaustive review of grey and published literature, and 48 key informant interviews. We validated our findings and conclusions at two separate multi-stakeholder meetings organised by the West African Health Organization. To guide our data collection and analysis, we developed a unique theoretical framework of the link between health systems and MNCH, in which we conceptualised health systems as the foundations, pillars and roofing of a shelter for MNCH, and context as the ground on which the foundation is laid.ResultsA multitude of MNCH policies and interventions were being piloted, researched or implemented at scale in the sub-region, most of which faced multiple interacting conducive and limiting health system factors to effective implementation, as well as contextual challenges. Context acted through its effect on health system factors as well as on the social determinants of health.ConclusionsTo accelerate and sustain improvements in MNCH outcomes in West Africa, an integrated approach to research and practice of simultaneously addressing health systems and contextual factors alongside MNCH service delivery interventions is needed. This requires multi-level, multi-sectoral and multi-stakeholder engagement approaches that span current geographical, language, research and practice community boundaries in West Africa, and effectively link the efforts of actors interested in health systems strengthening with those of actors interested in MNCH outcome improvement.

Strategies for reducing maternal mortality