Comparison Districts Research Articles

Impact of Suaahara, an at-scale multisectoral nutrition programme, on health workers' maternal and child health, and nutrition knowledge and skills in Nepal.

Suaahara, an at-scale multisectoral nutrition programme in Nepal, aimed to advance knowledge and skills of frontline health workers to improve the quality of nutrition and health services at health facility and community levels. This study assessed the impact of Suaahara interventions on knowledge and skills of health facility workers and Female Community Health Volunteers (FCHVs). The study used a quasi-experimental design in which four Suaahara intervention districts were compared with pair-matched comparison districts. One health facility worker and three FCHVs from each survey cluster were included. Baseline survey consisted of 93 health facility workers (2015) and 118 FCHVs (2012), and endline survey (2022) consisted of 40 health facility workers and 120 FCHVs. Difference-in-differences regression models employing intent-to-treat analysis, accounting for clustering at the district level, assessed the impact of intervention. The intervention, relative to comparison, had no effect on health facility workers' knowledge. There was a positive effect, however, on FCHVs' knowledge in intervention relative to comparison areas on exclusive breastfeeding, timing of introduction of complementary feeding, sick child feeding and growth monitoring and promotion (GMP) for children under 2 years. Health facility workers and FCHVs in intervention versus comparison districts had higher endline scores for skills related to measuring the weight of children and pregnant women, measuring the height/length of children, conducting GMP for children under 2 years and identifying malnourished children. Suaahara interventions improved the capacity of health workers, particularly nutrition-related knowledge among FCHVs and GMP-related skills of both health facility workers and FCHVs.

Impact of Suaahara, an integrated nutrition programme, on maternal and child nutrition at scale in Nepal.

Suaahara was an innovative, complex, multi-sectoral, large-scale, nutrition programme in Nepal to increase exposure to nutrition-related information and services, improve nutrition-related knowledge and practices among pregnant women and mothers of infants and young children, and improve their nutrition. This study evaluated the effectiveness of Suaahara to improve nutrition and nutrition-related practices by comparing changes over 10 years between intervention and comparison districts. The samples of households at baseline in 2012 and endline in 2022 were 2040 and 2480, respectively, from 120 old wards. The impact was estimated using intent-to-treat regression models in which survey year, armand their interaction were fixed effects, accounting for district clustering, with the interaction estimating differences between arms in changes over time. The intervention, relative to comparison, reduced maternal underweight by 8.43 percentage points (p < 0.001), consistent with improved maternal and fetal condition that was manifested as the greater length of 0.761 z-scores (p = 0.004) of infants 0-5.9 months. Complementary feeding practices with children between 6 and 23.9 months of age improved more in the intervention than comparison districts: child dietary diversity by 0.294 food groups (p = 0.072) and minimum dietary diversity by 9.51 percentage points (p = 0.028), feeding sick child more (p = 0.002) and administering oral rehydration solution and zinc for diarrhoea (p = 0.057) by about 17 percentage points each, and minimum meal frequency (p = 0.004) and minimum acceptable diet (p = 0.022) by about 15 percentage points each. Substantial impacts were demonstrated despite political restructuring, earthquakes, and other major challenges that Nepal and Suaahara faced and limitations in statistical power because of the reduced number of districts that then could be included in the study. Registered at clinicaltrials.gov with identifier NCT05448287.

Impact of a community-based primary healthcare programme on childhood diphtheria-tetanus-pertussis (DPT3) immunisation coverage in rural northern Ghana

BackgroundChild healthcare services such as diphtheria-tetanus-pertussis (DPT3) vaccination are known to reduce childhood mortality and morbidity. However, inequalities in access to these services in developing countries continue to constrain global efforts aimed at improving child health. This study examines the impact and equity effect of a community-based primary healthcare programme known as the Ghana Essential Health Intervention Programme (GEHIP) on improving the uptake of childhood DPT3 immunisation coverage in a remote rural region of Ghana.MethodsUsing baseline and end-line household survey data collected from mothers, the effect of GEHIP’s community-based healthcare programme on DPT3 immunisation coverage is evaluated using difference-in-differences multivariate logistic regression models. Household wealth index and maternal educational attainment were used as equity measures.ResultsAt end-line, both intervention and comparison districts recorded increases in DPT3 immunisation coverage although intervention districts had a relatively higher coverage than comparison districts (90% versus 88%). While children resident in intervention areas had slightly higher rates than children resident in comparison areas, regression results show that this difference was not statistically significant (DiD = 0.038, p-value = 0.102). There were also no significant equity disparities in the coverage of DPT3 vaccination for both household wealth index and maternal educational attainment.ConclusionDPT3 vaccination coverage in both study arms met the global vaccine action plan targets. However, because estimated effects are not significantly higher among treatment area children than among comparison districts counterparts, no equity/inequity effects of the community-based healthcare programme on DPT 3 coverage is evident.

Equity in maternal healthcare utilisation in Ghana: Do community-based primaryhealth care programmes matter?

Improving equity in the use of maternal health services in rural and remote communities is critical to meeting the Sustainable Development Goals targets on maternal and child health. This study examines the effect of a community-based primary healthcare strengthening programme on improving the utilisation of antenatal care (ANC4+), skilled delivery and health facility delivery. Baseline and endline survey data of women of reproductive age for intervention and comparison districts were used to examine the equity impact of the Ghana Essential Health Interventions Programme (GEHIP) on antenatal care visits, skilled delivery and health facility delivery. The Wagstaff extension of the concentration index and regression models are used to assess equity effects of the programme on the utilisation of these services by wealth index and educational attainment. Coverage rates increased for both intervention and comparison districts, but were generally higher in intervention districts than comparison districts at endline (90% vs. 88% for ANC4+, 88% vs. 84% for skilled delivery and 93% vs. 88% for health facility delivery). Only ANC4+ showed a statistically significant positive treatment effect of the intervention (Dif-in-Dif = 0.071, p-value = 0.010). Equity analysis showed a mixed picture with intervention districts achieving significant equity improvement for skilled delivery for both wealth index and maternal education but only education equity for health facility delivery, while comparison districts achieved both wealth and education equity improvements for two indicators (health facility delivery and skilled delivery). No significant equity/inequity effects were found for ANC4+. Efforts to improve community-based healthcare access have been associated with improved coverage of maternal health services; however, the effect on improving equity in service coverage is mixed. Results indicate a need to extend community-based primary health care development beyond general improvements in access to ensure equity in the coverage of maternal and child health services that such programmes provide.

Impact of mobile health on maternal and child health service utilization and continuum of care in Northern Ghana

Maternal and child mortality are of public health concern. Most of these deaths occur in rural communities of developing countries. Technology for maternal and child health (T4MCH) is an intervention introduced to increase Maternal and Child Health (MCH) services utilization and continuum of care in some health facilities across Ghana. The objective of this study is to assess the impact of T4MCH intervention on MCH services utilization and continuum of care in the Sawla-Tuna-Kalba District in the Savannah Region of Ghana. This is a quasi-experimental study with a retrospective review of records of MCH services of women who attended antenatal services in some selected health centers in the Bole (comparison district) and Sawla-Tuna-Kalba (intervention district) of the Savannah region, Ghana. A total of 469 records were reviewed, 263 in Bole and 206 in Sawla-Tuna-Kalba. A multivariable modified Poisson and logistic regression models with augmented inverse-probability weighted regression adjustment based on propensity scores were used to quantify the impact of the intervention on service utilization and continuum of care. The implementation of T4MCH intervention increased antenatal care attendance, facility delivery, postnatal care and continuum of care by 18 percentage points (ppts) [95% CI - 17.0, 52.0], 14 ppts [95% CI 6.0%, 21.0%], 27 ppts [95% CI 15.0, 26.0] and 15.0 ppts [95% CI 8.0, 23.0] respectively compared to the control districts. The study showed that T4MCH intervention improved antenatal care, skilled delivery, postnatal services utilization, and continuum of care in health facilities in the intervention district. The intervention is recommended for a scale-up in other rural areas of Northern Ghana and the West-African sub-region.

Quality of sick child management by health extension workers: role of a complex improvement intervention

BackgroundDespite the expansion of the Integrated Community Case Management services for childhood illness, quality and utilization of services have remained low. To address the problem, the Government of Ethiopia introduced a complex intervention that included community engagement, capacity building of health workers and enhanced district-level ownership of sick child management. We examined whether this complex intervention was associated with improved management of sick children by health extension workers.MethodsThe study was conducted in four Ethiopian regions. A baseline survey was conducted in 26 intervention and 26 comparison districts from December 2016 to February 2017, followed by an end-line survey 24 months later. We observed health extension workers’ consultations of sick 2–59 months old children. The analysis has evaluated if children with pneumonia, diarrhoea and malnutrition were assessed, classified and treated according to guidelines, and included difference-in-difference analyses.ResultsWe observed 1325 consultations of sick children. At baseline, 86% of the sick children with cough in the intervention areas and 85% in comparison areas were assessed according to the guidelines, without any change at end-line associated with the intervention (difference-in-difference = -21%, p = 0.55). Sixty-two percent of children were assessed for dehydration at baseline in intervention and 47% in comparison areas, with no improvement associated with the intervention. Similarly, 87% of sick children in intervention and 91% in comparison areas were assessed for malnutrition, with no change over time associated with the intervention (difference-in-difference = 5%, p = 0.16). Appropriate pneumonia treatment with antibiotics declined and diarrhea treatment increased in both areas. Half of the malnourished children received ready-to-use therapeutic foods without any improvement associated with the intervention.ConclusionThe intervention was not associated with improved quality of the health extension workers’ management of sick children. The lack of association may be linked to low fidelity in the implementation of the intervention. Our findings suggest that training healthcare providers without continued clinical mentoring and support does not improve the quality of care. Community-based programs can be strengthened by ensuring high coverage and continued clinical mentorships, supportive supervision, and supply of medicines and other essential commodities.Trial registration numberISRCTN12040912, retrospectively registered on 19/12/ 2017.

Improving Iron and Folic Acid Supplementation Among Pregnant Women: An Implementation Science Approach in East-Central Uganda.

To address maternal iron-deficiency anemia and low uptake of iron and folic acid supplementation (IFAS) among antenatal care (ANC) clinic attendees in East-Central Uganda, the Anemia Implementation Science Initiative embedded enhanced quality improvement (QI) activities into an integrated health project utilizing QI methodologies. To address 2 bottlenecks of stock-outs and inadequate health education for pregnant women during ANC, an enhanced QI intervention was implemented from July 2019 to September 2020 in 2 districts. We conducted a mixed-methods effectiveness quasi-experimental study to assess whether the intervention increased the availability of IFAS in the intervention districts. We used longitudinal facility-level data from 2 treatment districts and 1 comparison district for the quantitative results. Difference-in-difference estimation was used to measure the impact of the intervention on IFAS health education and IFA availability at the health facility. We used logistic regression modeling to control for factors associated with IFAS uptake and potential differences in baseline values. Researchers conducted exit interviews with ANC clients and in-depth interviews with providers and district managers for greater insights into the implementation process. The intervention increased the probability, at a statistically significant level, of pregnant women both receiving IFAS and receiving health education on IFAS during ANC. According to inter-viewees, the intervention approach improved stakeholder engagement and buy-in, which brought about change at all levels of the health system. The intervention successfully addressed the 2 main bottlenecks to availability of IFAS for pregnant women attending ANC-inadequate provision of IFAS education and a weak drug quantification process. Even without additional funds to purchase commodities, this approach improved district capacity to advocate for and manage IFAS commodities. It could also be used to strengthen overall ANC quality.

State Takeover of School Systems and Within-District Fiscal Equity

State takeovers of school districts typically involve dramatic changes to the workforce in the targeted school system and are often undertaken for the express purpose of improving a school system’s finances. However, little is known about how takeover affects education spending, particularly the distribution of funds across schools within districts. This has important implications for human resources because inequitable spending exacerbates teacher quality shortages for schools that serve marginalized students. We capitalize on a novel source of school-level education spending data for 2018–2019 to examine how takeover influences overall spending, equality of spending across schools within districts, and race-, ethnicity-, and class-based gaps in spending across schools. We do this for a national sample of 24 districts taken over between 2013 and 2019 matched to a set of untreated comparison districts with a high propensity for takeover. We find that state takeover is associated with higher levels of education spending, and that the greater funding promotes racial and ethnic fiscal equity but does not increase income-based school finance equity. Importantly, average increases in school spending are likely too small to substantially affect educational inequality. Therefore, takeover does not seem to be a sufficient mechanism for meaningfully mitigating within-district finance inequity.

The impact of a health systems strengthening initiative on child morbidity: The case of the Ghana Essential Health Interventions Program in rural northern Ghana.

BackgroundImproving child and maternal health remains a core objective of global health priorities, extending from the millennium development goal (MDG) era to the current focus on the Sustainable Development Goals (SGDs). This paper analyses the childhood morbidity effects of the Ghana Essential Heath Interventions Program (GEHIP), a community-based health systems strengthening in rural northern Ghana. GEHIP was a five-year embedded implementation science plausibility trial that implemented a set of health systems strengthening strategies and tested the proposition that their combined effect at the district, subdistrict and community levels could foster effective community engagement and thereby improve maternal and child health outcomes.MethodsA two stage random sample survey of reproductive-aged women residing in treatment and comparison districts at the GEHIP baseline and end line was used for Heckman Difference-in-differences (DiD) regression models for estimating the incremental effect of GEHIP exposure on three child morbidity conditions (diarrhea, fever and cough), as recalled by maternal respondents in the course of survey interviews.ResultsAfter controlling for child age and gender, maternal age, education, marital status, health insurance status, religion, ethnicity, occupation and household wealth index, regression results show that GEHIP had a statistically significant 45% reduction in fever (OR = 0.55, CI = 0.31–0.98) and 47% reduction in cough (OR = 0.53, CI = 0.30–0.94), over and above temporal reductions that prevailed in study districts. Although not significant, GEHIP also had 38% reduction in the incidence of diarrhea.ConclusionPrevious research has shown that GEHIP had a pronounced positive effect with a reduction in mortality. Our results show that household location in GEHIP districts also led to a significant reduction in morbidity due to cough and fever among under-five children. This association is a likely outcome of GEHIP’s impact on the accessibility of primary health care services. Results lend further support to the growing body of evidence that strengthening health systems in rural Africa through the provision of community-based strategies enhances prospects for achieving the United Nations child health SDGs.

Effect of health facility linkage with community using postnatal card on postnatal home visit coverage and newborn care practices in rural Ethiopia: A controlled quasi-experimental study design.

BackgroundPostnatal home visit has the potential to improve maternal and newborn health, but it remains as a missed opportunity in many low-and middle-income countries. This study examines the effect of health extension worker administered postnatal card combined with health facility strengthening intervention on postnatal home visit coverage, newborn care practices, and knowledge of newborn danger signs in rural Ethiopia.MethodsWe employed quasi-experimental design using controlled before-and-after study in intervention and comparison districts of rural Tigray, northern Ethiopia. Training of health extension workers (HEWs) on postnatal home visit (PNHV), training of healthcare providers on maternal and newborn care, and capacity building of healthcare authorities on leadership, management and governance together with health system strengthening were the implemented interventions. Baseline (n = 705) and end line (n = 980) data were collected from mothers who delivered a year before the commencement of the actual data collection in the respective surveys. We used difference-in-differences (DiD) analysis to assess the effect of the intervention on PNHV coverage, essential newborn care practices and maternal knowledge of newborn danger signs.ResultsA total of 1685 (100%) mothers participated in this study. In all districts, more than 1/3rd of the mothers 633(37.57%) were in the age of 30–39 years. The difference-in-differences estimator showed an average of 23.5% increase in coverage of PNHVs within three days (DiD, p<0.001) and the provision of most postnatal contents significantly increased in the intervention district in the end line survey. The knowledge of at least three danger signs increased by 13.6% (p = 0.012).The DiD estimator showed an average of 27.6% increase to check the mothers for heavy bleeding (DiD, p = 0.011). This study also revealed that the checking of maternal blood pressure increased from 5.8% to 11.8% in the comparison districts and from 9.4% to 93.3% in the intervention district. The difference-in-differences estimator result showed a 9% difference in clean cord care practices among the participants (p = 0.025), 12.2% in skin to skin care (p = 0.022), and borderline significant increase in early initiation of breastfeeding (10.5%, p = 0.051).ConclusionWe conclude that the intervention package was effective in improving the coverage of PNHV, increase in knowledge of newborn danger sign and essential newborn care practices. Hence, further strengthening the linkages between health facilities and community is imperative to improve the coverage of essential lifesaving maternal and newborn care services by HEWs at home.

Effects of community-led total sanitation and hygiene implementation on diarrheal diseases prevention in children less than five years of age in South Western Ethiopia: A quasi- experimental study.

BackgroundLack of improved sanitation is the most important contributing factor to diarrheal disease among under-five children in low and middle-income countries. There was no study to identify the effect of Community-Led Total Sanitation and Hygiene intervention on diarrheal diseases in the study area. Hence, this study was designed with the aim of finding the effects of Community-led Total Sanitation and Hygiene implementation for preventing diarrhea among under-five children.MethodsA community-based Quasi-Experimental study was conducted among a sample of 846 households selected from intervention (kersa) and comparison (mana) districts using the four-stage random cluster-sampling method. A Semi-structured questionnaire was used to collect data. The collected data was cleaned, coded, and entered into EpiData version 3.1 and exported to SPSS version 20 for analysis. Difference-in Difference method with McNemar’s tests was used to compare the prevalence of diarrhea between the intervention and comparison districts, and the significance of change between the pre-test and post-test was declared at p-value less than 0.05 with 95% confidence interval.ResultsThe intervention led to decreased diarrhea prevalence [pp = -8.2, 95% CI: -15.9, -0.5], increased latrine ownership [pp = 5.6, 95% CI: 0.5, 10.8], and increased latrine utilization [pp = 10.7, 95% CI: 4.7, 16.6] in intervention district at post-test compared to the baseline; while the presence of handwashing facility near the latrine, home-based water treatment, and proper water storage and handling practice were decreased at post-test compared to the baseline.ConclusionImplementation of Community-Led Total Sanitation improved sanitation and hygiene status of community that resulted in the reduction of diarrhea diseases in under-five children. Further implementation, evaluation, and scale-up of the interventions are needed to reduce diarrheal disease in under-five children.

Impact of the DREAMS Program on New HIV Diagnoses in Adolescent Girls and Young Women Attending Antenatal Care - Lesotho, 2015-2020.

Lesotho is a small, landlocked country in southern Africa with a population of approximately 2 million persons, approximately two thirds of whom live in rural areas (1). Lesotho has the second highest prevalence of HIV infection in the world (2). In 2017, 25.6% of persons aged 15-59 years living in Lesotho were HIV-positive (3). Strategies implemented in recent years to control HIV include efforts to reduce mother-to-child transmission and improve coverage with antiretroviral therapy, as well as increasing testing for HIV. Among persons aged 15-24 years, the HIV prevalence among females in 2017 (11.1%) was approximately three times that among males (3.4%) (3). The Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe (DREAMS)* program in Lesotho was started during October 2016 in two districts. DREAMS comprises a package of biomedical, behavioral, and structural interventions to address factors that make adolescent girls and young women vulnerable to HIV acquisition (4). The goal of the DREAMS program was to decrease HIV incidence among adolescent girls and young women by 25% after 1 year and by 40% after 2 years (4). After 3.5 years of program implementation in Lesotho, new HIV diagnoses among adolescent girls and young women attending antenatal care (ANC) decreased 71.4% in the two districts that implemented DREAMS compared with a reduction of 48.4% in three comparison districts without the program (p = 0.002). During 2016-2020, reductions in new HIV diagnoses among adolescent girls and young women attending ANC in Lesotho have been substantial, both in districts that have and have not implemented the DREAMS program (DREAMS and non-DREAMS districts). Apart from the DREAMS program, the decrease in new HIV diagnoses might be a result of the reduction in viral load in the population because more persons living with HIV infection became virally suppressed while on antiviral therapy, as well as other interventions such as preexposure prophylaxis, voluntary medical male circumcision, behavior change, and increased HIV diagnostic coverage.

Evaluation of long-lasting insecticidal net distribution through schools in Southern Tanzania

Universal coverage with effective vector control remains the mainstay of malaria vector control in sub-Saharan Africa. Tanzania has utilized a number of mechanisms for the maintenance of long-lasting insecticidal net (LLIN) coverage over time. Schools have been identified as one potential channel for continuous distribution of LLIN. This research aims to evaluate an annual school-based LLIN distribution programme in Tanzania that began in 2013, called the School Net Programme (SNP). Following each of the first four rounds of SNP distribution, a household survey was conducted in intervention and comparison districts in Southern and Lake zones of Tanzania (N = 5083 households). Measures of ownership, access and use were compared between intervention and comparison districts. Determinants of reach were assessed in intervention districts. Population access to an LLIN increased from 63.1% (95% CI: 58.8, 67.5) to 76.5% (95% CI: 72.9, 80.0) in the intervention districts between the first and last surveys. Access also rose in the comparison districts from 51.4% (95% CI: 46.9, 55.9) to 79.8% (95% CI: 77.3, 82.0) following mass distribution and implementation of school-based distribution during the study period. LLIN use increased in intervention districts from 44.9% (95% CI: 40.5, 49.3) to 65.6% (95% CI: 59.4, 71.8) and from 57.2% (95% CI: 49.7, 64.7) to 77.4% (95% CI: 69.3, 85.5) specifically amongst primary school-aged children. Households reached by the SNP were wealthier households with children enrolled in school. The SNP in Tanzania was able to maintain population level LLIN ownership, use and access in the absence of mass distribution. The SNP successfully reached households that housed school-aged children. Alternative delivery strategies may need to be considered to reach households without children enrolled in schools that experienced fewer benefits from the programme.

Evaluation of a city-wide school-located influenza vaccination program in Oakland, California with respect to race and ethnicity: A matched cohort study

BackgroundIncreasing influenza vaccination coverage in school-aged children may substantially reduce community transmission. School-located influenza vaccinations (SLIV) aim to promote vaccinations by increasing accessibility, which may be especially beneficial to race/ethnicity groups that face high barriers to preventative care. Here, we evaluate the effectiveness of a city-wide SLIV program by race/ethnicity from 2014 to 2018. MethodsWe used multivariate matching to pair schools in the intervention district in Oakland, CA with schools in a comparison district in West Contra Costa County, CA. We distributed cross-sectional surveys to measure caregiver-reported student vaccination status and estimated differences in vaccination coverage levels and reasons for non-vaccination between districts stratifying by race/ethnicity. We estimated difference-in-differences (DID) of laboratory confirmed influenza hospitalization incidence between districts stratified by race/ethnicity using surveillance data. ResultsDifferences in influenza vaccination coverage in the intervention vs. comparison district were larger among White (2017–18: 21.0% difference [95% CI: 9.7%, 32.3%]) and Hispanic/Latino (13.4% [8.8%, 18.0%]) students than Asian/Pacific Islander (API) (8.9% [1.3%, 16.5%]), Black (5.9% [−2.2%, 14.0%]), and multiracial (6.3% [−1.8%, 14.3%)) students. Concerns about vaccine effectiveness or safety were more common among Black and multiracial caregivers. Logistical barriers were less common in the intervention vs. comparison district, with the largest difference among White students. In both districts, hospitalizations in 2017–18 were higher in Blacks (Intervention: 111.5 hospitalizations per 100,00; Comparison: 134.1 per 100,000) vs. other races/ethnicities. All-age influenza hospitalization incidence was lower in the intervention site vs. comparison site among White/API individuals in 2016–17 (DID −25.14 per 100,000 [95% CI: −40.14, −10.14]) and 2017–18 (−36.6 per 100,000 [−52.7, −20.5]) and Black older adults in 2017–18 (−282.2 per 100,000 (−508.4, −56.1]), but not in other groups. ConclusionsSLIV was associated with higher vaccination coverage and lower influenza hospitalization, but associations varied by race/ethnicity. SLIV alone may be insufficient to ensure equitable influenza outcomes.

Long-term effects of payment for performance on maternal and child health outcomes: evidence from Tanzania

BackgroundThe success of payment for performance (P4P) schemes relies on their ability to generate sustainable changes in the behaviour of healthcare providers. This paper examines short-term and longer-term effects of...

Investment case approach for equitable access to maternal neonatal and child health services: Stakeholders' perspective in Nepal.

Investment Case is a participatory approach that has been used over the years for better strategic actions and planning in the health sector. Based on this approach, a District Investment Case (DIC) program was launched to improve maternal, neonatal and child health services in partnership with government, non-government sectors and UNICEF Nepal. In the meantime, this study aimed to explore perceptions and experiences of local stakeholders regarding health planning and budgeting and explore the role of the DIC program in ensuring equity in access to maternal and child health services. This study adopted an exploratory phenomenography design with a purposive sampling technique for data collection. Three DIC implemented districts and three comparison districts were selected and total 30 key informant interviews with district level stakeholders and six focus groups with community stakeholders were carried out. A deductive approach was used to explore the perception of local stakeholders of health planning and budgeting of the health care expenses on the local level. Investment Case approach helped stakeholders in planning systematically based on evidence through collaborative and participatory approach while in comparison areas previous year plan was mainly primarily considered as reference. Resource constraints and geographical difficulty were key barriers in executing the desired plan in both intervention and comparison districts. Positive changes were observed in coverage of maternal and child health services in both groups. A few participants reported no difference due to the DIC program. The participants specified the improvement in access to information, access and utilization of health services by women. This has influenced the positive health care seeking behavior. The decentralized planning and management approach at the district level helps to ensure equity in access to maternal, newborn and child health care. However, quality evidence, inclusiveness, functional feedback and support system and local resource utilization should be the key consideration.

Socio-protective effects of active case finding on catastrophic costs from tuberculosis in Ho Chi Minh City, Viet Nam: a longitudinal patient cost survey

BackgroundMany tuberculosis (TB) patients incur catastrophic costs. Active case finding (ACF) may have socio-protective properties that could contribute to the WHO End TB Strategy target of zero TB-affected families suffering catastrophic costs, but available evidence remains limited. This study measured catastrophic cost incurrence and socioeconomic impact of an episode of TB and compared those socioeconomic burdens in patients detected by ACF versus passive case finding (PCF).MethodsThis cross-sectional study fielded a longitudinal adaptation of the WHO TB patient cost survey alongside an ACF intervention from March 2018 to March 2019. The study was conducted in six intervention (ACF) districts and six comparison (PCF) districts of Ho Chi Minh City, Viet Nam. Fifty-two TB patients detected through ACF and 46 TB patients in the PCF cohort were surveyed within two weeks of treatment initiation, at the end of the intensive phase of treatment, and after treatment concluded. The survey measured income, direct and indirect costs, and socioeconomic impact based on which we calculated catastrophic cost as the primary outcome. Local currency was converted into US$ using the average exchange rates reported by OANDA for the study period (VNĐ1 = US$0.0000436, 2018–2019). We fitted logistic regressions for comparisons between the ACF and PCF cohorts as the primary exposures and used generalized estimating equations to adjust for autocorrelation.ResultsACF patients were poorer than PCF patients (multidimensional poverty ratio: 16 % vs. 7 %; p = 0.033), but incurred lower median pre-treatment costs (US$18 vs. US$80; p < 0.001) and lower median total costs (US$279 vs. US$894; p < 0.001). Fewer ACF patients incurred catastrophic costs (15 % vs. 30 %) and had lower odds of catastrophic cost (aOR = 0.17; 95 % CI: [0.05, 0.67]; p = 0.011), especially during the intensive phase (OR = 0.32; 95 % CI: [0.12, 0.90]; p = 0.030). ACF patient experienced less social exclusion (OR = 0.41; 95 % CI: [0.18, 0.91]; p = 0.030), but more often resorted to financial coping mechanisms (OR = 5.12; 95 % CI: [1.73, 15.14]; p = 0.003).ConclusionsACF can be effective in reaching vulnerable populations and mitigating the socioeconomic burden of TB, and can contribute to achieving the WHO End TB Strategy goals. Nevertheless, as TB remains a catastrophic life event, social protection efforts must extend beyond ACF.

JUE Insight: Desegregated but still separated? The impact of school integration on student suspensions and special education classification

In this paper I study the impact of court-mandated school desegregation by race on student suspensions and special education classification. Simple descriptive statistics using student enrollment and outcome data collected from the largest school districts across the country in the 1970s and 1980s show that Black-White school integration was increasing for districts under court order, but not for a set of comparison districts. Similarly, Black student suspension rates were increasing at faster rates in integrating districts relative to comparison districts, and their classification rates as having an intellectual disability were decreasing at slower rates. Differences-in-differences and event study models confirm these patterns I observe in the raw data: after integration, school districts experienced statistically and practically significant reductions in racial isolation across schools and growth in racial disparities in discipline and special education classification. The impacts of integration are immediate, sustained, and robust for student suspensions in particular. My results thus provide causal evidence confirming prior descriptive and theoretical work suggesting that the racial composition of schools may influence measures of categorical inequality by race.

A longitudinal impact evaluation of a comprehensive nutrition program for reducing stunting among children aged 6–23 months in rural Malawi

Growth failure in sub-Saharan Africa leads to a high prevalence of child stunting starting in infancy, and is attributed to dietary inadequacy, poor hygiene, and morbidity. To evaluate the impact of a program in Malawi providing a lipid-based nutrient supplement to infants from 6-23 months of age, accompanied by a social and behavior change communication intervention to optimize caregiver feeding and handwashing practices. This impact evaluation was a quasi-experimental, longitudinal study with 1 program and 1 comparison district. Infants were enrolled at 6-7 months of age. Anthropometry, child morbidity, and caregiver feeding and handwashing practices were assessed at enrollment and at 6, 12, and 18 month follow-ups (ages 6, 12, 18, and 24 months, respectively). Changes in the length-for-age z-score (LAZ), weight-for-length z-score (WLZ), and midupper arm circumference (MUAC) were compared using mixed-effects models. Program impacts on child stunting (LAZ < -2), wasting (WLZ < -2), morbidity, and feeding and handwashing practices were estimated using difference-in-differences. We enrolled 367 infants across the program (n = 176) and comparison (n = 191) districts. The combined prevalences of stunting and wasting at enrollment were 42.1% and 1.4%, respectively, and did not differ by district. At enrollment, the prevalence of severe stunting (LAZ < -3) was higher in the program (15.5%) versus comparison (7.6%) district (P = 0.02), with corresponding lower LAZ scores (-1.9 vs. -1.7, respectively; P = 0.12). Growth velocities favored program children, such that LAZ, WLZ, and MUAC measurements increased by +0.12/y (P = 0.06), +0.12/y (P = 0.04), and +0.24 cm/y (P < 0.001), respectively, leading to comparable LAZ distributions across districts by 24 months of age. Program exposure was associated with 19.8 percentage point (pp) and 13.8 pp reductions in the prevalences of malaria (P = 0.001) and fever (P = 0.02), respectively, at the 18-month follow-up. Improvements of 20 pp (P < 0.01) in minimum dietary diversity and minimum acceptable diet were seen in the program versus comparison district at 18 months of follow-up. The program improved child growth patterns, with benefits to health and diet apparent after 18 months of exposure. This trial was registered at clinicaltrials.gov as NCT02985359.

Impact of Performance-Based Financing on effective coverage for curative child health services in Burkina Faso: Evidence from a quasi-experimental design.

To evaluate the impact of Performance-Based Financing (PBF) on effective coverage of child curative health services in primary healthcare facilities in Burkina Faso. An impact evaluation of a PBF pilot programme, using an experiment nested within a quasi-experimental design, was carried out in 12 intervention and 12 comparison districts in six regions of Burkina Faso. Across the 24 districts, primary healthcare facilities (537 both at baseline and endline) and households (baseline=7978 endline=7898) were surveyed. Within these households, 12350 and 15021 under-five-year-olds caretakers were interviewed at baseline and endline respectively. Linking service quality to service utilisation, we used difference-in-differences to estimate the impact of PBF on effective coverage of curative child health services. Our study failed to detect any effect of PBF on effective coverage. Looking specifically into quality of care indicators, we detected a positive effect of PBF on structural elements of quality of care related to general service readiness, but not on the overall facility quality score, capturing both service readiness and the content of childcare. The current study makes a unique contribution to PBF literature, as this is the first study assessing PBF impact on effective coverage for curative child health services in low-income settings. The absence of any significant effects of PBF on effective coverage suggests that PBF programmes require a stronger design focus on quality of care elements especially when implemented in a context of free healthcare policy.