Comparison Districts Research Articles

Benefits and Limitations of a Community-Engaged Emergency Referral System in a Remote, Impoverished Setting of Northern Ghana.

Although Ghana has a well-organized primary health care system, it lacks policies and guidelines for developing or providing emergency referral services. In 2012, an emergency referral pilot-the Sustainable Emergency Referral Care (SERC) initiative-was launched by the Ghana Health Service in collaboration with community stakeholders and health workers in one subdistrict of the Upper East Region where approximately 20,000 people reside. The pilot program was scaled up in 2013 to a 3-district (12-subdistrict) plausibility trial that served a population of approximately 184,000 over 2 years from 2013 to 2015. The SERC initiative was fielded as a component of a 6-year health systems strengthening and capacity-building project known as the Ghana Essential Health Intervention Program. Implementation research using mixed methods, including quantitative analysis of key process and health indicators over time in the 12 intervention subdistricts compared with comparison districts, a survey of health workers, and qualitative systems appraisal with community members, provided data on effectiveness of the system as well as operational challenges and potential solutions. Monitoring data show that community exposure to SERC was associated with an increased volume of emergency referrals, diminished reliance on primary care facilities not staffed or equipped to provide surgical care, and increased caseloads at facilities capable of providing appropriate acute care (i.e., district hospitals). Community members strongly endorsed the program and expressed appreciation for the service. Low rates of adherence to some care protocols were noted: referring facilities often failed to alert receiving facilities of incoming patients, not all patients transported were accompanied by a health worker, and receiving facilities commonly failed to provide patient outcome feedback to the referring facility. Yet in areas where SERC worked to bypass substandard points of care, overall facility-based maternal mortality as well as accident-related deaths decreased relative to levels observed in facilities located in comparison areas.

Improving hepatitis B birth dose in rural Lao People’s Democratic Republic through the use of mobile phones to facilitate communication

BackgroundHepatitis B vaccine birth dose (HepB-BD) was introduced in Lao People’s Democratic Republic to prevent perinatal hepatitis B virus transmission in 2008; high coverage is challenging since only 38% of births occur in a health facility. Healthcare workers report being unaware of home births and thus unable to conduct timely postnatal care (PNC) home visits. A quasi-experimental pilot study was conducted wherein mobile phones and phone credits were provided to village health volunteers (VHV) and healthcare workers (HCWs) to assess whether this could improve HepB-BD administration, as well as birth notification and increase home visits. MethodsFrom April to September 2014, VHVs and HCWs in four selected intervention districts were trained, supervised, received outreach per diem for conducting home visits, and received mobile phones and phone credits. In three comparison districts, VHVs and HCWs were trained, supervised, and received outreach per diem for conducting home visits. A post-study survey compared HepB-BD coverage among children born during the study and children born one year before. HCWs and VHVs were interviewed about the study. FindingsAmong intervention districts, 463 study children and 406 pre-study children were enrolled in the survey; in comparison districts, 347 study children and 309 pre-study children were enrolled. In both arms, there was a significant improvement in the proportion of children reportedly receiving a PNC home visit (intervention p<0.0001, comparison p=0.04). The median difference in village level HepB-BD coverage (study cohort minus pre-study cohort), was 57% (interquartile range [IQR] 32–88%, p<0.0001) in intervention districts, compared with 20% (IQR 0–50%, p<0.0001) in comparison districts. The improvement in the intervention districts was greater than in the comparison districts (p=0.0009). ConclusionOur findings suggest that the provision of phones and phone credits might be one important factor for increasing coverage. However, reasons for improvement in both arms are multifactorial and discussed.

Pregnancy outcomes in Liberian women who conceived after recovery from Ebola virus disease.

BACKGROUND: Postpartum haemorrhage complicates approximately 10% of all deliveries and contributes to at least a quarter of all maternal deaths worldwide. The competency-based Helping Mothers Survive Bleeding after Birth (HMS BAB) training was developed to support evidence-based management of postpartum haemorrhage. This one-day training includes low-cost MamaNatalie(R) birthing simulators and addresses both prevention and first-line treatment of haemorrhage. While evidence is accumulating that the training improves health providers knowledge skills and confidence evidence is missing as to whether this translates into improved practices and reduced maternal morbidity and mortality. This cluster-randomised trial aims to assess whether this training package - involving a one-day competency-based HMS BAB in-facility training provided by certified trainers followed by 8 weeks of in-service peer-based practice - has an effect on the occurrence of haemorrhage-related morbidity and mortality. METHODS/DESIGN: In Tanzania and Uganda we randomise 20 and 18 districts (clusters) respectively with half receiving the training intervention. We use unblinded matched-pair randomisation to balance district health system characteristics and the main outcome which is in-facility severe morbidity due to haemorrhage defined by the World Health Organizationation-promoted disease and management-based near-miss criteria. Data are collected continuously in the intervention and comparison districts throughout the 6-month baseline and the 9-month intervention phase which commences after the training intervention. Trained facility midwives or clinicians review severe maternal complications to identify near misses on a daily basis. They abstract the case information from case notes and enter it onto programmed tablets where it is uploaded. Intention-to-treat analysis will be used taking the matched design into consideration using paired t test statistics to compare the outcomes between the intervention and comparison districts. We also assess the impact pathway from the effects of the training on the health providers skills care and interventions and health system readiness. DISCUSSION: This trial aims to generate evidence on the effect and limitations of this well-designed training package supported by birthing simulations. While the lack of blinding of participants and data collectors provides an inevitable limitation of this trial the additional evaluation along the pathway of implementation will provide solid evidence on the effects of this HMS BAB training package. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR201604001582128 . Registered on 12 April 2016.

Is it better to invest in place or people to maximize population health? Evaluation of the general health impact of urban regeneration in Dutch deprived neighbourhoods

AimTo study the general health impact of urban regeneration programmes in deprived Dutch districts. We compared initiatives that focused on the improvement of place with initiatives that mainly invested in people. MethodA quasi-experimental design compared the trend in good perceived general health in the target districts with comparison districts. Generalized general mixed models assessed the rate of change in prevalence of good health per half year during a prolonged period before and after the start of the interventions. ResultsNeither the target districts that invested mainly in place nor the ones with interventions focused on people showed trends in general health different than comparison districts (p>0.05). However, only districts with interventions focused on place showed no deterioration in general health during the intervention period. The trend change in these districts differed significantly from the change in the districts that invested mainly in people (p<0.05). ConclusionUrban regeneration programmes that focus on place may be effective in promoting general health.

Preschool and school performance of children from immigrant families

We study whether free preschool affects the subsequent school performance of children from immigrant families. Our difference-in-differences approach takes advantage of a policy intervention implemented in two districts in Oslo, leaving other similar districts unaffected. The grade point average of girls increases more in the intervention districts than in the comparison districts, resulting in effect estimates of about a tenth of the standard deviation. We find no consistent effects for boys.

Effectiveness of the Home Based Life Saving Skills training by community health workers on knowledge of danger signs, birth preparedness, complication readiness and facility delivery, among women in Rural Tanzania.

BackgroundIn spite of government efforts, maternal mortality in Tanzania is currently at more than 400 per 100,000 live births. Community-based interventions that encourage safe motherhood and improved health-seeking behaviour through acquiring knowledge on the danger signs and improving birth preparedness, and, ultimately, reduce maternal mortality, have been initiated in different parts of low-income countries. Our aim was to evaluate if the Home Based Life Saving Skills education by community health workers would improve knowledge of danger signs, birth preparedness and complication readiness and facility-based deliveries in a rural community in Tanzania.MethodsA quasi-experimental study design was used to evaluate the effectiveness of Home Based Life Saving Skills education to pregnant women and their families through a community intervention. An intervention district received training with routine care. A comparison district continued to receive routine antenatal care. A structured household questionnaire was used in order to gather information from women who had delivered a child within the last two years before the intervention. This questionnaire was used in both the intervention and comparison districts before and after the intervention. The net intervention effect was estimated using the difference between the differences in the intervention and control districts at baseline and endline.ResultsA total of 1,584 and 1,486 women were interviewed at pre-intervention and post intervention, respectively. We observed significant improvement of knowledge of three or more danger signs during pregnancy (15.2 % vs. 48.1 %) with a net intervention effect of 29.0 % (95 % CI: 12.8–36.2; p < .0001) compared to the comparison district. There was significant effect on the knowledge of three or more danger signs during childbirth (15.3 % vs. 43.1 %) with a net intervention effect of 18.3 % (95 % CI: 11.4–25.2; p < .0001) and postpartum for those mentioning three or more of the signs (8.8 % vs. 19.8 %) with net effect of 9.4 % (95 % CI: 6.4–15.7; p < .0001). Birth preparedness practice improved for those who made more than three actions (20.8 vs. 35.3 %) with a net intervention effect of 10.3 % (95 % CI: 10.3–20.3; p < .0001) between the intervention and control district at pre-intervention and post intervention. Utilisation of antenatal care with four visits improved significantly (43.4 vs. 67.8 %) with net effect of 25.3 % (95 % CI: 16.9–33.2; p < .0001), use of facility delivery improved in the intervention area (75.6 vs. 90.2 %; p = 0.0002) but there was no significant net effect 11.5 % (95 % CI: -5.1–39.6; p = 0.123) compared to comparison district.ConclusionThis study shows that a community-based intervention employing community health workers as teachers in delivering Home Based Life Saving Skills program to pregnant women and their families improved their knowledge of danger signs during pregnancy, childbirth and postpartum, preparedness for childbirth and increased deliveries at health facilities which employ skilled health workers in this rural community.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-016-0916-x) contains supplementary material, which is available to authorized users.

Hepatitis B vaccine stored outside the cold chain setting: a pilot study in rural Lao PDR

BackgroundHepatitis B vaccine birth dose (HepB-BD) was introduced in Lao People's Democratic Republic (Lao-PDR) to prevent perinatal hepatitis B virus transmission. HepB-BD, which is labeled for storage between 2 and 8°C, is not available at all health facilities, because of some lack of functional cold chain; however, previous studies show that HepB-BD is stable if stored outside the cold chain (OCC). A pilot study was conducted in Lao-PDR to evaluate impact of OCC policy on HepB-BD coverage. MethodsDuring the six month pilot, HepB-BD was stored OCC for up to 28 days in two intervention districts and stored in cold chain in two comparison districts. In the intervention districts, healthcare workers were educated about HepB-BD and OCC storage. A post-pilot survey compared HepB-BD coverage among children born during the pilot (aged 2–8 months) and children born 1 year before (aged 14–20 months). FindingsIn the intervention districts, 388 children aged 2–8 months and 371 children aged 14–20 months were enrolled in the survey; in the comparison districts, 190 children aged 2–8 months and 184 children aged 14–20 months were enrolled. Compared with the pre-pilot cohort, a 27% median increase in HepB-BD (interquartile range [IQR] 58%, p<0.0001) occurred in the pilot cohort in the intervention districts, compared with a 0% median change (IQR 25%, p=0.03) in comparison districts. No adverse reactions were reported. InterpretationOCC storage improved HepB-BD coverage with no increase in adverse reactions. Findings can guide Lao-PDR on implementation and scale-up options of OCC policy.

Community and District Empowerment for Scale-up (CODES): a complex district-level management intervention to improve child survival in Uganda: study protocol for a randomized controlled trial.

BackgroundInnovative and sustainable strategies to strengthen districts and other sub-national health systems and management are urgently required to reduce child mortality. Although highly effective evidence-based and affordable child survival interventions are well-known, at the district level, lack of data, motivation, analytic and planning capacity often impedes prioritization and management weaknesses impede implementation. The Community and District Empowerment for Scale-up (CODES) project is a complex management intervention designed to test whether districts when empowered with data and management tools can prioritize and implement evidence-based child survival interventions equitably.MethodsThe CODES strategy combines management, diagnostic, and evaluation tools to identify and analyze the causes of bottlenecks to implementation, build capacity of district management teams to implement context-specific solutions, and to foster community monitoring and social accountability to increase demand for services. CODES combines UNICEF tools designed to systematize priority setting, allocation of resources and problem solving with Community dialogues based on Citizen Report Cards and U-Reports used to engage and empower communities in monitoring health service provision and to demand for quality services. Implementation and all data collection will be by the districts teams or local Community-based Organizations who will be supported by two local implementing partners. The study will be evaluated as a cluster randomized trial with eight intervention and eight comparison districts over a period of 3 years. Evaluation will focus on differences in uptake of child survival interventions and will follow an intention-to-treat analysis. We will also document and analyze experiences in implementation including changes in management practices.DiscussionBy increasing the District Health Management Teams’ capacity to prioritize and implement context-specific solutions, and empowering communities to become active partners in service delivery, coverage of child survival interventions will increase. Lessons learned on strengthening district-level managerial capacities and mechanisms for community monitoring may have implications, not only in Uganda but also in other similar settings, especially with regard to accelerating effective coverage of key child survival interventions using locally available resources.Trial registration numberISRCTN15705788, Date of registration; 24 July 2015.

Community health workers can improve male involvement in maternal health: evidence from rural Tanzania

BackgroundMale involvement in maternal health is recommended as one of the interventions to improve maternal and newborn health. There have been challenges in realising this action, partly due to the position of men in society and partly due to health system challenges in accommodating men. The aim of this study was therefore to evaluate the effect of Home Based Life Saving Skills training by community health workers on improving male involvement in maternal health in terms of knowledge of danger signs, joint decision-making, birth preparedness, and escorting wives to antenatal and delivery care in a rural community in Tanzania.DesignA community-based intervention consisting of educating the community in Home Based Life Saving Skills by community health workers was implemented using one district as the intervention district and another as comparison district. A pre-/post-intervention using quasi-experimental design was used to evaluate the effect of Home Based Life Saving Skills training on male involvement and place of delivery for their partners. The effect of the intervention was determined using difference in differences analysis between the intervention and comparison data at baseline and end line.ResultsThe results show there was improvement in male involvement (39.2% vs. 80.9%) with a net intervention effect of 41.1% (confidence interval [CI]: 28.5–53.8; p <0.0001). There was improvement in the knowledge of danger signs during pregnancy, childbirth, and postpartum periods. The proportion of men accompanying their wives to antenatal and delivery also improved. Shared decision-making for place of delivery improved markedly (46.8% vs. 86.7%), showing a net effect of 38.5% (CI: 28.0–49.1; p <0.0001). Although facility delivery for spouses of the participants improved in the intervention district, this did not show statistical significance when compared to the comparison district with a net intervention effect of 12.2% (95% CI: −2.8–27.1: p=0.103).ConclusionThis community-based intervention employing community health workers to educate the community in the Home Based Life Saving Skills programme is both feasible and effective in improving male involvement in maternal healthcare.

The Effect of Indoor Residual Spraying on the Prevalence of Malaria Parasite Infection, Clinical Malaria and Anemia in an Area of Perennial Transmission and Moderate Coverage of Insecticide Treated Nets in Western Kenya.

BackgroundInsecticide treated nets (ITNs) and indoor residual spraying (IRS) have been scaled up for malaria prevention in sub-Saharan Africa. However, there are few studies on the benefit of implementing IRS in areas with moderate to high coverage of ITNs. We evaluated the impact of an IRS program on malaria related outcomes in western Kenya, an area of intense perennial malaria transmission and moderate ITN coverage (55–65% use of any net the previous night).MethodsThe Kenya Division of Malaria Control, with support from the US President’s Malaria Initiative, conducted IRS in one lowland endemic district with moderate coverage of ITNs. Surveys were conducted in the IRS district and a neighboring district before IRS, after one round of IRS in July-Sept 2008 and after a second round of IRS in April-May 2009. IRS was conducted with pyrethroid insecticides. At each survey, 30 clusters were selected for sampling and within each cluster, 12 compounds were randomly selected. The primary outcomes measured in all residents of selected compounds included malaria parasitemia, clinical malaria (P. falciparum infection plus history of fever) and anemia (Hb<8) of all residents in randomly selected compounds. At each survey round, individuals from the IRS district were matched to those from the non-IRS district using propensity scores and multivariate logistic regression models were constructed based on the matched dataset.ResultsAt baseline and after one round of IRS, there were no differences between the two districts in the prevalence of malaria parasitemia, clinical malaria or anemia. After two rounds of IRS, the prevalence of malaria parasitemia was 6.4% in the IRS district compared to 16.7% in the comparison district (OR = 0.36, 95% CI = 0.22–0.59, p<0.001). The prevalence of clinical malaria was also lower in the IRS district (1.8% vs. 4.9%, OR = 0.37, 95% CI = 0.20–0.68, p = 0.001). The prevalence of anemia was lower in the IRS district but only in children under 5 years of age (2.8% vs. 9.3%, OR = 0.30, 95% CI = 0.13–0.71, p = 0.006). Multivariate models incorporating both IRS and ITNs indicated that both had an impact on malaria parasitemia and clinical malaria but the independent effect of ITNs was reduced in the district that had received two rounds of IRS. There was no statistically significant independent effect of ITNs on the prevalence of anemia in any age group.ConclusionsBoth IRS and ITNs are effective tools for reducing malaria burden and when implemented in an area of moderate to high transmission with moderate ITN coverage, there may be an added benefit of IRS. The value of adding ITNs to IRS is less clear as their benefits may be masked by IRS. Additional monitoring of malaria control programs that implement ITNs and IRS concurrently is encouraged to better understand how to maximize the benefits of both interventions, particularly in the context of increasing pyrethroid resistance.

Assessing Community Based Improved Maternal Neonatal Child Survival (IMNCS) Program in Rural Bangladesh.

ObjectivesA community based approach before, during and after child birth has been proven effective address the burden of maternal, neonatal and child morbidity and mortality in the low and middle income countries. We aimed to examine the overall change in maternal and newborn health outcomes due the “Improved Maternal Newborn and Child Survival” (IMNCS) project, which was implemented by BRAC in rural communities of Bangladesh.MethodsThe intervention was implemented in four districts for duration of 5-years, while two districts served as comparison areas. The intervention was delivered by community health workers who were trained on essential maternal, neonatal and child health care services. A baseline survey was conducted in 2008 among 7, 200 women with pregnancy outcome in last year or having a currently alive child of 12–59 months. A follow-up survey was administered in 2012–13 among 4, 800 women of similar characteristics in the same villages.FindingsWe observed significant improvements in maternal and essential newborn care in intervention areas over time, especially in health care seeking behaviors. The proportion of births taking place at home declined in the intervention districts from 84.3% at baseline to 71.2% at end line (P<0.001). Proportion of deliveries with skilled attendant was higher in intervention districts (28%) compared to comparison districts (27.4%). The number of deliveries was almost doubled at public sector facility comparing with baseline (P<0.001). Significant improvement was also observed in healthy cord care practice, delayed bathing of the new-born and reduction of infant mortality in intervention districts compared to that of comparison districts.ConclusionsThis study demonstrates that community-based efforts offer encouraging evidence and value for combining maternal, neonatal and child health care package. This approach might be considered at larger scale in similar settings with limited resources.

Effect of Paying for Performance on Utilisation, Quality, and User Costs of Health Services in Tanzania: A Controlled Before and After Study.

BackgroundDespite widespread implementation across Africa, there is limited evidence of the effect of payment for performance (P4P) schemes in low income countries on the coverage of quality services and affordability, consistent with universal health coverage objectives. We examined the effect of a government P4P scheme on utilisation, quality, and user costs of health services in Tanzania.MethodsWe evaluated the effects of a P4P scheme on utilisation of all maternal and child immunization services targeted by the scheme, and non-targeted general outpatient service use. We also evaluated effects on patient satisfaction with care and clinical content of antenatal care, and user costs. The evaluation was done in 150 facilities across all 7 intervention districts and 4 comparison districts with two rounds of data collection over 13-months in January 2012 and February 2013. We sampled 3000 households of women who had delivered in the 12 months prior to interview; 1500 patients attending health facilities for targeted and non-targeted services at each round of data collection. Difference-in-difference regression analysis was employed.FindingsWe estimated a significant positive effect on two out of eight targeted indicators. There was an 8.2% (95% CI: 3.6% to 12.8%) increase in coverage of institutional deliveries among women in the intervention area, and a 10.3% (95% CI: 4.4% to 16.1%) increase in the provision of anti-malarials during pregnancy. Use of non-targeted services reduced at dispensaries by 57.5 visits per month among children under five (95% CI: -110.2 to -4.9) and by 90.8 visits per month for those aged over five (95% CI: -156.5 to -25.2). There was no evidence of an effect of P4P on patient experience of care for targeted services. There was a 0.05 (95% CI: 0.01 to 0.10) increase in the patient satisfaction score for non-targeted services. P4P was associated with a 5.0% reduction in those paying out of pocket for deliveries (95% CI: -9.3% to -0.7%) but there was no evidence of an effect on the average amount paid.ConclusionThis study adds to the very limited evidence on the effects of P4P at scale and highlights the potential risks of such schemes in relation to non-targeted service use. Further consideration of the design of P4P schemes is required to enhance progress towards universal health coverage, and close monitoring of effects on non-targeted services and user costs should be encouraged.

Catalyzing the scale-up of community-based primary healthcare in a rural impoverished region of northern Ghana.

Ghana's Community-based Health Planning and Services (CHPS) initiative develops accessible healthcare with participatory community support, using strategies developed and tested by a project of the Navrongo Health Research Centre. In 1996, the project was expanded to a district-wide four-celled trial. In response to evidence that strategies could reduce fertility and childhood mortality, a replication project was launched to develop methods for scale-up. Based on experience gained, CHPS scale-up was launched in 2000. Although CHPS now reaches all of Ghana's districts, the pace of scale-up within districts has been slow. In response, the Ministry of Health conducted a review of factors that constrain CHPS scale-up and problems that detract from its original evidence-based design. To resolve problems that were identified, a project was launched in 2010 to test means of accelerating CHPS scale-up and expand its range of care. Known as the Ghana Essential Health Interventions Program (GEHIP), the project provided catalytic revenue to four treatment district managers for 3 years, in conjunction with implementation of strategies for comprehensive leadership development and community partnership. Monitoring systems were developed to gauge CHPS coverage time trends in all nine study districts. GEHIP successfully accelerated CHPS implementation, producing 100% of its targeted community coverage within 5 years of implementation. Coverage in comparison districts also improved. However, the rate of coverage and per cent of the population reached by CHPS in comparison districts was only half that of GEHIP districts. GEHIP success in completing CHPS coverage represents the initial stage of a national program for strengthening community health systems in Ghana. Copyright © 2015 John Wiley & Sons, Ltd.

Protocol for the evaluation of a free health insurance card scheme for poor pregnant women in Mbeya region in Tanzania: a controlled-before and after study.

BackgroundThe use of demand-side financing mechanisms to increase health service utilisation among target groups and enhance service quality is gaining momentum in many low- and middle-income countries. However, there is limited evidence on the effects of such schemes on equity, financial protection, quality of care, and cost-effectiveness. A scheme providing free health insurance cards to poor pregnant women and their households was first introduced in two regions of Tanzania in 2011 and gradually expanded in 2012.MethodsA controlled before and after study will examine in one district the effect of the scheme on utilization, quality, and cost of healthcare services accessed by poor pregnant women and their households in Tanzania. Data will be collected 4 months before implementation of the scheme and 17 months after the start of implementation from a survey of 24 health facilities, 288 patients exiting consultations and 1500 households of women who delivered in the previous year in one intervention district (Mbarali). 288 observations of provider-client interactions will also be carried out. The same data will be collected from a comparison district in a nearby region. A process evaluation will ascertain how the scheme is implemented in practice and the level of implementation fidelity and potential moderators. The process evaluation will draw from impact evaluation data and from three rounds of data collection at the national, regional, district, facility and community levels. An economic evaluation will measure the cost-effectiveness of the scheme relative to current practice from a societal perspective.DiscussionThis evaluation will generate evidence on the impact and cost-effectiveness of targeted health insurance for pregnant women in a low income setting, as well as building a better understanding of the implementation process and challenges for programs of this nature.

Improving Health System Performance in a Decentralized Health System: Capacity Building in Pakistan

—Key policy questions on decentralization in health relate to whether and in which ways health sector decentralization can improve health outcomes. Focusing on a maternal, neonatal, and child health program in Pakistan, this study examines relationships between three dimensions of decentralization: the degree of local decision-making choice (“decision space”), individual and institutional capacities, and local accountability. Additionally, these relationships are examined at two points in time to assess whether “capacity building” interventions, as well as any changes in decision space, are related to improvements in health sector performance as measured by improved administrative processes and indicators of health coverage in important primary care services. The study is based on surveys administered in 2006 and 2009 to local health sector decision-makers in 15 districts in Pakistan—ten of which received capacity-building assistance from the US government–funded maternal and child health project (PAIMAN), and five control districts not receiving capacity-building interventions. Findings indicate that while local authorities in both districts reported using wider decision space by 2009, institutional capacities in PAIMAN districts improved to a higher degree than in comparison districts. Officials in neither set of districts reported significant changes in their accountability to local elected officials, although those districts with more decision space and institutional capacities mobilized greater local support for health programs. Extending findings from an earlier study focused on similar questions, there were strong synergies among the dimensions of decentralization for different health sector functions, as well as some evidence of associations between stronger institutional capacities/wider decision-space and improvements in health coverage and in better administration of the health system. Findings suggest that targeted capacity-building activities at the district level may contribute to improved decision-making abilities and, in turn, improved health system performance.

Spatial and socio-demographic determinants of contraceptive use in the Upper East region of Ghana.

BackgroundThis paper presents results of baseline data on the determinants of contraceptive use in 7 districts in northern Ghana where there is an ongoing integrated primary health care systems strengthening projectknown as the Ghana Essential Health Intervention Project (GEHIP).MethodsWe used a household survey data conducted within 66 randomly sampled census enumeration areas in seven rural districts of the Upper East Region of northern Ghana where health systems strengthening interventions are currently ongoing in three of the districts with four of the districts serving as comparison districts. This survey was conducted prior to the introduction of interventions. Data was collected on various indices included geographic information systems (GIS) and contraceptive use. The data was analyzed using survey design techniques that accounts for correct variance estimation. Categorical variables were summarized as proportions and associations between these variables and contraceptive use tested using Chi-square test. Uni-variable and multivariable logistic regression techniques were used to assess the effects of the selected covariates on contraceptive use. All tests were deemed to be statistically significant at 5% level statistical significance.ResultsResults show that contraceptive use is generally low (about 13 per cent) and use is nearly evenly for spacing and stopping purposes. Factors associated with the use of contraceptives include exposure to integrated primary healthcare services, the level of education, and socioeconomic status, couple fertility preference, marital status, and parity. For instance, the odds of contraceptive use among 15–45 year old women who live 2 km or more from a CHPS compound is 0.74 compared to women who live less than 2 km from a CHPS compound (p-value = 0.035).ConclusionThe findings suggest that rapid scale up of the Community based Health Planning and Services (CHPS) program accompanied with improved door-to-door health services would kindle uptake of modern contraceptive use, reduce unwanted pregnancies and hasten the attainment of MDG 4 & 5 in Ghana.

Promoting integration of immigrants: Effects of free child care on child enrollment and parental employment

Proficiency in the language spoken by the majority population may be crucial for the cognitive development of children from immigrant families. High-quality child care is believed to promote such language skills, and it is thus of concern that children from immigrant families are underrepresented in formal child care across OECD countries. How can we increase their participation, and can such participation improve family integration? We study an intervention in some districts of Oslo where children aged four and five were eligible for 20h of free childcare weekly. Taking advantage of the intervention being available in some city districts and not in others, we estimate the effect of the intervention on the enrollment of children and on their parents' employment and education, using outcomes measured for the same family before and after the child's age of eligibility. We find that the intervention increased the participation for children from immigrant families by 15%. However, we do not find support for effects on parental employment or education. The performance in tests at school entry (age six) for children from immigrant families in city districts with free child care is better than that of similar children in comparison districts. Overall, our results suggest that subsidizing center based child care can improve the cognitive development of children from immigrant families.

Assessing the impact of integrated community case management (iCCM) programs on child mortality: Review of early results and lessons learned in sub-Saharan Africa.

AimTo accelerate progress in reducing child mortality, many countries in sub–Saharan Africa have adopted and scaled–up integrated community case management (iCCM) programs targeting the three major infectious killers of children under–five. The programs train lay community health workers to assess, classify and treat uncomplicated cases of pneumonia with antibiotics, malaria with antimalarial drugs and diarrhea with Oral Rehydration Salts (ORS) and zinc. Although management of these conditions with the respective appropriate drugs has proven efficacious in randomized trials, the effectiveness of large iCCM scale–up programs in reducing child mortality is yet to be demonstrated. This paper reviews recent experience in documenting and attributing changes in under–five mortality to the specific interventions of a variety of iCCM programs.MethodsEight recent studies have been identified and assessed in terms of design, mortality measurement and results. Impact of the iCCM program on mortality among children age 2–59 months was assessed through a difference in differences approach using random effect Poisson regression.ResultsDesigns used by these studies include cluster randomized trials, randomized stepped–wedge and quasi–experimental trials. Child mortality is measured through demographic surveillance or household survey with full birth history conducted at the end of program implementation. Six of the eight studies showed a higher decline in mortality among children 2–59 months in program areas compared to comparison areas, although this acceleration was statistically significant in only one study with a decline of 76% larger in intervention than in comparison areas.ConclusionStudies that evaluate large scale iCCM programs and include assessment of mortality impact must ensure an appropriate design. This includes required sample sizes and sufficient number of program and comparison districts that allow adequate inference and attribution of impact. In addition, large–scale program utilization, and a significant increase in coverage of care seeking and treatment of targeted childhood illnesses are preconditions to measurable mortality impact. Those issues need to be addressed before large investments in assessing changes in child mortality is undertaken, or the results of mortality impact evaluation will most likely be inconclusive.

Impact of pharmacy worker training and deployment on access to essential medicines and health outcomes in Malawi: protocol for a cluster quasi-experimental evaluation.

BackgroundAccess to essential medicines is core to saving lives and improving health outcomes of people worldwide, particularly in the low- and middle-income countries. Having a trained pharmacy workforce to manage the supply chain and safely dispense medicines is critical to ensuring timely access to quality pharmaceuticals and improving child health outcomes.Methods/DesignThis study measures the impact of an innovative pharmacy assistant training program in the low-income country of Malawi on access to medicines and health outcomes. We employ a cluster quasi-experimental design with pre-and post-samples and decision analytic modeling to examine access to and the use of medicines for malaria, pneumonia, and diarrhea for children less than 5 years of age. Two intervention districts, with newly trained and deployed pharmacy assistants, and two usual care comparison districts, matched on socio-economic, geographic, and health-care utilization indicators, were selected for the study. A baseline household survey was conducted in March 2014, prior to the deployment of pharmacy assistants to the intervention district health centers. Follow-up surveys are planned at 12- and 24-months post-deployment. In addition, interviews are planned with caregivers, and time-motion studies will be conducted with health-care providers at the health centers to estimate costs and resources use.DiscussionThis impact evaluation is designed to provide data on the effects of a novel pharmacy assistant program on pharmaceutical systems performance, and morbidity and mortality for the most common causes of death for children under five. The results of this study should contribute to policy decisions about whether and how to scale up the health systems strengthening workforce development program to have the greatest impact on the supply chain and health outcomes in Malawi.

The use of continuous surveys to generate and continuously report high quality timely maternal and newborn health data at the district level in Tanzania and Uganda.

BackgroundThe lack of high quality timely data for evidence-informed decision making at the district level presents a challenge to improving maternal and newborn survival in low income settings. To address this problem, the EQUIP project (Expanded Quality Management using Information Power) implemented a continuous household and health facility survey for continuous feedback of data in two districts each in Tanzania and Uganda as part of a quality improvement innovation for mothers and newborns.MethodsWithin EQUIP, continuous survey data were used for quality improvement (intervention districts) and for effect evaluation (intervention and comparison districts). Over 30 months of intervention (November 2011 to April 2014), EQUIP conducted continuous cross-sectional household and health facility surveys using 24 independent probability samples of household clusters to represent each district each month, and repeat censuses of all government health facilities. Using repeat samples in this way allowed data to be aggregated at six four-monthly intervals to track progress over time for evaluation, and for continuous feedback to quality improvement teams in intervention districts.In both countries, one continuous survey team of eight people was employed to complete approximately 7,200 household and 200 facility interviews in year one. Data were collected using personal digital assistants. After every four months, routine tabulations of indicators were produced and synthesized to report cards for use by the quality improvement teams.ResultsThe first 12 months were implemented as planned. Completion of household interviews was 96% in Tanzania and 91% in Uganda. Indicators across the continuum of care were tabulated every four months, results discussed by quality improvement teams, and report cards generated to support their work.ConclusionsThe EQUIP continuous surveys were feasible to implement as a method to continuously generate and report on demand and supply side indicators for maternal and newborn health; they have potential to be expanded to include other health topics. Documenting the design and implementation of a continuous data collection and feedback mechanism for prospective description, quality improvement, and evaluation in a low-income setting potentially represents a new paradigm that places equal weight on data systems for course correction, as well as evaluation.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-014-0112-1) contains supplementary material, which is available to authorized users.