Country-level Progress Research Articles

Progress towards universal health coverage and inequalities in infant mortality: an analysis of 4·1 million births from 60 low-income and middle-income countries between 2000 and 2019

Expanding universal health coverage (UHC) might not be inherently beneficial to poorer populations without the explicit targeting and prioritising of low-income populations. This study examines whether the expansion of UHC between 2000 and 2019 is associated with reduced socioeconomic inequalities in infant mortality in low-income and middle-income countries (LMICs). We did a retrospective analysis of birth data compiled from Demographic and Health Surveys (DHSs). We analysed all births between 2000 and 2019 from all DHSs available for this period. The primary outcome was infant mortality, defined as death within 1 year of birth. Logistic regression models with country and year fixed effects assessed associations between country-level progress to UHC (using WHO's UHC service coverage index) and infant mortality (overall and by wealth quintile), adjusting for infant-level, mother-level, and country-level variables. A total of 4 065 868 births to 1 833 011 mothers were analysed from 177 DHSs covering 60 LMICs between 2000 and 2019. A one unit increase in the UHC index was associated with a 1·2% reduction in the risk of infant death (AOR 0·988, 95% CI 0·981-0·995; absolute measure of association, 0·57 deaths per 1000 livebirths). An estimated 15·5 million infant deaths were averted between 2000 and 2019 because of increases in UHC. However, richer wealth quintiles had larger associated reductions in infant mortality from UHC (quintile 5 AOR 0·983, 95% CI 0·973-0·993) than poorer quintiles (quintile 1 0·991, 0·985-0·998). In the early stages of UHC, UHC expansion was generally beneficial to poorer populations (ie, larger reductions in infant mortality for poorer households [infant deaths per 1000 per one unit increase in UHC coverage: quintile 1 0·84 vs quintile 5 0·59]), but became less so as overall coverage increased (quintile 1 0·64 vs quintile 5 0·57). Since UHC expansion in LMICs appears to become less beneficial to poorer populations as coverage increases, UHC policies should be explicitly designed to ensure lower income groups continue to benefit as coverage expands. UK National Institute for Health and Care Research.

Every rung counts–A retrospective analysis of global sanitation progress across the service-level ladder under the MDGs

The household sanitation target during the Millennium Development Goal (MDG) period used a binary “Improved”/”Unimproved” metric to evaluate progress. The “Unimproved” category was divided into three service levels: Shared Sanitation (facilities acceptable), Unimproved Facilities, and Open Defecation (no facility). Despite these data being publicly available, no analysis of country-level progress across these sanitation service levels during the MDGs has been published. We propose that retrospective analysis of progress across service levels can illuminate the diverse approaches used to address particular urban and rural sanitation deficits, and may provide insight to national and global actors in their ongoing efforts to address household sanitation. Additionally, we propose that a Sanitation Ladder Score, weighted to ascribe full, partial, and no credit to use of improved, shared and unimproved, and open defecation, respectively, is essential for concise communication of progress. Our analysis required gap-filling of data missing from the Joint Monitoring Programme (JMP) dataset; our final dataset consists of 190 countries representing 99.8% of global population. 149 countries achieved greater progress on the Sanitation Ladder Score than on the MDG metric. Using the four JMP progress categories, 144 countries fell into the same progress category and 41 achieved a higher category of Ladder Score progress. Countries with large gains in shared sanitation tended to have much greater progress on the Sanitation Ladder Score than on the MDG metric. A more detailed analysis is reported for six countries, with insight from the literature into their approaches. This Sanitation Ladder Score could be modified to incorporate the new “Safely Managed” service level tracked under the Sustainable Development Goals (SDGs) and likewise could be modified for other SDG targets for which multiple levels of service/achievement are reported. We encourage others to build upon our analysis; our complete dataset is freely available online (https://melliott.people.ua.edu/data.html).

Global status of essential medicine selection: a systematic comparison of national essential medicine lists with recommendations by WHO

ObjectivesExamining the availability of essential medicines is a necessary step to monitor country-level progress towards universal health coverage. We compared the 2017 essential medicine lists (EML) of 137 countries to...

Global Health Facility-Based Interventions to Achieve UNAIDS 90-90-90: A Systematic Review and Narrative Analysis.

To evaluate whether health facility-based HIV interventions align with UNAIDS 90-90-90 targets, we performed a systematic review through the lens of UNAIDS targets. We searched 11 databases, retrieving 5201 citations with 26 eligible studies classified by country income and UNAIDS target. We analyzed whether reporting of study outcome metrics was in line with UNAIDS targets using a standardized extraction form and results were summarized in a narrative synthesis given data heterogeneity. We also assessed the quality of randomized trials with the Cochrane Risk of Bias Tool and observational studies with the Newcastle-Ottawa Scale. Stratification of interventions by country income level revealed themes in successful interventions that provide insight for scale-up in similar resource contexts. Few studies reported outcomes using metrics according to UNAIDS targets. Standardization of reporting according to the UNAIDS framework could facilitate comparability of interventions and inform country-level progress on an international scale.

Achieving Universal Health Coverage (UHC): Dominance analysis across 183 countries highlights importance of strengthening health workforce.

Despite increasing political will to achieve Universal Health Coverage (UHC), there is a paucity of empiric data describing what health system indicators are useful surrogates of country-level progress towards UHC. We sought to determine what public health interventions were useful tracers of country-level UHC progress. Across 183 countries we evaluated the extent to which 16 service delivery indicators explained variability in the UHC Service Coverage Index, (UHC SCI) a WHO-validated indicator of country-level health coverage. Dominance analyses, stratifying countries by World Bank income criteria, were used to determine which indicators were most important in in predicting UHC SCI scores. Health workforce density ranked first overall, provision of basic sanitation and access to clean water ranked second, and provision of basic antenatal services ranked third. In analysis stratified by World Bank income criteria, health workforce density ranked first in Lower Middle Income-Countries (LMICs) (n = 45) and third in Upper Middle Income-Countries (UMICs) (n = 51). While each country will have a different approach to achieving UHC, strengthening the health workforce will need to be a key priority if they are to be successful in achieving UHC.

Nurse and health professional migration during COVID-19.

The COVID-19 pandemic has exposed the vulnerabilities of nursing supply flows, domestically and internationally. Its impact at the country-level has further highlighted preexisting nurse supply gaps and the effect of staffing shortages. Internationally, the pandemic has disrupted global supply chains. The world has witnessed the closing of borders, the interruption of travel, and, in some countries, the restriction of outflows. The State of the World's Nursing Report (SOWN) (WHO, 2020) noted a shortfall of almost six million nurses immediately pre-COVID-19, a shortage suffered particularly by low- and middle-income countries. This is of major concern given that increased international outflows of nurses in the new post-COVID era could undermine, even more than before, the readiness of those countries to meet healthcare demands (ICN, 2020). In this default scenario, some, but not all, highincome destination countries will continue to rely on international inflow of nurses to a significant extent, as they did pre-COVID- 19, further exacerbating the suffering of poor countries. Put simply, without country-level policy changes related to the nursing workforce and backed by international organisations, pre-COVID-19 trends of increased nurse flows from low- to high-income countries will likely continue. In this scenario, the iniquitous maldistribution of nurses may become more pronounced. This "do nothing" option risks undermining both country-level progress towards the attainment of Universal Health.

An international comparison of the deinstitutionalisation of mental health care: Development and findings of the Mental Health Services Deinstitutionalisation Measure (MENDit).

BackgroundDespite its inclusion as a key aspect of successful mental health care service provision by the World Health Organization, there exists a lack of consensus regarding the definition, key components and implementation of deinstitutionalisation. This lack of consensus has also contributed to subjectivity in assessments of countries’ progress towards deinstitutionalisation which act as a barrier to its evaluation and success. In order to provide for reliable within and cross country evaluations of the success of deinstitutionalisation we aimed to develop a quantitative measure of country-level progress towards deinstitutionalisation through the (1) identification of key markers of deinstitutionalisation; (2) development of an assessment tool based on the identified markers; (3) evaluation of the tool’s psychometric properties; and (4) comparison of progress towards deinstitutionalisation across Europe.MethodsNational care standards from 10 European countries and World Health Organization recommendations were used to identify items for the tool. A draft version was reviewed by an international expert panel and assessed for test-retest reliability and internal consistency. Once a final version had been agreed, progress towards deinstitutionalisation was assessed for 30 European countries. We used this opportunity to test convergent validity through comparison with local experts’ assessments. Country total as well as individual item scores were described and compared.ResultsThe five-item Mental Health Services Deinstitutionalisation Measure (MENDit) is an objective tool with moderate to very good test-retest reliability (Kappa range: 0.46-1.00) and internal consistency (α = 0.70, 95 % CI 0.25, 0.92). A statistically significant difference between groups was found by one-way ANOVA (F(3,26) = 6.77, p = 0.002). Post-hoc testing found significant differences between MENDit scores of countries categorised as having advanced levels of deinstitutionalisation and not started or just started. Across Europe, MENDit scores suggest substantial variety in progress towards deinstitutionalisation.ConclusionsThe MENDit has good psychometric properties which support its use in research and as a benchmarking tool to measure national progress towards deinstitutionalisation by policy makers. Across Europe a high proportion of psychiatric beds are still located in psychiatric hospitals. Additionally, low numbers of mental health professionals in many countries may hinder further deinstitutionalisation. These findings corroborate previous mental health systems research and highlight some of the difficulties of deinstitutionalisation.

Strengthening monitoring and evaluation (M&E) and building sustainable health information systems in resource limited countries: lessons learned from an M&E task-shifting initiative in Botswana.

BackgroundThe demand for quality data and the interest in health information systems has increased due to the need for country-level progress reporting towards attainment of the United Nations Millennium Development Goals and global health initiatives. To improve monitoring and evaluation (M&E) of health programs in Botswana, 51 recent university graduates with no experience in M&E were recruited and provided with on-the-job training and mentoring to develop a new cadre of health worker: the district M&E officer. Three years after establishment of the cadre, an assessment was conducted to document achievements and lessons learnt.MethodsThis qualitative assessment included in-depth interviews at the national level (n = 12) with officers from government institutions, donor agencies, and technical organizations; and six focus group discussions separately with district M&E officers, district managers, and program officers coordinating different district health programs.ResultsReported achievements of the cadre included improved health worker capacity to monitor and evaluate programs within the districts; improved data quality, management, and reporting; increased use of health data for disease surveillance, operational research, and planning purposes; and increased availability of time for nurses and other health workers to concentrate on core clinical duties. Lessons learnt from the assessment included: the importance of clarifying roles for newly established cadres, aligning resources and equipment to expectations, importance of stakeholder collaboration in implementation of sustainable programs, and ensuring retention of new cadres.ConclusionThe development of a dedicated M&E cadre at the district level contributed positively to health information systems in Botswana by helping build M&E capacity and improving data quality, management, and data use. This assessment has shown that such cadres can be developed sustainably if the initiative is country-led, focusing on recruitment and capacity-development of local counterparts, with a clear government retention plan.

Assessment of the health system and policy environment as a critical complement to tracking intervention coverage for maternal, newborn, and child health

In 2008, the Countdown to 2015 initiative identified 68 priority countries for action on maternal, newborn, and child health. Much attention was paid to monitoring country-level progress in achieving high and equitable coverage with interventions effective in reducing mortality of mothers, newborn infants, and children up to 5 years of age. To have a broader understanding of the environment in which health services are delivered and health outcomes are produced is essential to increase intervention coverage. Programmes to address MNCH rely on health systems to generate information needed for effective decisions and to achieve the expected outcomes. Governance and leadership are needed throughout the process not only to create policies and implement them but also to assure quality and efficiency of care, to finance health services sufficiently and in an equitable way, and to manage the health workforce. We present a systematic approach to assess the wider health system and policy environment needed to achieve positive outcomes for maternal, newborn, and child health. We report on results from 13 indicators and show gaps in policy adoption as well as weaknesses in other health system building blocks. We identify areas for future action in measurement of key indicators and their use to support decision making. We hope that this information will provide an additional dimension to the discussions on feasible and sustainable solutions to accelerate progress towards Millennium Development Goals 4 and 5, both at the global level but most importantly in individual countries.