Delivery Of Child Health Services Research Articles

The validation of the Western Canada Waiting List Children’s Mental Health-Priority Criteria Score Instrument: 2002 – 2015 results

Objective: To assess the validity of the Western Canada Waiting List Children’s Mental Health-Priority Criteria Score (WCWLCMH-PCS) Instrument.Methods: The WCWL-CMH-PCS Instrument was developed in order to prioritize the delivery of child and youth mental health (CYMH) services through standardized measures of urgency. We draw on two data sets describing the PCS scores among patients who have sought CYMH care. The first data set was collected during the first phase of pilot testing for the WCWL-CMH-PCS Instrument (from January – June 2000), during which trained intake workers applied the PCS items to 817 patients aged 5-18 years throughout the three western provinces. The second data set comprises the application of a refined version of the WCWL-CMH-PCS Instrument to 22,013 patients aged 0-19 throughout the Calgary Health Region from 2002 – 2015. For our analysis, we compare the two samples in order to determine the percentage of patients that correspond to specific risk categories for each priority score.Results: For the overall pairwise correlation by item, r = 0.96 and is statistically significant at the .05 level (p < .05). We discovered that there are small differences in the assessments of urgency for access to specialized care, severity of symptoms, family and social factors, and the expected results of care between the two samples. The absolute difference per item is not greater than 12.0%.Conclusions: Overall, our results support the empirical applicability and usefulness of the WCWL-CMH-PCS Instrument within CYMH clinical settings.

Maternal, newborn and child health needs, opportunities and preferred futures in Arusha and Ngorongoro: hearing women's voices.

Background With the approaching sunset on the Millennium Development Goals (MDGs), Tanzania continues with its final national push towards achievement of MDG #4 and MDG #5. The Mama Kwanza Socio-economic Health Initiative (MKSHI) was introduced in the hope of contributing to improving maternal, newborn, and child health in Arusha and Ngorongoro. The MKSHI project is a holistic, inter-sectoral approach to maternal, newborn, and child health which aligns with the Government of Tanzania’s Vision 2025. At the project onset, a baseline assessment was conducted to launch ongoing benchmarking, monitoring, and evaluation of the project’s impacts and implications. The aim of this baseline assessment was twofold. First it was to determine the state of maternal, newborn, and child health in the two project sites. Second it was to ensure that a baseline of key indicators was established as well as identification of unique indicators relevant to the populations of interest.ResultsThe baseline study was a mixed methods approach to identify maternal, newborn, and child risk factors and indicators in the two target sites. This paper focuses on the qualitative methods and findings. The qualitative component included a series of five community dialogue meetings and thirty-seven individual/dyad interviews with women, providers, and stakeholders. Initially, community meetings were held as open dialogues on maternal, newborn, and child health issues, opportunities, and preferred futures. Individual/dyad interviews were held with women, providers, and stakeholders who held unique information or experiences. Both community dialogue and interview data was analysed for themes and guiding or critical comments. Three over-arching findings emerged: What took you so long to come? How do we know what you know? and How will it change for our daughters?ConclusionsParticipant voices are vital in ensuring the achievement of local and global efforts and preferred futures for maternal, newborn, and child health services. This study contributes to the inclusion of women in all aspects of the planning, implementation, and delivery of maternal, newborn, and child health services in the target areas and beyond.

Prioritizing vulnerable children: strategies to address inequity.

While current strategies to address the needs of vulnerable child populations in Australia aim to reduce inequities, they are isolated, group specific and disparate. The aim of this study was to address health inequities by generating tools that are useful in clinical service settings to assist with the identification, prioritization and monitoring of all vulnerable populations. Current local and national initiatives to address inequities were reviewed. Shared strategies in delivering health services to vulnerable populations were highlighted, and existing tools used for identification and prioritization were adapted. Analysis of at-risk populations resulted in the formulation of four key questions to identify vulnerable children at presentation to services and strategies for prioritizing children within services. An existing refugee child health service delivery framework was adapted as a proposal for use in the development and evaluation of services for all vulnerable child populations. A systemic approach across all vulnerable populations, supplemented by group-specific measures, is likely to add value to health service delivery as well as be more efficient and sustainable than multiple group-specific interventions. Given the limited outcome evidence available, there is also a need to collect data on vulnerable children and to track the effectiveness of interventions designed to address their health needs.

Male engagement as a strategy to improve utilization and community-based delivery of maternal, newborn and child health services: evidence from an intervention in Odisha, India.

BackgroundIn response to persistently poor levels of maternal, newborn and child health (MNCH) in rural India, the National Rural Health Mission (NRHM) was launched to support the provision of accessible, affordable and quality health care in deprived and underserved communities. The Accredited Social Health Activists (ASHAs), local women, are trained as health promoters to generate demand for, and facilitate access to MNCH care in their communities. While they are also expected to provide husbands of expectant women with information on MNCH care and family planning, their reach to the husbands is limited. The aim of this study is to describe the influence of a male engagement project on the utilization and community-based delivery of MNCH care in a rural district of the country.MethodsWe used qualitative data from the evaluation of a project which recruited and trained male Community Health Workers (CHWs) known as Male Health Activists (MHAs) to complement the work of ASHAs and target outreach to men. This paper uses data from in-depth interviews (IDIs) with ASHAs (n=11), Anganwadi Workers (AWWs) (n=4) and Auxiliary Nurse Midwives (ANMs) (n=2); with women who had delivered at home, community health center or district hospital in the few months preceding the date of the interview (n=11); and with husbands of these women (n=7).ResultsParticipants’ responses are broadly organized around the facilitation of ASHAs’ work by MHAs, and male engagement activities undertaken by MHAs. More specifically, the narratives reflected gender-based divisions of work and space in three core areas of delivery and use of MNCH services: escorting women to health centers for facility-based deliveries; mobilizing women and children to attend Village Health and Nutrition Days and Immunization Days; and raising awareness among men on MNCH and family planning.ConclusionThis study sheds light on male engagement as a strategy to improve the delivery, access and uptake of maternal, newborn and child health in the context of prevailing gender norms and gendered roles in rural India. Ultimately, it unveils the complementarity of male and female CHWs in the community-based delivery of, and increased demand for, MNCH services.

Male engagement as a strategy to improve the delivery and use of maternal, newborn, and child health services

Abstract Background In response to persistently poor maternal and child health in rural India, the National Rural Health Mission (NRHM) was launched in 2005 as a framework for the provision of accessible, affordable, and quality health care in deprived and underserved communities. At the centre of the programme are the accredited social health activists—local women trained as health educators and promoters to generate demand for, and facilitate access to, maternal, newborn, and child health (MNCH) services in their communities. In this study, we aimed to examine the effect of a male community health worker project on the delivery and uptake of MNCH care in a rural district of India. The specific research questions are: did male community health workers complement the work of the accredited social health activists and fill important gaps in community MNCH service delivery? Further, what is the perceived effect of male community health workers' engagement with men? Methods We recruited and trained male community health workers, referred to as male health activists, to complement the work of the female social health activists and extend community-based delivery of MNCH services. The project was implemented between February, 2011, and March, 2013, in Keonjhar district in the state of Odisha, which is one of the six states in India with high rates of maternal and child deaths. We conducted in-depth interviews with 11 social health activists, 11 women who had recently delivered in a health facility, and seven husbands of women who had recently delivered. The interviews were conducted by locally based interviewers in the local language. Responses were audio-recorded, transcribed verbatim and translated to English, then coded manually. Findings From the interview responses, we identified three main gender-based divisions of work and space in three areas of delivery and use of MNCH services: the escorting of women to health facilities for MNCH care; awareness raising among men on MNCH and family planning; and mobilisation of parents and children to attend village health and nutrition days and immunisation days. The narratives from virtually all respondents pointed to the crucial roles played by male health activists around and during delivery, especially at night when they facilitate transport and provide security, a role that female community health workers would rarely assume. Women and social health activist respondents were appreciative of the increased engagement of male health activists with men, which they reported resulted in some positive behaviour changes, including on family planning. Finally, the accredited social health activists identified tangible constraints, such as the cost of transport, to the implementation of village health and nutrition days and immunisation days that could only be addressed by male health activists. Interpretation These findings highlight the potential for trained and equipped male community health workers to improve outcomes in maternal, newborn, and child health. Funding The project and its evaluation and data analysis for this study were funded by a grant from the Bill and Melinda Gates Foundation.

An innovation for improving maternal, newborn and child health (MNCH) service delivery in Jigawa State, northern Nigeria: a qualitative study of stakeholders' perceptions about clinical mentoring.

BackgroundAn effective capacity building process for healthcare workers is required for the delivery of quality health care services. Work-based training can be applied for the capacity building of health care workers while causing minimum disruption to service delivery within health facilities. In 2012, clinical mentoring was introduced into the Jigawa State Health System through collaboration between the Jigawa State Ministry of Health and the Partnership for Transforming Health Systems Phase 2 (PATHS2). This study evaluates the perceptions of different stakeholders about clinical mentoring as a strategy for improving maternal, newborn and child health service delivery in Jigawa State, northern Nigeria.MethodsInterviews were conducted in February 2013 with different stakeholders within Jigawa State in Northern Nigeria. There were semi-structured interviews with 33 mentored health care workers as well as the health facility departmental heads for Obstetrics and Pediatrics in the selected clinical mentoring health facilities. In-depth interviews were also conducted with the clinical mentors and two senior government health officials working within the Jigawa State Ministry of Health. The qualitative data were audio-recorded; transcribed and thematically analysed.ResultsThe study findings suggest that clinical mentoring improved service delivery within the clinical mentoring health facilities. Significant improvements in the professional capacity of mentored health workers were observed by clinical mentors, heads of departments and the mentored health workers. Best practices were introduced with the support of the clinical mentors such as appropriate baseline investigations for pediatric patients, the use of magnesium sulphate and misoprostol for the management of eclampsia and post-partum hemorrhage respectively. Government health officials indicate that clinical mentoring has led to more emphasis on the need for the provision of better quality health services.ConclusionStakeholders report that the introduction of clinical mentoring into the Jigawa State health system gave rise to an improved capacity of the mentored health care workers to deliver better quality maternal, newborn and child health services. It is anticipated that with a scale up of clinical mentoring, health outcomes will also significantly improve across northern Nigeria.

Rapid Assessment of Ebola-Related Implications for Reproductive, Maternal, Newborn and Child Health Service Delivery and Utilization in Guinea.

Introduction: Since March 2014, Guinea has been in the midst of the largest, longest, and deadliest outbreak of Ebola Virus Disease ever recorded. Due to sub-optimal health conditions prior to the outbreak, Guinean women and children may have been especially vulnerable to worsening health care conditions. A rapid assessment was conducted to better understand how the delivery and utilization of routine RMNCH services may have been affected by the extraordinary strain placed on the health system and its client population by the Ebola outbreak in Guinea. Methods: Data were collected January-February 2015 in a convenience sample of public and private facilities in areas of the country that were Ebola active, calm and inactive. Monthly data on a number of RMNCH services were collected by facility record abstraction for the period from October 1, 2013 through December 31, 2014. Structured interviews were also held with facility directors and RMNCH service providers. Results: Data on RMNCH services from forty five public facilities were obtained. A statistically significant decline of 31% was seen in outpatient visits between October-December 2013 (before the Ebola outbreak) and October-December 2014 (the advanced stage of the Ebola outbreak). Service declines appeared to be greater in hospitals compared to health centers. Child health services were more affected by the Ebola epidemic than other assessed health areas. For example, the number of children under five seen for diarrhea and Acute Respiratory Infection (ARI) showed a large decrease over the one-year period in both hospitals (60% for diarrhea and 58% for ARI) and health centers (25% and 23%, respectively). Results also suggest that the negative effects on service availability (such as reduced hours, closures, and service suspensions) are likely to be regional and/or facility-specific. Providers reported a number of improved infection control behaviors as a result of the Ebola outbreak, including more frequent hand-washing and the use of disinfectants. Nevertheless, 30% of interviewed staff had not received any training on Ebola infection control. Discussion: Although there may be differences in RMNCH service delivery and availability in selected versus non-selected facilities, a large number of indicators were assessed in order to provide needed information on the effects of the Ebola crisis on routine RMNCH service delivery and uptake in Guinea. This information is an important and timely contribution to ongoing efforts to understand and respond to the adverse effects of the Ebola crisis on essential RMNCH services in Guinea.

Paper 2: Using clinical and other applied psychologists effectively in the delivery of Child and Adolescent Mental Health Services (CAMHS) - recommendations about numbers, gradings and leadership

Paper 2: Using clinical and other applied psychologists effectively in the delivery of Child and Adolescent Mental Health Services (CAMHS) - recommendations about numbers, gradings and leadership

Assessing the quality of care in a new nation: South Sudan's first national health facility assessment.

We adapted a rapid quality of care monitoring method to a fragile state with two aims: to assess the delivery of child health services in South Sudan at the time of independence and to strengthen local capacity to perform regular rapid health facility assessments. Using a two-stage lot quality assurance sampling (LQAS) design, we conducted a national cross-sectional survey among 156 randomly selected health facilities in 10 states. In each of these facilities, we obtained information on a range of access, input, process and performance indicators during structured interviews and observations. Quality of care was poor with all states failing to achieve the 80% target for 14 of 19 indicators. For example, only 12% of facilities were classified as acceptable for their adequate utilisation by the population for sick-child consultations, 16% for staffing, 3% for having infection control supplies available and 0% for having all child care guidelines. Health worker performance was categorised as acceptable in only 6% of cases related to sick-child assessments, 38% related to medical treatment for the given diagnosis and 33% related to patient counselling on how to administer the prescribed drugs. Best performance was recorded for availability of in-service training and supervision, for seven and ten states, respectively. Despite ongoing instability, the Ministry of Health developed capacity to use LQAS for measuring quality of care nationally and state-by-state, which will support efficient and equitable resource allocation. Overall, our data revealed a desperate need for improving the quality of care in all states.

Bridging Human Resources for Health (HRH) gaps by applying clinical mentoring in selected health facilities: evidence from Jigawa State in northern Nigeria

Background In July 2012, a clinical mentoring intervention commenced in Jigawa State through collaboration between the Jigawa State Ministry of Health and the Partnership for Transforming Health Systems Phase 2 project. After 6 months, an evaluation was undertaken to assess whether clinical mentoring has benefits for the health workforce situation within the intervention health facilities as well as whether it improved maternal, newborn and child health service delivery in Jigawa State within northern Nigeria.

Health Privacy in India: A Legal Mapping

Laws are dynamic, in that they reflect the societal attitude at a particular period and are enacted to control the behaviour and practice of the society. Recent examples include the enactment of The Persons with Disabilities Act to empower, promote equality and participation of persons with disabilities, The Pre-Natal Diagnostic Techniques Act to curb female feticide and The Medical Council of India, Code of Ethics Regulations that set the professional standards for medical practice. Invariably, the general legislations governing healthcare are not robust enough as they fail to adequately include provisions of privacy and confidentiality. A uniform statute specifically protecting the privacy of health information in India does not exist. Broadly speaking, the existing legal framework is weak and complex. Recurring issues include lack of safeguards, implementation, redressal mechanisms and judicial inactivity. However, the last two decades have seen a phenomenal rise in health-related public litigation. Two notable cases reiterating the right to medical privacy include: Mr. "X" v. Hospital "Z" and Ms. X vs. Mr. Z & Anr. Currently in India, the Mother and Child Tracking System, an e-governance initiative to collate information of all pregnant women and infants to ensure delivery of maternal and child health services from conception till 42 days after delivery for pregnant women and up to five years for children as well as the UID objective of health and health related development schemes as a “killer application” have raised questions related to privacy, disclosure, confidentiality, and ethical use of information, informed consent, data sharing and security of information. In order to understand the legal and policy ecosystem of health privacy in India, mappings were undertaken of relevant legislation, legal policy and case law, analysis of which included collection, retention, security, access, use and disclosure and remedies and offences.

Evolution of the Child Health Day Strategy for the Integrated Delivery of Child Health and Nutrition Services

In efforts to meet the Millennium Development Goal for mortality among children under 5 years of age, countries require strategies for covering hard-to-reach and older children who are often missed by routine, fixed-site health services. To document the evolution of Child Health Days (CHDs), designed as regular events for the delivery of health and nutrition services to children under the age of five. We extracted information on service delivery strategies and codelivered interventions for the period 1999 to 2010from global monitoring databases for vitamin A and immunization. Our data illustrate a dramatic rise in CHDs over the decade: only two countries held CHDs in 1999; in 2010, 96 CHDs were conducted in 51 countries. Reliance on CHDs has been particularly marked in sub-Saharan Africa, where they are increasingly used to deliver five or more_services per event. Whereas early CHDs were largely defined by codelivery of vitamin A, immunizations, and deworming, they have since evolved into diverse packages including services such as water purification tablets and screening for severe malnutrition. The scale-up of CHDs is helping countries to achieve high and equitable coverage of essential health and nutrition services. Future research should consider whether the increasingly diverse services delivered via CHDs are guided by epidemiologic considerations, and whether the rising number of codelivered interventions is affecting coverage performance or service quality. Guidance is also needed to ensure that CHDs are implemented as part of systematic efforts to improve health systems.

Use of the Measure of Processes of Care (MPOC-20) to evaluate health service delivery for children with cerebral palsy and their families in Jordan: validation of Arabic-translated version (AR-MPOC-20).

Family-centred service (FCS) is widely accepted now as best practice in paediatric rehabilitation. The Measure of Processes of Care-20 items set (MPOC-20) is a valid and reliable self-report measure of parents' perceptions of the extent to which health services are family-centred. Arabic-translated and validated version of the MPOC-20 (AR-MPOC-20) is used to examine Jordanian families' perception of service providers' caregiving behaviours as they receive rehabilitation services for their children with cerebral palsy (CP). Parents of 114 children with CP who are receiving services at different settings in Jordan were interviewed using the AR-MPOC-20. Participating children aged 4.1 ± 4.4 years, 53.5% were males. Children varied across gross motor functional classification system (GMFCS). Parents were mostly mothers (76.3%), with at least high school education (71.9%). Factor analyses of the AR-MPOC-20 yielded a five-factor solution with items loaded differently from the original measure. All items correlated best and significantly with their own Arabic scale score (rs: 0.91-0.26, P < 0.01). Internal consistency values of AR-MPOC-20 scales were acceptable (Cronbach's α: 0.69-0.82). Scale 'Providing Written Information' has the lowest average score (1.9 ± 1.6), while scale 'Respectful & Coordinated Care' has the highest average score (5.2 ± 1.5). The AR-MPOC-20 is found to be a valid and reliable measure for use with Arabic-Jordanian families of children with CP. FCS is not yet well implemented in Jordan, with parents reporting more need for information about their children's health and available services. Service providers are encouraged to apply FCS in paediatric rehabilitation, and giving more attention to effective communication and information exchange with families. AR-MPOC-20 is recommended for use for program evaluation.

Life Course Perspective: Evidence for the Role of Nutrition

The "Life Course Perspective" proposes that environmental exposures, including biological, physical, social, and behavioral factors, as well as life experiences, throughout the entire life span, influence health outcomes in current and future generations. Nutrition, from preconception to adulthood, encompasses all of these factors and has the potential to positively or negatively shape the individual or population health trajectories and their intergenerational differences. This paper applies the T2E2 model (timing, timeline, equity and environment), developed by Fine and Kotelchuck, as an overlay to examine advances in nutritional science, as well as the complex associations between life stages, nutrients, nutrigenomics, and access to healthy foods, that support the life course perspective. Examples of the application of nutrition to each of the four constructs are provided, as well as a strong recommendation for inclusion of nutrition as a key focal point for all health professionals as they address solutions to optimize health outcomes, both domestically and internationally. The science of nutrition provides strong evidence to support the concepts of the life course perspective. These findings lend urgency to the need to improve population health across the life span and over generations by ensuring ready access to micronutrient-dense foods, opportunities to balance energy intake with adequate physical activity and the need for biological, social, physical, and macro-level environments that support critical phases of human development. Recommendations for the application of the life course perspective, with a focus on the emerging knowledge of nutritional science, are offered in an effort to improve current maternal and child health programs, policies, and service delivery.

The role of home-based records in the establishment of a continuum of care for mothers, newborns, and children in Indonesia

BackgroundThe provision of appropriate care along the continuum of maternal, newborn, and child health (MNCH) service delivery is a challenge in developing countries. To improve this, in the 1990s, Indonesia introduced the maternal and child health (MCH) handbook, as an integrated form of parallel home-based records.ObjectiveThis study aimed to identify the roles of home-based records both before and after childbirth, especially in provinces where the MCH handbook (MCHHB) was extensively promoted, by examining their association with MNCH service uptake.DesignThis was a cross-sectional study using nationally representative data sets, the Indonesia Demographic and Health Surveys (IDHSs) from 1997, 2002–2003, and 2007. The IDHS identifies respondents’ ownership of home-based records before and after childbirth. Multivariate logistic regression was used to examine associations between record ownership and service utilisation in national data and data from two provinces, West Sumatra and North Sulawesi, where ownership of pre- and post-natal records served as a proxy for MCHHB ownership.ResultsPre- and post-natal record ownership increased from 1997 to 2007. Provincial data from 2007 showed that handbook ownership was associated with having delivery assisted by trained personnel [adjusted odds ratio (aOR): 2.12, 95% confidence interval (CI): 1.05–4.25], receiving maternal care (aOR: 3.92, 95% CI: 2.35–6.52), completing 12 doses of child immunisation for seven diseases (aOR: 4.86, 95% CI: 2.37–9.95), and having immunisation before and after childbirth (aOR: 5.40, 95% CI: 2.28–12.76), whereas national data showed that service utilisation was associated with ownership of both records compared with owning a single record or none.ConclusionOur results suggest that pre- and post-natal home-based record use may be effective for ensuring service utilisation. In addition, since the handbook is an efficient home-based record for use throughout children's life courses, it could be an effective tool for promoting the continuum of MNCH care in Indonesia.

Context-specific, evidence-based planning for scale-up of family planning services to increase progress to MDG 5: health systems research.

BackgroundUnmet need for family planning is responsible for 7.4 million disability-adjusted life years and 30% of the maternity-related disease burden. An estimated 35% of births are unintended and some 200 million couples state a desire to delay pregnancy or cease fertility but are not using contraception. Unmet need is higher among the poorest, lesser educated, rural residents and women under 19 years. The barriers to, and successful strategies for, satisfying all demand for modern contraceptives are heavily influenced by context. Successfully overcoming this to increase the uptake of family planning is estimated to reduce the risk of maternal death by up to 58% as well as contribute to poverty reduction, women’s empowerment and educational, social and economic participation, national development and environmental protection.MethodsTo strengthen health systems for delivery of context-specific, equity-focused reproductive, maternal, newborn and child health services (RMNCH), the Investment Case study was applied in the Asia-Pacific region. Staff of local and central government and non-government organisations analysed data indicative of health service delivery through a supply–demand oriented framework to identify constraints to RMNCH scale-up. Planners developed contextualised strategies and the projected coverage increases were modelled for estimates of marginal impact on maternal mortality and costs over a five year period.ResultsIn Indonesia, Philippines and Nepal the constraints behind incomplete coverage of family planning services included: weaknesses in commodities logistic management; geographical inaccessibility; limitations in health worker skills and numbers; legislation; and religious and cultural ideologies. Planned activities included: streamlining supply systems; establishment of Community Health Teams for integrated RMNCH services; local recruitment of staff and refresher training; task-shifting; and follow-up cards. Modelling showed varying marginal impact and costs for each setting with potential for significant reductions in the maternal mortality rate; up to 28% (25.1-30.7) over five years, costing up to a marginal USD 1.34 (1.32-1.35) per capita in the first year.ConclusionLocal health planners are in a prime position to devise feasible context-specific activities to overcome constraints and increase met need for family planning to accelerate progress towards MDG 5.

Post-partum mother and child care: a comparison of four African countries

BackgroundRisk of morbidity and mortality during the post-partum period is high for mothers and children in sub-Saharan Africa. It is highest in the first 6 weeks after birth but stays high after 6 weeks because of issues such as untreated anaemia or repeat pregnancy. Improvement of delivery of post-partum care has been neglected as a strategy for improving maternal, infant, and child health. The Missed Opportunities for Maternal and Infant Health project aims to design, implement, and assess interventions for the first post-partum year in Burkina Faso, Kenya, Malawi, and Mozambique. We compared each site to understand how post-partum services could be more effectively organised. MethodsWe used a mixed methods approach to collect data about national post-partum policy, factors that affect health system change, and barriers to provision of, and demand for, post-partum care. We searched Google and Google Scholar, PubMed, and individual sites to identify major national and local documents, supplemented by advice from key local informants. In each setting, we consulted local implementers, managers, and policy makers. We did semi-structured interviews with between four and eight stakeholders at national, regional, and district levels, and two to three focus groups of ten to 15 participants at each site. Interviewees were selected on the basis that they would be able to provide the information that was needed. We collected data about current post-partum care processes and outcomes for each site. We critically analysed each setting and key similarities and contrasts between settings. FindingsIn all four study countries, maternal, infant, and child health is a national priority but specific policy for post-partum care, particularly for maternal health, is weak. All countries use a problem-driven approach to post-partum care; neither preventive care nor strategies that improve early identification of complications are prioritised. Emphasis on provision of evidence-based post-partum care varies between countries, with the most policy gaps in Burkina Faso. Dissemination of guidance at provincial to district levels is poor at all sites, which contributes to failure to implement, along with low staff capacity, poor quality of services, lack of knowledge in the community, and use of traditional practices that delay or inhibit care. 19% of women in Burkina Faso, 33% in Kenya, 41% in Malawi, and 40% in Mozambique received post-partum care in the first 7 days after delivery. For facility-based deliveries, immediate post-partum care was provided at almost all sites, usually by skilled health personnel, although women were often discharged early. Few health facilities provided subsequent post-partum care; 53 of 86 at 72 h and 28 of 86 at 7 days. The estimated proportion of deliveries that occur in the community ranged from 20% in Kaya, Burkina Faso to 60% in Kwale, Kenya, restricting skilled post-partum care. At least 70% of infants attended the health facility for BCG vaccine. InterpretationPost-partum care is poorly prioritised in maternal, infant, and child health national policy in all four study countries (although some variation exists), despite this period being high risk for both mother and child. This approach has led to implementation failures at district and service delivery levels. Increased knowledge and awareness among health providers of health-care needs in the first postnatal week, as part of general health systems strengthening, is needed to improve facility-based care. Service integration could be encouraged through international and national policy drives, and delivery of maternal and child health services could be more closely aligned—high rates of attendance at facilities for reasons related to child health, especially vaccination, provide an opportunity. Because delivery in the community is common, a well-developed strategy for raising awareness and provision of post-partum care in the community is needed to improve coverage and compensate for poor access to facility-based care. FundingEuropean Union.

The Political Economy of Child Mortality Decline in Tanzania and Uganda, 1995–2007

This article identifies political economy factors that help explain dramatic differences in the pace of child mortality reduction between Tanzania and Uganda from 1995 to 2007. The existing literature largely explains divergence in basic health outcomes with reference to economic variables such as GDP per capita. However, these factors cannot explain recent divergence across African countries with similar levels of GDP per capita, rates of economic growth, and levels of health funding. I argue that institutional and governance divergences between Tanzania and Uganda can be linked directly to differing coverage levels of key child health interventions (especially related to malaria control), and thus to differing child health outcomes. These institutional differences can be explained in part by historical factors, but more relevant causes can be found in recent political events. In Tanzania, there was an unusually effective project of institution building in the health sector, while in Uganda, by contrast, there was a negative political shock to the health system. This was driven by the repatrimonialization of the Ugandan state after President Yoweri Museveni’s decision to eliminate term limits in the 2001–2006 period. This repatrimonialization process reversed previous health sector institutional gains and had particularly negative effects on child health service delivery in Uganda over the period in question.

Systems of Care: New Partnerships for Community Psychology

For almost two decades, the federal government has supported the development of integrated models of mental health service delivery for children and families, known as systems of care (SOCs), that strive to be child-centered, family-focused, community-based, and culturally competent. These efforts align well with the values and principles (e.g., empowerment, collaboration, strengths emphasis, focus on macro-level social/system change) central to community psychology (CP; Kloos et al. in Community psychology, Cengage Learning, Belmont, 2012). Despite the convergence of many core values, CPs have historically been underrepresented in key roles in SOC initiatives. However, this has changed in recent years, with increasing examples of community psychology skills and principles applied to the development, implementation, and evaluation of SOCs. Because successful and sustainable implementation of SOCs requires community and system-level change, and SOCs are increasingly being urged to adopt a stronger "public health" orientation (Miles et al. in A public health approach to children's mental health: a conceptual framework, Georgetown University Center for Child and Human Development, National Technical Assistance Center for Children's Mental Health, Washington, DC, 2010), there is great potential for CPs to play important roles in SOCs. This paper discusses opportunities and roles for CPs in SOCs in applied research and evaluation, community practice, and training.

Experiences Integrating Delivery of Maternal and Child Health Services With Childhood Immunization Programs: Systematic Review Update

The World Health Organization and the United Nations Children's Fund promote integration of maternal and child health (MCH) and immunization services as a strategy to strengthen immunization programs. We updated our previous review of integrated programs and reviewed reports of integration of MCH services with immunization programs at the service delivery level. Published and unpublished reports of interventions integrating MCH and immunization service delivery were reviewed by searching journal databases and Web sites and by contacting organizations. Among 27 integrated activities, interventions included hearing screening, human immunodeficiency virus services, vitamin A supplementation, deworming tablet administration, malaria treatment, bednet distribution, family planning, growth monitoring, and health education. When reported, linked intervention coverage increased, though not to the level of the corresponding immunization coverage in all cases. Logistical difficulties, time-intensive interventions ill suited for campaign delivery, concern for harming existing services, inadequate overlap of target age groups, and low immunization coverage were identified as challenges. Results of this review reinforce our 2005 review findings, including importance of intervention compatibility and focus on immunization program strength. Ensuring proper planning and awareness of compatibility of service delivery requirements were found to be important. The review revealed gaps in information about costs, comparison to vertical delivery, and impact on all integrated interventions that future studies should aim to address.