Health-related Millennium Development Goals Research Articles

Organizational Capacity Building for Sustainable Health Information Systems: A Case Study from Ghana

Abstract Background and Purpose: Implementing ICT innovations especially in low resourced countries has been documented in the information systems (IS) literature as a very challenging feat because of the existence of weak organizational structures leading to manifestations of silos of fragmented country ICT projects lacking the basic organizational structures to scale and become sustainable over time [31, 11, 33]. In 2010 Ghana adopted the DHIS2 software as a replacement of the existing and challenged health information system (HIS) to enable it track progress on the health related millennium development goals (MDG). The outcome has been a successful nation-wide implementation of HIS in all public health facilities. This paper looked at the factors that enabled the successful implementation and sustenance of the adopted software in Ghana. Methods: Concepts from information infrastructure theory and the notion of the installed base were used as lenses to collect and analyse the empirical data. Data collection and analysis was qualitative using participant observation, focused group discussions, semi-structured interviews and document analysis. Results: This has been possible because of realignment of selected elements of the installed base necessary for achieving set objectives. For Ghana the elements identified were manpower development, resource mobilization, strengthening of institutions and networking with stakeholders to leverage on available resources and technology. Conclusions: Sustainability of HIS in resource constrained contexts requires selection of elements of the installed base necessary for effective organizational capacity building. And these elements must be interdependent otherwise the objective of sustainability might not be accomplished. Effective capacity building efforts of an organization therefore involves combining strategies synergistically to ensure long-term sustainability. Key words: Organizational Capacity Building, Installed Base, DHIS2

Scarcity of Nurses in India

The human resources for health (HRH), especially nurses, constitute an important part of health systems. It is difficult to ascertain comprehensive information on the availability of health workers globally due to irregular reporting of data from the countries. However, experts have proposed minimum thresholds for achieving certain health-related Millennium Development Goals (MDGs). These thresholds have been used as yardsticks by others for determining HRH shortages in their nations. As per the minimum threshold developed by the World Health Organization (WHO), not enough health workers are available in India, especially in the rural areas. The nurse to population ratio in India is even lower than some of the other developing countries in Asia. Various factors, such as low professional and socio-economic status, gender issues, lack of political will on part of the government and unregulated private sector, have led to scarcity of nurses in numbers as well as qualitatively in India. To overcome the dismal working and social conditions, many Indian nurses are migrating to developed nations, further exacerbating the nursing shortages in the country. Inclusive planning, adequate financing and political commitment on the part of all stakeholders are required for overcoming the shortage of health personnel existing in India.

Community health workers in Ghana: the need for greater policy attention

From the 1970s to the 1990s, the WHO, United Nations and other agencies mooted the idea of formally training and recognising community health workers (CHWs) to complement efforts to improve...

Improving Outcomes in the Nigeria Healthcare Sector through Public- Private Partnership

Nigeria’s healthcare sector over the years has continued to degenerate with health indicators currently below national targets and internationally set benchmarks. Budgetary allocations to the sector have remained far below the World Health Organization (WHO) and African Union (AU) recommendations of 11% and 15%, respectively, of a country’s Gross Domestic Product (GDP) dedicated to the health sector. The poor healthcare system has led to loss of confidence resulting in frustrations and unbearable consequences for the poor and low income segment of the society whereas, top government officials and the affluent resort to outbound medical tourism. Using a qualitative research methodology that focuses on descriptive analysis, the paper reviews health system performance in Nigeria in line with the achievement of United Nations health-related Millennium Development Goals (MDG’s) and targets. The paper recommends for institutionalization of the Public-Private Partnership (PPP) model in the Country’s healthcare sector. Public - Private Interaction offers opportunity of leveraging private sector investment in the sector and further enhances improvements in service delivery as well as increases access to quality healthcare. The paper contributes to current scholarly discussions on improving outcomes in healthcare delivery system and the curbing of excessive foreign medical tourism which is found to deplete the country’s foreign reserves. Key words : Nigeria, Healthcare Sector, Health Outcomes, Health Indicators, Public-Private Partnership

Improving Outcomes in the Nigeria Healthcare Sector through Public- Private Partnership

Nigeria’s healthcare sector over the years has continued to degenerate with health indicators currently below national targets and internationally set benchmarks. Budgetary allocations to the sector have remained far below the World Health Organization (WHO) and African Union (AU) recommendations of 11% and 15%, respectively, of a country’s Gross Domestic Product (GDP) dedicated to the health sector. The poor healthcare system has led to loss of confidence resulting in frustrations and unbearable consequences for the poor and low income segment of the society whereas, top government officials and the affluent resort to outbound medical tourism. Using a qualitative research methodology that focuses on descriptive analysis, the paper reviews health system performance in Nigeria in line with the achievement of United Nations health-related Millennium Development Goals (MDG’s) and targets. The paper recommends for institutionalization of the Public-Private Partnership (PPP) model in the Country’s healthcare sector. Public - Private Interaction offers opportunity of leveraging private sector investment in the sector and further enhances improvements in service delivery as well as increases access to quality healthcare. The paper contributes to current scholarly discussions on improving outcomes in healthcare delivery system and the curbing of excessive foreign medical tourism which is found to deplete the country’s foreign reserves. Key words : Nigeria, Healthcare Sector, Health Outcomes, Health Indicators, Public-Private Partnership

Dependency of Quality Education for Attaining the Health-related Sustainable Development Goals in Africa

Dependency of Quality Education for Attaining the Health-related Sustainable Development Goals in Africa

Frontline staff motivation levels and health care quality in rural and urban primary health facilities: a baseline study in the Greater Accra and Western regions of Ghana.

BackgroundThe population of Ghana is increasingly becoming urbanized with about 70 % of the estimated 26.9 million people living in urban and peri-urban areas. Nonetheless, eight out of the ten regions in Ghana remain predominantly rural where only 32.1 % of the national health sector workforce works. Doctor-patient ratio in a predominantly rural region is about 1:18,257 compared to 1:4,099 in an urban region. These rural–urban inequities significantly account for the inability of Ghana to attain the health related Millennium Development Goals (MDGs) before the end of 2015.PurposeTo ascertain whether or not rural-urban differences exist in health worker motivation levels and quality of health care in health facilities accredited by the National Health Insurance Authority in Ghana.MethodsThis is a baseline quantitative study conducted in 2012 among 324 health workers in 64 accredited clinics located in 9 rural and 7 urban districts in Ghana. Ordered logistic regression was performed to determine the relationship between facility geographic location (rural/urban) and staff motivation levels, and quality health care standards.ResultsQuality health care and patient safety standards were averagely low in the sampled health facilities. Even though health workers in rural facilities were more de-motivated by poor availability of resources and drugs than their counterparts in urban facilities (p < 0.05), quality of health care and patient safety standards were relatively better in rural facilities.ConclusionFor Ghana to attain the newly formulated sustainable development goals on health, there is the need for health authorities to address the existing rural–urban imbalances in health worker motivation and quality health care standards in primary healthcare facilities. Future studies should compare staff motivation levels and quality standards in accredited and non-accredited health facilities since the current study was limited to health facilities accredited by the National Health Insurance Authority.

Prevalence and pattern of self-medication among medical students of a private medical college in Kerala

There is a growing concern that the traditional-budget-based financing of health services does not have adequate incentive to stimulate health sector performance improvement in terms of outputs and quality. Despite increased development aid towards health over the years, most of the low-income countries remain far from attaining the health-related Millennium Development Goals (MDGs). Performance based financing (PBF) has slowly gained favor as one of the provider payment mechanism that can partly address current performance challenges in the health sector. Cordaid piloted PBF in level IIIs primary health care facilities of Jinja diocese for 3 years (from 2009/10 to 2011/12). We conducted this study to assess the effects of PBF on the performance of the HCIIIs. The descriptive, cross-sectional study with a comparative component was carried out in 4 HC IIIs of Jinja diocese from 12th June to 22nd July 2012. We collected and analyzed annual performance data from health facility records on selected outputs for the 2 years before and after roll-out of PBF – comparing the study health facilities with an equal number of controls of the same level. We also analyzed data on selected quality indicators. After start of PBF, there was a positive trend in performance of the PBF-implementing health facilities relative to the controls. Human resource as a proxy marker of quality of inputs stood lower in the study health facilities than controls. We concluded that there was a positive trend in performance in the selected indicators in the PBF H/Cs. To create credibility to the observed performance, there is need to have a rigorous, regular and independent data verification plan built within the implementation process. We recommend piloting of this PBF approach in more health facilities and of bigger coverage like level IV health facilities and hospitals so as to gain more insight on what effect it can have on Uganda’s health system and related contexts.

Developing and sustaining human resources in the health supply chain in Ethiopia: barriers and enablers

The health supply chain is often the weakest link in achieving the health-related Millennium Development Goals and universal health coverage, requiring trained professionals who are often unavailable. In Ethiopia there have been recent developments in the area of health supply chain management. The aim of this study was to explore the current status of the development of human resources in health supply chain management in Ethiopia and to identify important factors affecting this development. A series of face-to-face interviews with key stakeholders was carried out in 2014. The interviews were conducted using a semi-structured interview guide. The interview guide comprised 51 questions. A qualitative analysis of transcripts was made. A total of 25 interviews were conducted. Three themes were identified: General changes: recognition, commitment and resources, Education and training, and Barriers and enablers. Results confirm the development of human resources in health supply chain management in many areas. However, several problems were identified including lack of coordination, partly due to the large number of stakeholders; reported high staff mobility; and a lack of overall strategy regarding the job/career structures necessary for maintaining human resources. Rural areas have a particular set of problems, including in transportation of goods and personnel, attracting and keeping personnel, and in communication and access to information. Ethiopia is on the way to developing a nationwide viable system for health supply chain management. However, there are still challenges. Short-term challenges include the importance of highlighting strategies and programs for human resources in health supply chain management. In the long term, commitments to financial support must be obtained. A strategy is needed for the further development and sustainability of human resources in the health supply chain in Ethiopia.

Space and place for WHO health development dialogues in the African Region.

BackgroundMajority of the countries in the World Health Organization (WHO) African Region are not on track to achieve the health-related Millennium Development Goals, yet even more ambitious Sustainable Development Goals (SDGs), including SDG 3 on heath, have been adopted. This paper highlights the challenges - amplified by the recent Ebola virus disease (EVD) outbreak in West Africa - that require WHO and other partners’ dialogue in support of the countries, and debate on how WHO can leverage the existing space and place to foster health development dialogues in the Region.DiscussionTo realise SDG 3 on ensuring healthy lives and promoting well-being for all at all ages, the African Region needs to tackle the persistent weaknesses in its health systems, systems that address the social determinants of health and national health research systems. The performance of the third item is crucial for the development and innovation of systems, products and tools for promoting, maintaining and restoring health in an equitable manner.Under its new leadership, the WHO Regional Office for Africa is transforming itself to galvanise existing partnerships, as well as forging new ones, with a view to accelerating the provision of timely and quality support to the countries in pursuit of SDG 3. WHO in the African Region engages in dialogues with various stakeholders in the process of health development. The EVD outbreak in West Africa accentuated the necessity for optimally exploiting currently available space and place for health development discourse. There is urgent need for the WHO Regional Office for Africa to fully leverage the space and place arenas of the World Health Assembly, WHO Regional Committee for Africa, African Union, Regional economic communities, Harmonization for Health in Africa, United Nations Economic Commission for Africa, African Development Bank, professional associations, and WHO African Health Forum, when it is created, for dialogues to mobilise the required resources to give the African Region the thrust it needs to attain SDG 3.ConclusionsThe pursuit of SDG 3 amidst multiple challenges related to political leadership and governance, weak health systems, sub-optimal systems for addressing the socioeconomic determinants of health, and weak national health research systems calls for optimum use of all the space and place available for regional health development dialogues to supplement Member States’ efforts.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1452-0) contains supplementary material, which is available to authorized users.

Hope and despair 3/3: pluses and minuses for community health assistants in rural Zambia

Hope and despair 3/3: pluses and minuses for community health assistants in rural Zambia

2000 to 2015: How Far Have We Progressed in Achieving the Health Related Millennium Development Goals?

DEAR EDITOR, Millennium Development Goals (MDGs) are the eight goals formulated by the United Nations (UN) in 2000, to be achieved by 2015 by the UN member states.[1] The member states have committed to effectively tackle the issues of poverty, hunger, illiteracy, gender inequality, mother and child mortality, infectious diseases, environmental degradation, and to encourage partnership between different stakeholders.[1] The MDGs has given policy makers and stakeholders a target to work together and achieve the same within the stipulated time.[1,2] In fact, a set of targets has been proposed to monitor the progress toward all the eight goals by the end of 2015.[1] As 2015 was the last year for countries to accomplish the global targets, the World Health Organization (WHO) has done the analysis of various MDGs, including health-related MDGs.[2] Even though most of the developed nations have revealed a significant progress, the scenario has been quite worrisome for the developing nations [Table 1].[3,4,5,6,7] After a careful analysis, it has been shown that the results have been mixed with some of the targets being achieved (viz., halting and reversing the trends of HIV, malaria and tuberculosis, and increasing accessibility to safe water) and some requiring additional inputs to continuously move in the right direction. In an attempt to move continuously forward, the WHO and UN have together chalked down newer goals under the overview of sustainable development goals, set to be achieved by the year 2030.[2,8] Table 1 Status of MDGs To conclude, the MDGs has enabled the world to successfully progress on the health front, but at the same time it has even highlighted the various gaps present within the health care delivery system. Thus, it is high time that stakeholders should put in sustainable efforts to improve the quality of life of vulnerable sections of society.

Patterns of antenatal care seeking behavior in South East Nigeria: Exploring relationship with age, education, and socioeconomic status

Background : Maternal and infant morbidity and mortality are major public health problems in Nigeria. Although it is well-known that appropriate antenatal care (ANC) is important in reducing maternal morbidity and mortality, there is limited information on inequities on ANC seeking pattern among the pregnant women in Nigeria. Aim : The study was designed to explore inequities due to age, education, and socioeconomic status (SES) of women of childbearing age in seeking ANC services in Nigeria. Subjects and Methods: A household survey was conducted in 10 randomly selected villages in Nnewi, Anambra State, South-East Nigeria. An interviewer-administered questionnaire was used to collect relevant data from 420 women of childbearing age from the villages. The effects of age, education, SES, and ANC seeking behavior were analyzed. Results : It was found that 61.4% (254/420) of the respondents attended ANC clinic at least 6times. Although most of the respondents sought ANC in formal health, a greater percentage utilized private hospitals/clinics more than public health facilities. Age (P < 0.01), educational level (P < 0.001), and SES (P < 0.01) had statistically significant effects on respondents’ antenatal clinic attendance and choice of facilities. The highest SES group was more likely to utilize teaching hospitals and private clinics than other SES groups. Conclusions : There were inequities due to SES, educational level, and age of respondents in the pattern of ANC seeking behavior. These inequities could negate the achievement of millennium development goals (MDGs). Interventions that would address the inequities should be developed and implemented if the health-related MDGs are to be achieved. KEY WORDS : Antenatal care, health seeking behavior, inequities, Nigeria, women of childbearing age

Efficiency of private and public primary health facilities accredited by the National Health Insurance Authority in Ghana.

BackgroundDespite improvements in a number of health outcome indicators partly due to the National Health Insurance Scheme (NHIS), Ghana is unlikely to attain all its health-related millennium development goals before the end of 2015. Inefficient use of available limited resources has been cited as a contributory factor for this predicament. This study sought to explore efficiency levels of NHIS-accredited private and public health facilities; ascertain factors that account for differences in efficiency and determine the association between quality care and efficiency levels.MethodsThe study is a cross-sectional survey of NHIS-accredited primary health facilities (n = 64) in two regions in southern Ghana. Data Envelopment Analysis was used to estimate technical efficiency of sampled health facilities while Tobit regression was employed to predict factors associated with efficiency levels. Spearman correlation test was performed to determine the association between quality care and efficiency.ResultsOverall, 20 out of the 64 health facilities (31 %) were optimally efficient relative to their peers. Out of the 20 efficient facilities, 10 (50 %) were Public/government owned facilities; 8 (40 %) were Private-for-profit facilities and 2 (10 %) were Private-not-for-profit/Mission facilities. Mission (Coef. = 52.1; p = 0.000) and Public (Coef. = 42.9; p = 0.002) facilities located in the Western region (predominantly rural) had higher odds of attaining the 100 % technical efficiency benchmark than those located in the Greater Accra region (largely urban). No significant association was found between technical efficiency scores of health facilities and many technical quality care proxies, except in overall quality score per the NHIS accreditation data (Coef. = −0.3158; p < 0.05) and SafeCare Essentials quality score on environmental safety for staff and patients (Coef. = −0.2764; p < 0.05) where the association was negative.ConclusionsThe findings suggest some level of wastage of health resources in many healthcare facilities, especially those located in urban areas. The Ministry of Health and relevant stakeholders should undertake more effective need analysis to inform resource allocation, distribution and capacity building to promote efficient utilization of limited resources without compromising quality care standards.

An ex-ante economic evaluation of the Maternal and Child Health Voucher Scheme as a decision-making tool in Myanmar.

Reducing child and maternal mortality in order to meet the health-related Millennium Development Goals (MDGs) 4 and 5 remains a major challenge in Myanmar. Inadequate care during pregnancy and labour plays an important role in the maternal mortality rate in Myanmar. A Maternal and Child Health (MCH) Voucher Scheme comprising a subsidization for pregnant women to receive four antenatal care (ANC), delivery and postnatal care (PNC) free-of-charge was planned to help women overcome financial barriers in addition to raising awareness of ANC and delivery with skilled birth attendants (SBA), which can reduce the rate of maternal and neonatal death. This study is part of an ex-ante evaluation of a feasibility study of the MCH Voucher Scheme. A cost-utility analysis was conducted using a decision tree model to assess the cost per disability-adjusted life years (DALYs) averted from the MCH Voucher Scheme compared with the current situation. Most input parameters were obtained from Myanmar context. From the base-case analysis, where the financial burden on households was fully subsidized, the MCH Voucher Scheme increased utilization for ANC from 73% up to 93% and for delivery from SBAs from 51% up to and 71%, respectively; hence, it is considered to be very cost-effective with an incremental cost-effectiveness ratio of 381 027 kyats per DALY averted (2010, price year). From the probabilistic sensitivity analysis, the MCH Voucher Scheme had a 52% chance of being a cost-effective option at 1 GDP per capita threshold compared to the current situation. Given that the Voucher Scheme is currently being implemented in one township in Myanmar as a result of this study, ongoing evaluation of the effectiveness and cost-effectiveness of this scheme is warranted.

Using mobile phones and social media to facilitate education and support for rural-based midwives in South Africa.

BackgroundEmpirical studies show the value of mobile phones as effective educational tools to support learning in the nursing profession, predominantly in high income countries.Problem statementThe rapidly increasing prevalence of mobile phone technology in Africa nourishes hopes that these tools could be equally effective in lowly resourced contexts, specifically in efforts to achieve the health-related Millennium Development goals. The purpose of this study was to investigate the perception and use of mobile phones as educational and professional tools by nurses in lowly resourced settings.MethodologyA quantitative survey using self-administered questionnaires was conducted of rural advanced midwives.ResultsFifty-six nurses (49.6%) from the 113 rural-based midwives attending an advanced midwifery training programme at the University of KwaZulu-Natal, South Africa, filled in a questionnaire. The results showed that, whilst nurses regarded their technology competences as low and although they received very little official support from their educational and professional institutions, the majority frequently used mobile functions and applications to support their work and learning processes. They perceived mobile devices with their voice, text, and email functions as important tools for the educational and professional activities of searching for information and engaging with facilitators and peers from work and study contexts. To a lesser extent, the use of social networks, such as WhatsApp and Facebook, were also reported.Conclusion and recommendationIt is concluded that educational institutions should support the appropriate use of mobile phones more systematically; particularly in relation to the development of mobile network literacy skills.

Ethnic disparities in utilisation of maternal health care services in Ghana: evidence from the 2007 Ghana Maternal Health Survey

Objective. Disparities in utilisation of maternal health care remain a challenge to attainment of the maternal health-related Millennium Development Goals. The objective of this descriptive study was to examine disparities in utilisation of maternal health care among ethnic groups in Ghana.Design. Data from the 2007 Ghana Maternal Health Survey were analysed for disparities in antenatal care (ANC) visit, utilisation of tetanus toxoid immunisation and iron tablets/syrup intake during pregnancy, place of delivery, skilled birth attendance, caesarean section (CS) and post-natal care (PNC) among different ethnic groups.Results. Findings show that the proportion of women who received any form of skilled antenatal, delivery and PNC in the five years (2003–2007) preceding the survey was 96%, 55% and 55%, respectively. Despite the incremental progress Ghana made in improving access to skilled maternal health care services, large gradients of disparities exist. The ethnic difference in utilisation of institutional prenatal care was small; however, fewer births to women from majority ethnic groups such as the Akan (21%) took place at home compared with births to women from minority ethnic groups such as the Ewe (58.8%), Guan (42.7%), Grusi (53.4%), Mole-Dagbani (74.7%) and Gruma (58.8%). The rate of consultation of a skilled health care provider for delivery among the different ethnic groups also ranged from a low of 27% for births to Mole-Dagbani women to a high of 68.8% among births to Akan women.Conclusion. Minority ethnic groups reported lower utilisation levels for most of the components of skilled maternity care in Ghana. However, ethnic disparities in utilisation of all the components of ANC in Ghana were less compared to delivery in health facilities, skilled attendance at birth, use of CS and PNC. Therefore, efforts to promote universal access to skilled maternity care not only should target those sub-populations with significantly low utilisation levels but also must focus on those components of maternal health care such as skilled attendance at delivery that demonstrate the greatest disparities. There is also the need to further explore who continues to remain excluded from receiving needed care, and how to encourage such women, especially minority women, to seek skilled care.

Peer-Performance Review as a Strategy for Strengthening Health In-formation Systems: A Case Study from Ghana

Background and Purpose: The Ghana Health Service (GHS) in 2012 embarked on an ambitious programme to improve its health information system (HIS) in order to improve upon healthcare delivery and also to meet the health related millennium development goals (MDGs). This resulted in nation-wide implementation of the District Health Information Management System (DHIMS2), software based on the District Health Information Software (DHIS2), in all its facilities and some private and quasi government health facilities. The DHIMS2 is the Ghanaian version of the global DHIS2 software developed by the University of Oslo. Methods: As part of its mandate the GHS holds periodic peer reviews meetings at different levels of its structure as a mechanism for measuring service performance in order to identify service gaps that will lead to interventions to improving the coverage and quality of service to its client. This paper is a qualitative assessment of the DHIS2 software based on specified criteria from some of these review meetings in selected regions towards achieving the set goals. The paper will look at the status quo with respect to infrastructure, resources in general, human resource, stakeholder involvement, data quality and data use since the implementation of the DHIS2 project in Ghana. Data collection and analysis was qualitative using participant observation, focused group discussions, semi-structured interviews and document analysis. Results: Our research has shown that the GHS has successfully implemented an integrated and sustainable web-based HIS. Data quality in all aspects has been improved through institutional arrangements such as peer-performance reviews using DHIS2 data and establishment of data quality assurance teams at all levels. This implicitly has promoted data use for decision making. The online system has also ensured data transparency and accessibility. ‘Break-downs’ in the system such as lack of funds, faulty equipment, lack of adequate and skilled human resource for data management is seen as some major challenges to data quality. Such ‘break-downs’ may also be seen as opportunity for system strengthening and sustainability as end-users are compelled to use personal resources for managing data. Through institutionalized peer-performance review processes using data from the DHIS2 is improving the quality of health service data for planning and decision making. Conclusions: This research has demonstrated that with the right technology, policy and collaboration from interested stakeholders it is possible to implement a sustainable HIS in developing countries such as Ghana. We have also shown that institutionalized arrangements for data use has significantly improved the quality of service data generated which will aid planning and decision-making

Identification and Review of Common Challenges Militating against the Attainment of Health-related Millennium Development Goals in Rural Nigeria

Identification and Review of Common Challenges Militating against the Attainment of Health-related Millennium Development Goals in Rural Nigeria

Tracking progress towards health related millennium development goals in India

The millennium development goals (MDGs) adopted during the millennium summit in 2000 gave an opportunity to improve the health and overall development. The MDG framework had 8 goals, 21 targets, and 60 indicators. Of these, three are directly related to health and have other interrelated goals and targets that influence health. The year 1990 is baseline, and the targets are to be reached by 2015. India's progress towards health related MDGs is lagging in some areas, and more attention is needed to states and districts where the indicators are poor. The proportion of underweight children <3 years is around 40%. The under-five and infant mortality rate is 49 and 40/1000 live births in 2013, respectively. The country lags behind the maternal mortality ratio target of 109/100,000 live births. Regarding HIV, malaria, and tuberculosis, trend reversal had been achieved while providing basic sanitation facilities remains a big challenge.