Investment In Health Systems Research Articles

Why patients prefer high-level healthcare facilities: a qualitative study using focus groups in rural and urban China

IntroductionDespite policy measure to strengthen and promote primary care, Chinese patients increasingly choose to access higher level hospitals. The resulting overcrowding at higher level hospitals and underutilisation of primary care...

100 years on: the Spanish Flu, pandemics and keeping nurses safe.

100 years on: the Spanish Flu, pandemics and keeping nurses safe.

Service readiness for inpatient care of small and sick newborns: what do we need and what can we measure now?

BackgroundEach year an estimated 2.6 million newborns die, mainly from complications of prematurity, neonatal infections, and intrapartum events. Reducing these deaths requires high coverage of good quality care at birth, and inpatient care for small and sick newborns. In low- and middle-income countries, standardised measurement of the readiness of facilities to provide emergency obstetric care has improved tracking of readiness to provide care at birth in recent years. However, the focus has been mainly on obstetric care; service readiness for providing inpatient care of small and sick newborns is still not consistently measured or tracked.MethodsWe reviewed existing international guidelines and resources to create a matrix of the structural characteristics (infrastructure, equipment, drugs, providers and guidelines) for service readiness to deliver a package of inpatient care interventions for small and sick newborns. To identify gaps in existing measurement systems, we reviewed three multi-country health facility survey tools (the Service Availability and Readiness Assessment, the Service Provision Assessment and the Emergency Obstetric and Newborn Care Assessment) against our service readiness matrix.FindingsFor service readiness to provide inpatient care for small and sick newborns, our matrix detailed over 600 structural characteristics. Our review of the SPA, the SARA and the EmONC assessment tools identified several measurement omissions to capture information on key intervention areas, such as thermoregulation, feeding and respiratory support, treatment of specific complications (seizures, jaundice), and screening and follow up services, as well as specialised staff and service infrastructure.ConclusionsOur review delineates the required inputs to ensure readiness to provide inpatient care for small and sick newborns. Based on these findings, we detail where questions need to be added to existing tools and describe how measurement systems can be adapted to reflect small and sick newborns interventions. Such work can inform investments in health systems to end preventable newborn death and disability as part of the Every Newborn Action Plan.

The snakebite problem and antivenom crisis from a health-economic perspective

The scourge of snakebite has been well documented but largely ignored by the global health community for several decades, especially the role that economics has played in causing and exacerbating this crisis. Every year millions of people in low and middle-income countries face death, disability and disadvantage from snakebite envenoming (SBE) without access to appropriate treatment. Health-economic factors pervade every aspect of this neglected problem. A multitude of financial and commercial factors helped to cause, and now perpetuate, shortages of high quality, affordable and region-appropriate antivenom in areas where they are most needed. Alongside the death, physical disability and psychological anguish from SBE is a debilitating financial toll, which includes both direct costs of treatment and indirect costs from lost income. SBE is a problem that disproportionately affects poor, rural and agrarian communities, with most victims being young and industrious subsistence workers. The burden of envenoming is often felt by families and communities that can least afford it, and negatively impacts local and national productivity. The lack of long-term investment in health systems to properly manage SBE has led to insufficient funding for antivenom development, procurement, quality control and distribution, despite highly favourable cost effectiveness of some antivenoms. This has contributed to market failures that have seen antivenom output fall and become inaccessible to most victims. Solutions to these problems exist and are achievable, however the challenge for advocates is to appreciate the importance of health-economics and ensure that strategies to redress the economic causes and consequences of SBE are themselves cost-effective and financially sustainable.

How Does Self-Rated Health Differ among Older Vietnamese Men and Women?

Due to gender differences in life expectancy, women outlive their male counterparts but experience more years of poor health. Whereas the correlates of gender differences in later life health have been examined in Western countries there is a limited but growing body of research among older adults in developing countries. Utilizing data from the 2011 Vietnam National Aging Study, this study examines gender differentials in self-rated health among Vietnamese aged 60 years and over (N = 2467) within the differential exposure and differential vulnerability frameworks. Logistic regression analyses show women had higher odds of reporting poor health but this differential was significantly reduced after adjusting for socio-demographic factors. Differential exposure to socio-economic resources did not explain the gender gap in perceived health status. After controlling for health behaviors, physical and mental health conditions, the gender differential was reversed with women showing lower odds of reporting poor health than similar men. Gender specific associations were evidenced by social participation, educational attainment, and employment status, which were protective for women’s health but unrelated to men’s. Older Vietnamese men and women show many similarities in the correlates of self-rated health. Comorbidity of chronic conditions, functional limitations, symptoms of psychological distress, and living in the Central region of Viet Nam were positively associated with poor self-rated health for men and women. The findings provide insight for gender sensitive social policies and investments in health systems to address the changing health profile of the Vietnamese population.

The 2014-2015 Ebola virus disease outbreak and primary healthcare delivery in Liberia: Time-series analyses for 2010-2016.

BackgroundThe aim of this study is to estimate the immediate and lasting effects of the 2014–2015 Ebola virus disease (EVD) outbreak on public-sector primary healthcare delivery in Liberia using 7 years of comprehensive routine health information system data.Methods and findingsWe analyzed 10 key primary healthcare indicators before, during, and after the EVD outbreak using 31,836 facility-month service outputs from 1 January 2010 to 31 December 2016 across a census of 379 public-sector health facilities in Liberia (excluding Montserrado County). All indicators had statistically significant decreases during the first 4 months of the EVD outbreak, with all indicators having their lowest raw mean outputs in August 2014. Decreases in outputs comparing the end of the initial EVD period (September 2014) to May 2014 (pre-EVD) ranged in magnitude from a 67.3% decrease in measles vaccinations (95% CI: −77.9%, −56.8%, p < 0.001) and a 61.4% decrease in artemisinin-based combination therapy (ACT) treatments for malaria (95% CI: −69.0%, −53.8%, p < 0.001) to a 35.2% decrease in first antenatal care (ANC) visits (95% CI: −45.8%, −24.7%, p < 0.001) and a 38.5% decrease in medroxyprogesterone acetate doses (95% CI: −47.6%, −29.5%, p < 0.001). Following the nadir of system outputs in August 2014, all indicators showed statistically significant increases from October 2014 to December 2014. All indicators had significant positive trends during the post-EVD period, with every system output exceeding pre-Ebola forecasted trends for 3 consecutive months by November 2016. Health system outputs lost during and after the EVD outbreak were large and sustained for most indicators. Prior to exceeding pre-EVD forecasted trends for 3 months, we estimate statistically significant cumulative losses of −776,110 clinic visits (95% CI: −1,480,896, −101,357, p = 0.030); −24,449 bacille Calmette–Guérin vaccinations (95% CI: −45,947, −2,020, p = 0.032); −9,129 measles vaccinations (95% CI: −12,312, −5,659, p < 0.001); −17,191 postnatal care (PNC) visits within 6 weeks of birth (95% CI: −28,344, −5,775, p = 0.002); and −101,857 ACT malaria treatments (95% CI: −205,839, −2,139, p = 0.044) due to the EVD outbreak. Other outputs showed statistically significant cumulative losses only through December 2014, including losses of −12,941 first pentavalent vaccinations (95% CI: −20,309, −5,527, p = 0.002); −5,122 institutional births (95% CI: −8,767, −1,234, p = 0.003); and −45,024 acute respiratory infections treated (95% CI: −66,185, −24,019, p < 0.001). Compared to pre-EVD forecasted trends, medroxyprogesterone acetate doses and first ANC visits did not show statistically significant net losses. ACT treatment for malaria was the only indicator with an estimated net increase in system outputs through December 2016, showing an excess of +78,583 outputs (95% CI: −309,417, +450,661, p = 0.634) compared to pre-EVD forecasted trends, although this increase was not statistically significant. However, comparing December 2013 to December 2017, ACT malaria cases have increased 49.2% (95% CI: 33.9%, 64.5%, p < 0.001). Compared to pre-EVD forecasted trends, there remains a statistically significant loss of −15,144 PNC visits within 6 weeks (95% CI: −29,453, −787, p = 0.040) through December 2016.ConclusionsThe Liberian public-sector primary healthcare system has made strides towards recovery from the 2014–2015 EVD outbreak. All primary healthcare indicators tracked have recovered to pre-EVD levels as of November 2016. Yet, for most indicators, it took more than 1 year to recover to pre-EVD levels. During this time, large losses of essential primary healthcare services occurred compared to what would have been expected had the EVD outbreak not occurred. The disruption of malaria case management during the EVD outbreak may have resulted in increased malaria cases. Large and sustained investments in public-sector primary care health system strengthening are urgently needed for EVD-affected countries.

Does health facility service environment matter for the receipt of essential newborn care? Linking health facility and household survey data in Malawi.

BackgroundHealth facility service environment is an important factor for newborns survival and well–being in general and in particular in high mortality settings such as Malawi where despite high coverage of essential interventions, neonatal mortality remains high. The aim of this study is to assess whether the quality of the health service environment at birth is associated with quality of care received by the newborn.MethodsWe used data from the Malawi Millennium Development Goals Endline household survey conducted as part of MICS survey program and Service Provision Assessment Survey carried out in 2014. The analysis is based on 6218 facility births that occurred during the past 2 years. Descriptive statistics, bivariate and multivariate random effect models are used to assess the association of health facility service readiness score for normal deliveries and newborn care with newborns receiving appropriate newborn care, defined for this analysis as receiving 5 out of 6 recommended interventions during the first 2 days after birth.ResultsNewborns in districts with top facility service readiness score have 1.5 higher odds of receiving appropriate newborn care (adjusted odds ratio (aOR) = 1.52, 95% confidence interval CI = 1.19–1.95, P = 0.001), as compared to newborns in districts with a lower facility score after adjusting for potential confounders. Newborns in the Northern region were two times more likely to receive 5 newborn care interventions as compared to newborns in the Southern region (aOR = 2.06, 95% CI = 1.50–2.83, P < 0.001). Living in urban or rural areas did not have an impact on receiving appropriate newborn care.ConclusionsThere is need to increase the level of service readiness across all facilities, so that all newborns irrespective of the health facility, district or region of delivery are able to receive all recommended essential interventions. Investments in health systems in Malawi should concentrate on increasing training and availability of health staff in facilities that offer normal delivery and newborn care services at all levels in the country.

Progress Toward Regional Measles Elimination - Worldwide, 2000-2016.

The fourth United Nations Millennium Development Goal, adopted in 2000, set a target to reduce child mortality by two thirds by 2015. One indicator of progress toward this target was measles vaccination coverage (1). In 2010, the World Health Assembly (WHA) set three milestones for measles control by 2015: 1) increase routine coverage with the first dose of a measles-containing vaccine (MCV1) among children aged 1 year to ≥90% at the national level and to ≥80% in every district; 2) reduce global annual measles incidence to <5 cases per million population; and 3) reduce global measles mortality by 95% from the 2000 estimate (2).* In 2012, WHA endorsed the Global Vaccine Action Plan,† with the objective of eliminating measles in four World Health Organization (WHO) regions by 2015 and in five regions by 2020. Countries in all six WHO regions have adopted goals for measles elimination by or before 2020. Measles elimination is defined as the absence of endemic measles virus transmission in a region or other defined geographic area for ≥12 months, in the presence of a high quality surveillance system that meets targets of key performance indicators. This report updates a previous report (3) and describes progress toward global measles control milestones and regional measles elimination goals during 2000-2016. During this period, annual reported measles incidence decreased 87%, from 145 to 19 cases per million persons, and annual estimated measles deaths decreased 84%, from 550,100 to 89,780; measles vaccination prevented an estimated 20.4 million deaths. However, the 2015 milestones have not yet been met; only one WHO region has been verified as having eliminated measles. Improved implementation of elimination strategies by countries and their partners is needed, with focus on increasing vaccination coverage through substantial and sustained additional investments in health systems, strengthening surveillance systems, using surveillance data to drive programmatic actions, securing political commitment, and raising the visibility of measles elimination goals.

How Ethiopia achieved Millennium Development Goal 4 through multisectoral interventions: a Countdown to 2015 case study.

SummaryBackground3 years before the 2015 deadline, Ethiopia achieved Millennium Development Goal 4. The under-5 mortality decreased 69%, from 205 deaths per 1000 livebirths in 1990 to 64 deaths per 1000 livebirths in 2013. To understand the underlying factors that contributed to the success in achieving MDG4, Ethiopia was selected as a Countdown to 2015 case study.MethodsWe used a set of complementary methods to analyse progress in child health in Ethiopia between 1990 and 2014. We used Demographic Health Surveys to analyse trends in coverage and equity of key reproductive, maternal health, and child health indicators. Standardised tools developed by the Countdown Health Systems and Policies working group were used to understand the timing and content of health and non-health policies. We assessed longitudinal trends in health-system investment through a financial analysis of National Health Accounts, and we used the Lives Saved Tool (LiST) to assess the contribution of interventions towards reducing under-5 mortality.FindingsThe annual rate of reduction in under-5 mortality increased from 3·3% in 1990–2005 to 7·8% in 2005–13. The prevalence of stunting decreased from 60% in 2000 to 40% in 2014. Overall levels of coverage of reproductive, maternal health, and child health indicators remained low, with disparities between the lowest and highest wealth quintiles despite improvement in coverage for essential health interventions. Coverage of child immunisation increased the most (21% of children in 2000 vs 80% of children in 2014), followed by coverage of satisfied demand for family planning by women of reproductive age (19% vs 63%). Provision of antenatal care increased from 10% of women in 2000 to 32% of women in 2014, but only 15% of women delivered with a skilled birth attendant by 2014. A large upturn occurred after 2005, bolstered by a rapid increase in health funding that facilitated the accelerated expansion of health infrastructure and workforce through an innovative community-based delivery system. The LiST model could explain almost 50% of the observed reduction in child mortality between 2000 and 2011; and changes in nutritional status were responsible for about 50% of the 469 000 lives saved between 2000 and 2011. These developments occurred within a multisectoral policy platform, integrating child survival and stunting goals within macro-level policies and programmes for reducing poverty and improving agricultural productivity, food security, water supply, and sanitation.InterpretationThe reduction of under-5 mortality in Ethiopia was the result of combined activities in health, nutrition, and non-health sectors. However, Ethiopia still has high neonatal and maternal morbidity and mortality from preventable causes and an unfinished agenda in reducing inequalities, improving coverage of effective interventions, and strengthening multisectoral partnerships for further progress.FundingBill & Melinda Gates Foundation and Government of Canada.

Scaling up quality improvement intervention for perinatal care in Nepal (NePeriQIP); study protocol of a cluster randomised trial

IntroductionNepal Perinatal Quality Improvement Project (NePeriQIP) intends to scale up a quality improvement (QI) intervention for perinatal care according to WHO/National guidelines in hospitals of Nepal using the existing health...

Sustainability and economic investments in animal health systems.

The paper outlines a framework for shaping and prioritising improvements to investments in animal health systems in order to improve their sustainability. The framework includes financial inputs that can be separated between core investments and day-to-day expenditures. The latter financial inputs should differentiate between avoiding losses in production and reducing wider societal impacts such as negative implications for trade and the environment. Overall the framework provides information on the financial costs of the animal health system and the animal health outcomes that, if collected over time, will allow the efficiency of resource use across the system to be measured. It discusses an application of the framework using existing data, which highlighted problems with measuring and costing veterinary inputs, and with quantifying the range of outputs and the impact of veterinary activities. The paper recommends that the framework proposed is reviewed and compared with work that has been carried out on the human health accounting systems. A true application of the framework will require data sets that can differentiate between public-sector, private-sector and non-governmental organisation investments and the cost of day-to-day animal health goods and services paid by animal owners. Data sets are also needed on animal health outcomes in order to compare investments with animal health outcomes and thereby: demonstrate the success of previous investments, identify weaknesses in the investment profile and ensure that future investments sustain an animal health system, which functions well.

Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and middle-income countries.

SummaryBackgroundThe ambitious development agenda of the Sustainable Development Goals (SDGs) requires substantial investments across several sectors, including for SDG 3 (healthy lives and wellbeing). No estimates of the additional resources needed to strengthen comprehensive health service delivery towards the attainment of SDG 3 and universal health coverage in low-income and middle-income countries have been published.MethodsWe developed a framework for health systems strengthening, within which population-level and individual-level health service coverage is gradually scaled up over time. We developed projections for 67 low-income and middle-income countries from 2016 to 2030, representing 95% of the total population in low-income and middle-income countries. We considered four service delivery platforms, and modelled two scenarios with differing levels of ambition: a progress scenario, in which countries' advancement towards global targets is constrained by their health system's assumed absorptive capacity, and an ambitious scenario, in which most countries attain the global targets. We estimated the associated costs and health effects, including reduced prevalence of illness, lives saved, and increases in life expectancy. We projected available funding by country and year, taking into account economic growth and anticipated allocation towards the health sector, to allow for an analysis of affordability and financial sustainability.FindingsWe estimate that an additional $274 billion spending on health is needed per year by 2030 to make progress towards the SDG 3 targets (progress scenario), whereas US$371 billion would be needed to reach health system targets in the ambitious scenario—the equivalent of an additional $41 (range 15–102) or $58 (22–167) per person, respectively, by the final years of scale-up. In the ambitious scenario, total health-care spending would increase to a population-weighted mean of $271 per person (range 74–984) across country contexts, and the share of gross domestic product spent on health would increase to a mean of 7·5% (2·1–20·5). Around 75% of costs are for health systems, with health workforce and infrastructure (including medical equipment) as the main cost drivers. Despite projected increases in health spending, a financing gap of $20–54 billion per year is projected. Should funds be made available and used as planned, the ambitious scenario would save 97 million lives and significantly increase life expectancy by 3·1–8·4 years, depending on the country profile.InterpretationAll countries will need to strengthen investments in health systems to expand service provision in order to reach SDG 3 health targets, but even the poorest can reach some level of universality. In view of anticipated resource constraints, each country will need to prioritise equitably, plan strategically, and cost realistically its own path towards SDG 3 and universal health coverage.FundingWHO.

The impact of an intervention to introduce malaria rapid diagnostic tests on fever case management in a high transmission setting in Uganda: A mixed-methods cluster-randomized trial (PRIME).

BackgroundRapid diagnostic tests for malaria (mRDTs) have been scaled-up widely across Africa. The PRIME study evaluated an intervention aiming to improve fever case management using mRDTs at public health centers in Uganda.MethodsA cluster-randomized trial was conducted from 2010–13 in Tororo, a high malaria transmission setting. Twenty public health centers were randomized in a 1:1 ratio to intervention or control. The intervention included training in health center management, fever case management with mRDTs, and patient-centered services; plus provision of mRDTs and artemether-lumefantrine (AL) when stocks ran low. Three rounds of Interviews were conducted with caregivers of children under five years of age as they exited health centers (N = 1400); reference mRDTs were done in children with fever (N = 1336). Health worker perspectives on mRDTs were elicited through semi-structured questionnaires (N = 49) and in-depth interviews (N = 10). The primary outcome was inappropriate treatment of malaria, defined as the proportion of febrile children who were not treated according to guidelines based on the reference mRDT.FindingsThere was no difference in inappropriate treatment of malaria between the intervention and control arms (24.0% versus 29.7%, adjusted risk ratio 0.81 [95% CI: 0.56, 1.17] p = 0.24). Most children (76.0%) tested positive by reference mRDT, but many were not prescribed AL (22.5% intervention versus 25.9% control, p = 0.53). Inappropriate treatment of children testing negative by reference mRDT with AL was also common (31.3% invention vs 42.4% control, p = 0.29). Health workers appreciated mRDTs but felt that integrating testing into practice was challenging given constraints on time and infrastructure.ConclusionsThe PRIME intervention did not have the desired impact on inappropriate treatment of malaria for children under five. In this high transmission setting, use of mRDTs did not lead to the reductions in antimalarial prescribing seen elsewhere. Broader investment in health systems, including infrastructure and staffing, will be required to improve fever case management.

Public Health Emergencies of International Concern: Global, Regional, and Local Responses to Risk.

The declaration in 2009 that the H1N1 pandemic constituted a public health emergency of international concern (PHEIC) was the first such declaration under the revised International Health Regulations that were adopted in 2005. In the period since then PHEIC have been declared in relation to polio, Ebola, and Zika. This article evaluates initiatives that have been introduced globally, within the Asia-Pacific region, and within Australia, to strengthen preparedness for public health emergencies. Through analysis of evolving conceptualisations of risk, surveillance of zoonotic diseases, and development of public health capacities, the article argues that to date the global community has failed to make the necessary investments in health system strengthening, and that without these investments, global public health emergencies will continue to be an ongoing challenge.

Improving health-care quality in resource-poor settings.

Improvements in health-care quality can contribute to healthier populations. However, many global and national health strategies are not sufficiently considering the issues of measuring and improving health-care quality in low-resource settings. (1) The barriers to delivering high-quality care are often similar across different health systems. However, the extent and mechanisms through which these barriers affect quality improvement interventions may be different in resource-poor settings. (2) Investments in health systems strengthening without continuous quality improvement is thought to be a useless effort. (3) Conversely, only focusing on quality improvement in a resource-poor context without engaging the broader health system for support is of limited value. Hence, both areas must be improved simultaneously. Here, we call for renewed focus on quality improvement of health-system delivery by policy-makers, managers and health-care providers, working at all levels of health-care systems in resource-poor settings. To maximize the potential of quality improvements, we propose an approach focusing on five elements: (i) systems thinking; (ii) stakeholders' participation; (iii) accountability; (iv) evidence-based interventions; and (v) innovative evaluation (Box 1). Some of the elements are well supported by peer-reviewed literature, while other elements are lacking good evidence. We base our ideas on our experience in diverse countries and settings. We hope that bringing all these elements together into a unified approach will stimulate debate, highlight important research gaps and support policy-makers, healthcare providers and patient and community representatives working in this field. The first element, systems thinking, views health-care systems in a holistic manner and is often described as operating at micro- (clinical team), meso- (health facilities) and macro-level (health-care system). Systems thinking offers a useful framework for addressing the interdependency of these different levels that influence health-care delivery and health outcomes. (4) Interventions targeted to improve quality of care are unlikely to succeed or be sustained if designed without an adequate understanding of relevant contextual factors at these different levels. (5) Researchers and implementers are now recognizing the importance of these factors and their dynamic interaction in delivering safer, more effective care. (6) Failure to address these interdependencies may be particularly damaging in resource-poor settings, where constrained resources, lack of infrastructure and weak governance can exacerbate the difficulties of implementing an intervention. Examples range from unused expensive equipment due to lack of trained staff or electricity to operate it, to scarce health workers migrating to national and international organizations leading to understaffed primary, maternal and child care. Cultural and behavioural factors also affect these interdependencies and can contribute to problems during implementation. Interventions in resource-poor settings have to consider improvement across the different levels of the health system when trying to improve care at the clinical microsystems level. (7) Box 1 Elements to consider when improving health-care quality in resource-poor settings Systems thinking Health systems are dynamic complex adaptive systems, where all parts need to be considered. These parts are (I) the Inter-relationships between the patient, clinical and noncllnlcal workers In the health system; (II) the different levels of the health system ranging from the community to tertiary referral system; and (III) the required human and material resources and training, supervision and management structures. Participatory approach Participatory, grounded and bottom-up approaches Involving health-care professionals, patients and communities as well as researchers-in-resldence are Important to understand health systems. …

Zika virus in Africa: revitalising the discourse of health systems.

The Zika virus in Africa has the potential to create another source of morbidity for a continent affected by poverty. Oluwatosin Omole of the Department of Community and Family Medicine, Howard University Hospital, and Temitope Folaranmi of the OGEES Institute, Afe Babalola University, discuss the level of preparedness needed from African public health systems to respond to this epidemic .Although the current Zika virus outbreak was largely thought of as restricted to the Americas, the virus has spread to the islands of Cape Verde, off the coast of Africa,[1] and may eventually make landfall on continental Africa. The strain of the virus detected on Cape Verde is the same as the one responsible for the cases in the Americas, and over 7,500 suspected Zika cases and 3 cases of microcephaly have been reported.[2]Scientists and public health experts from many African countries have opined that the continent is ready to face the Zika virus but many hard questions remain about the level of preparedness and response when it finally makes landfall. Very much unlike the Ebola epidemic, which was extremely devastating and exposed the vulnerability of the health systems of Guinea, Liberia and Sierra Leone, the challenges of the Zika virus in Africa are different but equally serious. Most importantly, the effects of the Zika virus on pregnant women and women in the reproductive age group and its link to infant microcephaly and Guillain-Barre syndrome are a cause for concern.[3]As various epidemics in the past have shown, the African continent may suffer disproportionately if Zika eventually makes a landfall on the continent. The reasons for this are multiple. First, Africa's climate is conducive to Zika-carrying Aedes mosquitoes. Second, unlike Ebola in which public fear and high mortality rates jolted the governments of many African countries into action with the support of international development partners, the low mortality rate associated with the Zika virus may not have the same effect on the government's desire to take action. Third, the traditional culture in some African communities that permits polygamous family structures may amplify the sexual transmission of the virus and complicate the prevention and control strategies. Fourth, most surveillance systems are not advanced enough to detect changes in the epidemiology of health outcomes associated with Zika such as infant microcephaly and Guillain-Barre syndrome. Fifth, there are various other high-priority endemic diseases with high morbidity and mortality rates on the continent; hence, African countries may not have an incentive to channel funds to Zika given limited resources until it is too late. So, what should African countries, provinces and cities do with regard to the Zika virus?The most critical element needed in addressing the threat of emerging infectious disease such as Zika in Africa is the availability of infrastructure, and this can only be achieved through financing and long-term investments in public health systems. In contrast to the United States and other countries in the Americas, there have been limited reports of funds specifically earmarked by any African country towards activities focused on Zika. At the continental level, the African Union and other regional bodies are yet to start conversations regarding funding Zika preparedness activities, although the African Union recently approved the establishment of the African Centers for Disease Control and Prevention (CDC), modelled after the US CDC.[Image omitted: See PDF.]While the threat of Zika virus causing significant public health emergencies in Africa remains minimal, we would argue that the emergence of the Zika virus on the continent provides an important opportunity for health policy makers to re-evaluate the health system debate in Africa vis-a-vis improved accountability among public health leaders. There were allegations of the wastage and mismanagement of Ebola funds in some of the countries affected during the last Ebola epidemic. …

Trends in the completeness of birth registration in Nigeria: 2002-2010

1. IntroductionBirth is a fundamental right that affords children opportunity to be documented and establish their nationality. Unfortunately, this right is denied to many children, especially in less developed countries (Pais 2009; UNICEF 1989). Indeed, an estimated 230 million children worldwide have never had their births registered, thereby exposing them to various rights abuses (Bambas 2005; Bequele 2005; Cappa et al. 2014; Corbacho, Brito, and Rivas 2012; Dow 1998; UNICEF 2013). Like other global health challenges, Africa lags behind in of births and is only better than Asia (Bequele 2005; Mikkelsen et al. 2015; UNICEF 2013, 2014a). Less than 10% of Africa's population live in countries with complete (above 90% coverage) birth (Mahapatra et al. 2007). There is evidence that rate of birth stagnated between 1995 and 2004 (Mahapatra et al. 2007; Setel et al. 2007).The birth of a child is one of important events routinely recorded in a Civil Registration System (CRS) (United Nations 2001; World Health Organization 2008). According to United Nations, civil is defined as universal, continuous, permanent and compulsory recording of vital events provided through decree or regulation in accordance with legal requirements in a (World Health Organization and World Bank 2014). However, compliance with birth is still below 50% in sub-Saharan Africa and South Asia, 25 years after Convention on Rights of Child (CRC) (Cappa et al. 2014; UNICEF 2014a). CRC is an international treaty comprising 54 articles developed in 1989 to recognize rights of children. It is regarded as the most widely and rapidly ratified human rights treaty in history (UNICEF 2014a). right of children to have their births registered is seventh article of CRC.The importance of CRS data in monitoring health outcomes cannot be understated and requires national and international action to ensure its availability and reliability in monitoring performance of interventions. post-2015 global health agenda (the Sustainable Development Goals [SDGs]) has made strengthening birth one of its major targets (AbouZahr et al. 2015; United Nations 2015; World Health Organization and World Bank 2014). In particular, SDG goal 16.9 states as its aim that it will 2030, provide legal identity for all, including birth registration (United Nations 2015). This gives added impetus to measure performance of CRS and focus attention on where it is found suboptimal to ensure progress toward meeting universal birth target by deadline. To this end, World Health Organization, World Bank, and other partners have developed a ten-year plan, The Global Civil Registration and Vital Statistics Scaling up Plan (2015-2024), in hope of providing needed guidance to support governments toward achievement of this goal (World Health Organization and World Bank 2014). Other charities and recognized individuals have also made financial commitments to supporting improvement of CRS in developing countries (Lopez and Setel 2015; United Nations Economic and Social Commission for Asia and Pacific 2014).Birth statistics are a significant data source in measurement of health in populations, providing denominator data for calculating development indicators such as infant mortality and child mortality rates. These are also indicators that are used to measure quality of health care in a country and level of access to health care in population (Alarcon and Robles 2007). Poor data on these parameters can be misleading and drive suboptimal investments in health system. Additionally, birth statistics are important for monitoring policies and programs on fertility in a country. They can be a significant yardstick for assessing impact of interventions aimed at controlling population growth and determining need for an increased intensity of intervention. …

Institutional development: from legal pluralism to institutional bricolage in West African pastoralism.

Pastoralists in Africa are increasingly vulnerable to the effects of globalisation, climate change and changes in land use. They are confronted with problems related to access to scarce natural resources and their regulation, the management of mobility, and too little investment in health systems, livestock production and social service delivery. However, this paper focuses on positive trends and vital innovations in pastoral societies. These rely on robust institutions and policy frameworks that contribute to economically secure, politically stable, and environmentally sustainable livelihoods for African pastoral societies. The authors analyse ways in which internal and external efforts can improve the economic viability and social aspects of pastoralism. The institutions that manage natural resources and their effects on livelihoods and access to social services must be critically reviewed. The authors suggest that a new model for the economic and social development of African pastoralism should be positioned between donor- or governmentdriven development (in other words, 'seeing like a state') and the autonomous development goals of pastoralists ('seeing like a pastoralist'). Pastoralists are resourceful, entrepreneurial and innovative people, fully able to support new institutional systems and services which recognise their way of life and production systems. It seems evident that African pastoralism will maintain its vitality and creativity through a process of 'bricolage', with institutional and policy innovations based on a constant renegotiation of norms, the reinvention or transformation of tradition, the importance of legitimate authority and the role of the people themselves in shaping such arrangements.

PEPFAR Investments In Governance And Health Systems Were One-Fifth Of Countries' Budgeted Funds, 2004-14.

Launched in 2003, the US President's Emergency Plan for AIDS Relief (PEPFAR) is the largest disease-focused assistance program in the world. We analyzed PEPFAR budgets for governance and systems for the period 2004-14 to ascertain whether PEPFAR's stated emphasis on strengthening health systems has been manifested financially. The main outcome variable in our analysis, the first of its kind using these data, was the share of PEPFAR's total annual budget for a country that was designated for governance and systems. The share of planned PEPFAR funding for governance and systems increased from 14.9percent, on average, in 2004 to 27.5percent in 2013, but it declined in 2014 to 20.8percent. This study shows that the size of a country's PEPFAR budget was negatively associated with the share allocated for governance and systems (compared with other budget program areas); it also shows that there was no significant relationship between budgets for governance and systems and HIV prevalence. It is crucial for the global health policy community to better understand how such investments are allocated and used for health systems strengthening.

Military Occupational Outcomes in Canadian Armed Forces Personnel with and without Deployment-Related Mental Disorders.

Mental disorders are common in military organizations, and these frequently lead to functional impairments that can interfere with duties and lead to costly attrition. In Canada, the military mental health system has received heavy investment to improve occupational outcomes. We investigated military occupational outcomes of diagnosed mental disorders in a cohort of 30,513 personnel who deployed on the Afghanistan mission. Cohort members were military personnel who deployed on the Afghanistan mission from 2001 to 2008. Mental disorder diagnoses and their attribution to the Afghanistan mission were ascertained via medical records in a stratified random sample (n = 2014). Career-limiting medical conditions (that is, condition-associated restrictions that reliably lead to medically related attrition) were determined using administrative data. Outcomes were assessed from first Afghanistan-related deployment return. At 5 years of follow-up, the Kaplan-Meier estimated cumulative fraction with career-limiting medical conditions was 40.9% (95% confidence interval [CI] 35.5 to 46.4) among individuals with Afghanistan service-related mental disorders (ARMD), 23.6% (CI 15.5 to 31.8) with other mental disorders, and 11.1% (CI 8.9 to 13.3) without mental disorders. The adjusted Cox regression hazard ratios for career-limiting medical condition risk were 4.89 (CI 3.85 to 6.23) among individuals with ARMD and 2.31 (CI 1.48 to 3.60) with other mental disorders, relative to those without mental disorders. Notwithstanding the Canadian military's mental health system investments, mental disorders (particularly ARMD) still led to a high risk of adverse military occupational outcomes. Such investments have intrinsic value but may not translate into reduced medically related attrition without improvements in prevention and treatment effectiveness.