Operational demonstration and process evaluation of non-pneumatic anti-shock garment (NASG) introduction to the public health system of Northern Province, Zambia.

BACKGROUND: A disproportionate burden of maternal deaths occurs in low- and middle-income countries (LMICs), and obstetric hemorrhage (OH) is a leading cause of excess mortality. In Zambia, most of maternal deaths are directly caused by OH. The Non-Pneumatic Anti-Shock Garment (NASG) is a first aid tool that uses compression to the abdomen and lower body to stop and reverse hypovolemic shock secondary to OH. We describe the process and experiences introducing the NASG into the Zambia public health system to encourage the development of national policies, clinical guidelines, and implementation plans that feature the NASG. METHODS: We conducted an observational study of NASG introduction to 143 public health facilities in Northern Province, Zambia, organizing observations into the five dimensions of the RE-AIM evaluation framework: reach, effectiveness, adoption, implementation, and maintenance. The NASG was introduced in August 2019, and the introduction was evaluated for 18 months. Data on healthcare worker training and mentorship, cases where NASG was used, and NASG availability and use during the study period were collected and analyzed. RESULTS: The NASG was successfully introduced and integrated into the Zambia public health system, and appropriately used by healthcare workers when responding to cases of OH. Sixteen months after NASG introduction, NASGs were available and functional at 99% of study sites and 88% reported ever using a NASG. Of the 68 cases of recorded OH where a NASG was applied, 66 were confirmed as clinically appropriate, and among cases where shock index (SI) could be calculated, 59% had SI ≥ 0.9. Feedback from healthcare providers revealed that 97% thought introducing the NASG was a good decision, and 92% felt confident in their ability to apply the NASG after initial training. The RE-AIM average for this study was 0.65, suggesting a public health impact that is not equivocal, and that NASG introduction had a positive population-based effect. CONCLUSIONS: A successful NASG demonstration took place over the course of 18 months in the existing health system of Northern Province, Zambia, suggesting that incorporation of NASG into the standard of care for obstetric emergency in the Zambia public sector is feasible and can be maintained without external support.

Strengthening systems to provide long-acting reversible contraceptives (LARCs) in public sector health facilities in Uganda and Zambia: Program results and learnings.

INTRODUCTION: In Uganda and Zambia, both supply- and demand-side factors hamper availability of long-acting reversible contraceptives (LARCs), including implants and intrauterine devices (IUDs), at public sector facilities. This paper discusses results of a program aimed at increasing access to and uptake of LARC services in public sector facilities through capacity building of government health workers, strengthening government supply chains, and client mobilization. METHODS: From 2018-2021, the Ministries of Health (MOHs) in Uganda and Zambia and Clinton Health Access Initiative (CHAI) worked to increase readiness to provide LARC services within 51 focal facilities in Uganda and 85 focal facilities in Zambia. Annual facility assessments of LARC-related resources were conducted and routine service delivery data were monitored. RESULTS: At baseline, few focal facilities had supplies and skilled staff to provide LARC services. At endline, over 90% of focal facilities in both countries had a provider trained to provide both implants and IUDs and 55% had the commodities and equipment needed for implant provision. In Uganda and Zambia, respectively, 65% and 38% of focal facilities had commodities and equipment for IUD provision at endline. Both programs observed significant increases in the number of implants provided at focal facilities; in Uganda implant volumes increased five-fold from 4,560 at baseline to 23,463 at endline, and in Zambia implant volumes increased nearly four-fold from 1,884 at baseline to 7,394 at endline. Uganda did not observe growth in IUD volumes, whereas Zambia observed significantly increased IUD service volumes from 251 at baseline to 3,866 at endline. CONCLUSIONS: Public sector facilities can be rapidly and sustainably capacitated to provide LARCs when both catalytic and systems strengthening interventions are deployed for health worker capacity building, supply chain management, and community mobilization to ensure client flow. Investments should be intentionally sequenced and coordinated to generate a virtuous cycle that enables continued LARC service provision.

Reducing maternal and neonatal mortality through integrated and sustainability-focused programming in Zambia.

Reducing maternal and neonatal mortality is a critical health priority within Zambia and globally. Although evidence-based clinical interventions can prevent a majority of these deaths, scalable and sustainable delivery of interventions across low-resource settings remains uneven, particularly across rural and marginalized communities. The Zambian Ministry of Health and the Clinton Health Access Initiative implemented an integrated sexual, reproductive, maternal, and newborn health (SRMNH) program in Northern Province aimed at dramatically reducing mortality over four years. Interventions were implemented between 2018 and 2021 across 141 government-owned health facilities covering all 12 districts of Northern Province, the poorest performing province nationwide and home to over 1.4 million people, around six pillars of an integrated health system. Data on institutional delivery and antenatal and postnatal care were collected through the national Health Management Information System (HMIS). A community-based system for capturing birth outcomes was established using existing government tools and community volunteers since HMIS did not include community-based mortality. Baseline and endline population-based mortality rates were compared for program-supported areas. From the earliest period of population-based mortality reporting in 2019 to program end in 2021, there were statistically significant decreases of 41%, 45%, and 43% in maternal, neonatal, and perinatal mortality rates respectively. Between 2017 to 2021, institutional maternal, neonatal, and perinatal mortality rates across entirety of Northern Province reduced by 12%, 40%, and 41%, respectively. Service readiness and coverage for SRMNH services improved dramatically, supporting increased numbers of patients. Significant mortality reductions were achieved over a relatively short period, reinforced through an emphasis on sustainability and strengthening existing government systems. These results were attained through a consciously cost-efficient approach backed by substantially lower levels of external investment relative to prior programs, allowing many of the interventions to be successfully adopted by government within public sector budgets.