Erosion of the Capital City Advantage in Child Survival and Reproductive, Maternal, Newborn, and Child Health Intervention Coverage in Sub-Saharan Africa.

The place of residence is a major determinant of RMNCH outcomes, with rural areas often lagging in sub-Saharan Africa. This long-held pattern may be changing given differential progress across areas and increasing urbanization. We assessed inequalities in child mortality and RMNCH coverage across capital cities and other urban and rural areas. We analyzed mortality data from 163 DHS and MICS in 39 countries with the most recent survey conducted between 1990 and 2020 and RMNCH coverage data from 39 countries. We assessed inequality trends in neonatal and under-five mortality and in RMNCH coverage using multilevel linear regression models. Under-five mortality rates and RMNCH service coverage inequalities by place of residence have reduced substantially in sub-Saharan Africa, with rural areas experiencing faster progress than other areas. The absolute gap in child mortality between rural areas and capital cities and that between rural and other urban areas reduced respectively from 41 and 26 deaths per 1000 live births in 2000 to 23 and 15 by 2015. Capital cities are losing their primacy in child survival and RMNCH coverage over other urban areas and rural areas, especially in Eastern Africa where under-five mortality gap between capital cities and rural areas closed almost completely by 2015. While child mortality and RMNCH coverage inequalities are closing rapidly by place of residence, slower trends in capital cities and urban areas suggest gradual erosion of capital city and urban health advantage. Monitoring child mortality and RMNCH coverage trends in urban areas, especially among the urban poor, and addressing factors of within urban inequalities are urgently needed.

Identifying and Characterizing the Poorest Urban Population Using National Household Surveys in 38 Cities in Sub-Saharan Africa.

Identifying and classifying poor and rich groups in cities depends on several factors. Using data from available nationally representative surveys from 38 sub-Saharan African countries, we aimed to identify, through different poverty classifications, the best classification in urban and large city contexts. Additionally, we characterized the poor and rich groups in terms of living standards and schooling. We relied on absolute and relative measures in the identification process. For absolute ones, we selected people living below the poverty line, socioeconomic deprivation status and the UN-Habitat slum definition. We used different cut-off points for relative measures based on wealth distribution: 30%, 40%, 50%, and 60%. We analyzed all these measures according to the absence of electricity, improved drinking water and sanitation facilities, the proportion of children out-of-school, and any household member aged 10 or more with less than 6 years of education. We used the sample size, the gap between the poorest and richest groups, and the observed agreement between absolute and relative measures to identify the best measure. The best classification was based on 40% of the wealth since it has good discriminatory power between groups and median observed agreement higher than 60% in all selected cities. Using this measure, the median prevalence of absence of improved sanitation facilities was 82% among the poorer, and this indicator presented the highest inequalities. Educational indicators presented the lower prevalence and inequalities. Luanda, Ouagadougou, and N'Djaména were considered the worst performers, while Lagos, Douala, and Nairobi were the best performers. The higher the human development index, the lower the observed inequalities. When analyzing cities using nationally representative surveys, we recommend using the relative measure of 40% of wealth to characterize the poorest group. This classification presented large gaps in the selected outcomes and good agreement with absolute measures.

Examining the recent trends in adolescent sexual and reproductive health in five countries of sub-Saharan Africa based on PMA and DHS household surveys.

BACKGROUND: The annual collection of fertility, marriage, sexual behaviour, and contraceptive use data in the nationally representative rounds of Performance Monitoring and Accountability (PMA) surveys in sub-Saharan Africa may contribute to the periodic monitoring of adolescent sexual and reproductive health (ASRH). However, we need to understand the reliability of these data in monitoring the ASRH indicators. We assessed the internal and external consistencies in ASRH indicators in five countries. METHODS: We included countries with at least three nationally representative rounds of PMA surveys and two recent DHS: Ethiopia, Ghana, Kenya, Nigeria, and Uganda. Our analysis focused on four current status indicators of ASRH among girls 15-19 years: ever had sex, currently married, has given birth or currently pregnant, and currently using modern contraceptives among sexually active unmarried girls. We compared the PMA survey and DHS data and tested for statistical significance and assessed trends over time using Jonckheere-Terpstra test statistic. RESULTS: PMA and DHS survey methodologies were similar and, where there were differences, these were shown to have minimal impact on the indicator values. The comparison of the data points from PMA and DHS for the same years showed statistically significant differences in 12 of the 20 comparisons, which was most common for sexual behaviour (4/5) and least for contraceptive use (2/5). This is partly due to larger confidence intervals in both surveys. The time trends were consistent between the annual PMA surveys in most instances in Ethiopia, Kenya, and Nigeria but less so for Ghana and Uganda. However, both surveys highlight slow progress in adolescent and reproductive health indicators with major disparities between the countries. CONCLUSIONS: Despite the differences between PMA 2020 surveys and DHS surveys conducted in the same year, and inconsistencies of the PMA survey time series for several indicators in some countries, we found no systematic issues with PMA surveys and consider PMA surveys a valuable data source for the assessment of levels and trends of ASRH beyond contraceptive use and family planning for indicators of fertility, marriage, and sex among adolescent girls in sub-Saharan Africa.

HIV trends and disparities by gender and urban-rural residence among adolescents in sub-Saharan Africa.

BACKGROUND: In sub-Saharan Africa HIV transmission is a major challenge in adolescents, especially among girls and those living in urban settings. Major international efforts have aimed at reducing sexual transmission of HIV. This analysis aims to assess the trends in HIV prevalence by gender in adolescents, as well as urban-rural disparities. METHODS: HIV prevalence data at ages 15-19 years were obtained for 31 countries with a national survey since 2010 and for 23 countries with one survey circa 2005 and a recent survey circa 2015. Country medians and average annual rates of changes were used to summarize the trends for two subregions in sub-Saharan Africa, Eastern and Southern Africa and West and Central Africa, which largely correspond with higher and lower HIV prevalence countries. Data on HIV incidence at ages 15-24 and prevalence at 5-9 and 10-14 years were reviewed from 11 recent national surveys. Trends in urban-rural disparities in HIV prevalence and selected indicators of sexual and HIV testing behaviours were assessed for females and males 15-24 years, using the same surveys. RESULTS: HIV prevalence among girls 15-19 years declined in eastern and Southern Africa from 5.7 to 2.6% during 2005-2015 (country median), corresponding with an average annual rate of reduction of 6.5% per year. Among boys, the median HIV prevalence declined from 2.1 to 1.2%. Changes were also observed in West and Central Africa where median HIV prevalence among girls decreased from 0.7 to 0.4% (average annual rate of reduction 5.9%), but not for boys (0.3%). Girl-boy differences at 10-14 years were small with a country median HIV of 1.0% and 1.3%, respectively. Urban females and males 15-24 had at least 1.5 times higher HIV prevalence than their rural counterparts in both subregions, and since the urban-rural declines were similar, the gaps persisted during 2005-2015. CONCLUSIONS: HIV prevalence among adolescents declined in almost all countries during the last decade, in both urban and rural settings. The urban-rural gap persisted and HIV transmission to girls, but not boys, is still a major challenge in Eastern and Southern African countries.

Wealth-related inequalities in demand for family planning satisfied among married and unmarried adolescent girls and young women in sub-Saharan Africa.

BACKGROUND: The use of modern contraception has increased in much of sub-Saharan Africa (SSA). However, the extent to which changes have occurred across the wealth spectrum among adolescents is not well known. We examine poor-rich gaps in demand for family planning satisfied by modern methods (DFPSm) among sexually active adolescent girls and young women (AGYW) using data from national household surveys. METHODS: We used recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys to describe levels of wealth-related inequalities in DFPSm among sexually active AGYW using an asset index as an indicator of wealth. Further, we used data from countries with more than one survey conducted from 2000 to assess DFPSm trends. We fitted linear models to estimate annual average rate of change (AARC) by country. We fitted random effects regression models to estimate regional AARC in DFPSm. All analysis were stratified by marital status. RESULTS: Overall, there was significant wealth-related disparities in DFPSm in West Africa only (17.8 percentage points (pp)) among married AGYW. The disparities were significant in 5 out of 10 countries in Eastern, 2 out of 6 in Central, and 7 out of 12 in West among married AGYW and in 2 out of 6 in Central and 2 out of 9 in West Africa among unmarried AGYW. Overall, DFPSm among married AGYW increased over time in both poorest (AARC = 1.6%, p < 0.001) and richest (AARC = 1.4%, p < 0.001) households and among unmarried AGYW from poorest households (AARC = 0.8%, p = 0.045). DPFSm increased over time among married and unmarried AGYW from poorest households in Eastern (AARC = 2.4%, p < 0.001) and Southern sub-regions (AARC = 2.1%, p = 0.030) respectively. Rwanda and Liberia had the largest increases in DPFSm among married AGYW from poorest (AARC = 5.2%, p < 0.001) and richest (AARC = 5.3%, p < 0.001) households respectively. There were decreasing DFPSm trends among both married (AARC = - 1.7%, p < 0.001) and unmarried (AARC = - 4.7%, p < 0.001) AGYW from poorest households in Mozambique. CONCLUSION: Despite rapid improvements in DFPSm among married AGYW from the poorest households in many SSA countries there have been only modest reductions in wealth-related inequalities. Significant inequalities remain, especially among married AGYW. DFPSm stalled in most sub-regions among unmarried AGYW.

Inequalities in early marriage, childbearing and sexual debut among adolescents in sub-Saharan Africa.

BACKGROUND: Adolescent sexual and reproductive health (ASRH) is a major public health concern in sub-Saharan Africa (SSA). However, inequalities in ASRH have received less attention than many other public health priority areas, in part due to limited data. In this study, we examine inequalities in key ASRH indicators. METHODS: We analyzed national household surveys from 37 countries in SSA, conducted during 1990-2018, to examine trends and inequalities in adolescent behaviors related to early marriage, childbearing and sexual debut among adolescents using data from respondents 15-24 years. Survival analyses were conducted on each survey to obtain estimates for the ASRH indicators. Multilevel linear regression modelling was used to obtain estimates for 2000 and 2015 in four subregions of SSA for all indicators, disaggregated by sex, age, household wealth, urban-rural residence and educational status (primary or less versus secondary or higher education). RESULTS: In 2015, 28% of adolescent girls in SSA were married before age 18, declined at an average annual rate of 1.5% during 2000-2015, while 47% of girls gave birth before age 20, declining at 0.6% per year. Child marriage was rare for boys (2.5%). About 54% and 43% of girls and boys, respectively, had their sexual debut before 18. The declines were greater for the indicators of early adolescence (10-14 years). Large differences in marriage and childbearing were observed between adolescent girls from rural versus urban areas and the poorest versus richest households, with much greater inequalities observed in West and Central Africa where the prevalence was highest. The urban-rural and wealth-related inequalities remained stagnant or widened during 2000-2015, as the decline was relatively slower among rural and the poorest compared to urban and the richest girls. The prevalence of the ASRH indicators did not decline or increase in either education categories. CONCLUSION: Early marriage, childbearing and sexual debut declined in SSA but the 2015 levels were still high, especially in Central and West Africa, and inequalities persisted or became larger. In particular, rural, less educated and poorest adolescent girls continued to face higher ASRH risks and vulnerabilities. Greater attention to disparities in ASRH is needed for better targeting of interventions and monitoring of progress.

Wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions in 36 countries in the African Region.

OBJECTIVE: To investigate whether sub-Saharan African countries have succeeded in reducing wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions. METHODS: We analysed survey data from 36 countries, grouped into Central, East, Southern and West Africa subregions, in which at least two surveys had been conducted since 1995. We calculated the composite coverage index, a function of essential maternal and child health intervention parameters. We adopted the wealth index, divided into quintiles from poorest to wealthiest, to investigate wealth-related inequalities in coverage. We quantified trends with time by calculating average annual change in index using a least-squares weighted regression. We calculated population attributable risk to measure the contribution of wealth to the coverage index. FINDINGS: We noted large differences between the four regions, with a median composite coverage index ranging from 50.8% for West Africa to 75.3% for Southern Africa. Wealth-related inequalities were prevalent in all subregions, and were highest for West Africa and lowest for Southern Africa. Absolute income was not a predictor of coverage, as we observed a higher coverage in Southern (around 70%) compared with Central and West (around 40%) subregions for the same income. Wealth-related inequalities in coverage were reduced by the greatest amount in Southern Africa, and we found no evidence of inequality reduction in Central Africa. CONCLUSION: Our data show that most countries in sub-Saharan Africa have succeeded in reducing wealth-related inequalities in the coverage of essential health services, even in the presence of conflict, economic hardship or political instability.

Global epidemiology of use of and disparities in caesarean sections.

In this Series paper, we describe the frequency of, trends in, determinants of, and inequalities in caesarean section (CS) use, globally, regionally, and in selected countries. On the basis of data from 169 countries that include 98·4% of the world's births, we estimate that 29·7 million (21·1%, 95% uncertainty interval 19·9-22·4) births occurred through CS in 2015, which was almost double the number of births by this method in 2000 (16·0 million [12·1%, 10·9-13·3] births). CS use in 2015 was up to ten times more frequent in the Latin America and Caribbean region, where it was used in 44·3% (41·3-47·4) of births, than in the west and central Africa region, where it was used in 4·1% (3·6-4·6) of births. The global and regional increases in CS use were driven both by an increasing proportion of births occurring in health facilities (accounting for 66·5% of the global increase) and increases in CS use within health facilities (33·5%), with considerable variation between regions. Based on the most recent data available for each country, 15% of births in 106 (63%) of 169 countries were by CS, whereas 47 (28%) countries showed CS use in less than 10% of births. National CS use varied from 0·6% in South Sudan to 58·1% in the Dominican Republic. Within-country disparities in CS use were also very large: CS use was almost five times more frequent in births in the richest versus the poorest quintiles in low-income and middle-income countries; markedly high CS use was observed among low obstetric risk births, especially among more educated women in, for example, Brazil and China; and CS use was 1·6 times more frequent in private facilities than in public facilities.

Extra-couple HIV transmission in sub-Saharan Africa: a mathematical modelling study of survey data.

BACKGROUND: The proportion of heterosexual HIV transmission in sub-Saharan Africa that occurs within cohabiting partnerships, compared with that in single people or extra-couple relationships, is widely debated. We estimated the proportional contribution of different routes of transmission to new HIV infections. As plans to use antiretroviral drugs as a strategy for population-level prevention progress, understanding the importance of different transmission routes is crucial to target intervention efforts. METHODS: We built a mechanistic model of HIV transmission with data from Demographic and Health Surveys (DHS) for 2003-2011, of 27,201 cohabiting couples (men aged 15-59 years and women aged 15-49 years) from 18 sub-Saharan African countries with information about relationship duration, age at sexual debut, and HIV serostatus. We combined this model with estimates of HIV survival times and country-specific estimates of HIV prevalence and coverage of antiretroviral therapy (ART). We then estimated the proportion of recorded infections in surveyed cohabiting couples that occurred before couple formation, between couple members, and because of extra-couple intercourse. FINDINGS: In surveyed couples, we estimated that extra-couple transmission accounted for 27-61% of all HIV infections in men and 21-51% of all those in women, with ranges showing intercountry variation. We estimated that in 2011, extra-couple transmission accounted for 32-65% of new incident HIV infections in men in cohabiting couples, and 10-47% of new infections in women in such couples. Our findings suggest that transmission within couples occurs largely from men to women; however, the latter sex have a very high-risk period before couple formation. INTERPRETATION: Because of the large contribution of extra-couple transmission to new HIV infections, interventions for HIV prevention should target the general sexually active population and not only serodiscordant couples. FUNDING: US National Institutes of Health, US National Science Foundation, and J S McDonnell Foundation.

Learning from Ethiopia's success in reducing maternal and neonatal mortality through a health systems lens.

BACKGROUND: This study aimed to enhance insights into the key characteristics of maternal and neonatal mortality declines in Ethiopia, conducted as part of a seven-country study on Maternal and Newborn Health (MNH) Exemplars. METHODS: We synthesised key indicators for 2000, 2010 and 2020 and contextualised those with typical country values in a global five-phase model for a maternal, stillbirth and neonatal mortality transition. We reviewed health system changes relevant to MNH over the period 2000-2020, focusing on governance, financing, workforce and infrastructure, and assessed trends in mortality, service coverage and systems by region. We analysed data from five national surveys, health facility assessments, global estimates and government databases and reports on health policies, infrastructure and workforce. RESULTS: Ethiopia progressed from the highest mortality phase to the third phase, accompanied by typical changes in terms of fertility decline and health system strengthening, especially health infrastructure and workforce. For health coverage and financing indicators, Ethiopia progressed but remained lower than typical in the transition model. Maternal and neonatal mortality declines and intervention coverage increases were greater after 2010 than during 2000-2010. Similar patterns were observed in most regions of Ethiopia, though regional gaps persisted for many indicators. Ethiopia's progress is characterised by a well-coordinated and government-led system prioritising first maternal and later neonatal health, resulting major increases in access to services by improving infrastructure and workforce from 2008, combined with widespread community actions to generate service demand. CONCLUSION: Ethiopia has achieved one of the fastest declines in mortality in sub-Saharan Africa, with major intervention coverage increases, especially from 2010. Starting from a weak health infrastructure and low coverage, Ethiopia's comprehensive approach provides valuable lessons for other low-income countries. Major increases towards universal coverage of interventions, including emergency care, are critical to further reduce mortality and advance the mortality transition.

Patterns and trends in Pakistan's heterogeneous HIV epidemic.

BACKGROUND: Considerable HIV transmission occurs among injection drug users (IDUs) in Pakistan and recently the HIV prevalence has been increasing among male (MSW), hijra (transgender; HSW) and female (FSW) sex workers. We describe past and estimate future patterns of HIV emergence among these populations in several cities in Pakistan. METHODS: The density of these key populations per 1000 adult men was calculated using 2011 mapping data from Karachi, Lahore, Faisalabad, Larkana, Peshawar and Quetta, and surveillance data were used to assess bridging between these key populations. We used the UNAIDS Estimation and Projection Package model to estimate and project HIV epidemics among these key populations in Karachi, Lahore, Faisalabad and Larkana. RESULTS: The density and bridging of key populations varied across cities. Lahore had the largest FSW population (11.5/1000 adult men) and the smallest IDU population (1.7/1000 adult men). Quetta had the most sexual and drug injection bridging between sex workers and IDUs (6.7%, 7.0% and 3.8% of FSW, MSW and HSW, respectively, reported injecting drugs). Model evidence suggests that by 2015 HIV prevalence is likely to reach 17-22% among MSWs/HSWs in Karachi, 44-49% among IDUs in Lahore and 46-66% among IDUs in Karachi. Projection suggests the prevalence may reach as high as 65-75% among IDUs in Faisalabad by 2025. HIV prevalence is also estimated to increase among FSWs, particularly in Karachi and Larkana. CONCLUSIONS: There is a need to closely monitor regional and subpopulation epidemic patterns and implement prevention programmes customised to local epidemics.

Dynamics analysis of a multi-strain cholera model with an imperfect vaccine.

A new two-strain model, for assessing the impact of basic control measures, treatment and dose-structured mass vaccination on cholera transmission dynamics in a population, is designed. The model has a globally-asymptotically stable disease-free equilibrium whenever its associated reproduction number is less than unity. The model has a unique, and locally-asymptotically stable, endemic equilibrium when the threshold quantity exceeds unity and another condition holds. Numerical simulations of the model show that, with the expected 50% minimum efficacy of the first vaccine dose, vaccinating 55% of the susceptible population with the first vaccine dose will be sufficient to effectively control the spread of cholera in the community. Such effective control can also be achieved if 50% of the first vaccine dose recipients take the second dose. It is shown that a control strategy that emphasizes the use of antibiotic treatment is more effective than one that emphasizes the use of basic (non-pharmaceutical) anti-cholera control measures only. Numerical simulations show that, while the universal strategy (involving all three control measures) gives the best outcome in minimizing cholera burden in the community, the combined basic anti-cholera control measures and treatment strategy also has very effective community-wide impact.

Health service utilisation during the COVID-19 pandemic in sub-Saharan Africa in 2020: a multicountry empirical assessment with a focus on maternal, newborn and child health services.

INTRODUCTION: There are concerns about the impact of the COVID-19 pandemic on the continuation of essential health services in sub-Saharan Africa. Through the Countdown to 2030 for Women's, Children's and Adolescents' Health country collaborations, analysts from country and global public health institutions and ministries of health assessed the trends in selected services for maternal, newborn and child health, general service utilisation. METHODS: Monthly routine health facility data by district for the period 2017-2020 were compiled by 12 country teams and adjusted after extensive quality assessments. Mixed effects linear regressions were used to estimate the size of any change in service utilisation for each month from March to December 2020 and for the whole COVID-19 period in 2020. RESULTS: The completeness of reporting of health facilities was high in 2020 (median of 12 countries, 96% national and 91% of districts ≥90%), higher than in the preceding years and extreme outliers were few. The country median reduction in utilisation of nine health services for the whole period March-December 2020 was 3.9% (range: -8.2 to 2.4). The greatest reductions were observed for inpatient admissions (median=-17.0%) and outpatient admissions (median=-7.1%), while antenatal, delivery care and immunisation services generally had smaller reductions (median from -2% to -6%). Eastern African countries had greater reductions than those in West Africa, and rural districts were slightly more affected than urban districts. The greatest drop in services was observed for March-June 2020 for general services, when the response was strongest as measured by a stringency index. CONCLUSION: The district health facility reports provide a solid basis for trend assessment after extensive data quality assessment and adjustment. Even the modest negative impact on service utilisation observed in most countries will require major efforts, supported by the international partners, to maintain progress towards the SDG health targets by 2030.

Elucidating Drivers for Variations in the Explosive Human Immunodeficiency Virus Epidemic Among People Who Inject Drugs in Pakistan.

BACKGROUND: Pakistan's explosive human immunodeficiency virus (HIV) epidemic among people who inject drugs (PWID) varies widely across cities. We evaluated possible drivers for these variations. METHODS: Multivariable regression analyses were undertaken using data from 5 national surveys among PWID (n = 18 467; 2005-2017) to determine risk factors associated with variations in city-level HIV prevalence. A dynamic HIV model was used to estimate the population-attributable fraction (PAF; proportion of HIV infections prevented over 10 years when that risk factor is removed) of these risk factors to HIV transmission and impact on HIV incidence of reducing their prevalence. RESULTS: Regression analyses suggested that city-level HIV prevalence is strongly associated with the prevalence of using professional injectors at last injection, heroin use in last month, and injecting ≥4 times per day. Through calibrating a model to these associations, we estimate that the 10-year PAFs of using professional injectors, heroin use, and frequent injecting are 45.3% (95% uncertainty interval [UI], 4.3%-79.7%), 45.9% (95% UI, 8.1%-78.4%), and 22.2% (95% UI, 2.0%-58.4%), respectively. Reducing to lowest city-level prevalences of using professional injectors (2.8%; median 89.9% reduction), heroin use (0.9%; median 91.2% reduction), and frequent injecting (0.1%; median 91.8% reduction) in 2020 reduces overall HIV incidence by 52.7% (95% UI, 6.1%-82.0%), 53.0% (95% UI, 11.3%-80.2%), and 28.1% (95% UI, 2.7%-66.6%), respectively, over 10 years. CONCLUSIONS: Interventions should focus on these risk factors to control Pakistan's explosive HIV epidemic among PWID, including a concomitant expansion of high-coverage needle/syringe provision, opioid substitution therapy, and antiretroviral therapy.

Adolescent sexual and reproductive health in sub-Saharan Africa: who is left behind?

Adolescent sexual and reproductive health (ASRH) continues to be a major public health challenge in sub-Saharan Africa where child marriage, adolescent childbearing, HIV transmission and low coverage of modern contraceptives are common in many countries. The evidence is still limited on inequalities in ASRH by gender, education, urban-rural residence and household wealth for many critical areas of sexual initiation, fertility, marriage, HIV, condom use and use of modern contraceptives for family planning. We conducted a review of published literature, a synthesis of national representative Demographic and Health Surveys data for 33 countries in sub-Saharan Africa, and analyses of recent trends of 10 countries with surveys in around 2004, 2010 and 2015. Our analysis demonstrates major inequalities and uneven progress in many key ASRH indicators within sub-Saharan Africa. Gender gaps are large with little evidence of change in gaps in age at sexual debut and first marriage, resulting in adolescent girls remaining particularly vulnerable to poor sexual health outcomes. There are also major and persistent inequalities in ASRH indicators by education, urban-rural residence and economic status of the household which need to be addressed to make progress towards the goal of equity as part of the sustainable development goals and universal health coverage. These persistent inequalities suggest the need for multisectoral approaches, which address the structural issues underlying poor ASRH, such as education, poverty, gender-based violence and lack of economic opportunity.

Large and persistent subnational inequalities in reproductive, maternal, newborn and child health intervention coverage in sub-Saharan Africa.

Subnational inequalities have received limited attention in the monitoring of progress towards national and global health targets during the past two decades. Yet, such data are often a critical basis for health planning and monitoring in countries, in support of efforts to reach all with essential interventions. Household surveys provide a rich basis for interventions coverage indicators on reproductive, maternal, newborn and child health (RMNCH) at the country first administrative level (regions or provinces). In this paper, we show the large subnational inequalities that exist in RMNCH coverage within 39 countries in sub-Saharan Africa, using a composite coverage index which has been used extensively by Countdown to 2030 for Women's, Children's and Adolescent's Health. The analyses show the wide range of subnational inequality patterns such as low overall national coverage with very large top inequality involving the capital city, intermediate national coverage with bottom inequality in disadvantaged regions, and high coverage in all regions with little inequality. Even though nearly half of the 34 countries with surveys around 2004 and again around 2015 appear to have been successful in reducing subnational inequalities in RMNCH coverage, the general picture shows persistence of large inequalities between subnational units within many countries. Poor governance and conflict settings were identified as potential contributing factors. Major efforts to reduce within-country inequalities are required to reach all women and children with essential interventions.

Armed conflicts and national trends in reproductive, maternal, newborn and child health in sub-Saharan Africa: what can national health surveys tell us?

Armed conflicts are widespread in sub-Saharan Africa and considered to be an important factor in slowing down national progress in reproductive, maternal, newborn and child health (RMNCH). The measurement of the impact of conflicts on national levels and trends in RMNCH is difficult. National surveys conducted before and sometimes during and after conflicts are a major source of information on the national and local effects of conflicts on RMNCH. We examined data from national surveys in 13 countries in sub-Saharan Africa with major conflicts during 1990-2016 to assess the levels and trends in RMNCH intervention coverage, nutritional status and mortality in children under 5 years in comparison with subregional trends. The surveys provide substantive evidence of a negative association between levels and trends in national indicators of RMNCH service coverage, child growth and under-5 mortality with armed conflict, with some notable exceptions. National surveys are an important source of data to assess the longer term national consequences of conflicts for RMNCH in most countries, despite limitations due to sampling and timing of the surveys.

Generating statistics from health facility data: the state of routine health information systems in Eastern and Southern Africa.

Health facility data are a critical source of local and continuous health statistics. Countries have introduced web-based information systems that facilitate data management, analysis, use and visualisation of health facility data. Working with teams of Ministry of Health and country public health institutions analysts from 14 countries in Eastern and Southern Africa, we explored data quality using national-level and subnational-level (mostly district) data for the period 2013-2017. The focus was on endline analysis where reported health facility and other data are compiled, assessed and adjusted for data quality, primarily to inform planning and assessments of progress and performance. The analyses showed that although completeness of reporting was generally high, there were persistent data quality issues that were common across the 14 countries, especially at the subnational level. These included the presence of extreme outliers, lack of consistency of the reported data over time and between indicators (such as vaccination and antenatal care), and challenges related to projected target populations, which are used as denominators in the computation of coverage statistics. Continuous efforts to improve recording and reporting of events by health facilities, systematic examination and reporting of data quality issues, feedback and communication mechanisms between programme managers, care providers and data officers, and transparent corrections and adjustments will be critical to improve the quality of health statistics generated from health facility data.

Heterogeneity in geographical trends of HIV epidemics among key populations in Pakistan: a mathematical modeling study of survey data.

BACKGROUND: Assessing patterns and trends in new infections is key to better understanding of HIV epidemics, and is best done through monitoring changes in incidence over time. In this study, we examined disparities in geographical trends of HIV epidemics among people who inject drugs (PWIDs), female sex workers (FSWs) and hijra/transgender/male sex workers (H/MSWs), in Pakistan. METHODS: The UNAIDS Estimation and Projection Package (EPP) mathematical model was used to explore geographical trends in HIV epidemics. Four rounds of mapping and surveillance data collected among key populations (KPs) across 20 cities in Pakistan between 2005-2011 was used for modeling. Empirical estimates of HIV prevalence of each KP in each city were used to fit the model to estimate prevalence and incidence over time. RESULTS: HIV incidence among PWIDs in Pakistan reached its peak in 2011, estimated at 45.3 per 1000 person-years. Incidence was projected to continue to rise from 18.9 in 2015 to 24.3 in 2020 among H/MSWs and from 3.2 in 2015 to 6.3 in 2020 among FSWs. The number of people living with HIV in Pakistan was estimated to steadily increase through at least 2020. HIV incidence peak among PWIDs ranged from 16.2 in 1997 in Quetta to 71.0 in 2010 in Faisalabad (per 1000 person-years). Incidence among H/MSWs may continue to rise through 2020 in all the cities, except in Larkana where it peaked in the early 2000s. In 2015, model estimated incidence among FSWs was 8.1 in Karachi, 6.6 in Larkana, 2.0 in Sukkur and 1.2 in Lahore (per 1000 person-years). CONCLUSIONS: There exists significant geographical heterogeneity in patterns and trends of HIV sub-epidemics in Pakistan. Focused interventions and service delivery approaches, different by KP and city, are recommended.

Persistence to disease-modifying therapies for multiple sclerosis in a Canadian cohort.

PURPOSE: To examine the long-term persistence to the first-line injectable disease-modifying therapies (DMTs) for multiple sclerosis (MS) and to identify the factors associated with nonpersistence. PATIENTS AND METHODS: We used population-based administrative data from Manitoba, Canada. All adult subjects who were diagnosed with MS and dispensed a first-line injectable DMT (beta-interferon-1b, beta-interferon-1a, and glatiramer acetate) between 1996 and 2011 and had a minimum of 1 year of follow-up were included. The primary outcome was the median time to discontinuation of any DMT. The associations between potential predictors and persistence were estimated using multivariable Cox-proportional hazard models. RESULTS: Overall, 721 subjects were followed for a median of 7.8 years (interquartile range 6.1). The median time to discontinuation of all first-line DMTs was 4.2 years (25th and 75th percentile: 1.7, 10.6 years). Of the 451 (62.6%) subjects who discontinued their DMT during the study period, 259 (57.4%) eventually resumed or restarted a DMT. Subjects who were younger when starting a DMT, had prior MS-related hospitalizations, were more recently diagnosed with MS, or had a greater lag time between their MS diagnosis and DMT initiation were more likely to discontinue therapy. CONCLUSION: Over half of the individuals receiving a DMT for MS in Manitoba remained on therapy for at least 4 years. DMT discontinuation occurred in 60% of the cohort, but most restarted a DMT within 1 year. While not all of the factors identified with discontinuing DMT are modifiable, they may help practitioners enhance MS care by identifying individuals who may be at particular risk for DMT discontinuation.