Cross-country analysis of strategies for achieving progress towards global goals for women's and children's health.

OBJECTIVE: To identify how 10 low- and middle-income countries achieved accelerated progress, ahead of comparable countries, towards meeting millennium development goals 4 and 5A to reduce child and maternal mortality. METHODS: We synthesized findings from multistakeholder dialogues and country policy reports conducted previously for the Success Factors studies in 10 countries: Bangladesh, Cambodia, China, Egypt, Ethiopia, the Lao People's Democratic Republic, Nepal, Peru, Rwanda and Viet Nam. A framework approach was used to analyse and synthesize the data from the country reports, resulting in descriptive or explanatory conclusions by theme. FINDINGS: Successful policy and programme approaches were categorized in four strategic areas: leadership and multistakeholder partnerships; health sector; sectors outside health; and accountability for resources and results. Consistent and coordinated inputs across sectors, based on high-impact interventions, were assessed. Within the health sector, key policy and programme strategies included defining standards, collecting and using data, improving financial protection, and improving the availability and quality of services. Outside the health sector, strategies included investing in girls' education, water, sanitation and hygiene, poverty reduction, nutrition and food security, and infrastructure development. Countries improved accountability by strengthening and using data systems for planning and evaluating progress. CONCLUSION: Reducing maternal and child mortality in the 10 fast-track countries can be linked to consistent and coordinated policy and programme inputs across health and other sectors. The approaches used by successful countries have relevance to other countries looking to scale-up or accelerate progress towards the sustainable development goals.

Success factors for reducing maternal and child mortality.

Reducing maternal and child mortality is a priority in the Millennium Development Goals (MDGs), and will likely remain so after 2015. Evidence exists on the investments, interventions and enabling policies required. Less is understood about why some countries achieve faster progress than other comparable countries. The Success Factors for Women's and Children's Health studies sought to address this knowledge gap using statistical and econometric analyses of data from 144 low- and middle-income countries (LMICs) over 20 years; Boolean, qualitative comparative analysis; a literature review; and country-specific reviews in 10 fast-track countries for MDGs 4 and 5a. There is no standard formula--fast-track countries deploy tailored strategies and adapt quickly to change. However, fast-track countries share some effective approaches in addressing three main areas to reduce maternal and child mortality. First, these countries engage multiple sectors to address crucial health determinants. Around half the reduction in child mortality in LMICs since 1990 is the result of health sector investments, the other half is attributed to investments made in sectors outside health. Second, these countries use strategies to mobilize partners across society, using timely, robust evidence for decision-making and accountability and a triple planning approach to consider immediate needs, long-term vision and adaptation to change. Third, the countries establish guiding principles that orient progress, align stakeholder action and achieve results over time. This evidence synthesis contributes to global learning on accelerating improvements in women's and children's health towards 2015 and beyond.

La réduction de la mortalité maternelle et infantile est une priorité des objectifs du Millénaire pour le développement (OMD) et le restera probablement après l'échéance de 2015. Il existe des données sur les investissements, les interventions et les politiques habilitantes nécessaires. On comprend mal pourquoi certains pays ont réalisé des progrès plus rapidement que d'autres pays comparables. Les Facteurs de réussite des études sur la santé des femmes et des enfants ont cherché à combler ce manque de connaissances en utilisant les analyses statistiques et économétriques des données provenant de 144 pays à faible revenu et à revenu intermédiaire et recueillies depuis 20 ans: une analyse comparative qualitative booléenne; une étude bibliographique et des études spécifiques à chaque pays pour les 10 pays à progression rapide pour les points 4 et 5a des OMD. Il n'existe pas de formule standard ­ les pays à progression rapide ont déployé des stratégies personnalisées et se sont adaptés rapidement aux changements. Cependant, ces pays ont en commun des approches efficaces visant 3 grands axes afin de réduire la mortalité maternelle et infantile. Premièrement, ils impliquent de nombreux secteurs pour traiter les facteurs déterminants et cruciaux pour la santé. Près de la moitié de la réduction de la mortalité infantile dans les pays à faible revenu et à revenu intermédiaire depuis 1990 résulte des investissements dans le secteur de la santé, l'autre moitié étant attribuée aux investissements réalisés dans les secteurs extérieurs à la santé. Deuxièmement, ces pays utilisent des stratégies pour mobiliser les partenaires dans la société, en utilisant des données solides et opportunes pour la prise de décisions et la responsabilisation, ainsi qu'une approche de planification triple pour prendre en considération les besoins immédiats, la vision à long terme et l'adaptation aux changements. Troisièmement, ces pays établissent des principes directeurs qui orientent les progrès, harmonisent les actions des parties prenantes et génèrent des résultats dans le temps. Cette synthèse de données contribue à l'ensemble des connaissances requises pour accélérer les améliorations sur la santé des femmes et des enfants en vue de l'échéance de 2015 et au-delà.

La reducción de la mortalidad materna e infantil es una prioridad en los Objetivos de Desarrollo del Milenio (ODM), y probablemente lo seguirá siendo después de 2015. Existen evidencias sobre las inversiones, las intervenciones y las políticas necesarias, pero se sabe menos acerca de por qué algunos países logran un progreso más rápido que otros países comparables. Los estudios relativos a los Factores de Éxito en la Salud de las Mujeres y los Niños han tratado de abordar esta brecha de conocimiento por medio de análisis estadísticos y econométricos de datos de 144 países de ingresos bajos y medianos (PIBM) a lo largo de más de 20 años, análisis comparativos cualitativos booleanos, revisión de la literatura y revisiones específicas de cada país en 10 países bien encarrilados para los ODM 4 y 5a. No existe una fórmula estándar, estos países despliegan estrategias a medida y se adaptan rápidamente a los cambios. Sin embargo, comparten ciertos enfoques eficaces a la hora de abordar tres áreas principales para reducir la mortalidad materna e infantil. En primer lugar, involucran a numerosos sectores para hacer frente a los factores sanitarios decisivos. Alrededor de la mitad de la reducción de la mortalidad infantil en los PIBM desde 1990 es el resultado de inversiones en el sector de la salud, y la otra mitad se atribuye a las inversiones realizadas en sectores fuera del ámbito sanitario. En segundo lugar, estos países utilizan estrategias para movilizar a socios a través de la sociedad, utilizando evidencias oportunas y sólidas para la toma de decisiones y la rendición de cuentas, así como un enfoque de planificación triple para considerar las necesidades inmediatas, la visión a largo plazo y la adaptación al cambio. En tercer lugar, los países establecen principios rectores que orientan el progreso, armonizan las acciones de las partes interesadas y logran resultados en el tiempo. Este compendio de evidencias contribuye al aprendizaje global sobre cómo acelerar las mejoras en la salud de mujeres y niños hacia el 2015 y más adelante.

Measuring sustainability as a programming tool for health sector investments: report from a pilot sustainability assessment in five Nepalese health districts.

Sustainability is a critical determinant of scale and impact of health sector development assistance programs. Working with USAID/Nepal implementing partners, we adapted a sustainability assessment framework to help USAID test how an evaluation tool could inform its health portfolio management. The essential first process step was to define the boundaries of the local system being examined. This local system-the unit of analysis of the study-was defined as the health district.We developed a standardized set of assessment tools to measure 53 indicators. Data collection was carried out over 4 weeks by a Nepalese agency. Scaling and combining indicators into six component indices provided a map of progress toward sustainable maternal, child, health, and family planning results for the five districts included in this pilot study, ranked from "no sustainability" to "beginning of sustainability."We conclude that systematic application of the Sustainability Framework could improve the health sector investment decisions of development agencies. It could also give districts an information base on which to build autonomy and accountability. The ability to form and test hypotheses about the sustainability of outcomes under various funding strategies-made possible by this approach-will be a prerequisite for more efficiently meeting the global health agenda.

Findings and Lessons Learned From Strengthening the Provision of Voluntary Long-Acting Reversible Contraceptives With Postabortion Care in Guinea.

Integrating voluntary family planning into postabortion care (PAC) presents a critical opportunity to reduce future unintended pregnancies. Although Guinea has low contraceptive prevalence overall, acceptance of long-acting reversible contraceptives (LARCs) among PAC clients is higher than among interval LARC users and higher than the national average. In 2014, we assessed the extent of LARC provision within PAC services and the factors influencing integration. Primary and secondary data collected from 143 interviews, 75 provider assessments, and facility inventories and service statistics from all 38 public facilities providing PAC in Guinea allowed exploration of voluntary family planning uptake in the context of PAC. Study findings showed that 38 of 456 (8.3%) public health facilities or 38 of 122 (31.1%) facilities with a mandate to manage obstetric complications provided PAC services. Service statistics from 4,544 PAC clients in 2013 indicate that 95.2% received counseling and 73.0% voluntarily left the facility with contraception, with 29.6% of acceptors choosing a LARC. Family planning within PAC was emphasized in advocacy, policy and guidelines, quality improvement, and supervision, and the range of contraceptive options for postabortion clients was expanded to enable them to avoid a second unintended pregnancy. Factors that influenced provision of family planning within PAC included (1) the ability of champions both within and outside the Ministry of Public Health to advocate for PAC and leverage donor resources, (2) the incorporation of PAC with postabortion family planning into national policies, standards, and guidelines, (3) training of large numbers of providers in PAC and LARCs, and (4) integration of LARCs within PAC into quality improvement and supervision tools and performance standards. Guinea has gradually scaled up provision of PAC services nationwide and its experience may offer learning opportunities for other countries; however, continued advocacy for further expansion to more rural areas of the country and among private health facilities is necessary.

Integrated community case management: planning for sustainability in five African countries.

BACKGROUND: The World Health Organization (WHO) launched an initiative to plan for the sustainability of integrated community case management (iCCM) programmes supported by the Rapid Access Expansion (RAcE) Programme in five African countries in 2016. WHO contracted experts to facilitate sustainability planning among Ministries of Health, WHO, nongovernmental organisation grantees, and other stakeholders. METHODS: We designed an iterative and unique process for each RAcE project area which involved creating a sustainability framework to guide planning; convening meetings to identify and prioritise elements of the framework; forming technical working groups to build country ownership; and, ultimately, creating roadmaps to guide efforts to fully transfer ownership of the iCCM programmes to host countries. For this analysis, we compared priorities identified in roadmaps across RAcE project sites, examined progress against roadmaps via transition plans, and produced recommendations for short-term actions based on roadmap priorities that were unaddressed or needed further attention. RESULTS: This article describes the sustainability planning process, roadmap priorities, progress against roadmaps, and recommendations made for each project area. We found a few patterns among the prioritised roadmap elements. Overall, every project area identified priorities related to policy and coordination of external stakeholders including funders; supply chain management; service delivery and referral system; and communication and social mobilisation, indicating that these factors have persisted despite iCCM programme maturity, and are also of concern to new programmes. We also found that a facilitated process to identify and document programme priorities in roadmaps, along with deliberately planning for transition from an external implementer to a national system could support the sustainability of iCCM programmes by facilitating teams of stakeholders to accomplish explicit tasks related to transitioning the programme. CONCLUSIONS: Certain common elements are of concern for sustaining iCCM programmes across countries, among them political leadership, supply chain management, data processes, human resources, and community engagement. Adapting and using a sustainability planning approach created an inclusive and comprehensive dialogue about systemic factors that influence the sustainability of iCCM services and facilitated changes to health systems in each country.

Impact of multisectoral health determinants on child mortality 1980-2010: An analysis by country baseline mortality.

INTRODUCTION: Some health determinants require relatively stronger health system capacity and socioeconomic development than others to impact child mortality. Few quantitative analyses have analyzed how the impact of health determinants varies by mortality level. METHODS: 149 low- and middle-income countries were stratified into high, moderate, low, and very low baseline levels of child mortality in 1990. Data for 52 health determinants were collected for these countries for 1980-2010. To quantify how changes in health determinants were associated with mortality decline, univariable and multivariable regression models were constructed. An advanced statistical technique that is new for child mortality analyses-MM-estimation with first differences and country clustering-controlled for outliers, fixed effects, and variation across decades. FINDINGS: Some health determinants (immunizations, education) were consistently associated with child mortality reduction across all mortality levels. Others (staff availability, skilled birth attendance, fertility, water and sanitation) were associated with child mortality reduction mainly in low or very low mortality settings. The findings indicate that the impact of some health determinants on child mortality was only apparent with stronger health systems, public infrastructure and levels of socioeconomic development, whereas the impact of other determinants was apparent at all stages of development. Multisectoral progress was essential to mortality reduction at all baseline mortality levels. CONCLUSION: Policy-makers can use such analyses to direct investments in health and non-health sectors and to set five-year child mortality targets appropriate for their baseline mortality levels and local context.

Comparative evaluation of different modes of a national accident and emergency department-based injury surveillance system: Jamaican experience.

The objective was to conduct a comparative evaluation of two injury surveillance systems in operation in the Accident and Emergency departments of public hospitals in Jamaica. The evaluation was conducted at 12 hospitals across Jamaica offering varying levels of service delivery. It was designed in three phases: (1) a retrospective review of surveillance system data; (2) prospective process evaluation; (3) system environment evaluation. These data were analysed to determine the sensitivity and specificity of the manual Accident & Emergency Statistical Report (A&ESR) versus the computer-based Patient administration system/Jamaica injury surveillance system (PAS/JISS), and to determine an injury registration rate. Results showed a variation from 8% to 27% in injury registration rates at the hospitals reviewed. The sensitivity of the computer-based PAS ranged from 29.7% to 97.1% while the sensitivity of the manual system ranged from 22.1% to 100%. The computer-based system generally detected a greater percentage of injuries. Problems were identified with missing data fields in the computer-based system, while problems of recording and transcription were identified in the manually-based system. Recommendations were made to improve data quality in both data collection systems. Although shortcomings were identified with the A&ESR, the system is performing the function for which it was designed, that of tracking A&E workload. The PAS/JISS is more user-friendly and a truer reflection of the injury situation.

The establishment of a Jamaican all-injury surveillance system.

The impact of injuries on the Jamaican health care system is a growing problem. Based on the successful implementation of a Violence-Related Injury Surveillance System (VRISS) in the Accident and Emergency (A&E) department of the Kingston Public Hospital (KPH), Ministry of Health (MOH) officials decided to expand the system to the Jamaica Injury Surveillance System (JISS), allowing for the surveillance of both intentional and unintentional injuries. A working group designed the expanded injury surveillance system based on the International Classification of External Causes of Injury. The expanded system allowed for the collection of data on all injuries seen in the A&E departments by adding four injury projects to the computerized A&E registration process. These were (1) unintentional injury, (2) violence-related injury, (3) suicide attempt (also known as intentional self-harm) and (4) motor vehicle-related injuries. The expanded JISS was implemented at the KPH and four additional hospitals across the island. The geographic distribution of these hospitals provided a reflection of rural and urban, highland and coastal communities and their distinctive injury profiles. Data collected at registration were printed on trauma sheets and reviewed by medical staff before being incorporated into the patient's record. Monthly reports detailing demographics and summary statistics were generated and made available at the local and national level. By monitoring the national injury profile, the JISS provides data to support needed policy changes to minimize the impact of injuries on the health services and on the health of the population.

A profile of injuries in Jamaica.

This study analyses 6 months of data from three hospitals participating in the computerized emergency room-based Jamaica Injury Surveillance System (JISS) since 1999. The categories of injuries tracked were unintentional, violence-related and motor vehicle-related. The resultant data showed that injuries comprised 17% (12,179) of all Accident and Emergency (A&E) department registrations for the period. The highest percentage of injuries were violence-related (51%, 6,380), followed by unintentional injuries (33%, 4,030) and motor vehicle-related (15%, 1,769). Injury profiles varied by institution with the majority of Cornwall Regional Hospital's and Kingston Public Hospital's injuries being intentional while that of May Pen Hospital was unintentional. The data also demonstrate that young males are at highest risk for all types of injuries as well as for the more severe injuries requiring hospital admission. The risk factor data provided through the JISS will inform and guide private and public sector efforts to address the problem of injuries in Jamaica.