Linkages between the Sustainable Development Goals and health in Somalia.

BACKGROUND: The Sustainable Development Goals (SDGs) adopted in 2015 compromises 17 universal and indivisible goals for sustainable development, however the interactions between the SDGs in Somalia is not known which is vital for understanding potential synergies and trad-offs between the SDGs. Hence, this study aims to identify and classify the linkages between the SDGs with a focus on health and well-being (SDG 3) in Somalia. METHODS: Following the SDG Synergies approach, 35 leading experts from the public and private sectors as well as academia and civil society gathered for a 2-day workshop in Mogadishu and scored the interactions between the individual SDGs on a seven point-scale from - 3 to + 3. From this, a cross-impact matrix was created, and network models were used to showcase the direct and indirect interactions between the SDGs with a focus on SDG 3 (good health and well-being). RESULTS: Many promoting and a few restricting interactions between the different SDGs were found. Overall, SDG 16 (peace, justice, and strong institutions) influenced the other SDGs the most. When second-order interactions were considered, progress on SDG 16 (peace, justice, and strong institutions) showed the largest positive impact on SDG 3 (good health and well-being). SDG 3 (good health and well-being) was heavily influenced by progress on other SDGs in Somalia and making progress on SDG 3 (good health and well-being) positively influenced progress on all other SDGs. CONCLUSION: The findings revealed that in Somalia, the interactions between the SDGs are mostly synergistic and that SDG 16 (peace, justice, and strong institutions) has a strong influence on progress on other SDGs as well as progress on SDG 3 (good health and well-being). This study highlights the need for a multisectoral strategy to accelerate progress on the SDGs in Somalia in general, and particularly SDG 3 (good health and well-being).

Multi-sectoral collaborations in selected countries of the Eastern Mediterranean region: assessment, enablers and missed opportunities from the COVID-19 pandemic response.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has emphasized the importance of multi-sectoral collaboration to respond effectively to public health emergencies. This study aims to generate evidence on the extent to which multi-sectoral collaborations have been employed in the macro-level responses to the COVID-19 pandemic in nine selected countries of the Eastern Mediterranean region (EMR). METHODS: The study employed in-depth analytical research design and was conducted in two phases. In the first phase, data were collected using a comprehensive documentation review. In the second phase, key informant interviews were conducted to validate findings from the first phase and gain additional insights into key barriers and facilitators. We analysed the macro-level pandemic responses across the following seven components of the analytical framework for multi-sectoral collaborations: (1) context and trigger; (2) leadership, institutional mechanisms and processes; (3) actors; (4) administration, funding and evaluation; (5) degree of multi-sectoral engagement; (6) impact; and (7) enabling factors. RESULTS: Governments in the EMR have responded differently to the pandemic, with variations in reaction speed and strictness of implementation. While inter-ministerial committees were identified as the primary mechanism through which multi-sectoral action was established and implemented in the selected countries, there was a lack of clarity on how they functioned, particularly regarding the closeness of the cooperation and the working methods. Coordination structures lacked a clear mandate, joint costed action plan, sufficient resources and regular reporting on commitments. Furthermore, there was no evidence of robust communication planning both internally, focused on promoting internal consensual decision-making and managing power dynamics, and externally, concerning communication with the public. Across the selected countries, there was strong representation of different ministries in the pandemic response. Conversely, the contribution of non-state actors, including non-governmental organizations, civil society organizations, the private sector, the media and citizens, was relatively modest. Their involvement was more ad hoc, fragmented and largely self-initiated, particularly within the selected middle- and low income- countries of the EMR. Moreover, none of the countries incorporated explicit accountability framework or included anti-corruption and counter-fraud measures as integral components of their multi-sectoral plans and coordination mechanisms. Key enablers for the adoption of multi-sectoral collaborations have been identified, paving the way for more efficient responses in the future. DISCUSSION: Mirroring global efforts, this study demonstrates that the selected countries in the EMR are making efforts to integrate multi-sectoral action into their pandemic responses. Nevertheless, persistent challenges and gaps remain, presenting untapped opportunities that governments can leverage to enhance the efficiency of future public health emergency responses.

A qualitative study of Suaahara II influence on nutrition governance in Nepal.

Maternal and child undernutrition remain major public health problems in Nepal. Suaahara is a USAID-funded multi-sectoral nutrition programme aiming to strengthen local nutrition governance to reduce maternal and child undernutrition, among other objectives. The purpose of this study is to present findings from a recent qualitative evaluation of Suaahara II's influence on the decentralised implementation of Nepal's Multi-sectoral Nutrition Plan (MSNP) and identifying gaps and areas for improvement at the federal, provincial, and local levels to strengthen nutrition governance. This study employed multiple qualitative methods, engaging over 100 multi-sectoral nutrition stakeholders across three levels of government and eight districts. Thematic qualitative analysis was employed to identify emergent and salient themes, which were triangulated with other secondary data sources. Suaahara II had a positive influence on strengthening horizontal coordination for implementing the MSNP and effectively leveraged existing networks to strengthen implementation of nutrition-focused activities at the municipal level. Although there was an observable increased demand for nutrition budgets attributable to Suaahara II activities, sufficient allocation and utilisation, particularly in non-health sectors, did not meet these levels. Nepal's shift to federalism hindered vertical coordination of MSNP implementation. Some formal coordination mechanisms were strengthened, but variation in their effectiveness to strengthen horizontal and vertical coordination to implement MSNP activities continues. Finally, limited government ownership over nutrition activities and facilitating multi-sector coordination to implement the MSNP threatened sustainability of Suaahara II's outcomes on nutrition governance. Future programmes should continue to build on the progress made under Suaahara II, and specifically aim to address challenges in vertical coordination to strengthen nutrition governance in Nepal.

Understanding differential reductions in undernutrition among districts in Rwanda through the perspectives of mid-level and community actors on policy commitment and policy coherence.

Understanding the drivers of improvements in child undernutrition at only the national level can mask subnational differences. This paper aimed to understand the contributions of factors in the enabling environment to observed differences in stunting reduction between districts in Rwanda. In 2017, we conducted 58 semi-structured interviews with mid-level actors (n = 38) and frontline workers (n = 20) implementing Rwanda's multi-sectoral nutrition policy in five districts in which stunting decreased (reduced districts) and five where it increased or stagnated (non-reduced districts) based on Rwanda's 2010 and 2014/15 Demographic and Health Surveys. Mid-level actors are government officials and service providers at the subnational level who represent the frontline of government policy. Interviews focused on political commitment to and policy coherence in nutrition, and contributors to nutrition changes. Responses were coded to capture themes on the changes and challenges of these topics and compared between reduced and non-reduced districts. Descriptive statistics described district characteristics. Political commitment to nutrition was high in both reduced and non-reduced districts. Respondents from reduced districts were more likely to define commitment to nutrition as an optimal implementation of policy, whereas those from non-reduced districts focused more on financial commitment. Regarding coherence, respondents from reduced compared to non-reduced districts were more likely to report the optimal implementation of multi-sectoral nutrition planning meetings, using data to assess plans and progress in nutrition outcomes and integration of nutrition into the agriculture sector. In contrast, respondents from non-reduced districts more often reported challenges in their relationships with national-level stakeholders and nutrition and/or monitoring and evaluation capacities. Enhancing the integration of nutrition in different sectors and improving mid-level actors' capacity to plan and advocate for nutrition programming may contribute to reductions in stunting.

Operationalising multi-sectoral food- and nutrition-related policies to curb the rise in obesity in Ghana.

OBJECTIVE: To examine the governance of the food and nutrition policy space with particular reference to interests and power among stakeholders. DESIGN: We followed a case study research design to conduct a nutrition policy analysis. We triangulated three sources of data: key-informant interviews, learning journey and relevant policy documents (2010-2020). This study is grounded in a conceptual framework focused on power. SETTING: Ghana. PARTICIPANTS: Key informants (n 28) drawn from policy stakeholders from government (Health, Agriculture, Trade and Industry), academia, civil society, development partners, civil society organisation (CSO) and private sector in Accra and Kumasi. RESULTS: Power relations generated tensions, leading to weak multi-sectoral coordination among actors within the nutrition policy space. Governance and funding issues were identified as reasons for the weak multi-sectoral coordination. Formal power rested with government institutions while the private sector and CSO pushed to be invited during policy formulation. Visible stakeholders from industry were trade oriented and held a common interest of profit-making; they sought to receive support from government in order to be more competitive. There were no observed structures at the subnational levels for effective link with the national level. CONCLUSION: Formal responsibility for decision making within the nutrition and food policy space rested with the health sector and bringing on board nutrition-related sectors remained a challenge due to power tensions. Establishing a National Nutrition Council, with structures at the subnational level, will strengthen policy coordination and implementation. Taxation of sugar-sweetened beverages could provide a fund generation avenue for coordination of programmes to curb obesity.

Predictors of stunting among children aged 6-59 months, Zimbabwe.

OBJECTIVE: Stunted children have an increased risk of diminished cognitive development, diabetes, degenerative and CVD later in life. Numerous modifiable factors decrease the risk of stunting in children. This study aimed to assess the role of the individual, household and social factors on stunting in Zimbabwean children. DESIGN: A 1:2 unmatched case-control study. SETTING: This study was conducted in two predominantly rural provinces (one with the highest national prevalence of stunting and one with the lowest prevalence) in Zimbabwe. PARTICIPANTS: Data were obtained from the caregivers of 150 children aged between 6 and 59 months with stunting and from the caregivers of 300 children without stunting. RESULTS: Multiple (39) correlates of stunting were identified. Child's age, birth length, birth weight, and weight-for-age outcome (child-related factors), caregiver's age, maternal HIV status, occupation, and education (parental factors), breast-feeding status, number of meals, and dietary quality (dietary factors), child's appetite, diarrhoeal and worm infection (childhood illnesses), income status, access to safe water, access to a toilet, health clubs and maternal support in infant feeding (household, socio-cultural factors) were all found to be significant predictors of childhood stunting. CONCLUSION: Nearly all aspects under review from the individual-, household- to social-level factors were significantly associated with childhood stunting. These findings add to the growing body of evidence supporting the WHO stunting framework and strengthen the need to focus interventions on a multi-sectoral approach to effectively address stunting in high prevalence countries.

Multi-sectoral action to promote psychological wellbeing: Theorising the role of place-based policy.

ISSUES ADDRESSED: Several national governments are showing interest in policies to promote wellbeing. One common strategy is to devise systems to measure indictors of wellbeing, presuming that governments act on what they measure. This article will argue instead that formation of multisectoral policies to promote psychological wellbeing requires a different kind of theoretical and evidentiary basis. METHODS: The article integrates ideas from literature on wellbeing, health in all policies, political science, mental health promotion, and social determinants of health to make a case for place-based policy as the central feature of multi-sectoral policy for psychological wellbeing. RESULTS AND DISCUSSION: I argue that the required theoretical foundation for policy action on psychological wellbeing lies with understanding certain basic functions of human social psychology including the role of stress arousal. I then draw on policy theory to propose three steps to translate this theoretical understanding of psychological wellbeing into practicable, multi-sectoral policies. Step one is concerned with adopting a thoroughly revised conception of psychological wellbeing as a policy problem. Step two involves uptake of a theory of change in policy, grounded on recognition of essential social conditions required to promote psychological wellbeing. Proceeding from these, I will argue that a necessary (but not sufficient) third step is to implement place-based strategies involving government-community partnerships, to generate essential conditions for psychological wellbeing on a universal basis. Finally, I examine implications of the proposed approach for current theory and practice in mental health promotion policy. CONCLUSIONS: Place-based policy is foundational for effective multi-sectoral policy to promote psychological wellbeing. SO WHAT?: Governments aiming to promote psychological wellbeing should position place-based policy at the centre of their strategies.

"Hey, We Can Do This Together": Findings from an Evaluation of a Multi-sectoral Community Coalition.

Multi-sectoral coalitions focused on systemic health inequities are commonly promoted as important mechanisms to facilitate changes with lasting impacts on population health. However, the development and implementation of such initiatives present significant challenges, and evaluation results are commonly inconclusive. In an effort to add to the evidence base, we conducted a mixed-methods evaluation of the Claremont Healthy Village Initiative, a multi-sectoral partnership based in the Bronx, New York City. At an organizational level, there were positive outcomes with respect to expanded services, increased access to resources for programs, improved linkages, better coordination, and empowerment of local leaders-all consistent with a systemic, community building approach to change. Direct impacts on community members were more difficult to assess: perceived access to health and other services improved, while community violence and poor sanitation, which were also priorities for community members, remained important challenges. Findings suggest significant progress, as well as continued need.

Are rhetorical commitments to adolescents reflected in planning documents? An exploratory content analysis of adolescent sexual and reproductive health in Global Financing Facility country plans.

BACKGROUND: The Global Financing Facility (GFF) offers an opportunity to close the financing gap that holds back gains in women, children's and adolescent health. However, very little work exists examining GFF practice, particularly for adolescent health. As momentum builds for the GFF, we examine initial GFF planning documents to inform future national and multi-lateral efforts to advance adolescent sexual and reproductive health. METHODS: We undertook a content analysis of the first 11 GFF Investment Cases and Project Appraisal Documents available on the GFF website. The countries involved include Bangladesh, Cameroon, Democratic Republic of Congo, Ethiopia, Guatemala, Kenya, Liberia, Mozambique, Nigeria, Tanzania and Uganda. RESULTS: While several country documents signal understanding and investment in adolescents as a strategic area, this is not consistent across all countries, nor between Investment Cases and Project Appraisal Documents. In both types of documents commitments weaken as one moves from programming content to indicators to investment. Important contributions include how teenage pregnancy is a universal concern, how adolescent and youth friendly health services and school-based programs are supported in several country documents, how gender is noted as a key social determinant critical for mainstreaming across the health system, alongside the importance of multi-sectoral collaboration, and the acknowledgement of adolescent rights. Weaknesses include the lack of comprehensive analysis of adolescent health needs, inconsistent investments in adolescent friendly health services and school based programs, missed opportunities in not supporting multi-component and multi-level initiatives to change gender norms involving adolescent boys in addition to adolescent girls, and neglect of governance approaches to broker effective multi-sectoral collaboration, community engagement and adolescent involvement. CONCLUSION: There are important examples of how the GFF supports adolescents and their sexual and reproductive health. However, more can be done. While building on service delivery approaches more consistently, it must also fund initiatives that address the main social and systems drivers of adolescent health. This requires capacity building for the technical aspects of adolescent health, but also engaging politically to ensure that the right actors are convened to prioritize adolescent health in country plans and to ensure accountability in the GFF process itself.

Preventing the re-establishment of malaria in Sri Lanka amidst the COVID-19 pandemic.

The COVID-19 pandemic has had a considerable impact on other health programmes in countries, including on malaria, and is currently under much discussion. As many countries are accelerating efforts to eliminate malaria or to prevent the re-establishment of malaria from recently eliminated countries, the COVID-19 pandemic has the potential to cause major interruptions to ongoing anti-malaria operations and risk jeopardizing the gains that have been made so far. Sri Lanka, having eliminated malaria in 2012, was certified by the World Health Organization as a malaria-free country in 2016 and now implements a rigorous programme to prevent its re-establishment owing to the high receptivity and vulnerability of the country to malaria. Sri Lanka has also dealt with the COVID-19 epidemic quite successfully limiting the cumulative number of infections and deaths through co-ordinated efforts between the health sector and other relevant sectors, namely the military, the Police Department, Departments of Airport and Aviation and Foreign Affairs, all of which have been deployed for the COVID-19 epidemic under the umbrella of a Presidential Task Force. The relevance of imported infections and the need for a multi-sectoral response are features common to both the control of the COVID-19 epidemic and the Prevention of Re-establishment (POR) programme for malaria. Sri Lanka's malaria POR programme has, therefore, creatively integrated its activities with those of the COVID-19 control programme. Through highly coordinated operations the return to the country of Sri Lankan nationals stranded overseas by the COVID-19 pandemic, many from malaria endemic countries, are being monitored for malaria as well as COVID-19 in an integrated case surveillance system under quarantine conditions, to the success of both programmes. Twenty-three imported malaria cases were detected from February to October through 2773 microscopic blood examinations performed for malaria in quarantine centres, this number being not much different to the incidence of imported malaria during the same period last year. This experience highlights the importance of integrated case surveillance and the need for a highly coordinated multi-sectoral approach in dealing with emerging new infections. It also suggests that synergies between the COVID-19 epidemic control programme and other health programmes may be found and developed to the advantage of both.

What are the drivers of recurrent cholera transmission in Nigeria? Evidence from a scoping review.

BACKGROUND: The 2018 cholera outbreak in Nigeria affected over half of the states in the country, and was characterised by high attack and case fatality rates. The country continues to record cholera cases and related deaths to date. However, there is a dearth of evidence on context-specific drivers and their operational mechanisms in mediating recurrent cholera transmission in Nigeria. This study therefore aimed to fill this important research gap, with a view to informing the design and implementation of appropriate preventive and control measures. METHODS: Four bibliographic literature sources (CINAHL (Plus with full text), Web of Science, Google Scholar and PubMed), and one journal (African Journals Online) were searched to retrieve documents relating to cholera transmission in Nigeria. Titles and abstracts of the identified documents were screened according to a predefined study protocol. Data extraction and bibliometric analysis of all eligible documents were conducted, which was followed by thematic and systematic analyses. RESULTS: Forty-five documents met the inclusion criteria and were included in the final analysis. The majority of the documents were peer-reviewed journal articles (89%) and conducted predominantly in the context of cholera epidemics (64%). The narrative analysis indicates that social, biological, environmental and climatic, health systems, and a combination of two or more factors appear to drive cholera transmission in Nigeria. Regarding operational dynamics, a substantial number of the identified drivers appear to be functionally interdependent of each other. CONCLUSION: The drivers of recurring cholera transmission in Nigeria are diverse but functionally interdependent; thus, underlining the importance of adopting a multi-sectoral approach for cholera prevention and control.

Promotion of awareness and utilization of youth friendly service through multi-sectoral cooperation mechanism in China.

BACKGROUND: Youth friendly services (YFS) was established in pilot areas in China. This study aimed to explore the promoting level on the awareness and utilization of YFS after the implementing of a multi-sectoral cooperation mechanism (MSCM) supported by social network theory (SNT) among multiple sectors related to young people reproductive health (YRH) closely. METHODS: A cross-sectional study with two separate self-administered questionnaire surveys was conducted before and after the implementing of a MSCM supported by SNT in both in-school and out-school unmarried young people aged 12-24 year-old in pilot areas in China. Both pre- and post- implementation surveys were conducted between December, 2008 and January, 2009, and between October, 2010 and January, 2011 respectively. The collected categorical data about the awareness on YFS in young people was described in percentage (%). χ 2 test was used to compare the differences between interventional and control areas, pre and after intervention, and changes in investigated areas after the intervention respectively. Binary logistic regression was used to analyze interventional effects after adjusting gender, in-school or out-school, and other factors. Significance level α was 0.05. RESULTS: The percentages of young people in interventional areas who could receive YRH education including that about YFS in schools, working sites and communities increased (OR = 15.485, 6.166, 3.723; 95% CI: 2.939~4.715, 4.014~9.473, 11.421~20.994 respectively) statistically significantly (P < 0.05). The percentages of young people in interventional areas who "have heard of YFS clinic" and "know that YFS clinic has been established in local area" (OR = 9.325, 11.244; 95% CI: 7.433~11.699, 8.780~14.399 respectively), and knowledge rates on YFS manner and contents also increased (OR = 14.830, 8.676; 95% CI: 9.728~22.607, 5.175~14.548 respectively) statistically significantly (P < 0.05). The increments of knowledge rates on YFS price, time, hotline number, contents on contraception, pregnancy and sexual harass/violence were statistically significant (P < 0.05). The satisfaction degree on this service has also increased (OR = 6.394, 95% CI: 2.789~14.655) statistically significantly (P < 0.05). CONCLUSIONS: SNT is a helpful tool to facilitate the construction of an effective multi-sectoral cooperation mechanism to promote the awareness and satisfactory degree of YRH services.

Trends for Neonatal Deaths in Nepal (2001-2016) to Project Progress Towards the SDG Target in 2030, and Risk Factor Analyses to Focus Action.

INTRODUCTION: Nepal has made considerable progress on improving child survival during the Millennium Development Goal period, however, further progress will require accelerated reduction in neonatal mortality. Neonatal survival is one of the priorities for Sustainable Development Goals 2030. This paper examines the trends, equity gaps and factors associated with neonatal mortality between 2001 and 2016 to assess the likelihood of Every Newborn Action Plan (ENAP) target being reached in Nepal by 2030. METHODS: This study used data from the 2001, 2006, 2011 and 2016 Nepal Demographic and Health Surveys. We examined neonatal mortality rate (NMR) across the socioeconomic strata and the annual rate of reduction (ARR) between 2001 and 2016. We assessed association of socio-demographic, maternal, obstetric and neonatal factors associated with neonatal mortality. Based on the ARR among the wealth quintile between 2001 and 2016, we made projection of NMR to achieve the ENAP target. Using the Lorenz curve, we calculated the inequity distribution among the wealth quintiles between 2001 and 2016. RESULTS: In NDHS of 2001, 2006, 2011 and 2016, a total of 8400, 8600, 13,485 and 13,089 women were interviewed respectively. There were significant disparities between wealth quintiles that widened over the 15 years. The ARR for NMR declined with an average of 4.0% between 2001 and 2016. Multivariate analysis of the 2016 data showed that women who had not been vaccinated against tetanus had the highest risk of neonatal mortality (adjusted odds ratio [AOR] 3.38; 95% confidence interval [CI] 1.20-9.55), followed by women who had no education (AOR 1.87; 95% CI 1.62-2.16). Further factors significantly associated with neonatal mortality were the mother giving birth before the age of 20 (AOR 1.76; CI 95% 1.17-2.59), household air pollution (AOR 1.37; CI 95% 1.59-1.62), belonging to a poorest quintile (AOR 1.37; CI 95% 1.21-1.54), residing in a rural area (AOR 1.28; CI 95% 1.13-1.44), and having no toilet at home (AOR 1.21; CI 95% 1.06-1.40). If the trend of neonatal mortality rate of 2016 continues, it is projected that the poorest family will reach the ENAP target in 2067. CONCLUSIONS: Although neonatal mortality is declining in Nepal, if the current trend continues it will take another 50 years for families in the poorest group to attain the 2030 ENAP target. There are different factors associated with neonatal mortality, reducing the disparities for maternal and neonatal care will reduce mortality among the poorest families.

Developing co-funded multi-sectoral partnerships for chronic disease prevention: a qualitative inquiry into federal governmental public health staff experience.

BACKGROUND: Multi-sectoral partnerships (MSPs) are frequently cited as a means by which governments can improve population health while leveraging the resources and expertise of the private and non-profit sectors. As part of their efforts in this area, the Public Health Agency of Canada (the Agency) introduced a novel funding programme requiring applicants to procure matched resources from private sources to support large-scale interventions for chronic disease prevention. The current literature on MSPs is limited in its applicability to this model of multi-sectoral engagement. The purpose of this study was to explore the experiences of Agency staff working with potential partners to develop programme applications, such that we might identify lessons from adopting this type of partnership approach. METHODS: Semi-structured interviews were conducted with the 12 staff working in the MSP programme. Interviews were recorded, transcribed and analysed using thematic analysis. Preliminary themes were used to inform follow up focus-groups sessions. A second round of analysis was conducted guided by a coding paradigm focused on understanding process. RESULTS: We identified "experiencing uncertainty" to be a central concept in participants' accounts of the MSP process, related specifically to the MSP programme's novel conditions, shifts that occurred in sectoral roles and demands for new capacities. In response, Agency staff employed strategies to clarify partner interests, build trust in inter-sectoral relationships, and support internal and partner capacity. Outcomes associated with this process include impacts on trust between the Agency and potential partners, a deeper understanding of other sectors, and programme adaptations and refinements to address challenges related to the programme model. CONCLUSIONS: The co-funding model employed by the Agency is a potentially popular one for government bodies wanting to leverage funding from private sector sources. Our study identifies the potential challenges that can occur under this model. Some challenges are related to addressing material conditions related to partner capacity, whereas other challenges speak to deeper and more difficult to address concerns regarding trust and alignment of motivations and interests between partners. Future research exploring the challenges associated with specific models of MSP engagement is necessary to inform approaches to addressing complex problems through collaborative efforts.

Trends in the proportionate mortalities attributed to noncommunicable diseases in sub-Saharan Africa for the period 2000 to 2016.

Noncommunicable diseases (NCDs) remain a growing global health issue and sub-Saharan Africa (SSA) is no exception. Using secondary data obtained from the World Bank on 48 SSA countries, we describe the trends in the proportionate mortalities attributed to NCDs in SSA between 2000 and 2016. The baseline proportionate mortalities attributed to NCDs in SSA increased from 22.49% in 2000 to 33.69% in 2016, representing about 11% increase. The trend was replicated across the low-, middle-, and high-income countries in SSA. The highest change in the NCD mortalities in low-income SSA countries was seen in Eritrea where NCD mortalities increased from 19.3% in the year 2000 to 45.2% in 2016. In Rwanda, it rose from 24.8% to 44% during the same period. Ghana, a lower-middle-income country, also witnessed an increase from 27.3% in 2000 to 42.7% in 2016. The general increasing trend in the burden of NCD mortalities in SSA implies the need for higher prioritization of NCD prevention and control initiatives. There is a need for a greater contribution of nontraditional stakeholders in health through a multi-sectoral approach. We also recommend integrating NCD prevention and control strategies into existing public health structures being used for communicable disease control.

Health for all by all-pursuing multi-sectoral action on health for SDGs in the WHO Eastern Mediterranean Region.

The WHO Eastern Mediterranean Region is endowed with deep intellectual tradition, interesting cultural diversity, and a strong societal fabric; components of a vibrant platform for promoting health and wellbeing. Health has a central place in the Sustainable Development Goals (SDGs) for at least three reasons: Firstly, health is shaped by factors outside of the health sector. Secondly, health can be singled out among several SDGs as it provides a clear lens for examining the progress of the entire development process. Thirdly, in addition to being an outcome, health is also a contributor to achieving sustainable development. Realizing this central role of health in SDGs and the significance of collaboration among diverse sectors, the WHO is taking action. In its most recent General Program of Work 2019-2023 (GPW 13), the WHO has set a target of promoting the health of one billion more people by addressing social and other determinants of health through multi-sectoral collaboration. The WHO Regional Office for the Eastern Mediterranean Region, through Vision 2023, aims at addressing these determinants by adopting an equity-driven, leaving no one behind approach. Advocating for Health in All Policies, multi-sectoral action, community engagement, and strategic partnerships are the cornerstone for this approach. The focus areas include addressing the social and economic determinants of health across the life course, especially maternal and child health, communicable diseases, non-communicable diseases, and injuries. The aspirations are noteworthy - however, recent work in progress in countries has also highlighted some areas for improvement. Joint work among different ministries and departments at country level is essential to achieve the agenda of sustainable development. For collaboration, not only the ministries and departments need to be engaged, but the partnerships with other stakeholders such as civil society and private sector are a necessity and not a choice to effectively pursue achievement of SDGs.

Descriptive epidemiology of cholera outbreak in Nigeria, January-November, 2018: implications for the global roadmap strategy.

BACKGROUND: The cholera outbreak in 2018 in Nigeria reaffirms its public health threat to the country. Evidence on the current epidemiology of cholera required for the design and implementation of appropriate interventions towards attaining the global roadmap strategic goals for cholera elimination however seems lacking. Thus, this study aimed at addressing this gap by describing the epidemiology of the 2018 cholera outbreak in Nigeria. METHODS: This was a retrospective analysis of surveillance data collected between January 1st and November 19th, 2018. A cholera case was defined as an individual aged 2 years or older presenting with acute watery diarrhoea and severe dehydration or dying from acute watery diarrhoea. Descriptive analyses were performed and presented with respect to person, time and place using appropriate statistics. RESULTS: There were 43,996 cholera cases and 836 cholera deaths across 20 states in Nigeria during the outbreak period, with an attack rate (AR) of 127.43/100,000 population and a case fatality rate (CFR) of 1.90%. Individuals aged 15 years or older (47.76%) were the most affected age group, but the proportion of affected males and females was about the same (49.00 and 51.00% respectively). The outbreak was characterised by four distinct epidemic waves, with higher number of deaths recorded in the third and fourth waves. States from the north-west and north-east regions of the country recorded the highest ARs while those from the north-central recorded the highest CFRs. CONCLUSION: The severity and wide-geographical distribution of cholera cases and deaths during the 2018 outbreak are indicative of an elevated burden, which was more notable in the northern region of the country. Overall, the findings reaffirm the strategic role of a multi-sectoral approach in the design and implementation of public health interventions aimed at preventing and controlling cholera in Nigeria.

Health in All Policies (HiAP) governance: lessons from network governance.

The Health in All Policies (HiAP) approach requires formal and sustained governance structures and mechanisms to ensure that the policies of various non-health sectors maximize positive and minimize negative impacts on population health. In this paper, we demonstrate the usefulness of a network perspective in understanding and contributing to the effectiveness of HiAP. We undertook an exploratory, qualitative case study of a HiAP structure in Iran, the Kerman province Council of Health and Food Security (CHFS) with diverse members from health and non-health sectors. We analyzed relevant policy texts and interviewed 32 policy actors involved in the CHFS. Data were analyzed using within-case analysis and constant comparative methodology. Our findings suggest that CHFS governance from a network perspective drew in practice on elements of two competing network governance modes: the network administrative organization (NAO) and the lead organization mode. Our results also show that a shift from a hierarchical and market-based mode of interaction to a network logic within CHFS has not yet taken place. In addition, CHFS suffers from large membership and an inability to address complex 'wicked problems', as well as low trust, legitimacy and goal consensus among its members. Drawing on other HiAP studies and commentaries, insights from organization network theory, and in-depth findings from our case study, we conclude that a NAO may be the most effective mode of governance for tackling complex social problems in HiAP structures. Since similar studies are limited, and our single case study may not be transferable across all contexts, we suggest that further research be undertaken to explore HiAP structures from a network perspective in different institutional and cultural settings. With increasing emphasis given to HiAP approaches in national and international health policy discourse, it is important that comparative knowledge about the effectiveness of HiAP governance arrangements be developed.

Governance for public health and health equity: The Tröndelag model for public health work.

BACKGROUND: Multi-sectoral governance of population health is linked to the realization that health is the property of many societal systems. This study aims to contribute knowledge and methods that can strengthen the capacities of municipalities regarding how to work more systematically, knowledge-based and multi-sectoral in promoting health and health equity in the population. METHODS: Process evaluation was conducted, applying a mixed-methods research design, combining qualitative and quantitative data collection methods. RESULTS: Processes strengthening systematic and multi-sectoral development, implementation and evaluation of research-based measures to promote health, quality of life, and health equity in, for and with municipalities were revealed. A step-by-step model, that emphasizes the promotion of knowledge-based, systematic, multi-sectoral public health work, as well as joint ownership of local resources, initiatives and policies has been developed. CONCLUSIONS: Implementation of systematic, knowledge-based and multi-sectoral governance of public health measures in municipalities demand shared understanding of the challenges, updated overview of the population health and impact factors, anchoring in plans, new skills and methods for selection and implementation of measures, as well as development of trust, ownership, shared ethics and goals among those involved.

Multi-sectoral action in non-communicable disease prevention policy development in five African countries.

BACKGROUND: The rise of non-communicable diseases (NCDs) in Africa requires a multi-sectoral action (MSA) in their prevention and control. This study aimed to generate evidence on the extent of MSA application in NCD prevention policy development in five sub-Saharan African countries (Kenya, South Africa, Cameroon, Nigeria and Malawi) focusing on policies around the major NCD risk factors. METHODS: The broader study applied a multiple case study design to capture rich descriptions of policy contents, processes and actors as well as contextual factors related to the policies around the major NCD risk factors at single- and multi-country levels. Data were collected through document reviews and key informant interviews with decision-makers and implementers in various sectors. Further consultations were conducted with NCD experts on MSA application in NCD prevention policies in the region. For this paper, we report on how MSA was applied in the policy process. RESULTS: The findings revealed some degree of application of MSA in NCD prevention policy development in these countries. However, the level of sector engagement varies across different NCD policies, from passive participation to active engagement, and by country. There was higher engagement of sectors in developing tobacco policies across the countries, followed by alcohol policies. Multi-sectoral action for tobacco and to some extent, alcohol, was enabled through established structures at national levels including inter-ministerial and parliamentary committees. More often coordination was enabled through expert or technical working groups driven by the health sectors. The main barriers to multi-sectoral action included lack of awareness by various sectors about their potential contribution, weak political will, coordination complexity and inadequate resources. CONCLUSION: MSA is possible in NCD prevention policy development in African countries. However, the findings illustrate various challenges in bringing sectors together to develop policies to address the increasing NCD burden in the region. Stronger coordination mechanisms with clear guidelines for sector engagement are required for effective MSA in NCD prevention. Such a mechanisms should include approaches for capacity building and resource generation to enable multi-sectoral action in NCD policy formulation, implementation and monitoring of outcomes.