Achieving integrated disease surveillance in the Eastern Mediterranean Region.

Access to reliable and timely information is key for healthcare decision-making at the regional, national and sub-national levels. However, lack of access to such information hampers to progress towards achievement of the Sustainable Development Goals (SDGs) in the Eastern Mediterranean Region (EMR), as indicated in the Regional Progress Report on Health-Related Sustainable Development Goals.

Core health indicators in countries with high proportion of expatriates: Case study of Qatar.

Background: Population size and structure have a huge impact on health indicators. In countries with a high proportion of expatriates, there are some limitations in estimating, aggregating and reporting of the health indicators, and corrections may be required in the established estimation methodologies. We review the case of Qatar to see how its specific population characteristics affect its health indicators. Methods: We used routinely collected data and reviewed and calculated a selected list of health indicators for Qatari and non-Qatari populations residing in Qatar. Mortality and cancer incidence rates, stratified by nationality, were used for this purpose. Also, a direct method was used to estimate completeness of the death registry, compared to the mortuary data. Results: Age and sex distribution of Qatari and non-Qatari populations are completely different. Compared to the mortuary data, completeness of death registration for the total population was estimated at 98.9 and 94.3%, with and without considering overseas deaths, respectively. Both estimates were considerably higher than estimates from the indirect methods. Mortality patterns were different even after standardization of age and stratification of sex groups; male age-standardized mortality rates were 502.7 and 242.3 per 100,000 individuals, respectively for Qataris and non-Qataris. The rates were closer in female populations (315.6 and 291.5, respectively). The leading types of cancer incidents were different in Qataris and non-Qataris. Conclusions: Expatriates are a dynamic population with high-turnover, different from Qatari population in their age-sex structure and health status. They are more likely to be young or middle-aged and are less affected by age related diseases and cancers. Also, they might be at higher risks for specific diseases or injuries. Aggregating indicators of Qatari and non-Qatari populations might be mis-leading for policy making purposes, and common estimation correction approaches cannot alleviate the limitations. High-proportion of expatriate population also imposes significant errors to some of the key demographic estimates (such as completeness of death registry). We recommend a standardized approach to consider nationality in addition to age and sex distributions for analysis of health data in countries with a high proportion of expatriates.

WHO's support for COVID-19 research and knowledge management in the Eastern Mediterranean Region.

Health research, innovation and knowledge management remain major priorities of the WHO's response to the COVID-19 pandemic. WHO's Eastern Mediterranean Regional Office (EMRO) supports priority research initiatives that address gaps in current knowledge regarding the COVID-19 pandemic. Through a specific call for proposals, 122 research proposals were received and reviewed in 2020, of which 17 were recommended for funding from eight countries. Ten countries in the region participated in the global solidarity trial to assess potential therapies for COVID-19. In addition, WHO advocated for early serological and epidemiological investigations ('COVID-19 Unity Studies') on the general population, healthcare workers, pregnant women and neonates, and extending technical, financial and material support for them.Starting in early 2020, scholarly articles on COVID-19 have been published in every issue of the Eastern Mediterranean Health Journal More than 6300 publications on COVID-19 were made available on the WHO knowledge management portal in the last year alone. WHO is also supporting countries in conducting studies to assess the field effectiveness of vaccines deployed nationally. To build and strengthen country capacities, regional webinars and intercountry meetings were conducted on research ethics, national health information systems and evidence-based health policy making. With support from WHO EMRO's new research and knowledge management pillar, countries in the region were well equipped to contribute to a global understanding of the novel virus's characteristics, as well as employ a national response based on informed evidence.

Data gaps towards health development goals, 47 low- and middle-income countries.

OBJECTIVE: To assess the availability and gaps in data for measuring progress towards health-related sustainable development goals and other targets in selected low- and middle-income countries. METHODS: We used 14 international population surveys to evaluate the health data systems in the 47 least developed countries over the years 2015-2020. We reviewed the survey instruments to determine whether they contained tools that could be used to measure 46 health-related indicators defined by the World Health Organization. We recorded the number of countries with data available on the indicators from these surveys. FINDINGS: Twenty-seven indicators were measurable by the surveys we identified. The two health emergency indicators were not measurable by current surveys. The percentage of countries that used surveys to collect data over 2015-2020 were lowest for tuberculosis (2/47; 4.3%), hepatitis B (3/47; 6.4%), human immunodeficiency virus (11/47; 23.4%), child development status and child abuse (both 13/47; 27.7%), compared with safe drinking water (37/47; 78.7%) and births attended by skilled health personnel (36/47; 76.6%). Nineteen countries collected data on 21 or more indicators over 2015-2020 while nine collected data on no indicators; over 2018-2020 these numbers reduced to six and 20, respectively. CONCLUSION: Examining selected international surveys provided a quick summary of health data available in the 47 least developed countries. We found major gaps in health data due to long survey cycles and lack of appropriate survey instruments. Novel indicators and survey instruments would be needed to track the fast-changing situation of health emergencies.

Time trends in facility-based and private-sector childbirth care: analysis of Demographic and Health Surveys from 25 sub-Saharan African countries from 2000 to 2016.

BACKGROUND: Africa, and sub-Saharan Africa in particular, remains one of the regions with modest improvements to maternal and newborn survival and morbidity. Good quality intrapartum and early postpartum care in a health facility as well as delivery under the supervision of trained personnel is associated with improved maternal and newborn health outcomes and decreased mortality. We describe and contrast recent time trends in the scale and socio-economic inequalities in facility-based and private facility-based childbirth in sub-Saharan Africa. METHODS: We used Demographic and Health Surveys in two time periods (2000-2007 and 2008-2016) to analyse levels and time trends in facility-based and private facility-based deliveries for all live births in the five-year survey recall period to women aged 15-49. Household wealth quintiles were used for equity analysis. Absolute numbers of births by facility sector were calculated applying UN Population Division crude birth rates to the total country population. RESULTS: The percentage of all live births occurring in health facilities varied across countries (5%-85%) in 2000-2007. In 2008-2016, this ranged from 22% to 92%. The lowest percentage of all births occurring in private facilities in 2000-2007 period was in Ethiopia (0.3%) and the highest in the Democratic Republic of Congo at 20.5%. By 2008-2016, this ranged from 0.6% in Niger to 22.3% in Gabon. Overall, the growth in the absolute numbers of births in facilities outpaced the growth in the percentage of births in facilities. The largest increases in absolute numbers of births occurred in public sector facilities in all countries. Overall, the percentage of births occurring in facilities was significantly lower for poorest compared to wealthiest women. As the percentage of facility births increased in all countries over time, the extent of wealth-based differences had reduced between the two time periods in most countries (median risk ratio in 2008-2016 was 2.02). The majority of countries saw a narrowing in both the absolute and relative difference in facility-based deliveries between poorest and wealthiest. CONCLUSIONS: The growth in facility-based deliveries, which was largely driven by the public sector, calls for increased investments in effective interventions to improve service delivery and quality of life for the mother and newborn. The goal of universal health coverage to provide better quality services can be achieved by deploying interventions that are holistic in managing and regulating the private sector to enhance performance of the health care system in its entirety rather than interventions that only target service delivery in one sector.

Maternal and child health interventions in Nigeria: a systematic review of published studies from 1990 to 2014.

BACKGROUND: Poor maternal and child health indicators have been reported in Nigeria since the 1990s. Many interventions have been instituted to reverse the trend and ensure that Nigeria is on track to achieve the Millennium Development Goals. This systematic review aims at describing and indirectly measuring the effect of the Maternal, Newborn, and Child Health (MNCH) interventions implemented in Nigeria from 1990 to 2014. METHODS: PubMed and ISI Web of Knowledge were searched from 1990 to April 2014 whereas POPLINE® was searched until 16 February 2015 to identify reports of interventions targeting Maternal, Newborn, and Child Health in Nigeria. Narrative and graphical synthesis was done by integrating the results of extracted studies with trends of maternal mortality ratio (MMR) and under five mortality (U5MR) derived from a joint point regression analysis using Nigeria Demographic and Health Survey data (1990-2013). This was supplemented by document analysis of policies, guidelines and strategies of the Federal Ministry of Health developed for Nigeria during the same period. RESULTS: We identified 66 eligible studies from 2,662 studies. Three interventions were deployed nationwide and the remainder at the regional level. Multiple study designs were employed in the enrolled studies: pre- and post-intervention or quasi-experimental (n = 40; 61%); clinical trials (n = 6;9%); cohort study or longitudinal evaluation (n = 3;5%); process/output/outcome evaluation (n = 17;26%). The national MMR shows a consistent reduction (Annual Percentage Change (APC) = -3.10%, 95% CI: -5.20 to -1.00 %) with marked decrease in the slope observed in the period with a cluster of published studies (2004-2014). Fifteen intervention studies specifically targeting under-five children were published during the 24 years of observation. A statistically insignificant downward trend in the U5MR was observed (APC = -1.25%, 95% CI: -4.70 to 2.40%) coinciding with publication of most of the studies and development of MNCH policies. CONCLUSIONS: The development of MNCH policies, implementation and publication of interventions corresponds with the downward trend of maternal and child mortality in Nigeria. This systematic review has also shown that more MNCH intervention research and publications of findings is required to generate local and relevant evidence.

Performance based financing and uptake of maternal and child health services in yobe sate, northern Nigeria.

Reported maternal and child health (MCH) outcomes in Nigeria are amongst the worst in the world, with Nigeria second only to India in the number of maternal deaths. At the national level, maternal mortality ratios (MMRs) are estimated at 630 deaths per 100,000 live births (LBs) but vary from as low as 370 deaths per 100,000 LBs in the southern states to over 1,000 deaths per 100,000 LBs in the northern states. We report findings from a performance based financing (PBF) pilot study in Yobe State, northern Nigeria aimed at improving MCH outcomes as part of efforts to find strategies aimed at accelerating attainment of Millennium Development Goals for MCH. Results show that the demand-side PBF led to increased utilization of key MCH services (antenatal care and skilled delivery) but had no significant effect on completion of child immunization using measles as a proxy indicator. We discuss these results within the context of PBF schemes and the need for a careful consideration of all the critical processes and risks associated with demand-side PBF schemes in improving MCH outcomes in the study area and similar settings.

Variations in under-five mortality estimates in Nigeria: explanations and implications for program monitoring and evaluation.

Millennium Development Goal (MDG) 5 aims at reducing under-five mortality by two-thirds between 1990 and 2015. However, monitoring this goal is a challenging task. With an estimated 162 million people in 2011, Nigeria is Africa's most populous country with generally poor maternal and child health indicators. Maternal mortality ratio was estimated at 545 deaths per 100,000 live births in 2008 and recent data show that under-five mortality rates have varied tremendously. This paper provides a synthesis of the data collection and estimation procedures used by the two major sources of child mortality data in Nigeria (the Multiple Indicator Cluster Surveys; and Demographic and Health Surveys) and the importance of reflecting on these dynamics in order to utilize the mortality estimates in program monitoring and evaluation. While efforts to seek explanations for the unstable trends in mortality rates are ongoing, this study calls for stakeholders to seek studies that employ more detailed and robust disaggregation methods that take into account the relative impact of socio-demographic, medical, and public health variables on mortality rates. This will be crucial in assessing the effectiveness of selected interventions in reducing mortality. Further, the study encourages collection, use, and triangulation of health and demographic surveillance system (HDSS) and other available data which could assist in monitoring progress towards achieving MDGs since HDSS as well as census or survey data would provide an opportunity to measure and evaluate interventions through longitudinal follow-up of populations.

Maternal mortality in northern Nigeria: findings of a health and demographic surveillance system in Zamfara State, Nigeria.

The aim of this study was to estimate: (1) the lifetime risk (LTR) of maternal death; and (2) the maternal mortality ratio (MMR) in the Zamfara State of northern Nigeria. Data from the Nahuche Health and Demographic Surveillance System were utilized using the 'sisterhood method' for estimating maternal mortality. Female respondents (15-49 years) from six districts in the surveillance area were interviewed, creating a retrospective cohort of their sisters who had reached the reproductive age of 15 years. Based on population and fertility estimates, we calculated the LTR of maternal death and the MMR. A total of 17,087 respondents reported 38,761 maternal sisters of whom 3592 had died and of whom 1261 were maternal-related deaths. This corresponded to an LTR of maternal death of 8% (referring to a period of about 10.5 years prior to the survey) and an MMR of 1049 deaths per 100,000 live births (95% confidence interval, 1021-1136). The study provides documented evidence of high maternal mortality in the study area and the state as a whole. Thus, there is a need to improve the health system with an emphasis on interventions that will accelerate reduction in MMR such as the availability of skilled birth attendants and emergency obstetric care, promotion of facility delivery and antenatal care attendance. This can be achieved through a holistic approach and is critical in order to accelerate progress in meeting the Millennium Development Goal of maternal mortality reduction.