Systematic estimates of the global, regional and national under-5 mortality burden attributable to birth defects in 2000-2019: a summary of findings from the 2020 WHO estimates.

OBJECTIVES: To examine the potential for bias in the estimate of under-5 mortality due to birth defects recently produced by the WHO and the Maternal and Child Epidemiology Estimation research group. DESIGN: Systematic analysis. METHODS: We examined the estimated number of under-5 deaths due to birth defects, the birth defect specific under-5 mortality rate, and the per cent of under-5 mortality due to birth defects, by geographic region, national income and under-5 mortality rate for three age groups from 2000 to 2019. RESULTS: The under-5 deaths per 1000 live births from birth defects fell from 3.4 (95% uncertainty interval (UI) 3.1-3.8) in 2000 to 2.9 (UI 2.6-3.3) in 2019. The per cent of all under-5 mortality attributable to birth defects increased from 4.6% (UI 4.1%-5.1%) in 2000 to 7.6% (UI 6.9%-8.6%) in 2019. There is significant variability in mortality due to birth defects by national income level. In 2019, the under-5 mortality rate due to birth defects was less in high-income countries than in low-income and middle-income countries, 1.3 (UI 1.2-1.3) and 3.0 (UI 2.8-3.4) per 1000 live births, respectively. These mortality rates correspond to 27.7% (UI 26.6%-28.8%) of all under-5 mortality in high-income countries being due to birth defects, and 7.4% (UI 6.7%-8.2%) in low-income and middle-income countries. CONCLUSIONS: While the under-5 mortality due to birth defects is declining, the per cent of under-5 mortality attributable to birth defects has increased, with significant variability across regions globally. The estimates in low-income and middle-income countries are likely underestimated due to the nature of the WHO estimates, which are based in part on verbal autopsy studies and should be taken as a minimum estimate. Given these limitations, comprehensive and systematic estimates of the mortality burden due to birth defects are needed to estimate the actual burden.

The UN Decade of healthy ageing: strengthening measurement for monitoring health and wellbeing of older people.

Over the past 100 years, life expectancy has increased dramatically in nearly all nations. Yet, these extra years of life gained have not all been healthy, particularly for older people aged 60 years and over. In 2020, the World Health Organisation (WHO) and United Nations (UN) member states embraced a sweeping 10-year global plan of action to ensure all older people can live long and healthy lives, formally known as the UN Decade of Healthy Ageing (2021-2030). With the adoption of the UN Decade of Healthy Ageing resolution, countries are committed to implementing collaborative actions to improve the lives of older people, their families and the communities in which they reside. The Decade addresses four interconnected areas of action. Adopting the UN's resolution on the Decade of Healthy Ageing has caused excitement, but a question that has weighed on everyone's mind is how governments will be held accountable? Besides, there have been no goals or targets set for the UN Decade of Healthy Ageing from a programmatic perspective for the action areas, and guidance on measures, data collection, analysis and reporting are urgently needed to support global, regional and national monitoring of the national strategies, programmes and policies. To this end, WHO in collaboration with UN agencies and international agencies established a Technical Advisory Group for Measurement of Healthy Ageing (TAG4MHA) to provide advice on the measurement, monitoring and evaluation of the UN Decade of Healthy Ageing at the global, regional and national levels.

Creating a Global Legal and Policy Database and Document Repository: Challenges and Lessons Learned From the World Health Organization Sexual, Reproductive, Maternal, Newborn, Child and Adolescent Health Policy Survey.

The World Health Organization (WHO) has collected information on policies on sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) over many years. Creating a global survey that works for every country context is a well-recognized challenge. A comprehensive SRMNCAH policy survey was conducted by WHO from August 2018 through May 2019. WHO regional and country offices coordinated with Ministries of Health and/or national institutions who completed the questionnaire. The survey was completed by 150 of 194 WHO Member States using an online platform that allowed for submission of national source documents. A validation of the responses for selected survey questions against content of the national source documents was conducted for 101 countries (67%) for the first time in the administration of the survey. Data validation draws attention to survey questions that may have been misunderstood or where there was a lot of missing data, but varying methods for validating survey responses against source documents and separate analysis of laws from policies and guidelines may have hindered the overall conclusions of this process. The SRMNCAH policy survey both provided a platform for countries to track their progress in adopting WHO recommendations in national SRMNCAH-related legislation, policies, guidelines and strategies and was used to create a global database and searchable document repository. The outputs of the SRMNCAH policy survey are resources whose importance will be enriched through policy dialogues and wide utilization. Lessons learned from the methodology used for this survey can help to improve future updates and inform similar efforts.

A call for standardised age-disaggregated health data.

The 2030 Sustainable Development Goals agenda calls for health data to be disaggregated by age. However, age groupings used to record and report health data vary greatly, hindering the harmonisation, comparability, and usefulness of these data, within and across countries. This variability has become especially evident during the COVID-19 pandemic, when there was an urgent need for rapid cross-country analyses of epidemiological patterns by age to direct public health action, but such analyses were limited by the lack of standard age categories. In this Personal View, we propose a recommended set of age groupings to address this issue. These groupings are informed by age-specific patterns of morbidity, mortality, and health risks, and by opportunities for prevention and disease intervention. We recommend age groupings of 5 years for all health data, except for those younger than 5 years, during which time there are rapid biological and physiological changes that justify a finer disaggregation. Although the focus of this Personal View is on the standardisation of the analysis and display of age groups, we also outline the challenges faced in collecting data on exact age, especially for health facilities and surveillance data. The proposed age disaggregation should facilitate targeted, age-specific policies and actions for health care and disease management.

Child health and the implementation of Community and District-management Empowerment for Scale-up (CODES) in Uganda: a randomised controlled trial.

INTRODUCTION: Uganda's district-level administrative units buttress the public healthcare system. In many districts, however, local capacity is incommensurate with that required to plan and implement quality health interventions. This study investigates how a district management strategy informed by local data and community dialogue influences health services. METHODS: A 3-year randomised controlled trial (RCT) comprised of 16 Ugandan districts tested a management approach, Community and District-management Empowerment for Scale-up (CODES). Eight districts were randomly selected for each of the intervention and comparison areas. The approach relies on a customised set of data-driven diagnostic tools to identify and resolve health system bottlenecks. Using a difference-in-differences approach, the authors performed an intention-to-treat analysis of protective, preventive and curative practices for malaria, pneumonia and diarrhoea among children aged 5 and younger. RESULTS: Intervention districts reported significant net increases in the treatment of malaria (+23%), pneumonia (+19%) and diarrhoea (+13%) and improved stool disposal (+10%). Coverage rates for immunisation and vitamin A consumption saw similar improvements. By engaging communities and district managers in a common quest to solve local bottlenecks, CODES fostered demand for health services. However, limited fiscal space-constrained district managers' ability to implement solutions identified through CODES. CONCLUSION: Data-driven district management interventions can positively impact child health outcomes, with clinically significant improvements in the treatment of malaria, pneumonia and diarrhoea as well as stool disposal. The findings recommend the model's suitability for health systems strengthening in Uganda and other decentralised contexts. TRIAL REGISTRATION NUMBER: ISRCTN15705788.

Monitoring the status of selected health related sustainable development goals: methods and projections to 2030.

Background: Monitoring Sustainable Development Goal indicators (SDGs) and their targets plays an important role in understanding and advocating for improved health outcomes for all countries. We present the United Nations (UN) Inter-agency groups' efforts to support countries to report on SDG health indicators, project progress towards 2030 targets and build country accountability for action. Objective: We highlight common principles and practices of each Inter-agency group and the progress made towards SDG 3 targets using seven health indicators as examples. The indicators used provide examples of best practice for modelling estimates and projections using standard methods, transparent data collection and country consultations. Methods: Practices common to the UN agencies include multi-UN agency participation, expert groups to advise on estimation methods, transparent publication of methods and data inputs, use of UN-derived population estimates, country consultations, and a common reporting platform to present results. Our seven examples illustrate how estimates, using mostly Bayesian models, make use of country data to track progress towards SDG targets for 2030. Results: Progress has been made over the past decade. However, none of the seven indicators are on track to achieve their respective SDG targets by 2030. Accelerated efforts are needed, especially in low- and middle-income countries, to reduce the burden of maternal, child, communicable and noncommunicable disease mortality, and to provide access to modern methods of family planning to all women. Conclusion: Our analysis shows the benefit of UN interagency monitoring which prioritizes transparent country data sources, UN population estimates and life tables, and rigorous but replicable modelling methods. Countries are supported to build capacity for data collection, analysis and reporting. Through these monitoring efforts we support countries to tackle even the most intransient health issues, including the pandemic caused by SARS-CoV-2 that is reversing the hard-earned gains of all countries.

Effective coverage measurement in maternal, newborn, child, and adolescent health and nutrition: progress, future prospects, and implications for quality health systems.

Intervention coverage-the proportion of the population with a health-care need who receive care-does not account for intervention quality and potentially overestimates health benefits of services provided to populations. Effective coverage introduces the dimension of quality of care to the measurement of intervention coverage. Many definitions and methodological approaches to measuring effective coverage have been developed, resulting in confusion over definition, calculation, interpretation, and monitoring of these measures. To develop a consensus on the definition and measurement of effective coverage for maternal, newborn, child, and adolescent health and nutrition (MNCAHN), WHO and UNICEF convened a group of experts, the Effective Coverage Think Tank Group, to make recommendations for standardising the definition of effective coverage, measurement approaches for effective coverage, indicators of effective coverage in MNCAHN, and to develop future effective coverage research priorities. Via a series of consultations, the group recommended that effective coverage be defined as the proportion of a population in need of a service that resulted in a positive health outcome from the service. The proposed effective coverage measures and care cascade steps can be applied to further develop effective coverage measures across a broad range of MNCAHN services. Furthermore, advances in measurement of effective coverage could improve monitoring efforts towards the achievement of universal health coverage.

Monitoring maternal and newborn health outcomes globally: a brief history of key events and initiatives.

OBJECTIVE: Over time, we have seen a major evolution of measurement initiatives, indicators and methods, such that today a wide range of maternal and perinatal indicators are monitored and new indicators are under development. Monitoring global progress in maternal and newborn health outcomes and development has been dominated in recent decades by efforts to set, measure and achieve global goals and targets: the Millennium Development Goals followed by the Sustainable Development Goals. This paper aims to review, reflect and learn on accelerated progress towards global goals and events, including universal health coverage, and better tracking of maternal and newborn health outcomes. METHODS: We searched for literature of key events and global initiatives over recent decades related to maternal and newborn health. The searches were conducted using PubMed/MEDLINE and the World Health Organization Global Index Medicus. RESULTS: This paper describes global key events and initiatives over recent decades showing how maternal and neonatal mortality and morbidity, and stillbirths, have been viewed, when they have achieved higher priority on the global agenda, and how they have been measured, monitored and reported. Despite substantial improvements, the enormous maternal and newborn health disparities that persist within and between countries indicate the urgent need to renew the focus on reducing inequities. CONCLUSION: The review has featured the long story of the progress in monitoring improving maternal and newborn health outcomes, but has also underlined current gaps and significant inequities. The many global initiatives described in this paper have highlighted the magnitude of the problems and have built the political momentum over the years for effectively addressing maternal and newborn health and well-being, with particular focus on improved measurement and monitoring.

Chaque jour, environ 810 femmes meurent de causes évitables liées à la grossesse et à l'accouchement, près de 7.000 nouveau-nés décèdent et plus de 7.000 bébés sont mort-nés, selon les dernières estimations annuelles. Au fil du temps, nous avons assisté à une évolution majeure des initiatives, indicateurs et méthodes de mesure, de sorte qu'aujourd'hui un grand nombre d'indicateurs maternels et périnatals sont monitorés et de nouveaux indicateurs sont en cours d'élaboration. Le suivi des progrès mondiaux en matière de santé et de développement a été dominé au cours des dernières décennies par les efforts visant à définir, mesurer et atteindre les objectifs et cibles mondiaux: les Objectifs de Développement pour le Millénaire, suivis des Objectifs de Développement Durable. Le but de cette revue est d'encourager la réflexion et l'éducation en vue d'accélérer les progrès vers les objectifs mondiaux, y compris la couverture de santé universelle et un meilleur suivi des résultats pour la santé de la mère et du nouveau-né. Cet article décrit les événements et les initiatives clés des dernières décennies montrant comment la mortalité et la morbidité maternelles et néonatales, ainsi que les mortinaissances, ont été considérées lorsqu'elles ont atteint un rang de priorité plus élevé dans l'agenda mondial, et comment elles ont été mesurées, suivies et rapportées. En dépit des améliorations substantielles, les énormes disparités de santé maternelle et néonatale qui persistent dans et entre les pays indiquent qu'il est urgent de recentrer l'attention sur la réduction des inégalités. Nous devons intensifier les initiatives fondées sur des preuves et sur les droits de l'homme visant à améliorer la sécurité de la grossesse, de l'accouchement et des périodes néonatale et post-partum (en particulier l'amélioration de la couverture, de la qualité et de l'équité des soins pendant le travail et l'accouchement, ainsi que les soins pour les nouveau-nés petits et malades), ainsi que la qualité, et la rapidité des données de surveillance (notamment l'enregistrement précis des naissances et des décès).

Implementation research: new imperatives and opportunities in global health.

Implementation research is important in global health because it addresses the challenges of the know-do gap in real-world settings and the practicalities of achieving national and global health goals. Implementation research is an integrated concept that links research and practice to accelerate the development and delivery of public health approaches. Implementation research involves the creation and application of knowledge to improve the implementation of health policies, programmes, and practices. This type of research uses multiple disciplines and methods and emphasises partnerships between community members, implementers, researchers, and policy makers. Implementation research focuses on practical approaches to improve implementation and to enhance equity, efficiency, scale-up, and sustainability, and ultimately to improve people's health. There is growing interest in the principles of implementation research and a range of perspectives on its purposes and appropriate methods. However, limited efforts have been made to systematically document and review learning from the practice of implementation research across different countries and technical areas. Drawing on an expert review process, this Health Policy paper presents purposively selected case studies to illustrate the essential characteristics of implementation research and its application in low-income and middle-income countries. The case studies are organised into four categories related to the purposes of using implementation research, including improving people's health, informing policy design and implementation, strengthening health service delivery, and empowering communities and beneficiaries. Each of the case studies addresses implementation problems, involves partnerships to co-create solutions, uses tacit knowledge and research, and is based on a shared commitment towards improving health outcomes. The case studies reveal the complex adaptive nature of health systems, emphasise the importance of understanding context, and highlight the role of multidisciplinary, rigorous, and adaptive processes that allow for course correction to ensure interventions have an impact. This Health Policy paper is part of a call to action to increase the use of implementation research in global health, build the field of implementation research inclusive of research utilisation efforts, and accelerate efforts to bridge the gap between research, policy, and practice to improve health outcomes.

Global implementation survey of Integrated Management of Childhood Illness (IMCI): 20 years on.

OBJECTIVE: To assess the extent to which Integrated Management of Childhood Illness (IMCI) has been adopted and scaled up in countries. SETTING: The 95 countries that participated in the survey are home to 82% of the global under-five population and account for 95% of the 5.9 million deaths that occurred among children less than 5 years of age in 2015; 93 of them are low-income and middle-income countries (LMICs). METHODS: We conducted a cross-sectional self-administered survey. Questionnaires and data analysis focused on (1) giving a general overview of current organisation and financing of IMCI at country level, (2) describing implementation of IMCI's three original components and (3) reporting on innovations, barriers and opportunities for expanding access to care for children. A single data file was created using all information collected. Analysis was performed using STATA V.11. PARTICIPANTS: In-country teams consisting of representatives of the ministry of health and country offices of WHO and Unicef. RESULTS: Eighty-one per cent of countries reported that IMCI implementation encompassed all three components. Almost half (46%; 44 countries) reported implementation in 90% or more districts as well as all three components in place (full implementation). These full-implementer countries were 3.6 (95% CI 1.5 to 8.9) times more likely to achieve Millennium Development Goal 4 than other (not full implementer) countries. Despite these high reported implementation rates, the strategy is not reaching the children who need it most, as implementation is lowest in high mortality countries (39%; 7/18). CONCLUSION: This survey provides a unique opportunity to better understand how implementation of IMCI has evolved in the 20 years since its inception. Results can be used to assist in formulating strategies, policies and activities to support improvements in the health and survival of children and to help achieve the health-related, post-2015 Sustainable Development Goals.

Research on health equity in the SDG era: the urgent need for greater focus on implementation.

BACKGROUND: The tremendous increase in knowledge on inequities in health and their drivers in recent decades has not been matched by improvements in health inequities themselves, or by systematic evidence of what works to reduce health inequities. Within health equity research there is a skew towards diagnostic studies in comparison to intervention studies showing evidence of how interventions can reduce disparities. MAIN TEXT: The lack of sufficient specific evidence on how to implement specific policies and interventions in specific contexts to reduce health inequities creates policy confusion and partly explains the lack of progress on health inequities. In the field of research on equity in health, the time has come to stop focusing so much energy on prevalence and pathways, and instead shift to proposing and testing solutions. Four promising approaches to do so are implementation research, natural experimental policy studies, research on buy-in by policy-makers to action on health inequities, and geospatial analysis. CONCLUSION: The case for action on social determinants and health inequities has well and truly been made. The community of researchers on health equity now need to turn their attention to supporting implementation efforts towards achievements of the Sustainable Development Goals and substantive reductions in health inequities.

The role of traditional treatment on health care seeking by caregivers for sick children in Sierra Leone: results of a baseline survey.

In Sierra Leone, traditional treatment is at times used in lieu of seeking allopathic healthcare for major illnesses causing child death. This paper describes the nature of traditional treatment for diarrhea and fever (presumed malaria). Weighted analysis and multi-logistic regression was applied to a household cluster survey (n=5951) conducted in 4 districts in June 2010. Using structured questionnaires, heads of households, and caregivers of children under five years of age were interviewed about child morbidity and care seeking. A thematic analysis of qualitative data based on focus group discussions and in-depth interviews with family members from twelve villages in these same four districts, was also done. Illness-specific herbal remedies were described by respondents. Among 1511 children with diarrhea, 31% used traditional treatment. Among 3851 children with fever, 22% used traditional treatment. Traditional treatment for diarrhea was associated with being from a tribe other than the Mende, using government recommended salt sugar solution, not having a vaccine card, having more than two illnesses, and not seeking any allopathic medical treatment for diarrhea. For fever, traditional treatment was associated with being a tribe other than the Mende, having more than two illnesses, not having a vaccine card, Muslim religion, and not seeking any allopathic medical treatment for fever. Qualitatively, respondents describe herbalists as trusted with remedies that are seen to be appropriate due to the perceived cause of illness and due to barriers to seeking care from government providers. The social determinants of traditional treatment use and the prominent role of herbalists in providing them need to be addressed to improve child survival in Sierra Leone.

The association of socioeconomic status and use of crack/cocaine with unprotected anal sex in a cohort of men who have sex with men in Rio de Janeiro, Brazil.

To evaluate the relation between illicit drug use, sexual practices, and socioeconomic status, we analyzed data from the baseline interview of a cohort of 675 men who have sex with men conducted from 1994 to 1999 in Rio de Janeiro, Brazil. Bivariate analyses of factors associated with crack/cocaine use with sex revealed that men who reported crack/cocaine use were significantly ( p <.05) more likely than men who did not report drug use to be unemployed (42.7% vs. 29.1%), to have an income of <$250 per month (70.7% vs. 60.9%), to have <8 years of education (69.5% vs. 50.9%), to report bisexual activity (81.7% vs. 41.7%), and to engage in commercial sex (72.0% vs. 37.9%). Multivariate analysis of factors associated with unprotected anal sex with casual male partners in the last 6 months demonstrated that the following variables were associated with this outcome: an income <$250 per month (adjusted odds ratio [AOR] = 1.73, 95% confidence interval [CI]: 1.04-2.87), less than 8 years of education (AOR = 2.21, CI: 1.38-3.53), a greater sense of vulnerability (AOR = 2.58, CI: 1.54-4.33), a willingness to participate in vaccine trials (AOR = 1.91, CI: 1.20-3.05), and use of crack/cocaine (AOR = 1.91, CI: 1.05-3.46). Our findings suggest that HIV prevention programs for these men need to address drug use and how drug use may influence sexual behaviors.