Health system strengthening-Reflections on its meaning, assessment, and our state of knowledge.

Comprehensive reviews of health system strengthening (HSS) interventions are rare, partly because of lack of clarity on definitions of the term but also the potentially huge scale of the evidence. We reflect on the process of undertaking such an evidence review recently, drawing out suggestions on definitions of HSS and approaches to assessment, as well as summarising some key conclusions from the current evidence base. The key elements of a clear definition include, in our view, consideration of scope (with effects cutting across building blocks in practice, even if not in intervention design, and also tackling more than one disease), scale (having national reach and cutting across levels of the system), sustainability (effects being sustained over time and addressing systemic blockages), and effects (impacting on health outcomes, equity, financial risk protection, and responsiveness). We also argue that agreeing a framework for design and evaluation of HSS is urgent. Most HSS interventions have theories of change relating to specific system blocks, but more work is needed on capturing their spillover effects and their contribution to meeting overarching health system process goals. We make some initial suggestions about such goals, to reflect the features that characterise a "strong health system." We highlight that current findings on "what works" are just indicative, given the limitations and biases in what has been studied and how, and argue that there is need to rethink evaluation methods for HSS beyond finite interventions and narrow outcomes. Clearer concepts, frameworks, and methods can support more coherent HSS investment.

Temporal and regional variations in use, equity and quality of antenatal care in Egypt: a repeat cross-sectional analysis using Demographic and Health Surveys.

BACKGROUND: Egypt has seen substantial decreases in maternal mortality and reached near universal coverage for antenatal care (ANC). The objective of this paper is to describe the changes over time (1991-2014) in the use of ANC in Egypt, focusing on sector of provision (public versus private), and the content and equity of this care, to inform future policies for improving maternal and newborn health. METHODS: We used Demographic and Health surveys (DHS) conducted in Egypt in 1995, 2000, 2005, 2008 and 2014 to explore national and regional trends in ANC. To assess content of care, we calculated the percentage of ANC users who reported receiving seven ANC components measured in DHS in 2014. RESULTS: During the period under consideration, the percentage of women in need of ANC who received facility-based ANC increased from 42 to 90%, the majority of which was private-sector ANC. The mean number of ANC visits among ANC users increased over time from 7.5 (95% confidence interval [CI] = 7.1-7.9) in 1991-1995 to 9.7 (95%CI 9.6-9.9) in 2010-2014. In 2010-2014, 44% of women using public ANC reported eight or more visits compared to 71% in private ANC. In the same period, 24% of ANC users received all seven care components. This percentage ranged from 10% of women reporting fewer than four ANC visits to 29% of women reporting eight or more. The poorest ANC users received all seven measured components of care less often than the wealthiest (20% versus 28%, p-value< 0.001). CONCLUSIONS: Egypt's improvements in ANC coverage were characterized by decreasing reliance on public services and a rising number of ANC visits. However, despite rising ANC coverage, less than a third of women received the seven essential ANC components measured at least once during pregnancy, with differences between poorer and wealthier women. Policymakers need to ensure that high ANC coverage translates into equity-focused interventions targeting ANC quality. Further research needs to support this effort by assessing the determinants behind poor quality of ANC and evaluating potential interventions.