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.

Punching above their weight: a network to understand broader determinants of increasing life expectancy.

BACKGROUND: Life expectancy initially improves rapidly with economic development but then tails off. Yet, at any level of economic development, some countries do better, and some worse, than expected - they either punch above or below their weight. Why this is the case has been previously researched but no full explanation of the complexity of this phenomenon is available. NEW RESEARCH NETWORK: In order to advance understanding, the newly formed Punching Above Their Weight Research Network has developed a model to frame future research. It provides for consideration of the following influences within a country: political and institutional context and history; economic and social policies; scope for democratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles and power dynamics; the extent of civil society activity and disease burdens. CONCLUSION: Further research using this framework has considerable potential to advance effective policies to advance health and equity.

Countdown to 2015: a decade of tracking progress for maternal, newborn, and child survival.

Conceived in 2003 and born in 2005 with the launch of its first report and country profiles, the Countdown to 2015 for Maternal, Newborn, and Child Survival has reached its originally proposed lifespan. Major reductions in the deaths of mothers and children have occurred since Countdown's inception, even though most of the 75 priority countries failed to achieve Millennium Development Goals 4 and 5. The coverage of life-saving interventions tracked in Countdown increased steadily over time, but wide inequalities persist between and within countries. Key drivers of coverage such as financing, human resources, commodities, and conducive health policies also showed important, yet insufficient increases. As a multistakeholder initiative of more than 40 academic, international, bilateral, and civil society institutions, Countdown was successful in monitoring progress and raising the visibility of the health of mothers, newborns, and children. Lessons learned from this initiative have direct bearing on monitoring progress during the Sustainable Development Goals era.

Countdown to 2015 and beyond: fulfilling the health agenda for women and children.

The end of 2015 will signal the end of the Millennium Development Goal era, when the world can take stock of what has been achieved. The Countdown to 2015 for Maternal, Newborn, and Child Survival (Countdown) has focused its 2014 report on how much has been achieved in intervention coverage in these groups, and on how best to sustain, focus, and intensify efforts to progress for this and future generations. Our 2014 results show unfinished business in achievement of high, sustained, and equitable coverage of essential interventions. Progress has accelerated in the past decade in most Countdown countries, suggesting that further gains are possible with intensified actions. Some of the greatest coverage gaps are in family planning, interventions addressing newborn mortality, and case management of childhood diseases. Although inequities are pervasive, country successes in reaching of the poorest populations provide lessons for other countries to follow. As we transition to the next set of global goals, we must remember the centrality of data to accountability, and the importance of support of country capacity to collect and use high-quality data on intervention coverage and inequities for decision making. To fulfill the health agenda for women and children both now and beyond 2015 requires continued monitoring of country and global progress; Countdown is committed to playing its part in this effort.

The Effect of Community-Based Prevention and Care on Ebola Transmission in Sierra Leone.

OBJECTIVES: To examine the acceptability, use, effects on early isolation, and contribution to Ebola virus disease (EVD) transmission of Community Care Centers (CCCs), which were rapidly deployed in Sierra Leone during an accelerated phase of the 2014-2015 EVD epidemic. METHODS: Focus group discussions, triads, and key informant interviews assessed acceptability of the CCCs. Facility registers, structured questionnaires, and laboratory records documented use, admission, and case identification. We estimated transmission effects by comparing time between symptom onset and isolation at CCCs relative to other facilities with the national Viral Hemorrhagic Fever data set. RESULTS: Between November 2014 and January 2015, 46 CCCs were operational. Over 13 epidemic weeks, 6129 patients were triaged identifying 719 (12%) EVD suspects. Community acceptance was high despite initial mistrust. Nearly all patients presented to CCCs outside the national alert system. Isolation of EVD suspects within 4 days of symptoms was higher in CCCs compared with other facilities (85% vs 49%; odds ratio = 6.0; 95% confidence interval = 4.0, 9.1), contributing to a 13% to 32% reduction in the EVD reproduction number (Ro). CONCLUSIONS: Community-based approaches to prevention and care can reduce Ebola transmission.

Who has been caring for the baby?

Nearly a decade ago, The Lancet published the Neonatal Survival Series, with an ambitious call for integration of newborn care across the continuum of reproductive, maternal, newborn, and child health and nutrition (RMNCH). In this first of five papers in the Every Newborn Series, we consider what has changed during this decade, assessing progress on the basis of a systematic policy heuristic including agenda-setting, policy formulation and adoption, leadership and partnership, implementation, and evaluation of effect. Substantial progress has been made in agenda setting and policy formulation for newborn health, as witnessed by the shift from maternal and child health to maternal, newborn, and child health as a standard. However, investment and large-scale implementation have been disappointingly small, especially in view of the size of the burden and potential for rapid change and synergies throughout the RMNCH continuum. Moreover, stillbirths remain invisible on the global health agenda. Hence that progress in improvement of newborn survival and reduction of stillbirths lags behind that of maternal mortality and deaths for children aged 1-59 months is not surprising. Faster progress is possible, but with several requirements: clear communication of the interventions with the greatest effect and how to overcome bottlenecks for scale-up; national leadership, and technical capacity to integrate and implement these interventions; global coordination of partners, especially within countries, in provision of technical assistance and increased funding; increased domestic investment in newborn health, and access to specific commodities and equipment where needed; better data to monitor progress, with local data used for programme improvement; and accountability for results at all levels, including demand from communities and mortality targets in the post-2015 framework. Who will step up during the next decade to ensure decision making in countries leads to implementation of stillbirth and newborn health interventions within RMNCH programmes?

From evidence to action to deliver a healthy start for the next generation.

Remarkable progress has been made towards halving of maternal deaths and deaths of children aged 1-59 months, although the task is incomplete. Newborn deaths and stillbirths were largely invisible in the Millennium Development Goals, and have continued to fall between maternal and child health efforts, with much slower reduction. This Series and the Every Newborn Action Plan outline mortality goals for newborn babies (ten or fewer per 1000 livebirths) and stillbirths (ten or fewer per 1000 total births) by 2035, aligning with A Promise Renewed target for children and the vision of Every Woman Every Child. To focus political attention and improve performance, goals for newborn babies and stillbirths must be recognised in the post-2015 framework, with corresponding accountability mechanisms. The four previous papers in this Every Newborn Series show the potential for a triple return on investment around the time of birth: averting maternal and newborn deaths and preventing stillbirths. Beyond survival, being counted and optimum nutrition and development is a human right for all children, including those with disabilities. Improved human capital brings economic productivity. Efforts to reach every woman and every newborn baby, close gaps in coverage, and improve equity and quality for antenatal, intrapartum, and postnatal care, especially in the poorest countries and for underserved populations, need urgent attention. We have prioritised what needs to be done differently on the basis of learning from the past decade about what has worked, and what has not. Needed now are four most important shifts: (1) intensification of political attention and leadership; (2) promotion of parent voice, supporting women, families, and communities to speak up for their newborn babies and to challenge social norms that accept these deaths as inevitable; (3) investment for effect on mortality outcome as well as harmonisation of funding; (4) implementation at scale, with particular attention to increasing of health worker numbers and skills with attention to high-quality childbirth care for newborn babies as well as mothers and children; and (5) evaluation, tracking coverage of priority interventions and packages of care with clear accountability to accelerate progress and reach the poorest groups. The Every Newborn Action Plan provides an evidence-based roadmap towards care for every woman, and a healthy start for every newborn baby, with a right to be counted, survive, and thrive wherever they are born.

Advancing social and economic development by investing in women's and children's health: a new Global Investment Framework.

A new Global Investment Framework for Women's and Children's Health demonstrates how investment in women's and children's health will secure high health, social, and economic returns. We costed health systems strengthening and six investment packages for: maternal and newborn health, child health, immunisation, family planning, HIV/AIDS, and malaria. Nutrition is a cross-cutting theme. We then used simulation modelling to estimate the health and socioeconomic returns of these investments. Increasing health expenditure by just $5 per person per year up to 2035 in 74 high-burden countries could yield up to nine times that value in economic and social benefits. These returns include greater gross domestic product (GDP) growth through improved productivity, and prevention of the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. These gains could be achieved by an additional investment of $30 billion per year, equivalent to a 2% increase above current spending.

From joint thinking to joint action: a call to action on improving water, sanitation, and hygiene for maternal and newborn health.

Yael Velleman and colleagues argue for stronger integration between the water, sanitation, and hygiene (WASH) and maternal and newborn health sectors. Please see later in the article for the Editors' Summary.

Ending of preventable deaths from pneumonia and diarrhoea: an achievable goal.

Global under-5 mortality has fallen rapidly from 12 million deaths in 1990, to 6·9 million in 2011; however, this number still falls short of the target of a two-thirds reduction or a maximum of 4 million deaths by 2015. Acceleration of reductions in deaths due to pneumonia and diarrhoea, which together account for about 2 million child deaths every year, is essential if the target is to be met. Scaling up of existing interventions against the two diseases to 80% and immunisation to 90% would eliminate more than two-thirds of deaths from these two diseases at a cost of US$6·715 billion by 2025. Modelling in this report shows that if all countries could attain the rates of decline of the regional leaders, then cause-specific death rates of fewer than three deaths per 1000 livebirths from pneumonia and less than one death per 1000 livebirths from diarrhoea could be achieved by 2025. These rates are those at which preventable deaths have been avoided. Increasing of awareness of the size of the problem; strengthening of leadership, intersectoral collaboration, and resource mobilisation; and increasing of efficiency through the selection of the optimum mix of a growing set of cost-effective interventions depending on local contexts are the priority actions needed to achieve the goal of ending preventable deaths from pneumonia and diarrhoea by 2025.

Goodstart: a cluster randomised effectiveness trial of an integrated, community-based package for maternal and newborn care, with prevention of mother-to-child transmission of HIV in a South African township.

BACKGROUND: Progress towards MDG4 for child survival in South Africa requires effective prevention of mother-to-child transmission (PMTCT) of HIV including increasing exclusive breastfeeding, as well as a new focus on reducing neonatal deaths. This necessitates increased focus on the pregnancy and early post-natal periods, developing and scaling up appropriate models of community-based care, especially to reach the peri-urban poor. METHODS: We used a randomised controlled trial with 30 clusters (15 in each arm) to evaluate an integrated, scalable package providing two pregnancy visits and five post-natal home visits delivered by community health workers in Umlazi, Durban, South Africa. Primary outcomes were exclusive and appropriate infant feeding at 12 weeks post-natally and HIV-free infant survival. RESULTS: At 12 weeks of infant age, the intervention was effective in almost doubling the rate of exclusive breastfeeding (risk ratio 1.92; 95% CI: 1.59-2.33) and increasing infant weight and length-for-age z-scores (weight difference 0.09; 95% CI: 0.00-0.18, length difference 0.11; 95% CI: 0.03-0.19). No difference was seen between study arms in HIV-free survival. Women in the intervention arm were also more likely to take their infant to the clinic within the first week of life (risk ratio 1.10; 95% CI: 1.04-1.18). CONCLUSIONS: The trial coincided with national scale up of ARVs for PMTCT, and this could have diluted the effect of the intervention on HIV-free survival. We have demonstrated that implementation of a pro-poor integrated PMTCT and maternal, neonatal and child health home visiting model is feasible and effective. This trial could inform national primary healthcare reengineering strategies in favour of home visits. The dose effect on exclusive breastfeeding is notable as improving exclusive breastfeeding has been resistant to change in other studies targeting urban poor families.

Antenatal depression case finding by community health workers in South Africa: feasibility of a mobile phone application.

Randomized controlled trials conducted in resource-limited settings have shown that once women with depressed mood are evaluated by specialists and referred for treatment, lay health workers can be trained to effectively administer psychological treatments. We sought to determine the extent to which community health workers could also be trained to conduct case finding using short and ultrashort screening instruments programmed into mobile phones. Pregnant, Xhosa-speaking women were recruited independently in two cross-sectional studies (N = 1,144 and N = 361) conducted in Khayelitsha, South Africa and assessed for antenatal depression. In the smaller study, community health workers with no training in human subject research were trained to administer the Edinburgh Postnatal Depression Scale (EPDS) during the routine course of their community-based outreach. We compared the operating characteristics of four short and ultrashort versions of the EPDS with the criterion standard of probable depression, defined as an EPDS-10 ≥ 13. The prevalence of probable depression (475/1144 [42 %] and 165/361 [46 %]) was consistent across both samples. The 2-item subscale demonstrated poor internal consistency (Cronbach's α ranged from 0.55 to 0.58). All four subscales demonstrated excellent discrimination, with area under the receiver operating characteristic curve (AUC) values ranging from 0.91 to 0.99. Maximal discrimination was observed for the 7-item depressive symptoms subscale: at the conventional screening threshold of ≥10, it had 0.97 sensitivity and 0.76 specificity for detecting probable antenatal depression. The comparability of the findings across the two studies suggests that it is feasible to use community health workers to conduct case finding for antenatal depression.

The cost of inaction on health equity and its social determinants.

Rising levels of inflation, debt and macrofiscal tightening are putting expenditures on the social sectors including health under immense scrutiny. Already, there are worrying signs of reductions in social sector investments. However, even before the pandemic, evidence showed the significant returns on investments in health equity and its social determinants. Emerging data and trends show that these potential returns have increased during the COVID-19 pandemic - investments in social determinants can mitigate widespread reductions in human capital and the increasing likelihood of costly syndemics, while promoting access to healthcare innovations that have thus far been inequitably distributed. Therefore, we argue that, despite immediate fiscal pressures, this is exactly the time to invest in health equity and its broader social determinants, as the returns on such investments have never been greater.

Setting research priorities for global pandemic preparedness: An international consensus and comparison with ChatGPT's output.

Background: In this priority-setting exercise, we sought to identify leading research priorities needed for strengthening future pandemic preparedness and response across countries. Methods: The International Society of Global Health (ISoGH) used the Child Health and Nutrition Research Initiative (CHNRI) method to identify research priorities for future pandemic preparedness. Eighty experts in global health, translational and clinical research identified 163 research ideas, of which 42 experts then scored based on five pre-defined criteria. We calculated intermediate criterion-specific scores and overall research priority scores from the mean of individual scores for each research idea. We used a bootstrap (n = 1000) to compute the 95% confidence intervals. Results: Key priorities included strengthening health systems, rapid vaccine and treatment production, improving international cooperation, and enhancing surveillance efficiency. Other priorities included learning from the coronavirus disease 2019 (COVID-19) pandemic, managing supply chains, identifying planning gaps, and promoting equitable interventions. We compared this CHNRI-based outcome with the 14 research priorities generated and ranked by ChatGPT, encountering both striking similarities and clear differences. Conclusions: Priority setting processes based on human crowdsourcing - such as the CHNRI method - and the output provided by ChatGPT are both valuable, as they complement and strengthen each other. The priorities identified by ChatGPT were more grounded in theory, while those identified by CHNRI were guided by recent practical experiences. Addressing these priorities, along with improvements in health planning, equitable community-based interventions, and the capacity of primary health care, is vital for better pandemic preparedness and response in many settings.

Strategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition.

Implementation of innovative strategies to improve coverage of evidence-based interventions, especially in the most marginalised populations, is a key focus of policy makers and planners aiming to improve child survival, health, and nutrition. We present a three-step approach to improvement of the effective coverage of essential interventions. First, we identify four different intervention delivery channels--ie, clinical or curative, outreach, community-based preventive or promotional, and legislative or mass media. Second, we classify which interventions' deliveries can be improved or changed within their channel or by switching to another channel. Finally, we do a meta-review of both published and unpublished reviews to examine the evidence for a range of strategies designed to overcome supply and demand bottlenecks to effective coverage of interventions that improve child survival, health, and nutrition. Although knowledge gaps exist, several strategies show promise for improving coverage of effective interventions-and, in some cases, health outcomes in children-including expanded roles for lay health workers, task shifting, reduction of financial barriers, increases in human-resource availability and geographical access, and use of the private sector. Policy makers and planners should be informed of this evidence as they choose strategies in which to invest their scarce resources.

How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys.

BACKGROUND: Achievement of global health goals will require assessment of progress not only nationally but also for population subgroups. We aimed to assess how the magnitude of socioeconomic inequalities in health changes in relation to different rates of national progress in coverage of interventions for the health of mothers and children. METHODS: We assessed coverage in low-income and middle-income countries for which two Demographic Health Surveys or Multiple Indicator Cluster Surveys were available. We calculated changes in overall coverage of skilled birth attendants, measles vaccination, and a composite coverage index, and examined coverage of a newly introduced intervention, use of insecticide-treated bednets by children. We stratified coverage data according to asset-based wealth quintiles, and calculated relative and absolute indices of inequality. We adjusted correlation analyses for time between surveys and baseline coverage levels. FINDINGS: We included 35 countries with surveys done an average of 9·1 years apart. Pro-rich inequalities were very prevalent. We noted increased coverage of skilled birth attendants, measles vaccination, and the composite index in most countries from the first to the second survey, while inequalities were reduced. Rapid changes in overall coverage were associated with improved equity. These findings were not due to a capping effect associated with limited scope for improvement in rich households. For use of insecticide-treated bednets, coverage was high for the richest households, but countries making rapid progress did almost as well in reaching the poorest groups. National increases in coverage were primarily driven by how rapidly coverage increased in the poorest quintiles. INTERPRETATION: Equity should be accounted for when planning the scaling up of interventions and assessing national progress. FUNDING: Bill & Melinda Gates Foundation; World Bank; Governments of Australia, Brazil, Canada, Norway, Sweden, and UK.

The comparative cost-effectiveness of an equity-focused approach to child survival, health, and nutrition: a modelling approach.

Progress on child mortality and undernutrition has seen widening inequities and a concentration of child deaths and undernutrition in the most deprived communities, threatening the achievement of the Millennium Development Goals. Conversely, a series of recent process and technological innovations have provided effective and efficient options to reach the most deprived populations. These trends raise the possibility that the perceived trade-off between equity and efficiency no longer applies for child health--that prioritising services for the poorest and most marginalised is now more effective and cost effective than mainstream approaches. We tested this hypothesis with a mathematical-modelling approach by comparing the cost-effectiveness in terms of child deaths and stunting events averted between two approaches (from 2011-15 in 14 countries and one province): an equity-focused approach that prioritises the most deprived communities, and a mainstream approach that is representative of current strategies. We combined some existing models, notably the Marginal Budgeting for Bottlenecks Toolkit and the Lives Saved Tool, to do our analysis. We showed that, with the same level of investment, disproportionately higher effects are possible by prioritising the poorest and most marginalised populations, for averting both child mortality and stunting. Our results suggest that an equity-focused approach could result in sharper decreases in child mortality and stunting and higher cost-effectiveness than mainstream approaches, while reducing inequities in effective intervention coverage, health outcomes, and out-of-pocket spending between the most and least deprived groups and geographic areas within countries. Our findings should be interpreted with caution due to uncertainties around some of the model parameters and baseline data. Further research is needed to address some of these gaps in the evidence base. Strategies for improving child nutrition and survival, however, should account for an increasing prioritisation of the most deprived communities and the increased use of community-based interventions.

Child survival: a message of hope but a call for renewed commitment in UNICEF report.

A recent UNICEF report Committing to Child Survival: A Promise Renewed Progress Report 2013 presents a comprehensive analysis of levels and trends in child mortality and progress towards MDG 4. The global under-five mortality rate has been cut nearly in half (47%) since 1990. However, during this same period, 216 million children are estimated to have died before their fifth birthday. Most of these deaths were from leading infectious diseases such as pneumonia, diarrhoea or malaria, or were caused by preventable neonatal causes such as those related to intra-partum complications. The highest mortality rates in the world are observed in low-income countries in sub-Saharan Africa and South Asia. Sub-Saharan Africa faces a particular challenge in that it not only has the highest under-five mortality in the world but it also has the fastest population growth. Progress is possible, however, and sharp reductions in child mortality have been observed at all levels of national income and in all regions. Some of the world's poorest countries in terms of national income have made the strongest gains in child survival. Within countries, new analysis suggests that disparities in under-five mortality between the richest and the poorest households have declined in most regions of the world, with the exception of Sub-Saharan Africa. Furthermore, under-five mortality rates have fallen even among the poorest households in all regions. The report highlights the growing importance of neonatal deaths; roughly 44% of global under-five deaths - now 2.9 million a year - occur during the neonatal period, with up to 50% dying during their first day of life and yet over two-thirds of these deaths are preventable without intensive care. The report stresses how a continuum of care approach across the whole life cycle is the most powerful way of understanding and accelerating further progress.