Area-specific covid-19 effects on health services utilization in the Democratic Republic of the Congo using routine health information system data.

BACKGROUND: Since March 2020, the COVID-19 pandemic has shocked health systems worldwide. This analysis investigated the effects of the pandemic on basic health services utilization in the Democratic Republic of the Congo (DRC) and examined the variability of COVID effects in the capital city Kinshasa, in other urban areas, and in rural areas. METHODS: We estimated time trends models using national health information system data to replicate pre-COVID-19 (i.e., January 2017-February 2020) trajectories of health service utilization, and then used those models to estimate what the levels would have been in the absence of COVID-19 during the pandemic period, starting in March 2020 through March 2021. We classified the difference between the observed and predicted levels as the effect of COVID-19 on health services. We estimated 95% confidence intervals and p-values to examine if the effect of the pandemic, nationally and within specific geographies, was statistically significant. RESULTS: Our results indicate that COVID-19 negatively impacted health services and subsequent recovery varied by service type and by geographical area. COVID-19 had a lasting impact on overall service utilization as well as on malaria and pneumonia-related visits among young children in the DRC. We also found that the effects of COVID-19 were even more immediate and stronger in the capital city of Kinshasa compared with the national effect. Both nationally and in Kinshasa, most affected services had slow and incomplete recovery to expected levels. Therefore, our analysis indicates that COVID-19 continued to affect health services in the DRC throughout the first year of the pandemic. CONCLUSIONS: The methodology used in this article allows for examining the variability in magnitude, timing, and duration of the COVID effects within geographical areas of the DRC and nationally. This analytical procedure based on national health information system data could be applied to surveil health service disruptions and better inform rapid responses from health service managers and policymakers.

Multimorbidity patterns and health-related quality of life in Jamaican adults: a cross sectional study exploring potential pathways.

Introduction: Multimorbidity and health-related quality of life (HRQoL) are intimately linked. Multiple chronic conditions may adversely affect physical and mental functioning, while poorer HRQoL may contribute to the worsening course of diseases. Understanding mechanisms through which specific combinations of diseases affect HRQoL outcomes can facilitate identification of factors which are amenable to intervention. Jamaica, a middle-income country with high multimorbidity prevalence, has a health service delivery system dominated by public sector provision via a broad healthcare network. This study aims to examine whether multimorbidity classes differentially impact physical and mental dimensions of HRQoL in Jamaicans and quantify indirect effects on the multimorbidity-HRQoL relationship that are mediated by health system factors pertaining to financial healthcare access and service use. Materials and methods: Latent class analysis (LCA) was used to estimate associations between multimorbidity classes and HRQoL outcomes, using latest available data from the nationally representative Jamaica Health and Lifestyle Survey 2007/2008 (N = 2,551). Multimorbidity measurement was based on self-reported presence/absence of 11 non-communicable diseases (NCDs). HRQoL was measured using the 12-item short-form (SF-12) Health Survey. Mediation analyses guided by the counterfactual approach explored indirect effects of insurance coverage and service use on the multimorbidity-HRQoL relationship. Results: LCA revealed four profiles, including a Relatively Healthy class (52.7%) characterized by little to no morbidity and three multimorbidity classes characterized by specific patterns of NCDs and labelled Metabolic (30.9%), Vascular-Inflammatory (12.2%), and Respiratory (4.2%). Compared to the Relatively Healthy class, Vascular-Inflammatory class membership was associated with lower physical functioning (ß = -5.5; p < 0.001); membership in Vascular-Inflammatory (ß = -1.7; p < 0.05), and Respiratory (ß = -2.5; p < 0.05) classes was associated with lower mental functioning. Significant mediated effects of health service use, on mental functioning, were observed for Vascular-Inflammatory (p < 0.05) and Respiratory (p < 0.05) classes. Conclusion: Specific combinations of diseases differentially impacted HRQoL outcomes in Jamaicans, demonstrating the clinical and epidemiological value of multimorbidity classes for this population, and providing insights that may also be relevant to other settings. To better tailor interventions to support multimorbidity management, additional research is needed to elaborate personal experiences with healthcare and examine how health system factors reinforce or mitigate positive health-seeking behaviours, including timely use of services.

The impact of community-based health insurance on health service utilization and financial risk protection in Ethiopia.

BACKGROUND: Evidence on the effectiveness of community-based health insurance (CBHI) in low-income countries is inconclusive. This study assessed the impact of CBHI on health service utilization and financial risk protection in Ethiopia. METHODS: We conducted a comparative cross-sectional study nested within a larger national household survey in 2020. Data was collected from three groups of households-CBHI member households (n = 1586), non-member households from CBHI implementing woredas (n = 1863), and non-member households from non-CBHI implementing woredas (n = 789). Indicators of health service utilization, out-of-pocket health spending, catastrophic health expenditure, and impoverishment due to health spending among CBHI members were compared with non-members from CBHI implementing woredas and households from non-CBHI implementing woredas. Propensity score matching (PSM) was used to account for possible selection bias. RESULTS: The annual number of OPD visits per capita among CBHI member households was 2.09, compared to 1.53 among non-member households from CBHI woredas and 1.75 among households from non-CBHI woredas. PSM estimates indicated that CBHI members had 0.36 (95% CI: 0.25, 0.44) and 0.17 (95% CI: -0.04, 0.19) more outpatient department (OPD) visits per capita per year than their matched non-member households from CBHI-implementing and non-CBHI implementing woredas, respectively. CBHI membership resulted in a 28-43% reduction in annual OOP payments as compared to non-member households. CBHI member households were significantly less likely to incur catastrophic health expenditures (measured as annual OOP payments of more than 10% of the household's total expenditure) compared to non-members (p < 0.01). CONCLUSION: CBHI membership increases health service utilization and financial protection. CBHI proves to be an important strategy for promoting universal health coverage. Implementing CBHI in all woredas and increasing membership among households in woredas that are already implementing CBHI will further expand its benefits.

A decade of conditional cash transfer programs for reproductive health in India: How did equality fare?

BACKGROUND: Since 2005, India has implemented conditional cash transfer [CCT] programs to promote the uptake of institutional delivery services [ID]. The study aims to assess changes in wealth-based inequality in the use of ID and other maternal health care services during the first decade of Janani Suraksha Yojana and related CCT programs. METHODS: Data from two Demographic and Health Surveys were used to calculate changes in service inequality from 2005 to 2015-16 in the use of three or more antenatal care [ANC] visits, ID, and postnatal care [PNC]. The changes were assessed at the national level, within high and low performing states [HPS and LPS, respectively] and within urban and rural areas of each state category. Erreygers Index [EI] and Wagstaff Index [WI], superior to concentration index, were used to gain different insights into the nature of inequality. EI is an objective measure of inequality irrespective of prevalence while WI is a combined measure of inequality and the average distribution of an indicator that puts more weight on the poor. RESULTS: The results suggest that wealth-based inequalities decreased significantly at the national level. For ID, both indices showed a decline in both HPS and LPS though the change in WI in HPS was insignificant. For ANC, there was a significant decrease in inequality using both indices in HPS but not in LPS. For PNC, there was a significant decrease in inequality using both indices in HPS, and when using WI in LPS, but not when using EI in LPS. CONCLUSION: Overall, the first decade of India's CCT programs saw an impressive reduction in EI for ID but less so for WI suggesting that the benefit of CCTs did not go disproportionately to the poor, which suggests that there is a need to reduce or eliminate the evident leakages. The improvement in uptake and inequality in ANC and PNC was not at par with ID, stressing the need to place greater focus on the continuum of care. The urban rural difference in HPS versus LPS in the changes in inequality reveals that infrastructure is important for CCTs to be more effective.

Projecting the Impact of the COVID-19 Pandemic on Child Marriage.

PURPOSE: The study projects the potential impact of COVID-19 on child marriage in the five countries in which the burden of child marriage is the largest: Bangladesh, Brazil, Ethiopia, India, and Nigeria. METHODS: The projected impact of the pandemic on child marriage is based on a Markov model. A review of empirical and theoretical literature informed construction and parameter estimates of five pathways through which we expect an elevated marriage hazard: death of a parent, interruption of education, pregnancy risk, household income shocks, and reduced access to programs and services. Models are produced for an unmitigated scenario and a mitigated scenario in which effective interventions are applied to reduce the impact. RESULTS: The total number of excess child marriages in these five countries could range from 3.5 million to 4.9 million in the unmitigated scenario and from 1.8 million to 2.7 million in the mitigated scenario. The elevated risk compared with the baseline projection would continue until 2035. CONCLUSIONS: These projections represent the impact in five countries that account for 50% of child marriages globally, implying that if similar patterns hold, we might expect the number of excess child marriages due to the pandemic to reach 7 million to 10 million globally. These estimates are necessarily subject to high levels of uncertainty because of limited evidence on the impacts in relation to child marriage and for parameter estimates. It will likely take years to understand the full impact of the pandemic. Despite these limitations, the potential for harm is unquestionably large.

Assessing the effects of disease-specific programs on health systems: An analysis of the Bangladesh Lymphatic Filariasis Elimination Program's impacts on health service coverage and catastrophic health expenditure.

This study presents a methodology for using tracer indicators to measure the effects of disease-specific programs on national health systems. The methodology is then used to analyze the effects of Bangladesh's Lymphatic Filariasis Elimination Program, a disease-specific program, on the health system. Using difference-in-differences models and secondary data from population-based household surveys, this study compares changes over time in the utilization rates of eight essential health services and incidences of catastrophic health expenditures between individuals and households, respectively, of lymphatic filariasis hyper-endemic districts (treatment districts) and of hypo- and non-endemic districts (control districts). Utilization of all health services increased from year 2000 to year 2014 for the entire population but more so for the population living in treatment districts. However, when the services were analyzed individually, the difference-in-differences between the two populations was insignificant. Disadvantaged populations (i.e., populations that lived in rural areas, belonged to lower wealth quintiles, or did not attend school) were less likely to access essential health services. After five years of program interventions, households in control districts had a lower incidence of catastrophic health expenditures at several thresholds measured using total household expenditures and total non-food expenditures as denominators. Using essential health service coverage rates as outcome measures, the Lymphatic Filariasis Elimination Program cannot be said to have strengthened or weakened the health system. We can also say that there is a positive association between the Lymphatic Filariasis Elimination Program's interventions and lowered incidence of catastrophic health expenditures.

Social determinants of multimorbidity in Jamaica: application of latent class analysis in a cross-sectional study.

BACKGROUND: Non-communicable disease (NCD) multimorbidity is associated with impaired functioning, lower quality of life and higher mortality. Susceptibility to accumulation of multiple NCDs is rooted in social, economic and cultural contexts, with important differences in the burden, patterns, and determinants of multimorbidity across settings. Despite high prevalence of individual NCDs within the Caribbean region, exploration of the social epidemiology of multimorbidity remains sparse. This study aimed to examine the social determinants of NCD multimorbidity in Jamaica, to better inform prevention and intervention strategies. METHODS: Latent class analysis (LCA) was used to examine social determinants of identified multimorbidity patterns in a sample of 2551 respondents aged 15-74 years, from the nationally representative Jamaica Health and Lifestyle Survey 2007/2008. Multimorbidity measurement was based on self-reported presence/absence of 11 chronic conditions. Selection of social determinants of health (SDH) was informed by the World Health Organization's Commission on SDH framework. Multinomial logistic regression models were used to estimate the association between individual-level SDH and class membership. RESULTS: Approximately one-quarter of the sample (24.05%) were multimorbid. LCA revealed four distinct profiles: a Relatively Healthy class (52.70%), with a single or no morbidity; and three additional classes, characterized by varying degrees and patterns of multimorbidity, labelled Metabolic (30.88%), Vascular-Inflammatory (12.21%), and Respiratory (4.20%). Upon controlling for all SDH (Model 3), advancing age and recent healthcare visits remained significant predictors of all three multimorbidity patterns (p < 0.001). Private insurance coverage (relative risk ratio, RRR = 0.63; p < 0.01) and higher educational attainment (RRR = 0.73; p < 0.05) were associated with lower relative risk of belonging to the Metabolic class while being female was a significant independent predictor of Vascular-Inflammatory class membership (RRR = 2.54; p < 0.001). Material circumstances, namely housing conditions and features of the physical and neighbourhood environment, were not significant predictors of any multimorbidity class. CONCLUSION: This study provides a nuanced understanding of the social patterning of multimorbidity in Jamaica, identifying biological, health system, and structural determinants as key factors associated with specific multimorbidity profiles. Future research using longitudinal designs would aid understanding of disease trajectories and clarify the role of SDH in mitigating risk of accumulation of diseases.

Health services utilization and out-of-pocket (OOP) expenditures in public and private facilities in Pakistan: an empirical analysis of the 2013-14 OOP health expenditure survey.

BACKGROUND: As low- and middle-income countries progress toward Universal Health Coverage, there is an increasing focus on measuring out-of-pocket (OOP) expenditure and health services utilization within countries. While there have been several reforms to improve health services coverage and financial protection in Pakistan, there is limited empirical research comparing OOP expenditure and health services utilization between public and private facilities and exploring their determinants, a knowledge gap addressed in this study. METHODS: We used data from 2013 to 14 OOP Health Expenditure Survey, a population-based household survey carried out for Pakistan's National Health Accounts. The analysis included 7969 encounters from 4293 households. We conducted bivariate analyses to describe patterns of care utilization, estimated annualized expenditures by type and sector of care, and assessed expenditure composition. We used multivariable logistic regression modeling to identify factors associated with sector of care and generalized linear model (GLM) with log link and gamma distribution to identify determinants of OOP expenditures stratified by type of care (inpatient and outpatient). RESULTS: Most encounters (82.5%) were in the private sector and were for outpatient visits (85%). Several public-private differences were observed in annualized expenditures and expenditure components. Logistic regression results indicate males, wealthier individuals, Punjab and Sindh residents, and those in smaller households were more likely to access private outpatient care. In the inpatient model, rural residents were more likely to use a private provider, while Khyber Pakhtunkhwa residents were less likely to use private care. GLM results indicate private sector inpatient expenditures were approximately PKR 6660 (USD 61.8) higher than public sector expenditures, but no public-private differences were observed for outpatient expenditures. Several demographic factors were significantly associated with outpatient and inpatient expenditures. Of note, expenditures increased with increasing wealth, decreased with increasing household size, and differed by province and region. CONCLUSIONS: This is the first study comprehensively investigating how healthcare utilization and OOP expenditures vary by sector, type of care, and socio-economic characteristics in Pakistan. The findings are expected to be particularly useful for the next phase of social health protection programs and supply side reforms, as they highlight sub-populations with higher OOP and private sector utilization.

Prevalence and patterns of multimorbidity in the Jamaican population: A comparative analysis of latent variable models.

BACKGROUND: Evidence suggests that the single-disease paradigm does not accurately reflect the individual experience, with increasing prevalence of chronic disease multimorbidity, and subtle yet important differences in types of co-occurring diseases. Knowledge of multimorbidity patterns can aid clarification of individual-level burden and needs, to inform prevention and treatment strategies. This study aimed to estimate the prevalence of multimorbidity in Jamaica, identify population subgroups with similar and distinct disease profiles, and examine consistency in patterns identified across statistical techniques. METHODS: Latent class analysis (LCA) was used to examine multimorbidity patterns in a sample of 2,551 respondents aged 15-74 years, based on data from the nationally representative Jamaica Health and Lifestyle Survey 2007/2008 and self-reported presence/absence of 11 chronic conditions. Secondary analyses compared results with patterns identified using exploratory factor analysis (EFA). RESULTS: Nearly one-quarter of the sample (24.1%) were multimorbid (i.e. had ≥2 diseases), with significantly higher burden in females compared to males (31.6% vs. 16.1%; p<0.001). LCA revealed four distinct classes, including a predominant Relatively Healthy class, comprising 52.7% of the sample, with little to no morbidity. The remaining three classes were characterized by varying degrees and patterns of multimorbidity and labelled Metabolic (30.9%), Vascular-Inflammatory (12.2%), and Respiratory (4.2%). Four diseases determined using physical assessments (obesity, hypertension, diabetes, hypercholesterolemia) were primary contributors to multimorbidity patterns overall. EFA identified three patterns described as "Vascular" (hypertension, obesity, hypercholesterolemia, diabetes, stroke); "Respiratory" (asthma, COPD); and "Cardio-Mental-Articular" (cardiovascular disease, arthritis, mental disorders). CONCLUSION: This first study of multimorbidity in the Caribbean has revealed a high burden of co-existing conditions in the Jamaican population, that is predominantly borne by females. Consistency across methods supports the validity of patterns identified. Future research into the causes and consequences of multimorbidity patterns can guide development of clinical and public health strategies that allow for targeted prevention and intervention.

Community-level factors associated with the use of facility-based delivery assistance in Uganda: a multilevel analysis.

BACKGROUND: In low- and middle-income countries, the proportion of pregnant women who use health facilities for delivery remains low. Although delivering in a health facility with skilled health providers can make the critical difference between survival and death for both mother and child, in 2016, more than 25% of pregnant women did not deliver in a health facility in Uganda. This study examines the association of contextual factors measured at the community-level with use of facility-based delivery in Uganda, after controlling for household and individual-level factors. METHODS: Pooled household level data of 3310 observations of women who gave birth in the last five years is linked to community level data from the Uganda National Panel Survey (UNPS). A multilevel model that adequately accounted for the clustered nature of the data and the binary outcome of whether or not the woman delivered in a health facility was estimated. RESULTS: The study findings show a positive association at the county level between place of delivery, education and access to health services, and a negative association between place of delivery and poverty. Individuals living in communities with a high level of education amongst the household heads were 1.67 times (95% Confidence Interval: 1.07-2.61) more likely to have had a facility-based delivery compared to women living in communities where household heads did not have high levels of education. Women who lived in counties with a short travel time (less than 33 min) were 1.66 times (95% CI: 1.11-2.48) more likely to have had a facility-based delivery compared to women who lived in counties with longer travel time to any health facility. Women living in poor counties were only 0.64 times (95% CI: 0.42-0.97) as likely to have delivered in a health facility compared to pregnant women from communities with more affluent individuals. CONCLUSIONS: The findings on household head's education, community economic status and travel time to a health facility are useful for defining the attributes for targeting and developing relevant nation-wide community-level health promotion campaigns. However, limited evidence was found in broad support of the role of community level factors.

Assessing the Efficiency of Sub-National Units in Making Progress Towards Universal Health Coverage: Evidence from Pakistan.

The World Health Report 2010 encourages countries to reduce wastage and increase efficiency to achieve Universal Health Coverage (UHC). This research examines the efficiency of divisions (sub-provincial geographic units) in Pakistan in moving towards UHC using Data Envelop Analysis. We have used data from the Pakistan National Accounts 2011-12 and the Pakistan Social Living and Measurement Survey 2012-13 to measure per capita pooled public health spending in the divisions as inputs, and a set of UHC indicators (health service coverage and financial protection) as outputs. Sensitivity analysis for factors outside the health sector influencing health outcomes was conducted to refine the main model specification. Spider radar graphs were generated to illustrate differences between divisions with similar public spending but different performances for UHC. Pearson product-moment correlation was used to explore the strength and direction of the associations between proxy health systems organization variables and efficiency scores.The results showed a large variation in performance of divisions for selected UHC outputs. The results of the sensitivity analysis were also similar. Overall, divisions in Sindh province were better performing and divisions in Balochistan province were the least performing. Access to health care, the responsiveness of health systems, and patients' satisfaction were found to be correlated with efficiency scores.This research suggests that progress towards UHC is possible even at relatively low levels of public spending. Given the devolution of health system responsibilities to the provinces, this analysis will be a timely reference for provinces to gauge the performance of their divisions and plan the ongoing reforms to achieve UHC.

What Happens When Donors Pull Out? Examining Differences in Motivation Between Health Workers Who Recently Had Performance-Based Financing (PBF) Withdrawn With Workers Who Never Received PBF in the Democratic Republic of Congo.

BACKGROUND: A motivated workforce is necessary to ensure the delivery of high quality health services. In developing countries, performance-based financing (PBF) is often employed to increase motivation by providing financial incentives linked to performance. However, given PBF schemes are usually funded by donors, their long-term financing is not always assured, and the effects of withdrawing PBF on motivation are largely unknown. This cross-sectional study aimed to identify differences in motivation between workers who recently had donor-funded PBF withdrawn, with workers who had not received PBF. METHODS: Quantitative data were collected from 485 health workers in 5 provinces using a structured survey containing questions on motivation which were based on an established motivation framework. Confirmatory factor analysis was used to verify dimensions of motivation, and multiple regression to assess differences in motivation scores between workers who had previously received PBF and those who never had. Qualitative interviews were also carried out in Kasai Occidental province with 16 nurses who had previously or never received PBF. RESULTS: The results indicated that workers in facilities where PBF had been removed scored significantly lower on most dimensions of motivation compared to workers who had never received PBF. The removal of the PBF scheme was blamed for an exodus of staff due to the dramatic reduction in income, and negatively impacted on relationships between staff and the local community. CONCLUSION: Donors and governments unable to sustain PBF or other donor-payments should have clear exit strategies and institute measures to mitigate any adverse effects on motivation following withdrawal.

Assessing out-of-pocket expenditures for primary health care: how responsive is the Democratic Republic of Congo health system to providing financial risk protection?

BACKGROUND: The goal of universal health coverage is challenging for chronically under-resourced health systems. Although household out-of-pocket payments are the most important source of health financing in low-income countries, relatively little is known about the drivers of primary health care expenditure and the predictability of the burden associated with high fee-for-service payments. This study describes out-of-pocket health expenditure and investigates demand- and supply-side drivers of excessive costs in the Democratic Republic of Congo (DRC), a central African country in the midst of a process of reforming its health financing system towards universal health coverage. METHODS: A population-based household survey was conducted in four provinces of the DRC in 2014. Data included type, level and utilization of health care services, accessibility to care, patient satisfaction and disaggregated health care expenditure. Multivariate logistic regressions of excessive expenditure for outpatient care using alternative thresholds were performed to explore the incidence and predictors of atypically high expenditure incurred by individuals. RESULTS: Over 17% (17.5%) of individuals living in sample households reported an illness or injury without being hospitalized. Of 3341 individuals reporting an event in the four-week period prior to the survey, 65.6% sought outpatient care with an average of one visit (SD = 0.0). The overall mean expenditure per visit was US$ 6.7 (SD = 10.4) with 29.4% incurring excessive expenditure. The main predictors of a financial risk burden included utilizing public services offering the complementary benefit package, dissatisfaction with care received, being a member of a large household, expenditure composition, severity of illness, residence and wealth (p < .05). The insured status influenced the expenditure level, with no association with catastrophe. Those who did not seek care when needed reported financial constraints as the major reason for postponing or foregoing care. Wealth-related inequities were found in service and population coverage and in out-of-pocket payment for outpatient care. CONCLUSION: Burdensome expenditure for primary care and its key drivers are of utmost importance. Forthcoming health financing reform agendas must incorporate a strategy for getting data used in the design of financial risk protection. Realizing equitable and efficient access to outpatient care is a vital ingredient for sustainable health systems.

Comparison of objective measures and patients' perceptions of quality of services in government health facilities in the Democratic Republic of Congo.

OBJECTIVE: Examine the relationship between patients' perceptions of quality and the objective level of quality at government health facilities, and determine whether the pre-existing attitudes and beliefs of patients regarding health services interfere with their ability to accurately assess quality of care. DESIGN: Cross-sectional, visit-level analysis. SETTING: Three regions (Nord-Ubangi, Kasai/Kasai-Central and Maniema/Tshopo) of the Democratic Republic of Congo. PARTICIPANTS: Data related to the inpatient and outpatient visits to government health facilities made by all household members who were included in the survey was used for the analysis. Data were collected from patients and the facilities they visited. MAIN OUTCOME MEASURES: Patients' perceptions of the level of quality related to availability of drugs and equipment; patient-centeredness and safety serve compared with objective measures of quality. RESULTS: Objective measures and patient perceptions of the drug supply were positively associated (ß = 0.16, 95% CI = 0.03, 0.28) and of safety were negatively associated (ß = -0.12, 95% CI = -0.23, -0.01). Several environmental factors including facility type, region and rural/peri-urban setting were found to be significantly associated with respondents' perceptions of quality across multiple outcomes. CONCLUSIONS: Overall, patients are not particularly accurate in their assessments of quality because their perceptions are impacted by their expectations and prior experience. Future research should examine whether improving patients' knowledge of what they should expect from health services, and the transparency of the facility's quality data can be a strategy for improving the accuracy of patients' assessments of the quality of the health services, particularly in low-resourced settings.

A cross-sectional study of the income sources of primary care health workers in the Democratic Republic of Congo.

BACKGROUND: In the Democratic Republic of Congo (DRC), the state system to remunerate health workers is poorly functional, encouraging diversification of income sources and corruption. Given the central role that health workers play in health systems, policy-makers need to ensure health workers are remunerated in a way which best incentivises them to provide effective and good quality services. This study describes the different sources and quantities of income paid to primary care health workers in Equateur, Maniema, Kasai Occidental, Province Orientale and Kasai Oriental provinces. It also explores characteristics associated with the receipt of different sources of income. METHODS: Quantitative data on the income received by health workers were collected through baseline surveys. Descriptive statistics explored the demographic characteristics of health workers surveyed, and types and amounts of incomes received. A series of regression models were estimated to examine the health worker and facility-level determinants of receiving each income source and of levels received. Qualitative data collection was carried out in Kasai Occidental province to explore perceptions of each income source and reasons for receiving each. RESULTS: Nurses made up the majority of workers in primary care. Only 31% received a government salary, while 75% reported compensation from user fees. Almost half of all nurses engaged in supplemental non-clinical activities. Receipt of government payments was associated with income from private practice and non-clinical activities. Male nurses were more likely to receive per diems, performance payments, and higher total remuneration compared to females. Contextual factors such as provincial location, presence of externally financed health programmes and local user fee policy also influenced the extent to which nurses received many income sources. CONCLUSIONS: The receipt of government payments was unreliable and had implications for receipt of other income sources. A mixture of individual, facility and geographical factors were associated with the receipt of various income sources. Greater co-ordination is needed between partners involved in health worker remuneration to design more effective financial incentive packages, reduce the fragmentation of incomes and improve transparency in the payment of workers in the DRC.

Differential effects of young maternal age on child growth.

BACKGROUND: The association of early maternal birthing age with smaller children has been widely observed. However, it is unclear if this is due to confounding by factors such as socioeconomic status, or the age at which child growth restriction first occurs. OBJECTIVE: To examine the effect of early maternal birthing age on the first-born child's height-for-age in a sample of developing countries in Africa, Asia, and Latin America. DESIGN: Cross-sectional data from Demographic Health Surveys from 18 countries were used, to select the first-born child of mothers aged 15-24 years and a range of potential confounding factors, including maternal height. Child length/height-for-age z-scores (HAZs) was estimated in age bands of 0-11, 12-23, 24-35, 36-47, and 48-59 months; HAZ was first compared between maternal age groups of 15-17, 18-19, and 20-24 years. RESULTS: 1) There were significant bivariate associations between low child HAZ and young maternal age (71 of 180 possible cases; at p<0.10), but the majority of these did not persist when controlling for confounders (41 cases, 23% of the 180). 2) For children <12 months, when controlling for confounders, three out of seven Asian countries showed a significant association between lower infant HAZ and low maternal age, as did six out of nine African countries (15-17 or 15-19 years vs. the older group). 3) The association (adjusted) continued after 24 months in 12 of the 18 countries, in Africa, Asia, and Latin America. 4) The stunting differences for children between maternal age groups were around 9 percentage points (ppts) in Asia, 14 ppts in Africa, and 10 ppts in Latin America. These data do not show whether this is due to, for example, socioeconomic factors that were not included, an emerging effect of intrauterine growth restriction, or the child feeding or caring behaviors of young mothers. The latter is considered to be the most likely. CONCLUSIONS: The effect of low maternal age on child height restriction from 0 to 11 months occurred in half the countries studied after adjusting for confounders. Poorer growth continuing after 24 months in children of younger mothers was observed in all regions, but needs further research to determine the causes. The effects were about double (in stunting prevalence terms) in Africa, where there was an increase in 10 ppts in stunting for children of young mothers.

Exploring the barriers to rigorous monitoring and evaluation of health systems strengthening activities: qualitative evidence from international development partners.

The number of health systems strengthening (HSS) programs has increased in the last decade. However, a limited number of studies providing robust evidence for the value and impact of these programs are available. This study aims to identify knowledge gaps and challenges that impede rigorous monitoring and evaluation (M&E) of HSS, and to ascertain the extent to which these efforts are informed by existing technical guidance. Interviews were conducted with HSS advisors at United States Agency for International Development-funded missions as well as senior M&E advisors at implementing partner and multilateral organizations. Findings showed that mission staff do not use existing technical resources, either because they do not know about them or do not find them useful. Barriers to rigorous M&E included a lack suitable of indicators, data limitations, difficulty in demonstrating an impact on health, and insufficient funding and resources. Consensus and collaboration between international health partners and local governments may mitigate these challenges. Copyright © 2016 John Wiley & Sons, Ltd.

Predicting Maternal Health Care Use by Age at Marriage in Multiple Countries.

PURPOSE: In light of the global pervasiveness of child marriage and given that improving maternal health care use is an effective strategy in reducing maternal and child morbidity and mortality, the available empirical evidence on the association of child marriage with maternal health care utilization seems woefully inadequate. Furthermore, existing studies have not considered the interaction of type of place of residence and parity with child marriage, which can give added insight to program managers. METHODS: Demographic Health Survey data for seven countries are used to estimate logistic regression models including interactions of age at marriage with area of residence and birth order. Adjusted predicted probabilities at representative values and marginal effects are computed for each outcome. RESULTS: The results show a negative association between child marriage and maternal health care use in most study countries, and this association is more negative in rural areas and with higher orders of parity. However, the association between age at marriage and maternal health care use is not straightforward but depends on parity and area of residence and varies across countries. The marginal effects in use of delivery care services between women married at age 14 years or younger and those married at age 18 years or older are more than 10% and highly significant in Bangladesh, Burkina Faso, and Nepal. CONCLUSIONS: The study's findings call for the formulation of country-and age at marriage-specific recommendations to improve maternal and child health outcomes.

Risk factors associated with the practice of child marriage among Roma girls in Serbia.

BACKGROUND: Relatively little research on the issue of child marriage has been conducted in European countries where the overall prevalence of child marriage is relatively low, but relatively high among marginalized ethnic sub-groups. The purpose of this study is to assess the risk factors associated with the practice of child marriage among females living in Roma settlements in Serbia and among the general population and to explore the inter-relationship between child marriage and school enrollment decisions. METHODS: The study is based on data from a nationally representative household survey in Serbia conducted in 2010 - and a separate survey of households living in Roma settlements in the same year. For each survey, we estimated a bivariate probit model of risk factors associated with being currently married and currently enrolled in school based on girls 15 to 17 years of age in the nationally representative and Roma settlements samples. RESULTS: The practice of child marriage among the Roma was found to be most common among girls who lived in poorer households, who had less education, and who lived in rural locations. The results of the bivariate probit analysis suggest that, among girls in the general population, decisions about child marriage school attendance are inter-dependent in that common unobserved factors were found to influence both decisions. However, among girls living in Roma settlements, there is only weak evidence of simultaneous decision making. CONCLUSION: The study finds evidence of the interdependence between marriage and school enrollment decisions among the general population and, to a lesser extent, among the Roma. Further research is needed on child marriage among the Roma and other marginalized sub-groups in Europe, and should be based on panel data, combined with qualitative data, to assess the role of community-level factors and the characteristics of households where girls grow up on child marriage and education decisions.