'We stay silent and keep it in our hearts': a qualitative study of failure of complaints mechanisms in Malawi's health system.

A responsive health system must have mechanisms in place that ensure it is accountable to those it serves. Patients in Malawi have to overcome many barriers to obtain care. Many of these barriers reflect weak accountability. There are at least 30 mechanisms through which Malawian patients in the public sector can assert their rights, yet few function well and, as a consequence, they are underused. Our aim was to identify the various channels for complaints and why patients are reluctant to use them when they experience poor quality or inappropriate care, as well as the institutional, social and political factors that give rise to these problems. The study was set in the Blantyre district. We used qualitative methods, including ethnographic observations, focus group discussions, document analysis and interviews with stakeholders involved in complaint handling both in Blantyre and in the capital, Lilongwe. We found that complaints mechanisms and redress procedures are underutilized because of lack of trust, geographical inaccessibility and lack of visibility leading to limited awareness of their existence. Drawing on these results, we propose a series of recommendations for the way forward.

Preferences for onward health data use in the electronic age among maternity patients and providers in South Africa: a qualitative study.

Despite the expanding digitisation of individual health data, informed consent for the collection and use of health data is seldom explicitly sought in public sector clinics in South Africa. This study aims to identify perceptions of informed consent practices for health data capture, access, and use in Gauteng and the Western Cape provinces of South Africa. Data collection from September to December 2021 included in-depth interviews with healthcare providers (n = 12) and women (n = 62) attending maternity services. Study findings suggest that most patients were not aware that their data were being used for purposes beyond the individualised provision of medical care. Understanding the concept of anonymised use of electronic health data was at times challenging for patients who understood their data in the limited context of paper-based folders and booklets. When asked about preferences for electronic data, patients overwhelmingly were in favour of digitisation. They viewed electronic access to their health data as facilitating rapid and continuous access to health information. Patients were additionally asked about preferences, including delivery of health information, onward health data use, and recontacting. Understanding of these use cases varied and was often challenging to convey to participants who understood their health data in the context of information inputted into their paper folders. Future systems need to be established to collect informed consent for onward health data use. In light of perceived ties to the care received, these systems need to ensure that patient preferences do not impede the content nor quality of care received.

Diagnostic performance of host protein signatures as a triage test for active pulmonary TB.

The current four-symptom screen recommended by the World Health Organization (WHO) is widely used as screen to initiate diagnostic testing for active pulmonary tuberculosis (TB), yet the performance is poor especially when TB prevalence is low. In contrast, more sensitive molecular tests are less suitable for placement at primary care level in low-resource settings. In order to meet the WHO End TB targets, new diagnostic approaches are urgently needed to find the missing undiagnosed cases. Proteomics-derived blood host biomarkers have been explored because protein detection technologies are suitable for the point-of-care setting and could meet cost targets. This study aimed to find a biomarker signature that fulfills WHO's target product profile (TPP) for a TB screening. Twelve blood-based protein biomarkers from three sample populations (Vietnam, Peru, and South Africa) were analyzed individually and in combinations via advanced statistical methods and machine learning algorithms. The combination of I-309, SYWC and kallistatin showed the most promising results to discern active TB throughout the data sets meeting the TPP for a triage test in adults from two countries (Peru and South Africa). The top-performing individual markers identified at the global level (I-309 and SYWC) were also among the best-performing markers at country level in South Africa and Vietnam. This analysis clearly shows that a host protein biomarker assay is feasible in adults for certain geographical regions based on one or two biomarkers with a performance that meets minimal WHO TPP criteria.

Task shifting and community engagement as the keys to increasing access to modern contraception: Findings from mixed methods operational research in coastal Kenya.

RATIONALE: Kilifi County, Kenya, has a modern contraceptive prevalence of 44%, compared to the national prevalence of 61%. In 2018, the Government of Kenya and Population Services Kenya implemented a pilot project in Kilifi to improve contraceptive awareness and access. AIMS AND OBJECTIVES: The Riziki Demonstration Project task shifted contraceptive injectable and implant provision to community health extension workers (CHEWs) and supported community engagement led by community health volunteers (CHVs). This mixed methods evaluation examined the effect of Riziki on contraceptive service provision and identified drivers of the intervention's success in increasing public sector contraceptive uptake. METHOD: We obtained monthly contraceptive service provision data from DHIS2 for intervention and comparison facilities from June 2018 to July 2020. Controlled interrupted time series analyses were used to assess difference-in-differences effects on the levels and trends in service provision. Qualitative data included key informant interviews with health workers, community-based focus group discussions and contraceptive journey mapping. Topics included contraception-related shifts in the health system and social environment and changes to contraceptive accessibility and demand. RESULTS: We found positive difference-in-differences effects for levels of provision for implant (adj. ß = 7.4 per month, per facility, 95% confidence interval [CI]: 2.8-12.0) and all methods combined (adj. ß = 12.2, 95% CI: 3.0-21.3). The health system provided a legal framework and management support for the pilot. Community engagement by CHVs and CHEWs, including with men and religious leaders, bolstered supportive social norms by emphasizing birth spacing and family wellbeing. Awareness and supportive social norms were strengthened among women and their husbands through counselling that leveraged CHEW and CHV community embeddedness. CONCLUSION: Findings demonstrate the potential for task sharing combined with community engagement efforts to improve contraceptive awareness, knowledge and supply. Community engagement should include men, traditional leaders and other influencers to strengthen norms that position family planning in alignment with community values.

Can we design the next generation of digital health communication programs by leveraging the power of artificial intelligence to segment target audiences, bolster impact and deliver differentiated services? A machine learning analysis of survey data from rural India.

OBJECTIVES: Direct to beneficiary (D2B) mobile health communication programmes have been used to provide reproductive, maternal, neonatal and child health information to women and their families in a number of countries globally. Programmes to date have provided the same content, at the same frequency, using the same channel to large beneficiary populations. This manuscript presents a proof of concept approach that uses machine learning to segment populations of women with access to phones and their husbands into distinct clusters to support differential digital programme design and delivery. SETTING: Data used in this study were drawn from cross-sectional survey conducted in four districts of Madhya Pradesh, India. PARTICIPANTS: Study participant included pregnant women with access to a phone (n=5095) and their husbands (n=3842) RESULTS: We used an iterative process involving K-Means clustering and Lasso regression to segment couples into three distinct clusters. Cluster 1 (n=1408) tended to be poorer, less educated men and women, with low levels of digital access and skills. Cluster 2 (n=666) had a mid-level of digital access and skills among men but not women. Cluster 3 (n=1410) had high digital access and skill among men and moderate access and skills among women. Exposure to the D2B programme 'Kilkari' showed the greatest difference in Cluster 2, including an 8% difference in use of reversible modern contraceptives, 7% in child immunisation at 10 weeks, 3% in child immunisation at 9 months and 4% in the timeliness of immunisation at 10 weeks and 9 months. CONCLUSIONS: Findings suggest that segmenting populations into distinct clusters for differentiated programme design and delivery may serve to improve reach and impact. TRIAL REGISTRATION NUMBER: NCT03576157.

Cost-effectiveness of a direct to beneficiary mobile communication programme in improving reproductive and child health outcomes in India.

INTRODUCTION: Kilkari is the largest maternal messaging programme of its kind globally. Between its initiation in 2012 in Bihar and its transition to the government in 2019, Kilkari was scaled to 13 states across India and reached over 10 million new and expectant mothers and their families. This study aims to determine the cost-effectiveness of exposure to Kilkari as compared with no exposure across 13 states in India. METHODS: The study was conducted from a programme perspective using an analytic time horizon aligned with national scale-up efforts from December 2014 to April 2019. Economic costs were derived from the financial records of implementing partners. Data on incremental changes in the practice of reproductive maternal newborn and child health (RMNCH) outcomes were drawn from an individually randomised controlled trial in Madhya Pradesh and inputted into the Lives Saved Tool to yield estimates of maternal and child lives saved. One-way and probabilistic sensitivity analyses were carried out to assess uncertainty. RESULTS: Inflation adjusted programme costs were US$8.4 million for the period of December 2014-April 2019, corresponding to an average cost of US$264 298 per year of implementation in each state. An estimated 13 842 lives were saved across 13 states, 96% among children and 4% among mothers. The cost per life saved ranged by year of implementation and with the addition of new states from US$392 ($385-$393) to US$953 ($889-$1092). Key drivers included call costs and incremental changes in coverage for key RMNCH practices. CONCLUSION: Kilkari is highly cost-effective using a threshold of India's national gross domestic product of US$1998. Study findings provide important evidence on the cost-effectiveness of a national maternal messaging programme in India. TRIAL REGISTRATION: NCT03576157.

Translating the consent form is the tip of the iceberg: using cognitive interviews to assess the barriers to informed consent in South African health facilities.

The increasing digitisation of personal health data has led to an increase in the demand for onward health data. This study sought to develop local language scripts for use in public sector maternity clinics to capture informed consent for onward health data use. The script considered five possible health data uses: 1. Sending of general health information content via mobile phones; 2. Delivery of personalised health information via mobile phones; 3. Use of women's anonymised health data; 4. Use of child's anonymised health data; and 5. Use of data for recontact. Qualitative interviews (n = 54) were conducted among women attending maternity services in three public health facilities in Gauteng and Western Cape, South Africa. Using cognitive interviewing techniques, interviews sought to:(1) explore understanding of the consent script in five South African languages, (2) assess women's understanding of what they were consenting to, and (3) improve the consent script. Multiple rounds of interviews were conducted, each followed by revisions to the consent script, until saturation was reached, and no additional cognitive failures identified. Cognitive failures were a result of: (1) words and phrases that did not translate easily in some languages, (2) cognitive mismatches that arose as a result of different world views and contexts, (3) linguistic gaps, and (4) asymmetrical power relations that influence how consent is understood and interpreted. Study activities resulted in the development of an informed consent script for onward health data use in five South African languages for use in maternity clinics.

In the wake of growing digitisation of personal health data, greater scrutiny is needed on the language of informed consent and the processes for soliciting consent in health care facilities. Qualitative interviews using cognitive interviewing techniques were used to develop and refine consent language in English, Sesotho, isiXhosa, isiZulu and Setswana for the onward use of health data among maternity clients in public sector primary health clinics in the Western Cape and Gauteng provinces of South Africa. We found that translation in local languages and addressing individual words and phrases was only one barrier to requesting informed consent. Other barriers were cognitive mismatches between the question intent and how women understood the question, linguistic gaps that were linked to language and identity, and power dynamics that affected how women understood the consent script. Emerging language scripts used "/" to present words in multiple languages; a reflection of the multi-linguistic nature of communities in this context.

How can community participation strengthen a health insurance system? The case of health insurer's user associations in Colombia.

BACKGROUND: Colombia's universal health coverage programme has enrolled 98% of the population, thereby improving financial protection and health outcomes. The right to participate in the organisation of healthcare is enshrined in the 1991 Colombian Constitution. One participatory mechanism is the legal and regulatory provision that citizens can form user associations. This study examines the functionality of health insurance user associations and their influence on citizen empowerment and health insurance responsiveness. METHODS: The mixed methods study includes document review (n=72), a survey of beneficiaries (n=1311), a survey of user associations members (n=27), as well as interviews (n=19), focus group discussions (n=6) and stakeholder consultations (n=6) with user association members, government officials, and representatives from insurers, the pharmaceutical industry, and patient associations. Analysis used a content-process-context framework to understand how user associations are designed to work according to policy content, how they actually work in terms of coverage, public awareness, membership, and effectiveness, and contextual influences. FINDINGS: Colombia's user associations have a mandate to represent citizens' interests, enable participation in insurer decision-making, 'defend users' and oversee quality services. Insurers are mandated to ensure their enrollees create user associations, but are not required to provide resources to support their work. Thus, we found that user associations had been formed throughout the country, but the public was widely unaware of their existence. Many associations were weak, passive or entirely inactive. Limited market competition and toothless policies about user associations made insurers indifferent to community involvement. CONCLUSION: Currently, the initiative suffers from low awareness and low participation levels that can hardly lead to empowered enrollees and more responsive health insurance programmes. Yet, most stakeholders value the space to participate and still see potential in the initiative. This warrants a range of policy recommendations to strengthen user associations and truly enable them to effect change.

The challenge of ensuring elderly people can access their health insurance entitlements: a mixed methods study on the Republic of Srpska's Protector of Patients' Health Insurance Entitlements.

INTRODUCTION: Healthcare utilisation requires knowing one's entitlements and how to access them (navigation) and having access to grievance redressal when entitlements are denied. To ensure citizen access to and use of health insurance entitlements, the Health Insurance Fund established an initiative called the Protector of Patients' Health Insurance Entitlements (PPHIE). PPHIEs are supposed to provide patient navigation and grievance redressal services. This paper explores to what extent this initiative meets its objectives and is used by the elderly in rural areas. METHODS: This study employed a mixed methods approach. We conducted in-depth interviews with elderly patients in rural areas, PPHIEs, health providers and health insurance managers (N=39), as well as focus groups (N=5) and a household survey (N=715) with elderly rural patients. Qualitative data were analysed using content analysis, and the household survey results were analysed using descriptive statistics. RESULTS: The majority of elderly patients were not aware of the PPHIE initiative and instead received patient navigation support from their healthcare providers. The PPHIE programme was poorly publicised among the population. Although PPHIEs had a mandate to pursue grievance redressal they rarely did so, and their role in the system was more symbolic than functional. CONCLUSION: While healthcare providers have (by default) filled the navigation role left by inactive PPHIEs, the grievance redressal role remains unfilled. Information about health insurance entitlements and access to grievance redressal must be provided through visible, accessible and efficient mechanisms that should be continuously monitored and improved.

Optimising the reach of mobile health messaging programmes: an analysis of system generated data for the Kilkari programme across 13 states in India.

Kilkari is an outbound service that makes weekly, stage-based, prerecorded calls about reproductive, maternal, neonatal and child health directly to families' mobile phones, starting from the second trimester of pregnancy and until the child is 1 year old. Since its initiation in 2012-2013, Kilkari has scaled to 13 states across India. In this analysis article, we explored the subscriber's journey from entry to programme to engagement with calls. Data sources included call data records and household survey data from the 2015 National Family Health Survey. In 2018, of the 13.6 million records received by MOTECH, the technology platform that powers Kilkari, 9.5 million (~70%) were rejected and 4.1 million new subscribers were created. Overall, 21% of pregnant women across 13 states were covered by the programme in 2018, with West Bengal and Himachal Pradesh reaching a coverage of over 50%. Among new subscriptions in 2018, 63% were subscribed during pregnancy and 37% after childbirth. Of these, over 80% were ever reached by Kilkari calls and 39% retained in the programme. The main causes for deactivation of subscribers from the system were low listenership and calls going unanswered for six continuous weeks. Globally, Kilkari is the largest maternal mobile messaging programme of its kind in terms of number of subscribers but the coverage among pregnant women remains low. While call reach appears to be on the higher side, subscriber retention is low; this highlights broader challenges with providing mobile health services at scale across India.

The impact of a direct to beneficiary mobile communication program on reproductive and child health outcomes: a randomised controlled trial in India.

BACKGROUND: Direct-to-beneficiary communication mobile programmes are among the few examples of digital health programmes to have scaled widely in low-resource settings. Yet, evidence on their impact at scale is limited. This study aims to assess whether exposure to mobile health information calls during pregnancy and postpartum improved infant feeding and family planning practices. METHODS: We conducted an individually randomised controlled trial in four districts of Madhya Pradesh, India. Study participants included Hindi speaking women 4-7 months pregnant (n=5095) with access to a mobile phone and their husbands (n=3842). Women were randomised to either an intervention group where they received up to 72 Kilkari messages or a control group where they received none. Intention-to-treat (ITT) and instrumental variable (IV) analyses are presented. RESULTS: An average of 65% of the 2695 women randomised to receive Kilkari listened to ≥50% of the cumulative content of calls answered. Kilkari was not observed to have a significant impact on the primary outcome of exclusive breast feeding (ITT, relative risk (RR): 1.04, 95% CI 0.88 to 1.23, p=0.64; IV, RR: 1.10, 95% CI 0.67 to 1.81, p=0.71). Across study arms, Kilkari was associated with a 3.7% higher use of modern reversible contraceptives (RR: 1.12, 95% CI 1.03 to 1.21, p=0.007), and a 2.0% lower proportion of men or women sterilised since the birth of the child (RR: 0.85, 95% CI 0.74 to 0.97, p=0.016). Higher reversible method use was driven by increases in condom use and greatest among those women exposed to Kilkari with any male child (9.9% increase), in the poorest socioeconomic strata (15.8% increase), and in disadvantaged castes (12.0% increase). Immunisation at 10 weeks was higher among the children of Kilkari listeners (2.8% higher; RR: 1.03, 95% CI 1.00 to 1.06, p=0.048). Significant differences were not observed for other maternal, newborn and child health outcomes assessed. CONCLUSION: Study findings provide evidence to date on the effectiveness of the largest mobile health messaging programme in the world. TRIAL REGISTRATION NUMBER: Trial registration clinicaltrials.gov; ID 90075552, NCT03576157.

'[We] learned how to speak with love': a qualitative exploration of accredited social health activist (ASHA) community health worker experiences of the Mobile Academy refresher training in Rajasthan, India.

INTRODUCTION: Mobile Academy is a mobile-based training course for India's accredited social health activist (ASHA) community health workers (CHW). The course, which ASHAs access by dialling a number from their phones, totals 4 hours of audio content. It consists of 11 chapters, each with their own quiz, and provides a cumulative pass or fail score at the end. This qualitative study of Mobile Academy explores how the programme was accessed and experienced by CHWs, and how they perceive it to have influenced their work. METHODS: We conducted in-depth interviews (n=25) and focus group discussions (n=5) with ASHAs and other health system actors. Open-ended questions explored ASHA perspectives on Mobile Academy, the course's perceived influence on ASHAs and preferences for future training programmes. After applying a priori codes to the transcripts, we identified emergent themes and grouped them according to our CHW mLearning framework. RESULTS: ASHAs reported enjoying Mobile Academy, specifically praising its friendly tone and the ability to repeat content. They, and higher level health systems actors, conceived it to primarily be a test not a training. ASHAs reported that they found the quizzes easy but generally did not consider the course overly simplistic. ASHAs considered Mobile Academy's content to be a useful knowledge refresher but said its primary benefit was in modelling a positive communications approach, which inspired them to adopt a kinder, more 'loving' communication style when speaking to beneficiaries. ASHAs and health system actors wanted follow-on mLearning courses that would continue to compliment but not replace face-to-face training. CONCLUSION: This mLearning programme for CHWs in India was well received by ASHAs across a wide range of education levels and experience. Dial-in audio training has the potential to reinforce topical knowledge and showcase positive ways to communicate.

"The Videos Gave Weight to Our Work": Animated mHealth Videos and Tablet Technology Boost Community Health Workers' Perceived Credibility in Khayelitsha, South Africa.

Mobile health (mHealth) interventions are increasingly used to support community health workers (CHWs) in low-and middle-income countries. As near-peers within their communities, the credibility of CHWs is sometimes questioned-a recognized barrier to their efficacy. Nested within a large, randomized-controlled trial, this qualitative study captured the experiences of South African CHWs, called "Mentor-Mothers," using tablets and animated videos to promote exclusive breastfeeding. We conducted in-depth telephone interviews with 26 tablet-carrying Mentor-Mothers. We analyzed interview transcripts using a Grounded Theory approach, then developed a theoretical framework, based on an emerging theme, for understanding how tablet technology boosts the perceived credibility of CHWs. Tablet-carrying Mentor-Mothers described an increase in their perceived credibility, which they attributed to overt and signaling effects related to enhanced credibility of (1) their messages, (2) themselves as messengers, and (3) the program employing them. Mobile technology investments in CHWs could enhance their credibility, translating into meaningful investments in the health of under-served communities.

Assessing the reliability of phone surveys to measure reproductive, maternal and child health knowledge among pregnant women in rural India: a feasibility study.

OBJECTIVES: Efforts to understand the factors influencing the uptake of reproductive, maternal, newborn, child health and nutrition (RMNCH&N) services in high disease burden low-resource settings have often focused on face-to-face surveys or direct observations of service delivery. Increasing access to mobile phones has led to growing interest in phone surveys as a rapid, low-cost alternatives to face-to-face surveys. We assess determinants of RMNCH&N knowledge among pregnant women with access to phones and examine the reliability of alternative modalities of survey delivery. PARTICIPANTS: Women 5-7 months pregnant with access to a phone. SETTING: Four districts of Madhya Pradesh, India. DESIGN: Cross-sectional surveys administered face-to-face and within 2 weeks, the same surveys were repeated among two random subsamples of the original sample: face-to-face (n=205) and caller-attended telephone interviews (n=375). Bivariate analyses, multivariable linear regression, and prevalence and bias-adjusted kappa scores are presented. RESULTS: Knowledge scores were low across domains: 52% for maternal nutrition and pregnancy danger signs, 58% for family planning, 47% for essential newborn care, 56% infant and young child feeding, and 58% for infant and young child care. Higher knowledge (≥1 composite score) was associated with older age; higher levels of education and literacy; living in a nuclear family; primary health decision-making; greater attendance in antenatal care and satisfaction with accredited social health activist services. Survey questions had low inter-rater and intermodal reliability (kappa<0.70) with a few exceptions. Questions with the lowest reliability included true/false questions and those with unprompted, multiple response options. Reliability may have been hampered by the sensitivity of the content, lack of privacy, enumerators' and respondents' profile differences, rapport, social desirability bias, and/or enumerator's ability to adequately convey concepts or probe. CONCLUSIONS: Phone surveys are a reliable modality for generating population-level estimates data about pregnant women's knowledge, however, should not be used for individual-level tracking. TRIAL REGISTRATION NUMBER: NCT03576157.

At the frontlines of digitisation: a qualitative study on the challenges and opportunities in maintaining accurate, complete and timely digital health records in India's government health system.

OBJECTIVES: To understand factors underpinning the accuracy and timeliness of mobile phone numbers and other health information captured in India's government registry for pregnant and postpartum women. Accurate and timely registration of mobile phone numbers is necessary for beneficiaries to receive mobile health services. SETTING: Madhya Pradesh and Rajasthan states in India at the community, clinical, and administrative levels of the health system. PARTICIPANTS: Interviews (n=59) with frontline health workers (FLHWs), data entry operators, and higher level officials. Focus group discussions (n=12) with pregnant women to discuss experiences with sharing data in the health system. Observations (n=9) of the process of digitization and of interactions between stakeholders for data collection. PRIMARY AND SECONDARY OUTCOME MEASURES: Thematic analysis identified how key actors experienced the data collection and digitisation process, reasons for late or inaccurate data, and mechanisms that can bolster timeliness and accuracy. RESULTS: Pregnant women were comfortable sharing mobile numbers with health workers, but many were unaware that their data moved beyond their FLHW. FLHWs valued knowing up-to-date beneficiary mobile numbers, but felt little incentive to ensure accuracy in the digital record system. Delays in registering pregnant women in the online portal were attributed to slow movement of paper records into the digital system and difficulties in gathering required documents from beneficiaries. Data, including women's phone numbers, were handwritten and copied multiple times by beneficiaries and health workers with variable literacy. Supervision tended to focus on completeness rather than accuracy. Health system actors noted challenges with the digital system but valued the broader project of digitisation. CONCLUSIONS: Increased focus on training, supportive supervision, and user-friendly data processes that prioritise accuracy and timeliness should be considered. These inputs can build on existing positive patient-provider relationships and health system actors' enthusiasm for digitisation.

HDX-MS and MD Simulations Provide Evidence for Stabilization of the IgG1-FcγRIa (CD64a) Immune Complex Through Intermolecular Glycoprotein Bonds.

Previous reports present different models for the stabilization of the Fc-FcγRI immune complex. Although accord exists on the importance of L235 in IgG1 and some hydrophobic contacts for complex stabilization, discord exists regarding the existence of stabilizing glycoprotein contacts between glycans of IgG1 and a conserved FG-loop (171MGKHRY176) of FcγRIa. Complexes formed from the FcγRIa receptor and IgG1s containing biantennary glycans with N-acetylglucosamine, galactose, and α2,6-N-acetylneuraminic terminations were measured by hydrogen-deuterium exchange mass spectrometry (HDX-MS), classified for dissimilarity with Welch's ANOVA and Games-Howell post hoc procedures, and modeled with molecular dynamics (MD) simulations. For each glycoform of the IgG1-FcγRIa complex peptic peptides of Fab, Fc and FcγRIa report distinct H/D exchange rates. MD simulations corroborate the differences in the peptide deuterium content through calculation of the percent of time that transient glycan-peptide bonds exist. These results indicate that stability of IgG1-FcγRIa complexes correlate with the presence of intermolecular glycoprotein interactions between the IgG1 glycans and the 173KHR175 motif within the FG-loop of FcγRIa. The results also indicate that intramolecular glycan-protein bonds stabilize the Fc region in isolated and complexed IgG1. Moreover, HDX-MS data evince that the Fab domain has glycan-protein binding contacts within the IgG1-FcγRI complex.

Power analysis in health policy and systems research: a guide to research conceptualisation.

Power is a growing area of study for researchers and practitioners working in the field of health policy and systems research (HPSR). Theoretical development and empirical research on power are crucial for providing deeper, more nuanced understandings of the mechanisms and structures leading to social inequities and health disparities; placing contemporary policy concerns in a wider historical, political and social context; and for contributing to the (re)design or reform of health systems to drive progress towards improved health outcomes. Nonetheless, explicit analyses of power in HPSR remain relatively infrequent, and there are no comprehensive resources that serve as theoretical and methodological starting points. This paper aims to fill this gap by providing a consolidated guide to researchers wishing to consider, design and conduct power analyses of health policies or systems. This practice article presents a synthesis of theoretical and conceptual understandings of power; describes methodologies and approaches for conducting power analyses; discusses how they might be appropriately combined; and throughout reflects on the importance of engaging with positionality through reflexive praxis. Expanding research on power in health policy and systems will generate key insights needed to address underlying drivers of health disparities and strengthen health systems for all.

Community health workers at the dawn of a new era: 11. CHWs leading the way to "Health for All".

BACKGROUND: This is the concluding paper of our 11-paper supplement, "Community health workers at the dawn of a new era". METHODS: We relied on our collective experience, an extensive body of literature about community health workers (CHWs), and the other papers in this supplement to identify the most pressing challenges facing CHW programmes and approaches for strengthening CHW programmes. RESULTS: CHWs are increasingly being recognized as a critical resource for achieving national and global health goals. These goals include achieving the health-related Sustainable Development Goals of Universal Health Coverage, ending preventable child and maternal deaths, and making a major contribution to the control of HIV, tuberculosis, malaria, and noncommunicable diseases. CHWs can also play a critical role in responding to current and future pandemics. For these reasons, we argue that CHWs are now at the dawn of a new era. While CHW programmes have long been an underfunded afterthought, they are now front and centre as the emerging foundation of health systems. Despite this increased attention, CHW programmes continue to face the same pressing challenges: inadequate financing, lack of supplies and commodities, low compensation of CHWs, and inadequate supervision. We outline approaches for strengthening CHW programmes, arguing that their enormous potential will only be realized when investment and health system support matches rhetoric. Rigorous monitoring, evaluation, and implementation research are also needed to enable CHW programmes to continuously improve their quality and effectiveness. CONCLUSION: A marked increase in sustainable funding for CHW programmes is needed, and this will require increased domestic political support for prioritizing CHW programmes as economies grow and additional health-related funding becomes available. The paradigm shift called for here will be an important step in accelerating progress in achieving current global health goals and in reaching the goal of Health for All.

Avoiding the Road to Nowhere: Policy Insights on Scaling up and Sustaining Digital Health.

Digital health solutions offer tremendous potential to enhance the reach and quality of health services and population-level outcomes in low- and middle-income countries (LMICs). While the number of programs reaching scale increases yearly, the long-term sustainability for most remains uncertain. In this article, as researchers and implementors, we draw on experiences of designing, implementing and evaluating digital health solutions at scale in Africa and Asia, and provide examples from India and South Africa to illustrate ten considerations to support scale and sustainability of digital health solutions in LMICs. Given the investments being made in digital health solutions and the urgent concurrent needs to strengthen health systems to ensure their responsiveness to marginalized populations in LMICs, we cannot afford to go down roads that 'lead to nowhere'. These ten considerations focus on drivers of equity and innovation, the foundations for a digital health ecosystem, and the elements for systems integration. We urge technology enthusiasts to consider these issues before and during the roll-out of large-scale digital health initiatives to navigate the complexities of achieving scale and enabling sustainability.

Freedom within a cage: how patriarchal gender norms limit women's use of mobile phones in rural central India.

INTRODUCTION: India has one of the highest gender gaps in mobile phone access in the world. As employment opportunities, health messaging (mHealth), access to government entitlements, banking, civic participation and social engagement increasingly take place in the digital sphere, this gender gap risks further exacerbating women's disadvantage in Indian society. This study identifies the factors driving women's unequal use of phones in rural Madhya Pradesh, India. METHODS: We interviewed mothers of 1-year-old children (n=29) who reported that they had at least some access to a mobile phone. Whenever possible, we also spoke to their husbands (n=23) and extended family members (n=34) through interviews or family group discussions about the use of phones in their households, as well as their perspectives on gender and phone use more broadly. Our analysis involved comparing wife-husband pairs to assess differences in phone access and use, and thematic coding on the determinants of women's phone use using an iteratively developed conceptual framework. RESULTS: While respondents reported that women could use the phone without needing permission, this apparent 'freedom' existed in a context that severely constrained women's actual use, most directly through: (1) narrow expectations and desires around how women would use phones, (2) women's dependence on men for phone ownership and lower proximity to phones, (3) the poorer functionality of women's phones; (4) women's limited digital skills, and (5) time allocation constraints, wherein women had less leisure time and were subject to social norms that discouraged using a phone for leisure. CONCLUSION: Our framework, presenting the distal and proximate determinants of women's phone use, enables more nuanced understanding of India's digital divide. Addressing these determinants is vital to shift from re-entrenching unequal gender relations to transforming them through digital technology.