Optimizing immunization services: A Data Envelopment Analysis (DEA) of child immunization facilities in Pakistan.

INTRODUCTION: Child immunization, though cost-beneficial, experiences varying costs influenced by individual facility-level factors. A real-time solution is to optimize resources and enhance vaccination services through proper method to measure immunization facility efficiency using existing data. Additionally, examine the impact of COVID-19 on facility efficiency, with the primary goal of comprehensively assessing child immunization facility efficiency in Pakistan. METHODS: Utilizing survey data collected in four rounds from May 2018 to December 2020, the research focuses on doses administered and stock records for the preceding six months in each phase. In the initial stage, Data Envelopment Analysis (DEA) is utilized to compute facility efficiency, employing two models with varied outputs while maintaining consistent inputs. Model 1 assesses doses administered, encompassing three outputs (pentavalent vaccine 1, 2, and 3). Meanwhile, Model 2, focuses on stock used featuring a single output (total doses used). The inputs considered in both models include stock availability, staff members, cold chain equipment, vaccine carriers, and vaccine sessions. The second stage involves the application of two competing regression specifications (Tobit and Simar-Wilson) to explore the impact of the COVID-19 pandemic and external factors on the efficiency of these facilities. RESULTS: In 12 districts across Punjab and Sindh, we assess 466 facilities in Model 1 and 455 in Model 2. Model 1 shows 59% efficiency, and Model 2 shows 70%, indicating excess stock. Stock of vaccines need to be reduced by from 36% to 43%. In the stage, COVID-19 period reduced efficiency in Model 1 by 10%, however, insignificant in Model 2. CONCLUSIONS: The proposed methodology, utilizing DEA, emerges as a valuable tool for immunization facilities seeking to improve resource utilization and overall efficiency. Model 1, focusing on doses administered indicates facilities low efficiency at average 59% and proves more pertinent for efficiency analysis as it directly correlates with the number of children vaccinated. The prevalent issue of overstocking across all facilities significantly impacts efficiency. This study underscores the critical importance of optimizing resources through the redistribution of excess stock with low efficiency.

Ensuring vaccine potency and availability: how evidence shaped Gavi's Immunization Supply Chain Strategy.

BACKGROUND: In 2014, Gavi and partners developed a global Immunization Supply Chain (iSC) Strategy, 2015-2020, which prioritized functioning cold chain equipment (CCE) and additional storage capacity. In 2016, Gavi launched the Cold Chain Equipment Optimization Platform (CCEOP) as a funding mechanism to improve CCE availability. In 2018, Gavi commissioned an evaluation of CCEOP in Guinea, Kenya and Pakistan. The global iSC Strategy has recently been revised, drawing on findings from effective vaccine management assessments and practical experiences. This case study presents the CCEOP evaluation and how its findings reinforced the revision of the iSC strategy. METHODS: The CCEOP evaluation used a prospective mixed-methods research design in all three countries involving key informant interviews at multiple levels of the health system, document reviews, direct observation (as and when possible), and a health facility assessment. RESULTS: Results show that CCEOP was effective at increasing the number of available and reliable CCE, and establishing improved management processes using the project management team (PMT) approach for country management systems and the service bundle provider approach for installation and maintenance. CCEOP also extended the iSC and immunization services in countries. The evaluation results also show gaps in the overall supply chain system, including CCE maintenance. DISCUSSION: Gavi has recently revised its iSC strategy, which has addressed gaps identified through assessments and practical experiences from stakeholders. Results of the CCEOP evaluation reinforce many of these findings. The strategy now provides more emphasis on supporting the fundamental infrastructure and establishing strong processes for maintenance. It also emphasizes strategic planning and forward thinking for iSC decisions, building on the processes established for the PMT through CCEOP. The original iSC strategy was an impetus for the establishment of CCEOP. The new strategy reflects shifting trends and priorities to fill gaps identified through practical experience, advocated for by stakeholders and thought leaders engaged in the iSC, and validated by the evaluation. It demonstrates the importance of aligning stakeholders with clear objectives and a sound strategy.

A Tale of 2 Countries: Implementation of the Cold Chain Equipment Optimization Platform in Guinea and Kenya.

In 2016, the Gavi Cold Chain Equipment Optimization Platform (CCEOP) was approved and launched in recognition of the fact that functional cold chain equipment (CCE) is essential to strengthening vaccine supply chains and ultimately achieving Gavi's immunization equity and coverage goals. Through CCEOP, Gavi committed to investing US$250 million between 2016 and 2021 to commission CCE in more than 63,000 facilities to upgrade and expand their CCE footprint while stimulating the market to provide affordable, technologically advanced, and accessible equipment. We present case studies from Guinea and Kenya, both of which received CCEOP support, that highlight 2 ways for countries to prioritize investments and implement activities through a large funding and support mechanism. The studies explore the different ways that each country implemented CCEOP and consider how aspects of leadership and technical capacity influence country priorities and results. They also uncover key lessons on sustainability of a large immunization supply chain effort. The experiences of Guinea and Kenya can help other countries embarking on similarly large health system interventions, especially related to supply chain strengthening and immunization programs. In particular, these experiences offer important lessons in leadership, processes and systems, country ownership, technical capacity, and sustainability.

'Let me move to another level': career advancement desires and opportunities for community health nurses in Ghana.

Career advancement and continued education are critical components of health worker motivation and retention. Continuous advancement also builds health system capacity by ensuring that leaders are those with experience and strong performance records. To understand more about the satisfaction, desires, and career opportunities available to community health nurses (CHNs) in Ghana, we conducted 29 in-depth interviews and four focus group discussions across five predominantly rural districts. Interview transcripts and summary notes were coded in NVivo based on pre-defined and emergent codes using thematic content analysis. Frustration with existing opportunities for career advancement and continued education emerged as key themes. Overall, the CHNs desired greater opportunities for career development, as most aspired to return to school to pursue higher-level health positions. While workshops were available to improve CHNs knowledge and skills, they were infrequent and irregular. CHNs wanted greater recognition for their work experience in the form of respect from leaders within the Ghana Health System and credit towards future degree programs. CHNs are part of a rapidly expanding cadre of salaried community-based workers in sub-Saharan Africa, and information about their experiences and needs can be used to shape future health policy and program planning.

Supervision of community health nurses in Ghana: a mixed-methods study on experiences and mentorship needs.

Adequate supervision is critical to maintain the performance of health workers who provide essential maternal and child health services in low-resource areas. Supportive supervision emphasizing problem-solving, skill development and mentorship has been shown to improve the motivation and effectiveness of health workers, especially at the community level, but it is not always routinely provided. Previous studies have assessed the uptake of supportive supervision among volunteer health workers and paid health centre staff, but less is known about the supervision experiences of paid community-based staff, such as community health nurses (CHNs) in Ghana. This mixed-methods study explores the frequency and content of CHN supervision in five districts in the Greater Accra and Volta regions of Ghana. We analysed quantitative data from 197 satisfaction surveys and qualitative data from 29 in-depth interviews (IDIs) and four focus group discussions (FGDs) with CHNs. While the majority of CHNs received supervision at least monthly, they reported that supervision was primarily focused on meeting clinical targets (48%) rather than on handling specific cases or patients (23%). Over a third (34%) of CHNs did not agree that supervisors help them with job-related challenges and nearly half (43%) were unsatisfied with their jobs. When asked about their mentorship needs, CHNs reported wanting feedback on how to improve their job performance (40%) and encouragement (30%). There were only slight variations in the frequency and content of supervision based on type of supervisor. During IDIs and FGDs, CHNs offered ideas for how to improve supervision, including more frequent field visits so that supervisors could see the on-the-ground realities of their work, greater respect and positive reinforcement. Overall, CHN motivation and job satisfaction may be strengthened by aligning supervision more closely with the principles of supportive supervision.

Conducting mixed-methods research with Ebola survivors in a complex setting in Sierra Leone.

BACKGROUND: In late 2015, the Sierra Leone government established the Comprehensive Program for Ebola Survivors (CPES) to improve the well-being of 3466 registered Ebola virus disease (EVD) survivors. This case analysis outlines the challenges of conducting research studies on the health situation of these EVD survivors in a complicated, post-Ebola context. It outlines strategies to address these challenges without compromising research quality. The mixed-methods study sought to determine EVD survivors' access to health services offered through CPES, their health and disability status, and psychosocial and mental health issues faced. Qualitative data from survivors and stakeholders at multiple levels complemented and contextualized the survey results to help understand the unique health and associated socioeconomic challenges that EVD survivors face, which could be applied to other crisis settings. Study findings indicated that CPES had lasting impacts on Sierra Leone's health system, enabling it to respond to EVD survivors, who increasingly accessed health services and showed lower levels of disability after receiving care. DISCUSSION: Understanding the health service needs of this specialized population in a country with an overloaded health system after the Ebola epidemic makes this research study important and timely. The study faced several challenges, including working in a low-resource and low-capacity setting marked by constantly changing priorities and activities of CPES donors and implementers. Further, the study aimed to measure sensitive topics, such as mental health and disability, with standardized tools that required careful contextualization for accurate reporting of findings. Strategies to overcome these challenges included utilizing a mixed-methods approach to contextualize and validate survey results. The study also enabled capacity building of local research teams to ensure that they could follow lines of inquiry and navigate the complex post-Ebola context. CONCLUSIONS: Flexibility is paramount when conducting high-quality research for representative and useful results. Timely research and ongoing sharing of the findings with stakeholders is critical to ensure that they benefit study subjects. Furthermore, in such settings, there is a need to balance engagement of stakeholders with maintaining independence and impartiality in the research design and subsequent data produced.

Mental health among Ebola survivors in Liberia, Sierra Leone and Guinea: results from a cross-sectional study.

OBJECTIVES: To describe the prevalence and correlates of depression and anxiety among adult Ebola virus disease (EVD) survivors in Liberia, Sierra Leone and Guinea. DESIGN: Cross-sectional. SETTING: One-on-one surveys were conducted in EVD-affected communities in Liberia, Sierra Leone and Guinea in early 2018. PARTICIPANTS: 1495 adult EVD survivors (726 male, 769 female). PRIMARY AND SECONDARY OUTCOME MEASURES: Patient Health Questionnaire-9 (PHQ-9) depression scores and Generalised Anxiety Disorder-7 (GAD-7) scores. RESULTS: Prevalence and severity of depression and anxiety varied across the three countries. Sierra Leone had the highest prevalence of depression, with 22.0% of participants meeting the criteria for a tentative diagnosis of depression, compared with 20.2% in Liberia and 13.0% in Guinea. Sierra Leone also showed the highest prevalence of anxiety, with 10.7% of participants meeting criteria for generalized anxiety disorder (GAD-7 score ≥10), compared with 9.9% in Liberia and 4.2% in Guinea. Between one-third and one-half of respondents reported little interest or pleasure in doing things in the previous 2 weeks (range: 47.0% in Liberia to 37.6% in Sierra Leone), and more than 1 in 10 respondents reported ideation of self-harm or suicide (range: 19.4% in Sierra Leone to 10.4% in Guinea). Higher depression and anxiety scores were statistically significantly associated with each other and with experiences of health facility-based stigma in all three countries. Other associations between mental health scores and respondent characteristics varied across countries. CONCLUSIONS: Our results indicate that both depression and anxiety are common among EVD survivors in Liberia, Sierra Leone and Guinea, but that there is country-level heterogeneity in prevalence, severity and correlates of these conditions. All three countries should work to make mental health services available for survivors, and governments and organisations should consider the intersection between EVD-related stigma and mental health when designing programmes and training healthcare providers.

Quality of TB services assessment: The unique contribution of patient and provider perspectives in identifying and addressing gaps in the quality of TB services.

Ambitious efforts to detect and treat tuberculosis (TB) are required to reduce the burden of disease in low resource settings, and the provision of high quality TB services is critical to reaching global TB targets. The quality of TB services assessment (QTSA) is a facility-based approach aimed at identifying gaps in TB services and prioritizing interventions to improve care across multiple countries with high TB burden. Randomly sampled facilities are assessed with standardized instruments to collect data on structures, processes, and outcomes of TB care, with adaption for local diagnostic and treatment algorithms. The sampling strategy is modified to ensure representation of all levels of the health system where TB services are provided, as well as inclusion of private sector or other facility types relevant to the context. Instruments include a facility audit, provider and patient interviews, and a review of TB registers. A recent QTSA in the Philippines generated important data on provider and patient perspectives on quality of care, showing that providers are more likely to report that they counseled current TB patients on key aspects of TB diagnosis and treatment than patients are to report having received the information. These comparisons highlight areas where refresher training or interpersonal communication and counseling skills may be needed.

Marine protected areas and children's dietary diversity in the Philippines.

Fish living around the coral reefs in the Philippines provide livelihoods for more than a million local fishers and are an important source of protein for coastal communities. However, this rich resource is at risk from myriad threats, which consequently threaten human livelihoods, nutrition, and health. In this paper, we examine the degree to which marine protected areas (MPAs), which aim to conserve marine biodiversity, are associated with improved nutritional outcomes in children under age 5. This analysis, which uses data from the 2008 Philippines Demographic and Health Survey and MPA data from the Coastal Conservation and Education Fund, found a positive association between MPAs and children's dietary diversity when the MPAs were located closer than 2 km to a child's community. MPA characteristics such as age or type of management were not consistently associated with dietary diversity. These results suggest a positive association of proximity to MPAs with certain aspects of children's diet.

Examining domains of community health nurse satisfaction and motivation: results from a mixed-methods baseline evaluation in rural Ghana.

BACKGROUND: A strong health system requires a competent and caring workforce. A more satisfied and motivated health workforce should be more willing to serve in difficult areas, have lower turnover, and theoretically provide better care to patients. This paper examines the motivation, satisfaction, and correlation with clinical knowledge, of community health nurses (CHNs), a cadre of provider focused on maternal, newborn and child health in rural Ghana. METHODS: This study employed three methods of evaluation. Two quantitative measurements were used: (1) a survey of health worker satisfaction and motivation and (2) a clinical knowledge assessment focusing on maternal, newborn and child health. Both were administered to all rostered CHNs working in the five sampled districts in the Greater Accra and Volta regions in Eastern Ghana (N = 205). Qualitative interviews (N = 29) and focus group discussions (N = 4) were held with selected CHNs in the same districts. These data were analysed using NVivo (Version 10) and Stata (Version 13.0) based on domains of extrinsic and intrinsic motivation including general satisfaction, work environment and access to resources, respect and recognition received and opportunities for advancement. RESULTS: CHNs desired more training, especially those who were posted at the community level (a Community-based Health Planning and Services post or "CHPS") versus at a health facility. CHNs working at CHPS believed their work to be more difficult than those posted at health facilities, due to challenges associated with foot travel to visit patients at home, and they were more likely to report having insufficient resources to do their jobs (48% vs 36%). However, CHNs posted at health facilities were more likely to report insufficient opportunities for career advancement than the CHPS nurses (49% vs 33%). CHNs generally reported good relationships with colleagues and being respected by patients but desired more respect from supervisors. The median score on the knowledge assessment was 78%. On average, subgroups of CHNs with different reported levels of satisfaction did not perform differently on the knowledge assessment. CONCLUSIONS: CHNs in Ghana were satisfied overall but desired more training, more guidance and supervision, fair pay and opportunities to advance in their career. Improving health worker satisfaction and morale may be important for health worker retention and certain aspects of care but may not have a significant influence on clinical knowledge or performance.

Strengthening community health supply chain performance through an integrated approach: Using mHealth technology and multilevel teams in Malawi.

BACKGROUND: In 2010, 7.6 million children under five died globally - largely due to preventable diseases. Majority of these deaths occurred in sub-Saharan Africa. As a strategy to reduce child mortality, the Government of Malawi, in 2008, initiated integrated community case management allowing health surveillance assistants (HSAs) to treat sick children in communities. Malawi however, faces health infrastructure challenges, including weak supply chain systems leading to low product availability. A baseline assessment conducted in 2010 identified data visibility, transport and motivation of HSAs as challenges to continuous product availability. The project designed a mHealth tool as part of two interventions to address these challenges. METHODS: A mobile health (mHealth) technology - cStock, for reporting on community stock data - was designed and implemented as an integral component of Enhanced Management (EM) and Efficient Product Transport (EPT) interventions. We developed a feasibility and acceptability framework to evaluate the effectiveness and predict the likelihood of scalability and ownership of the interventions. Mixed methods were used to conduct baseline and follow up assessments in May 2010 and February 2013, respectively. Routine monitoring data on community stock level reports, from cStock, were used to analyze supply chain performance over 18-month period in the intervention groups. RESULTS: Mean stock reporting rate by HSAs was 94% in EM group (n = 393) and 79% in EPT group (n = 253); mean reporting completeness was 85% and 65%, respectively. Lead time for HSA drug resupply over the 18-month period was, on average, 12.8 days in EM and 26.4 days in EPT, and mean stock out rate for 6 tracer products was significantly lower in EM compared to EPT group. CONCLUSIONS: Results demonstrate that cStock was feasible and acceptable to test users in Malawi, and that based on comparison with the EPT group, the team component of the EM group was an essential pairing with cStock to achieve the best possible supply chain performance and supply reliability. Establishing multi-level teams serves to connect HSAs with decision makers at higher levels of the health system, align objectives, clarify roles and promote trust and collaboration, thereby promoting country ownership and scalability of a cStock-like system.

Who gives birth in private facilities in Asia? A look at six countries.

Over the past two decades, multilateral organizations have encouraged increased engagement with private healthcare providers in developing countries. As these efforts progress, there are concerns regarding how private delivery care may effect maternal health outcomes. Currently available data do not allow for an in-depth study of the direct effect of increasing private sector use on maternal health across countries. As a first step, however, we use demographic and health surveys (DHS) data to (1) examine trends in growth of delivery care provided by private facilities and (2) describe who is using the private sector within the healthcare system. As Asia has shown strong increases in institutional coverage of delivery care in the last decade, we will examine trends in six Asian countries. We hypothesize that if the private sector competes for clients based on perceived quality, their clientele will be wealthier, more educated and live in an area where there are enough health facilities to allow for competition. We test this hypothesis by examining factors of socio-demographic, economic and physical access and actual/perceived need related to a mother's choice to deliver in a health facility and then, among women delivering in a facility, their use of a private provider. Results show a significant trend towards greater use of private sector delivery care over the last decade. Wealth and education are related to private sector delivery care in about half of our countries, but are not as universally related to use as we would expect. A previous private facility birth predicted repeat private facility use across nearly all countries. In two countries (Cambodia and India), primiparity also predicted private facility use. More in-depth work is needed to truly understand the behaviour of the private sector in these countries; these results warn against making generalizations about private sector delivery care.

Teachers' education, classroom quality, and young children's academic skills: results from seven studies of preschool programs.

In an effort to provide high-quality preschool education, policymakers are increasingly requiring public preschool teachers to have at least a Bachelor's degree, preferably in early childhood education. Seven major studies of early care and education were used to predict classroom quality and children's academic outcomes from the educational attainment and major of teachers of 4-year-olds. The findings indicate largely null or contradictory associations, indicating that policies focused solely on increasing teachers' education will not suffice for improving classroom quality or maximizing children's academic gains. Instead, raising the effectiveness of early childhood education likely will require a broad range of professional development activities and supports targeted toward teachers' interactions with children.