Evaluating the implementation of home delivery of medication by community health workers during the COVID-19 pandemic in Cape Town, South Africa: a convergent mixed methods study.

BACKGROUND: Primary care services in South Africa have been challenged by increasing numbers of people with communicable and non-communicable chronic diseases. There was a need to develop alternative approaches for stable patients to access medication. With the onset of the coronavirus pandemic there was an urgent need to decongest facilities and protect people from infection. In this crisis the Metro Health Services rapidly implemented home delivery of medication by community health workers. This study aimed to evaluate the implementation of home delivery of medication by community health workers during the coronavirus pandemic in Cape Town, South Africa. METHODS: A convergent mixed methods study evaluated six implementation outcomes: adoption, feasibility, fidelity, coverage, cost, and sustainability of the initiative. Data sources included routinely collected data, a telephonic survey of 138 patients, an analysis of set-up and recurrent costs as well as 17 descriptive exploratory qualitative semi-structured interviews with 68 key informants. RESULTS: Over a 6-month period 1,054,657 pre-packaged parcels were sent to primary care facilities, 819,649 (77.7%) were delivered and of those 97,297 (11.9%) returned. The additional costs were estimated as 1.3% of a total health budget of R2,2 billion. The initiative was rapidly adopted as it decongested facilities and protected vulnerable patients. Although it was feasible to implement at scale, numerous challenges were encountered, such as incorrect addresses and contact details, transporting parcels, communicating with patients, having a reliable audit trail, and handling out-of-area patients. All role players thought the service should continue and 42.3% of patients reported better adherence to their medication. CONCLUSION: Home delivery of medication by community health workers is feasible at scale and affordable. It should continue, but as one of a menu of options for alternative delivery of medication. The following need to be improved: efficiency of the system, the audit trail, adequate support and resources for community health workers, transport of medication, communication with patients, empanelment of patients, governance of the system and training of the community health workers.

Costs of common perinatal mental health problems in South Africa.

Background: Perinatal mental health problems, defined as mental health problems occurring from the start of pregnancy to one year after birth, substantially affect women's and children's quality of life in low- and middle-income countries. In South Africa, despite high prevalence and documented negative impacts, most women do not receive any care. Methods: A modelling study examined the costs of perinatal mental health problems, namely depression and anxiety, for a hypothetical cohort of women and their children in South Africa over part of their life course (10 years for women, 40 years for children). In sensitivity analysis, additional impacts of post-traumatic stress disorder (PTSD) and completed suicide were included. Data sources were published findings from cohort studies, as well as epidemiological and economic data from South Africa. Data from international studies were considered where no data from South Africa were available. Results: Lifetime costs of perinatal depression and anxiety in South Africa amount to USD 2.8 billion per annual cohort of births. If the impacts of PTSD and suicide are included, costs increase to USD 2.9 billion. This includes costs linked to losses in quality of life (USD 1.8 billion), losses in income (USD 1.1 billion) and public sector costs (USD 3.5 million). Conclusions: Whilst important progress has been made in South Africa with regards to mental health policies and interventions that include assessment and management of perinatal mental health problems, substantial underinvestment prevents progress. Findings from this study strengthen the economic case for investing in perinatal mental health care.

Integrated community case management of childhood illness in low- and middle-income countries.

BACKGROUND: The leading causes of mortality globally in children younger than five years of age (under-fives), and particularly in the regions of sub-Saharan Africa (SSA) and Southern Asia, in 2018 were infectious diseases, including pneumonia (15%), diarrhoea (8%), malaria (5%) and newborn sepsis (7%) (UNICEF 2019). Nutrition-related factors contributed to 45% of under-five deaths (UNICEF 2019). World Health Organization (WHO) and United Nations Children's Fund (UNICEF), in collaboration with other development partners, have developed an approach - now known as integrated community case management (iCCM) - to bring treatment services for children 'closer to home'. The iCCM approach provides integrated case management services for two or more illnesses - including diarrhoea, pneumonia, malaria, severe acute malnutrition or neonatal sepsis - among under-fives at community level (i.e. outside of healthcare facilities) by lay health workers where there is limited access to health facility-based case management services (WHO/UNICEF 2012). OBJECTIVES: To assess the effects of the integrated community case management (iCCM) strategy on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for children younger than five years of age in low- and middle-income countries. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and CINAHL on 7 November 2019, Virtual Health Library on 8 November 2019, and Popline on 5 December 2018, three other databases on 22 March 2019 and two trial registers on 8 November 2019. We performed reference checking, and citation searching, and contacted study authors to identify additional studies. SELECTION CRITERIA: Randomized controlled trials (RCTs), cluster-RCTs, controlled before-after studies (CBAs), interrupted time series (ITS) studies and repeated measures studies comparing generic WHO/UNICEF iCCM (or local adaptation thereof) for at least two iCCM diseases with usual facility services (facility treatment services) with or without single disease community case management (CCM). We included studies reporting on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for under-fives in low- and middle-income countries. DATA COLLECTION AND ANALYSIS: At least two review authors independently screened abstracts, screened full texts and extracted data using a standardised data collection form adapted from the EPOC Good Practice Data Collection Form. We resolved any disagreements through discussion or, if required, we consulted a third review author not involved in the original screening. We contacted study authors for clarification or additional details when necessary. We reported risk ratios (RR) for dichotomous outcomes and hazard ratios (HR) for time to event outcomes, with 95% confidence intervals (CI), adjusted for clustering, where possible. We used estimates of effect from the primary analysis reported by the investigators, where possible. We analysed the effects of randomized trials and other study types separately. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS: We included seven studies, of which three were cluster RCTs and four were CBAs. Six of the seven studies were in SSA and one study was in Southern Asia. The iCCM components and inputs were fairly consistent across the seven studies with notable variation for the training and deployment component (e.g. on payment of iCCM providers) and the system component (e.g. on improving information systems). When compared to usual facility services, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (RR 0.96, 95% CI 0.77 to 1.19; 2 CBA studies, 5898 children; very low-certainty evidence). iCCM may have little to no effect on neonatal mortality (HR 1.01, 95% 0.73 to 1.28; 2 trials, 65,209 children; low-certainty evidence). We are uncertain of the effect of iCCM on infant mortality (HR 1.02, 95% CI 0.83 to 1.26; 2 trials, 60,480 children; very low-certainty evidence) and under-five mortality (HR 1.18, 95% CI 1.01 to 1.37; 1 trial, 4729 children; very low-certainty evidence). iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness by 68% (RR 1.68, 95% CI 1.24 to 2.27; 2 trials, 9853 children; moderate-certainty evidence). None of the studies reported quality of care, severity of illness or adverse events for this comparison. When compared to usual facility services plus CCM for malaria, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (very low-certainty evidence) and iCCM may have little or no effect on careseeking to an appropriate provider for any iCCM illness (RR 1.06, 95% CI 0.97 to 1.17; 1 trial, 811 children; low-certainty evidence). None of the studies reported quality of care, case load or severity of illness at health facilities, mortality or adverse events for this comparison. AUTHORS' CONCLUSIONS: iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness. However, the evidence presented here underscores the importance of moving beyond training and deployment to valuing iCCM providers, strengthening health systems and engaging community systems.

The impact of social, national and community-based health insurance on health care utilization for mental, neurological and substance-use disorders in low- and middle-income countries: a systematic review.

BACKGROUND: Whilst several systematic reviews conducted in Low- and Middle-Income Countries (LMICs) have revealed that coverage under social (SHI), national (NHI) and community-based (CBHI) health insurance has led to increased utilization of health care services, it remains unknown whether, and what aspects of, these shifts in financing result in improvements to mental health care utilization. The main aim of this review was to examine the impact of SHI, NHI and CBHI enrollment on mental health care utilization in LMICs. METHODS: Systematic searches were performed in nine databases of peer-reviewed journal articles: Pubmed, Scopus, SciELO via Web of Science, Africa Wide, CINAHL, PsychInfo, Academic Search Premier, Health Source Nursing Academic and EconLit for studies published before October 2018. The quality of the studies was assessed using the Effective Public Health Practice Project quality assessment tool for quantitative studies. The systematic review was reported according to the PRISMA guidelines (PROSPERO;2018; CRD42018111576). RESULTS: Eighteen studies were included in the review. Despite some heterogeneity across countries, the results demonstrated that enrollment in SHI, CBHI and NHI schemes increased utilization of mental health care. This was consistent for the length of inpatient admissions, number of hospitalizations, outpatient use of rehabilitation services, having ever received treatment for diagnosed schizophrenia and depression, compliance with drug therapies and the prescriptions of more favorable medications and therapies, when compared to the uninsured. The majority of included studies did not describe the insurance schemes and their organizational details at length, with limited discussion of the links between these features and the outcomes. Given the complexity of mental health service utilization in these diverse contexts, it was difficult to draw overall judgements on whether the impact of insurance enrollment was positive or negative for mental health care outcomes. CONCLUSIONS: Studies that explore the impact of SHI, NHI and CBHI enrollment on mental health care utilization are limited both in number and scope. Despite the fact that many LMICs have been hailed for financing reforms towards universal health coverage, evidence on the positive impact of the reforms on mental health care utilization is only available for a small sub-set of these countries.

Resource requirements for community-based care in rural, deep-rural and peri-urban communities in South Africa: A comparative analysis in 2 South African provinces.

INTRODUCTION: As South Africa embarks on the implementation of the community health care worker (CHW) 2018 policy, quantifying the resource requirements to effectively manage the programme across different geographical communities is essential. This study was conducted to quantify and compare costs associated with travel and service delivery demands on CHWs between area types in two districts. METHODS: This economic analysis adopted a provider perspective to cost CHW services between January and November 2016. A total of 221 CHWs completed diaries for 10 days to document their activities. Quintile regression and the Kruskall Wallis test were used to test for differences in time and activities across urban and rural sites. RESULTS: While travel time across rural and urban settings within each district did differ it was not the most significant predictor of differences in time utilization. Time on activities showed more significant differences with overall median time by unit of activity being 15% longer in rural than urban areas in Sedibeng and 10% longer in uMzinyathi respectively. Most CHW time was spent conducting home visits (57% in rural,66% in peri-urban/urban). Median time per home visit in uMzinyathi was 50% longer in deep-rural areas than urban areas and 20% longer in rural than urban areas in Sedibeng. Referrals and number of home visits per capita (0.4 visits in rural and 0.7 in urban/peri-urban areas) were low in both districts. Expenditure on the programme translated to under 4% of PHC expenditure per capita and remains under 5% if despite the new national minimum wage (R3,500/$245). CONCLUSION: Because home visits take longer and CHWs spend a lower share of time on visits, a higher number is required in rural and deep rural areas (33% and 66% respectively) than in urban areas. Effective budget planning will therefore need to recognize the different geographical needs.

Mental health system costs, resources and constraints in South Africa: a national survey.

The inclusion of mental health in the Sustainable Development Goals represents a global commitment to include mental health among the highest health and development priorities for investment. Low- and middle-income countries (LMICs), such as South Africa, contemplating mental health system scale-up embedded into wider universal health coverage-related health system transformations, require detailed and locally derived estimates on existing mental health system resources and constraints. The absence of these data has limited scale-up efforts to address the burden of mental disorders in most LMICs. We conducted a national survey to quantify public expenditure on mental health and evaluate the constraints of the South African mental health system. The study found that South Africa's public mental health expenditure in the 2016/17 financial year was USD615.3 million, representing 5.0% of the total public health budget (provincial range: 2.1-7.7% of provincial health budgets) and USD13.3 per capita uninsured. Inpatient care represented 86% of mental healthcare expenditure, with nearly half of total mental health spending occurring at the psychiatric hospital-level. Almost one-quarter of mental health inpatients are readmitted to hospital within 3 months of a previous discharge, costing the public health system an estimated USD112 million. Crude estimates indicate that only 0.89% and 7.35% of the uninsured population requiring care received some form of public inpatient and outpatient mental healthcare, during the study period. Further, mental health human resource availability, infrastructure and medication supply are significant constraints to the realization of the country's progressive mental health legislation. For the first time, this study offers a nationally representative reflection of the state of mental health spending and elucidates inefficiencies and constraints emanating from existing mental health investments in South Africa. With this information at hand, the government now has a baseline for which a rational process to planning for system reforms can be initiated.

Mobile Messaging Support Versus Usual Care for People With Type 2 Diabetes on Glycemic Control: Protocol for a Multicenter Randomized Controlled Trial.

BACKGROUND: Health outcomes for people treated for type 2 diabetes could be substantially improved in sub-Saharan Africa. Failure to take medicine regularly to treat diabetes has been identified as a major problem. Resources to identify and support patients who are not making the best use of medicine in low- and middle-income settings are scarce. Mobile phones are widely available in these settings, including among people with diabetes; linked technologies, such as short message service (SMS) text messaging, have shown promise in delivering low-cost interventions efficiently. However, evidence showing that these interventions will work when carried out at a larger scale and measuring the extent to which they will improve health outcomes when added to usual care is limited. OBJECTIVE: The objective of this trial is to test the effectiveness of sending brief, automated SMS text messages for improving health outcomes and medication adherence in patients with type 2 diabetes compared to an active control. METHODS: We will carry out a randomized trial recruiting from clinics in two contrasting settings in sub-Saharan Africa: Cape Town, South Africa, and Lilongwe, Malawi. Intervention messages will advise people about the benefits of their diabetes treatment and offer motivation and encouragement around lifestyle and use of medication. We allocated patients, using randomization with a minimization algorithm, to receive either three to four intervention messages per week or non-health-related messages every 6 weeks. We will follow up with participants for 12 months, measuring important risk factors for poor health outcomes and complications in diabetes. This will enable us to estimate potential health benefits, including the primary outcome of hemoglobin A1c (HbA1c) levels as a marker for long-term blood glucose control and a secondary outcome of blood pressure control. We will record the costs of performing these activities and estimate cost-effectiveness. We will also use process evaluation to capture the collection of medication and assess the reception of the intervention by participants and health care workers. RESULTS: Recruitment to the trial began in September 2016 and follow-up of participants was completed in October 2018. Data collection from electronic health records and other routinely collected sources is continuing. The database lock is anticipated in June 2019, followed by analysis and disclosing of group allocation. CONCLUSIONS: The knowledge gained from this study will have wide applications and advance the evidence base for effectiveness of mobile phone-based, brief text messaging on clinical outcomes and in large-scale, operational settings. It will provide evidence for cost-effectiveness and acceptability that will further inform policy development and decision making. We will work with a wide network that includes patients, clinicians, academics, industry, and policy makers to help us identify opportunities for informing people about the work and raise awareness of what is being developed and studied. TRIAL REGISTRATION: ISRCTN Registry ISRCTN70768808; http://www.isrctn.com/ISRCTN70768808 (Archived by WebCite at http://www.webcitation.org/786316Zqk). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12377.

MDR-TB patients in KwaZulu-Natal, South Africa: Cost-effectiveness of 5 models of care.

BACKGROUND: South Africa has a high burden of MDR-TB, and to provide accessible treatment the government has introduced different models of care. We report the most cost-effective model after comparing cost per patient successfully treated across 5 models of care: centralized hospital, district hospitals (2), and community-based care through clinics or mobile injection teams. METHODS: In an observational study five cohorts were followed prospectively. The cost analysis adopted a provider perspective and economic cost per patient successfully treated was calculated based on country protocols and length of treatment per patient per model of care. Logistic regression was used to calculate propensity score weights, to compare pairs of treatment groups, whilst adjusting for baseline imbalances between groups. Propensity score weighted costs and treatment success rates were used in the ICER analysis. Sensitivity analysis focused on varying treatment success and length of hospitalization within each model. RESULTS: In 1,038 MDR-TB patients 75% were HIV-infected and 56% were successfully treated. The cost per successfully treated patient was 3 to 4.5 times lower in the community-based models with no hospitalization. Overall, the Mobile model was the most cost-effective. CONCLUSION: Reducing the length of hospitalization and following community-based models of care improves the affordability of MDR-TB treatment without compromising its effectiveness.

Roles played by community cadres to support retention in PMTCT Option B+ in four African countries: a qualitative rapid appraisal.

OBJECTIVES: To explore the roles of community cadres in improving access to and retention in care for PMTCT (prevent mother-to-child transmission of HIV) services in the context of PMTCT Option B+ treatment scale-up in high burden low-income and lower-middle income countries. DESIGN/METHODS: Qualitative rapid appraisal study design using semistructured in-depth interviews and focus group discussions (FGDs) between 8 June and 31 July 2015. SETTING AND PARTICIPANTS: Interviews were conducted in the offices of Ministry of Health Staff, Implementing partners, district offices and health facility sites across four low-income and lower-middle income countries: Cote D'Ivoire, Democratic Republic of Congo (DRC), Malawi and Uganda. A range of individual interviews and FGDs with key stakeholders including Ministry of Health employees, Implementation partners, district management teams, facility-based health workers and community cadres. A total number of 18, 28, 31 and 83 individual interviews were conducted in Malawi, Cote d'Ivoire, DRC and Uganda, respectively. A total number of 15, 9, 10 and 16 mixed gender FGDs were undertaken in Malawi, Cote d'Ivoire, DRC and Uganda, respectively. RESULTS: Community cadres either operated solely in the community, worked from health centres or in combination and their mandates were PMTCT-specific or included general HIV support and other health issues. Community cadres included volunteers, those supported by implementing partners or employed directly by the Ministry of Health. Their complimentary roles along the continuum of HIV care and treatment include demand creation, household mapping of pregnant and lactating women, linkage to care, infant follow-up and adherence and retention support. CONCLUSIONS: Community cadres provide an integral link between communities and health facilities, supporting overstretched health workers in HIV client support and follow-up. However, their role in health systems is neither standardised nor systematic and there is an urgent need to invest in the standardisation of and support to community cadres to maximise potential health impacts.

Does adjusting for recall in trend analysis affect coverage estimates for maternal and child health indicators? An analysis of DHS and MICS survey data.

BACKGROUND: The Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) are the major data sources in low- and middle-income countries (LMICs) for evaluating health service coverage. For certain maternal and child health (MCH) indicators, the two surveys use different recall periods: 5 years for DHS and 2 years for MICS. OBJECTIVE: We explored whether the different recall periods for DHS and MICS affect coverage trend analyses as well as missing data and coverage estimates. DESIGNS: We estimated coverage, using proportions with 95% confidence intervals, for four MCH indicators: intermittent preventive treatment of malaria in pregnancy, tetanus vaccination, early breastfeeding and postnatal care. Trends in coverage were compared using data from 1) standard 5-year DHS and 2-year MICS recall periods (unmatched) and 2) DHS restricted to 2-year recall to match the MICS 2-year recall periods (matched). Linear regression was used to explore the relationship between length of recall, missing data and coverage estimates. RESULTS: Differences in coverage trends were observed between matched and unmatched data in 7 of 18 (39%) comparisons performed. The differences were in the direction of the trend over time, the slope of the coverage change or the significance levels. Consistent trends were seen in 11 of the 18 (61%) comparisons. Proportion of missing data was inversely associated with coverage estimates in both short (2 years) and longer (5 years) recall of the DHS (r=-0.3, p=0.02 and r=-0.4, p=0.004, respectively). The amount of missing information was increased for longer recall compared with shorter recall for all indicators (significant odds ratios ranging between 1.44 and 7.43). CONCLUSIONS: In a context where most LMICs are dependent on population-based household surveys to derive coverage estimates, users of these types of data need to ensure that variability in recall periods and the proportion of missing data across data sources are appropriately accounted for when trend analyses are conducted.

Strategies to improve male involvement in PMTCT Option B+ in four African countries: a qualitative rapid appraisal.

BACKGROUND: The World Health Organization recommends that antiretroviral therapy be started as soon as possible, irrespective of stage of HIV infection. This 'test and treat' approach highlights the need to ensure that men are involved in prevention of mother-to-child HIV transmission (PMTCT). This article presents findings from a rapid appraisal of strategies to increase male partner involvement in PMTCT services in Uganda, Democratic Republic of Congo, Malawi, and Côte d'Ivoire in the context of scale-up of Option B+ protocol. DESIGN: Data were collected through qualitative rapid appraisal using focus groups and individual interviews during field visits to the four countries. Interviews were conducted in the capital city with Ministry of Health staff and implementing partners (IPs) and at district level with district management teams, facility-based health workers and community health cadres in each country. RESULTS: Common strategies were adopted across the countries to effect social change and engender greater participation of men in maternal, child and women's health, and PMTCT services. Community-based strategies included engagement of community leaders through dialogue and social mobilization, involving community health workers and the creation and strengthening of male peer cadres. Facility-based strategies included provision of incentives such as shorter waiting time, facilitating access for men by altering clinic hours, and creation of family support groups. CONCLUSIONS: The approaches implemented at both community and facility levels were tailored to the local context, taking into account cultural norms and geographic regional variations. Although intentions behind such strategies aim to have positive impacts on families, unintended negative consequences do occur, and these need to be addressed and strategies adapted.A consistent definition of 'male involvement' in PMTCT services and a framework of indicators would be helpful to capture the impact of strategies on cultural and behavioral shifts. National policies around male involvement would be beneficial to streamline approaches across IPs and ensure wide-scale implementation, to achieve significant improvements in family health outcomes.

The 'community' in community case management of childhood illnesses in Malawi.

BACKGROUND: Malawi has achieved a remarkable feat in reducing its under-5 mortality in time to meet its MDG 4 target despite high levels of poverty, low female literacy rates, recurrent economic crises, a severe shortage of human resources for health, and poor health infrastructure. The country's community-based delivery platform (largely headed by Health Surveillance Assistants, or HSAs) has been well established since the 1960s, although their tasks and responsibilities have evolved from surveillance to health promotion and prevention, and more recently to include curative services. However, the role of and the form that community involvement takes in community-based service delivery in Malawi is unclear. DESIGN: A qualitative rapid appraisal approach was utilised to explore the role of community involvement in the HSA programme in Malawi to better understand how the various community providers intersect to support the delivery of integrated community case management by HSAs. Twelve focus group discussions and 10 individual interviews were conducted with HSAs, HSA supervisors, mothers, members of village health committees (VHCs), senior Ministry of Health officials, district health teams, and implementing partners. RESULTS: Our findings reveal that HSAs are often deployed to areas outside of their village of residence as communities are not involved in selecting their own HSAs in Malawi. Despite this lack of involvement in selection, the high acceptance of the HSAs by community members and community accountability structures such as VHCs provide the programme with legitimacy and credibility. CONCLUSIONS: This study provides insight into how community involvement plays out in the context of a government-managed professionalised community service delivery platform. It points to the need for further research to look at the impact of removing the role of HSA selection and deployment from the community and placing it at the central level.

Niger's Child Survival Success, Contributing Factors and Challenges to Sustainability: A Retrospective Analysis.

BACKGROUND: Household surveys undertaken in Niger since 1998 have revealed steady declines in under-5 mortality which have placed the country 'on track' to reach the fourth Millennium Development goal (MDG). This paper explores Niger's mortality and health coverage data for children under-5 years of age up to 2012 to describe trends in high impact interventions and the resulting impact on childhood deaths averted. The sustainability of these trends are also considered. METHODS AND FINDINGS: Estimates of child mortality using the 2012 Demographic and Health Survey were developed and maternal and child health coverage indicators were calculated over four time periods. Child survival policies and programmes were documented through a review of documents and key informant interviews. The Lives Saved Tool (LiST) was used to estimate the number of child lives saved and identify which interventions had the largest impact on deaths averted. The national mortality rate in children under-5 decreased from 286 child deaths per 1000 live births (95% confidence interval 177 to 394) in the period 1989-1990 to 128 child deaths per 1000 live births in the period 2011-2012 (101 to 155), corresponding to an annual rate of decline of 3.6%, with significant declines taking place after 1998. Improvements in the coverage of maternal and child health interventions between 2006 and 2012 include one and four or more antenatal visits, maternal Fansidar and tetanus toxoid vaccination, measles and DPT3 vaccinations, early and exclusive breastfeeding, oral rehydration salts (ORS) and proportion of children sleeping under an insecticide-treated bed net (ITN). Approximately 26,000 deaths of children under-5 were averted in 2012 due to decreases in stunting rates (27%), increases in ORS (14%), the Hib vaccine (14%), and breastfeeding (11%). Increases in wasting and decreases in vitamin A supplementation negated some of those gains. Care seeking at the community level was responsible for an estimated 7,800 additional deaths averted in 2012. A major policy change occurred in 2006 enabling free health care provision for women and children, and in 2008 the establishment of a community health worker programme. CONCLUSION: Increases in access and coverage of care for mothers and children have averted a considerable number of childhood deaths. The 2006 free health care policy and health post expansion were paramount in reducing barriers to care. However the sustainability of this policy and health service provision is precarious in light of persistently high fertility rates, unpredictable GDP growth, a high dependence on donor support and increasing pressures on government funding.

Reduction in child mortality in Ethiopia: analysis of data from demographic and health surveys.

BACKGROUND: To examine changes in under-5 mortality, coverage of child survival interventions and nutritional status of children in Ethiopia between 2000 and 2011. Using the Lives Saved Tool, the impact of changes in coverage of child survival interventions on under-5 lives saved was estimated. METHODS: Estimates of child mortality were generated using three Ethiopia Demographic and Health Surveys undertaken between 2000 and 2011. Coverage indicators for high impact child health interventions were calculated and the Lives Saved Tool (LiST) was used to estimate child lives saved in 2011. RESULTS: The mortality rate in children younger than 5 years decreased rapidly from 218 child deaths per 1000 live births (95% confidence interval 183 to 252) in the period 1987-1991 to 88 child deaths per 1000 live births in the period 2007-2011 (78 to 98). The prevalence of moderate or severe stunting in children aged 6-35 months also declined significantly. Improvements in the coverage of interventions relevant to child survival in rural areas of Ethiopia between 2000 and 2011 were found for tetanus toxoid, DPT3 and measles vaccination, oral rehydration solution (ORS) and care-seeking for suspected pneumonia. The LiST analysis estimates that there were 60 700 child deaths averted in 2011, primarily attributable to decreases in wasting rates (18%), stunting rates (13%) and water, sanitation and hygiene (WASH) interventions (13%). CONCLUSIONS: Improvements in the nutritional status of children and increases in coverage of high impact interventions most notably WASH and ORS have contributed to the decline in under-5 mortality in Ethiopia. These proximal determinants however do not fully explain the mortality reduction which is plausibly also due to the synergistic effect of major child health and nutrition policies and delivery strategies.

Assessment of Malawi's success in child mortality reduction through the lens of the Catalytic Initiative Integrated Health Systems Strengthening programme: Retrospective evaluation.

BACKGROUND: Malawi is estimated to have achieved its Millennium Development Goal (MDG) 4 target. This paper explores factors influencing progress in child survival in Malawi including coverage of interventions and the role of key national policies. METHODS: We performed a retrospective evaluation of the Catalytic Initiative (CI) programme of support (2007-2013). We developed estimates of child mortality using four population household surveys undertaken between 2000 and 2010. We recalculated coverage indicators for high impact child health interventions and documented child health programmes and policies. The Lives Saved Tool (LiST) was used to estimate child lives saved in 2013. RESULTS: The mortality rate in children under 5 years decreased rapidly in the 10 CI districts from 219 deaths per 1000 live births (95% confidence interval (CI) 189 to 249) in the period 1991-1995 to 119 deaths (95% CI 105 to 132) in the period 2006-2010. Coverage for all indicators except vitamin A supplementation increased in the 10 CI districts across the time period 2000 to 2013. The LiST analysis estimates that there were 10 800 child deaths averted in the 10 CI districts in 2013, primarily attributable to the introduction of the pneumococcal vaccine (24%) and increased household coverage of insecticide-treated bednets (19%). These improvements have taken place within a context of investment in child health policies and scale up of integrated community case management of childhood illnesses. CONCLUSIONS: Malawi provides a strong example for countries in sub-Saharan Africa of how high impact child health interventions implemented within a decentralised health system with an established community-based delivery platform, can lead to significant reductions in child mortality.

The role of 'hidden' community volunteers in community-based health service delivery platforms: examples from sub-Saharan Africa.

Community-based research on child survival in sub-Saharan Africa has focussed on the increased provision of curative health services by a formalised cadre of lay community health workers (CHWs), but we have identified a particular configuration, that deserves closer scrutiny. We identified a two-tiered CHW system, with the first tier being the lessor known or 'hidden' community/village level volunteers and the second tier being formal, paid CHWs, in Ethiopia, Mali, and Niger. Whilst the disease-focussed tasks of the formal CHW tier may be more amenable to classic epidemiological surveillance, we postulate that understanding the relationship between formalised CHWs and volunteer cadres, in terms of scope, location of practice and ratio to population, would be important for a comprehensive evaluation of child survival in these countries. We report on the findings from our joint qualitative and quantitative investigations, highlighting the need to recognise the 'hidden' contribution of volunteers. We need to better characterize the volunteers' interaction with community-based and primary care services and to better understand ways to improve the volunteer systems with the right type of investments. This is particularly important for considering the models for scale-up of CHWs in sub-Saharan Africa.

Combination HIV prevention for female sex workers: what is the evidence?

Sex work occurs in many forms and sex workers of all genders have been affected by HIV epidemics worldwide. The determinants of HIV risk associated with sex work occur at several levels, including individual biological and behavioural, dyadic and network, and community and social environmental levels. Evidence indicates that effective HIV prevention packages for sex workers should include combinations of biomedical, behavioural, and structural interventions tailored to local contexts, and be led and implemented by sex worker communities. A model simulation based on the South African heterosexual epidemic suggests that condom promotion and distribution programmes in South Africa have already reduced HIV incidence in sex workers and their clients by more than 70%. Under optimistic model assumptions, oral pre-exposure prophylaxis together with test and treat programmes could further reduce HIV incidence in South African sex workers and their clients by up to 40% over a 10-year period. Combining these biomedical approaches with a prevention package, including behavioural and structural components as part of a community-driven approach, will help to reduce HIV infection in sex workers in different settings worldwide.

Afferent input modulates the chronic hypercapnia-induced increase in respiratory-related central pH/CO2 chemosensitivity in the cane toad (Bufo marinus).

The goal of this study was to examine the role of respiratory-related afferent input on the chronic hypercapnia (CHC)-induced increase in central respiratory-related pH/CO2 chemosensitivity in cane toads (Bufo marinus). Toads were exposed to CHC (3.5% CO2) for 10 days, following which in vitro brainstem-spinal cord preparations were used to assess central respiratory-related pH/CO2 chemosensitivity. Motor output from the vagus nerve root was used as an index of breathing (fictive breathing). Olfactory denervation (OD), prior to exposure to CHC, was used to remove the influence of CO2-sensitive olfactory chemoreceptors, which inhibit breathing. Exposure to chronic hyperoxic hypercapnia (CHH) was used to reduce the level of arterial chemoreceptor input compared with CHC alone. In vivo experiments examined the effects of CHC, CHH and OD on the acute hypercapnic ventilatory response of intact animals. In vitro, a reduction in artifical cerebral spinal fluid (aCSF) pH increased fictive breathing in preparations taken from control and CHC animals. CHC caused an increase in fictive breathing compared with controls. OD and CHH abolished the CHC-induced augmentation of fictive breathing. In vivo, CHC did not cause an augmentation of the acute hypercapnic ventilatory response. CHH reduced the in vivo acute hypercapnic ventilatory response compared with animals exposed to CHC. In vivo, OD reduced breathing frequency and increased breath amplitude in both control and CHC animals. The results suggest that afferent input from olfactory and arterial chemoreceptors, during CHC, is involved in triggering the CHC-induced increase in central respiratory-related pH/CO2 chemosensitivity.