Development assistance for community health workers in 114 low- and middle-income countries, 2007-2017.

OBJECTIVE: To estimate the level and trend of development assistance for community health worker-related projects in low- and middle-income countries between 2007 and 2017. METHODS: We extracted data from the Organisation for Economic Co-operation and Development's creditor reporting system on aid funding for projects to support community health workers (CHWs) in 114 countries over 2007-2017. We produced estimates for projects specifically described by relevant keywords and for projects which could include components on CHWs. We analysed the pattern of development assistance by purpose, donors, recipient regions and countries, and trends over time. FINDINGS: Between 2007 and 2017, total development assistance targeting CHW projects was around United States dollars (US$) 5 298.02 million, accounting for 2.5% of the US$ 209 277.99 million total development assistance for health. The top three donors (Global Fund to Fight AIDS, Tuberculosis and Malaria, the government of Canada and the government of the United States of America) provided a total of US$ 4 350.08 million (82.1%) of development assistance for these projects. Sub-Saharan Africa received a total US$ 3 717.93 million, the largest per capita assistance over 11 years (US$ 0.39; total population: 9 426.25 million). Development assistance to projects that focused on infectious diseases and child and maternal health received most funds during the study period. CONCLUSION: The share of development assistance invested in the CHW projects was small, unstable and decreasing in recent years. More research is needed on tracking government investments in CHW-related projects and assessing the impact of investments on programme effectiveness.

Ongoing training of community health workers in low-income andmiddle-income countries: a systematic scoping review of the literature.

OBJECTIVES: Understanding the current landscape of ongoing training for community health workers (CHWs) in low-income and middle-income countries (LMICs) is important both for organisations responsible for their training, as well as researchers and policy makers. This scoping review explores this under-researched area by mapping the current delivery implementation and evaluation of ongoing training provision for CHWs in LMICs. DESIGN: Systematic scoping review. DATA SOURCES: MEDLINE, Embase, AMED, Global Health, Web of Science, Scopus, ASSIA, LILACS, BEI and ERIC. STUDY SELECTION: Original studies focusing on the provision of ongoing training for CHWs working in a country defined as low income and middle income according to World Bank Group 2012 classification of economies. RESULTS: The scoping review found 35 original studies that met the inclusion criteria. Ongoing training activities for CHWs were described as supervision (n=19), inservice or refresher training (n=13) or a mixture of both (n=3). Although the majority of studies emphasised the importance of providing ongoing training, several studies reported no impact of ongoing training on performance indicators. The majority of ongoing training was delivered inperson; however, four studies reported the use of mobile technologies to support training delivery. The outcomes from ongoing training activities were measured and reported in different ways, including changes in behaviour, attitudes and practice measured in a quantitative manner (n=16), knowledge and skills (n=6), qualitative assessments (n=5) or a mixed methods approach combining one of the aforementioned modalities (n=8). CONCLUSIONS: This scoping review highlights the diverse range of ongoing training for CHWs in LMICs. Given the expansion of CHW programmes globally, more attention should be given to the design, delivery, monitoring and sustainability of ongoing training from a health systems strengthening perspective.

The Millennium Villages Project: a retrospective, observational, endline evaluation.

BACKGROUND: The Millennium Villages Project (MVP) was a 10 year, multisector, rural development project, initiated in 2005, operating across ten sites in ten sub-Saharan African countries to achieve the Millennium Development Goals (MDGs). In this study, we aimed to estimate the project's impact, target attainment, and on-site spending. METHODS: In this endline evaluation of the MVP, we retrospectively selected comparison villages that best matched the project villages on possible confounding variables. Cross-sectional survey data on 40 outcomes of interest were collected from both the project and the comparison villages in 2015. Using these data, as well as on-site spending data collected during the project, we estimated project impacts as differences in outcomes between the project and comparison villages; target attainment as differences between project outcomes and prespecified targets; and on-site spending as expenditures reported by communities, donors, governments, and the project. Spending data were not collected in the comparison villages. FINDINGS: Averaged across the ten project sites, we found that impact estimates for 30 of 40 outcomes were significant (95% uncertainty intervals [UIs] for these outcomes excluded zero) and favoured the project villages. In particular, substantial effects were seen in agriculture and health, in which some outcomes were roughly one SD better in the project villages than in the comparison villages. The project was estimated to have no significant impact on the consumption-based measures of poverty, but a significant favourable impact on an index of asset ownership. Impacts on nutrition and education outcomes were often inconclusive (95% UIs included zero). Averaging across outcomes within categories, the project had significant favourable impacts on agriculture, nutrition, education, child health, maternal health, HIV and malaria, and water and sanitation. A third of the targets were met in the project sites. Total on-site spending decreased from US$132 per person in the first half of the project (of which $66 was from the MVP) to $109 per person in the second half of the project (of which $25 was from the MVP). INTERPRETATION: The MVP had favourable impacts on outcomes in all MDG areas, consistent with an integrated rural development approach. The greatest effects were in agriculture and health, suggesting support for the project's emphasis on agriculture and health systems strengthening. The project conclusively met one third of its targets. FUNDING: The Open Society Foundations, the Islamic Development Bank, and the governments of Japan, South Korea, Mali, Senegal, and Uganda.

Early detection of maternal deaths in Senegal through household-based death notification integrating verbal and social autopsy: a community-level case study.

BACKGROUND: Reliable detection of maternal deaths is an essential prerequisite for successful diagnosis of barriers to care and formulation of relevant targeted interventions. In a community-level case study, the use of household-level surveillance in Senegal unveiled an apparent increase in maternal deaths, which triggered a rapid-cycle collaborative response to implement a multipronged set of quick-win and sustained interventions intended to improve quality care. METHODS: Part of a multi-country effort, the Millennium Villages Project is implementing a routine community-level information system in Senegal, able to detect maternal deaths in real-time and uncover clinical and social factors contributing to mortality. Within this geographically demarcated area of approximately 32 000 inhabitants, with a well-structured health system with patient referral services, deaths were registered and notified by community health workers, followed by timely verbal and social autopsies. Using the Pathway to Survival conceptual framework, case analysis and mortality reviews were conducted for evaluation and quality improvement purposes. RESULTS: The estimated maternal mortality rates rose from 67/100000 births in 2009 (1 death), to 202/100000 births in 2010 (3 deaths) and 392/100000 births (5 deaths) in 2011. Although absolute numbers of maternal deaths remained too small for robust statistical analysis, following verbal autopsy analyses in 2011, it became evident that an unexpectedly high proportion of maternal deaths were occurring at the referral hospital, mostly post-Caesarian section. Inadequate case management of post-partum haemorrhage at the referral hospital was the most frequently identified probable cause of death. A joint task team systematically identified several layers of inefficiencies, with a potential negative impact on a larger catchment area than the study community. CONCLUSIONS: In this study, routine community-based surveillance identified inefficiencies at a tertiary level of care. Community-level surveillance systems that include pregnancy, birth and death tracking through household visits by community health workers , combined with verbal and social autopsy can identify barriers within the continuum of maternal care. Use of mHealth data collection tools sensitive enough to detect small changes in community-level mortality trends in real-time, can facilitate rapid-cycle quality improvement interventions, particularly when associated with social accountability structures of mortality reviews.

Emergency response in resource-poor settings: a review of a newly-implemented EMS system in rural Uganda.

INTRODUCTION: The goal of an Emergency Medical Services (EMS) system is to prevent needless death or disability from time-sensitive disease processes. Despite growing evidence that these processes contribute significantly to mortality in low- and middle- income countries (LMICs), there has been little focus on the development of EMS systems in poor countries. Problem The objective of this study was to understand the utilization pattern of a newly-implemented EMS system in Ruhiira, Uganda. METHODS: An EMS system based on community priorities was implemented in rural Uganda in 2009. Six months of ambulance logs were reviewed. Patient, transfer, and clinical data were extracted and analyzed. RESULTS: In total, 207 cases were reviewed. Out of all transfers, 66% were for chief complaints that were obstetric related, while 12% were related to malaria. Out of all activations, 77.8% were for female patients. Among men, 34% and 28% were related to malaria and trauma, respectively. The majority of emergency transfers were from district to regional hospitals, including 52% of all obstetric transfers, 65% of malaria transfers, and 62% of all trauma transfers. There was no significant difference in the call to arrival on scene time, the time to scene or the scene to treatment time during the day and night (P > .05). Cost-benefit analysis revealed a cost of $89.95 per life saved with an estimated $0.93/capita to establish the system and $0.09/capita/year to maintain the system. CONCLUSION: Contrary to current belief, EMS systems in rural Africa can be affordable and highly utilized, particularly for life-threatening, nontrauma complaints. Construction of a simple but effective EMS system is feasible, acceptable, and an essential component to the primary health care system of LMICs.

The effect of an integrated multisector model for achieving the Millennium Development Goals and improving child survival in rural sub-Saharan Africa: a non-randomised controlled assessment.

BACKGROUND: Simultaneously addressing multiple Millennium Development Goals (MDGs) has the potential to complement essential health interventions to accelerate gains in child survival. The Millennium Villages project is an integrated multisector approach to rural development operating across diverse sub-Saharan African sites. Our aim was to assess the effects of the project on MDG-related outcomes including child mortality 3 years after implementation and compare these changes to local comparison data. METHODS: Village sites averaging 35,000 people were selected from rural areas across diverse agroecological zones with high baseline levels of poverty and undernutrition. Starting in 2006, simultaneous investments were made in agriculture, the environment, business development, education, infrastructure, and health in partnership with communities and local governments at an annual projected cost of US$120 per person. We assessed MDG-related progress by monitoring changes 3 years after implementation across Millenium Village sites in nine countries. The primary outcome was the mortality rate of children younger than 5 years of age. To assess plausibility and attribution, we compared changes to reference data gathered from matched randomly selected comparison sites for the mortality rate of children younger than 5 years of age. Analyses were done on a per-protocol basis. This trial is registered with ClinicalTrials.gov, number NCT01125618. FINDINGS: Baseline levels of MDG-related spending averaged $27 per head, increasing to $116 by year 3 of which $25 was spent on health. After 3 years, reductions in poverty, food insecurity, stunting, and malaria parasitaemia were reported across nine Millennium Village sites. Access to improved water and sanitation increased, along with coverage for many maternal-child health interventions. Mortality rates in children younger than 5 years of age decreased by 22% in Millennium Village sites relative to baseline (absolute decrease 25 deaths per 1000 livebirths, p=0·015) and 32% relative to matched comparison sites (30 deaths per 1000 livebirths, p=0·033). INTERPRETATION: An integrated multisector approach for addressing the MDGs can produce rapid declines in child mortality in the first 3 years of a long-term effort in rural sub-Saharan Africa. FUNDING: UN Human Security Trust Fund, the Lenfest Foundation, Bill & Melinda Gates Foundation, and Becton Dickinson.

Nutritional status of under-five children in HIV-affected households in western Kenya.

BACKGROUND: Households affected by HIV/AIDS are at an increased risk for food insecurity and malnutrition. Poor nutrition contributes to more than a third of all deaths associated with infectious diseases among children under 5 years of age in developing countries. With increased household food insecurity, and a greater disease burden associated with HIV/AIDS, the growth of children under five could be impacted, resulting in increased malnutrition for this vulnerable group. OBJECTIVE: To determine whether there is an association between the type of household (HIV-affected compared with HIV-unaffected) and the nutritional status of children under 5 years of age residing in these households. METHODS: The study was set in a Millennium Village Project site in western Kenya and used a cross-sectional design to compare the stunting, wasting, and underweight status among 102 and 99 under-five children living in HIV-affected and -unaffected households, respectively. Height-for-age, weight-for-age, and weight-for-age z-scores were calculated based on the World Health Organization growth standards and compared. Proportions, means, and standard deviations were used to describe the data. The data were analyzed with the use of the chi-square test for comparison of proportions and the independent t-test for comparison of means. RESULTS: Children in HIV-affected households had a significantly higher degree of stunting (height-for-age < -2 SD) than children in unaffected households (25.5% vs. 9.1%, p = .002). The degree of wasting and underweight did not differ significantly between HIV-affected and -unaffected households. CONCLUSIONS: Residing in HIV-affected households is associated with stunting in children under 5 years of age.

Risk factors for non-communicable diseases among older adults in rural Africa.

OBJECTIVE: To expand the evidence base on the prevalence of non-communicable disease (NCD) risk factors in rural Africa, in particular among older adults aged 50 and older. METHODS: Cross-sectional study in three rural sites in Malawi, Rwanda and Tanzania. One person was interviewed from each of 665 households selected through a stratified random sampling procedure across the three sites. The questionnaire included socio-demographic characteristics, smoking and alcohol intake as well as a food frequency questionnaire. RESULTS: Smoking rates among older men and women were higher than among adults under 50. While only 2.3% of women under 50 were current smokers, 21.0% of older women smoked (P<0.0001). Among men, 19.0% of men under 50 smoked versus 36.6% of older men (P=0.001). Alcohol consumption among older women aged 50 and older (45.0%) was more common (P=0.005) than among women under 50 (27.6%). Examining a set of five risk factors, more men aged 50 and older (49.5%) had two or more risk factors than men under 50 (25.5%) (P<0.0001). Similarly, 52.0% of women aged 50 and older had two or more risk factors, versus 24.1% of women under 50 (P<0.0001). CONCLUSION: Contrary to what is seen in developed country settings, this study reveals high rates of smoking and alcohol consumption among men and women aged 50 years and older in rural Africa that puts them at risk of NCDs. The health of older adults in rural Africa has been neglected, and these findings highlight the importance of reaching out to older adults with messaging regarding diet, smoking, alcohol use and general health.

Millennium Global Village-Net: bringing together Millennium Villages throughout sub-Saharan Africa.

The Millennium Villages Project (MVP), based at The Earth Institute at Columbia University, is a bottom-up, community led approach to show how villages in developing countries can get out of the poverty trap that afflicts more than a billion people worldwide. With well-targeted, practical inputs can help the community invest in a path leading to self-sustaining development. There are 80 Millennium Villages clustered in 10 countries throughout sub-Saharan Africa. MVP is an important development process for empowering communities to invest in a package of integrated interventions aiming to increase food production, improve access to safe water, health care, education and infrastructure. The process benefits from synergies of the integrated approach and relies on community leadership as empowered by proven technological inputs. MVP is committed to a science-based approach to assess and monitor the progress of the communities towards clear objectives; the Millennium Development Goals (MDGs) and to do so with mechanisms that are scalable and sustainable. This approach offers much more than simply collecting and analyzing data since the mechanism used for recording progress would provide a bridge over the divide which separates the haves and the have-nots (by facilitating the sharing of solutions from one community to another bidirectionally). By so doing, it allows people to enhance their own futures in a sustainable manner. Solutions found in one community are transferable to similar communities in other MVP villages. To achieve this goal, the MVP requires an information and communication system which can provide both necessary infrastructure for monitoring and evaluation, and tools for communicating among the villages, cities and countries. This system is called the Millennium Global Village-Net (MGV-Net). It takes advantage of the latest in open source software (OpenMRS), databases (MySQL), interface terminology, a centralized concept dictionary, and uses appropriate technology locally for data entry.

The African Millennium Villages.

We describe the concept, strategy, and initial results of the Millennium Villages Project and implications regarding sustainability and scalability. Our underlying hypothesis is that the interacting crises of agriculture, health, and infrastructure in rural Africa can be overcome through targeted public-sector investments to raise rural productivity and, thereby, to increased private-sector saving and investments. This is carried out by empowering impoverished communities with science-based interventions. Seventy-eight Millennium Villages have been initiated in 12 sites in 10 African countries, each representing a major agro-ecological zone. In early results, the research villages in Kenya, Ethiopia, and Malawi have reduced malaria prevalence, met caloric requirements, generated crop surpluses, enabled school feeding programs, and provided cash earnings for farm families.

A global index representing the stability of malaria transmission.

To relate stability of malaria transmission to biologic characteristics of vector mosquitoes throughout the world, we derived an index representing the contribution of regionally dominant vector mosquitoes to the force of transmission. This construct incorporated published estimates describing the proportion of blood meals taken from human hosts, daily survival of the vector, and duration of the transmission season and of extrinsic incubation. The result of the calculation was displayed globally on a 0.5 degrees grid. We found that these biologic characteristics of diverse vector mosquitoes interact with climate to explain much of the regional variation in the intensity of transmission. Due to the superior capacity of many tropical mosquitoes as vectors of malaria, particularly those in sub-Saharan Africa, antimalaria interventions conducted in the tropics face greater challenges than were faced by formerly endemic nations in more temperate climes.