Embedded implementation research in programming at scale - the new normal to be!

If you want to run faster, don't just buy a new pair of shoes; also consider your training methods and where you run.This supplement examines six countries that have run faster than others in reducing under-five mortality, taking an implementation research approach, with country case studies done with local researchers and local institutions. Key generalizable learnings are to choose and adapt implementation strategies to context, design strategies to target the most vulnerable, systematically learn from implementation experience, and to leverage non-health-sector contributions.Embedding implementation research in programming has the potential to greatly improve and accelerate the contextualization and implementation of evidence-based child survival interventions to improve equity in coverage and overall effectiveness in reducing under-five mortality. It is now time to build such capacity in local institutions at scale, and incentives for concerned stakeholders to make this the new normal. Regional institutions should now take the lead in making this happen, not just in individual institutions and countries, but across entire regions, supported by global partners.Trial registration N/A.

Primary health care and nutrition.

Globally, dietary factors are responsible for about one in five deaths. In many low- and middle-income countries different forms of malnutrition (including obesity and undernutrition) can co-exist within the same population. This double burden of malnutrition is placing a disproportional strain on health systems, slowing progress towards universal health coverage (UHC). Poor nutrition also impedes the growth of local economies, ultimately affecting the global economy. In this article, we argue that comprehensive primary health care should be used as a platform to address the double burden of malnutrition. We use a conceptual framework based on human rights and the Astana Declaration on primary health care to examine existing recommendations and propose guidance on how policy-makers and providers of community-oriented primary health care can strengthen the role of nutrition within the UHC agenda. Specifically, we propose four thematic areas for action: (i) bridging narratives and strengthening links between the primary health care and the nutrition agenda with nutrition as a human rights issue; (ii) encouraging primary health-care providers to support local multisectoral action on nutrition; (iii) empowering communities and patients to address unhealthy diets; and (iv) ensuring the delivery of high-quality promotive, preventive, curative and rehabilitative nutrition interventions. For each theme we summarize the available strategies, policies and interventions that can be used by primary health-care providers and policy-makers to strengthen nutrition in primary health care and thus the UHC agenda.

Environ un décès sur cinq dans le monde est dû à des facteurs alimentaires. Dans de nombreux pays à faible et moyen revenu, différentes formes de malnutrition (y compris l'obésité et la dénutrition) peuvent coexister au sein d'une même population. Ce double fardeau de malnutrition exerce une pression démesurée sur les systèmes de santé, ralentissant la progression vers une couverture maladie universelle (CMU). Une mauvaise alimentation entrave également la croissance des économies locales, ce qui en fin de compte affecte l'économie mondiale. Dans cet article, nous estimons qu'il est impératif d'utiliser une approche globale des soins de santé primaires comme plateforme pour s'attaquer au double fardeau de la malnutrition. Nous avons employé un cadre conceptuel fondé sur les droits humains et la Déclaration d'Astana sur les soins de santé primaires. D'une part pour examiner les recommandations existantes, et d'autre part pour fournir un éclairage sur la manière dont les législateurs et les prestataires de soins de santé primaires, implantés au niveau communautaire, peuvent renforcer le rôle de la nutrition dans le programme de CMU. Nous proposons plus exactement quatre champs d'action : (i) aligner les discours et consolider les liens entre les soins de santé primaires et le programme de nutrition, en intégrant ce dernier dans la thématique des droits humains; (ii) encourager les prestataires de soins de santé primaires à soutenir les initiatives locales multisectorielles portant sur la nutrition; (iii) donner aux patients et aux collectivités le pouvoir de lutter contre l'alimentation déséquilibrée; et enfin, (iv) assurer la mise en œuvre d'interventions de qualité pour la promotion, la prévention, le traitement et la réhabilitation en matière de nutrition. Pour chaque champ d'action, nous résumons les stratégies, politiques et interventions à la disposition des législateurs et prestataires de soins de santé primaires pour renforcer le rôle de la nutrition dans les soins de santé primaires et, par conséquent, le programme de CMU.

Los factores alimentarios son responsables de aproximadamente una de cada cinco muertes en todo el mundo. Diferentes tipos de malnutrición (incluidas la obesidad y la desnutrición) pueden coexistir en la misma población de muchos países de ingresos bajos y medios. Esta doble carga de la malnutrición está ejerciendo una presión desproporcionada sobre los sistemas sanitarios, lo que ralentiza los progresos hacia la cobertura sanitaria universal (CSU). Además, la mala nutrición dificulta el crecimiento de las economías locales, lo que en última instancia afecta a la economía global. En este artículo, se argumenta que la atención primaria de salud integral se debería utilizar como plataforma para abordar la doble carga de la malnutrición. Se utiliza un marco conceptual basado en los derechos humanos y en la Declaración de Astaná sobre la atención primaria de salud para analizar las recomendaciones existentes y proponer directrices sobre cómo los responsables de formular las políticas y los proveedores de atención primaria de salud orientada a la comunidad pueden fortalecer la función de la nutrición dentro del programa de la CSU. En concreto, se proponen cuatro áreas temáticas de acción: (i) narrativas de vinculación y fortalecimiento de los vínculos entre la atención primaria de salud y el programa de nutrición en donde la nutrición sea una cuestión de derechos humanos; (ii) alentar a los proveedores de atención primaria de salud a que apoyen la medida multisectorial local sobre la nutrición; (iii) potenciar a las comunidades y a los pacientes para tratar las dietas poco saludables; y (iv) garantizar la realización de intervenciones de nutrición de alta calidad de tipo promocional, preventivo, curativo y de rehabilitación. Para cada tema se resumen las estrategias, políticas e intervenciones disponibles que los proveedores de atención primaria de salud y los responsables de formular las políticas pueden utilizar para fortalecer la nutrición en la atención primaria de salud y, por consiguiente, el programa de la CSU.

Decision-making in district health planning in Uganda: does use of district-specific evidence matter?

BACKGROUND: In a decentralised health system, district health managers are tasked with planning for health service delivery, which should be evidence based. However, planning in low-income countries such as Uganda has been described as ad hoc. A systematic approach to the planning process using district-specific evidence was introduced to district health managers in Uganda. However, little is known about how the use of district-specific evidence informs the planning process. In this study, we investigate how the use of this evidence affects decision-making in the planning process and how stakeholders in the planning process perceived the use of evidence. METHODS: A convergent parallel mixed-methods study design was used, where quantitative data was collected from district health annual work plans for the financial years 2012/2013, 2013/2014, 2014/2015 and 2015/2016 as well as from bottleneck analysis reports for 2012, 2013, 2014 and 2015. Qualitative data was collected through semi-structured interviews with key informants from the two study districts. RESULTS: District managers reported that they were able to produce more robust district annual work plans when they used the systematic approach of using district-specific evidence. Approximately half of the prioritised activities in the annual work plans were evidence based. Procurement and logistics, training, and support supervision activities were the most prioritised activities. Between 4% and 5.5% of the total planned expenditure was for child survival, of which 47% to 94% was from donor and other partner contributions. CONCLUSION: District-specific evidence and a structured process for its use to prioritise activities and make decisions in the planning process at the district level helped systematise the planning process. However, the reported limited decision and fiscal space, inadequate funding and high dependency on donor funding did not always allow for the use of district-specific evidence in the planning process.

Private retail drug shops: what they are, how they operate, and implications for health care delivery in rural Uganda.

BACKGROUND: Retail drug shops play a significant role in managing pediatric fevers in rural areas in Uganda. Targeted interventions to improve drug seller practices require understanding of the retail drug shop market and motivations that influence practices. This study aimed at describing the operational environment in relation to the Uganda National Drug Authority guidelines for setup of drug shops; characteristics, and dispensing practices of private retail drug shops in managing febrile conditions among under-five children in rural western Uganda. METHODS: Cross sectional survey of 74 registered drug shops, observation checklist, and 428 exit interviews using a semi-structured questionnaire with care-seekers of children under five years of age, who sought care at drug shops during the survey period. The survey was conducted in Mbarara and Bushenyi districts, South Western Uganda, in May 2013. RESULTS: Up to 90 and 79% of surveyed drug shops in Mbarara and Bushenyi, largely operate in premises that meet National Drug Authority requirements for operational suitability and ensuring medicines safety and quality. Drug shop attendants had some health or medical related training with 60% in Mbarara and 59% in Bushenyi being nurses or midwives. The rest were clinical officers, pharmacists. The most commonly stocked medicines at drug shops were Paracetamol, Quinine, Cough syrup, ORS/Zinc, Amoxicillin syrup, Septrin® syrup, Artemisinin-based combination therapies, and multivitamins, among others. Decisions on what medicines to stock were influenced by among others: recommended medicines from Ministry of Health, consumer demand, most profitable medicines, and seasonal disease patterns. Dispensing decisions were influenced by: prescriptions presented by client, patients' finances, and patient preferences, among others. Most drug shops surveyed had clinical guidelines, iCCM guidelines, malaria and diarrhea treatment algorithms and charts as recommended by the Ministry of Health. Some drug shops offered additional services such as immunization and sold non-medical goods, as a mechanism for diversification. CONCLUSION: Most drug shops premises adhered to the recommended guidelines. Market factors, including client demand and preferences, pricing and profitability, and seasonality largely influenced dispensing and stocking practices. Improving retail drug shop practices and quality of services, requires designing and implementing both supply-side and demand side strategies.

Enablers and barriers to evidence based planning in the district health system in Uganda; perceptions of district health managers.

BACKGROUND: The District Health System was endorsed as the key strategy to achieve 'Health for all' during the WHO organized inter-regional meeting in Harare in 1987. Many expectations were put upon the district health system, including planning. Although planning should be evidence based to prioritize activities, in Uganda it has been described as occurring more by chance than by choice. The role of planning is entrusted to the district health managers with support from the Ministry of Health and other stakeholders, but there is limited knowledge on the district health manager's capacity to carry out evidence-based planning. The aim of this study was to determine the barriers and enablers to evidence-based planning at the district level. METHODS: This qualitative study collected data through key informant interviews with district managers from two purposefully selected districts in Uganda that have been implementing evidence-based planning. A deductive process of thematic analysis was used to classify responses within themes. RESULTS: There were considerable differences between the districts in regard to the barriers and enablers for evidence-based planning. Variations could be attributed to specific contextual and environmental differences such as human resource levels, date of establishment of the district, funding and the sociopolitical environment. The perceived lack of local decision space coupled with the perception that the politicians had all the power while having limited knowledge on evidence-based planning was considered an important barrier. CONCLUSION: There is a need to review the mandate of the district managers to make decisions in the planning process and the range of decision space available within the district health system. Given the important role elected officials play in a decentralized system a concerted effort should be made to increase their knowledge on evidence-based planning and the district health system as a whole.

It could be viral but you don't know, you have not diagnosed it: health worker challenges in managing non-malaria paediatric fevers in the low transmission area of Mbarara District, Uganda.

BACKGROUND: In 2012, Uganda initiated nationwide deployment of malaria rapid diagnostic tests (RDT) as recommended by national guidelines. Yet growing concerns about RDT non-compliance in various settings have spurred calls to deploy RDT as part of enhanced support packages. An understanding of how health workers currently manage non-malaria fevers, particularly for children, and challenges faced in this work should also inform efforts. METHODS: A qualitative study was conducted in the low transmission area of Mbarara District (Uganda). In-depth interviews with 20 health workers at lower level clinics focused on RDT perceptions, strategies to differentiate non-malaria paediatric fevers, influences on clinical decisions, desires for additional diagnostics, and any challenges in this work. Seven focus group discussions were conducted with caregivers of children under 5 years of age in facility catchment areas to elucidate their RDT perceptions, understandings of non-malaria paediatric fevers and treatment preferences. Data were extracted into meaning units to inform codes and themes in order to describe response patterns using a latent content analysis approach. RESULTS: Differential diagnosis strategies included studying fever patterns, taking histories, assessing symptoms, and analysing other factors such as a child's age or home environment. If no alternative cause was found, malaria treatment was reportedly often prescribed despite a negative result. Other reasons for malaria over-treatment stemmed from RDT perceptions, system constraints and provider-client interactions. RDT perceptions included mistrust driven largely by expectations of false negative results due to low parasite/antigen loads, previous anti-malarial treatment or test detection of only one species. System constraints included poor referral systems, working alone without opportunity to confer on difficult cases, and lacking skills and/or tools for differential diagnosis. Provider-client interactions included reported caregiver RDT mistrust, demand for certain drugs and desire to know the 'exact' disease cause if not malaria. Many health workers expressed uncertainty about how to manage non-malaria paediatric fevers, feared doing wrong and patient death, worried caregivers would lose trust, or felt unsatisfied without a clear diagnosis. CONCLUSIONS: Enhanced support is needed to improve RDT adoption at lower level clinics that focuses on empowering providers to successfully manage non-severe, non-malaria paediatric fevers without referral. This includes building trust in negative results, reinforcing integrated care initiatives (e.g., integrated management of childhood illness) and fostering communities of practice according to the diffusion of innovations theory.

Integrated paediatric fever management and antibiotic over-treatment in Malawi health facilities: data mining a national facility census.

BACKGROUND: There are growing concerns about irrational antibiotic prescription practices in the era of test-based malaria case management. This study assessed integrated paediatric fever management using malaria rapid diagnostic tests (RDT) and Integrated Management of Childhood Illness (IMCI) guidelines, including the relationship between RDT-negative results and antibiotic over-treatment in Malawi health facilities in 2013-2014. METHODS: A Malawi national facility census included 1981 observed sick children aged 2-59 months with fever complaints. Weighted frequencies were tabulated for other complaints, assessments and prescriptions for RDT-confirmed malaria, IMCI-classified non-severe pneumonia, and clinical diarrhoea. Classification trees using model-based recursive partitioning estimated the association between RDT results and antibiotic over-treatment and learned the influence of 38 other input variables at patient-, provider- and facility-levels. RESULTS: Among 1981 clients, 72 % were tested or referred for malaria diagnosis and 85 % with RDT-confirmed malaria were prescribed first-line anti-malarials. Twenty-eight percent with IMCI-pneumonia were not prescribed antibiotics (under-treatment) and 59 % 'without antibiotic need' were prescribed antibiotics (over-treatment). Few clients had respiratory rates counted to identify antibiotic need for IMCI-pneumonia (18 %). RDT-negative children had 16.8 (95 % CI 8.6-32.7) times higher antibiotic over-treatment odds compared to RDT-positive cases conditioned by cough or difficult breathing complaints. CONCLUSIONS: Integrated paediatric fever management was sub-optimal for completed assessments and antibiotic targeting despite common compliance to malaria treatment guidelines. RDT-negative results were strongly associated with antibiotic over-treatment conditioned by cough or difficult breathing complaints. A shift from malaria-focused 'test and treat' strategies toward 'IMCI with testing' is needed to improve quality fever care and rational use of both anti-malarials and antibiotics in line with recent global commitments to combat resistance.

Effect of diagnostic testing on medicines used by febrile children less than five years in 12 malaria-endemic African countries: a mixed-methods study.

BACKGROUND: In 2010, WHO revised guidelines to recommend testing all suspected malaria cases prior to treatment. Yet, evidence to assess programmes is largely derived from limited facility settings in a limited number of countries. National surveys from 12 sub-Saharan African countries were used to examine the effect of diagnostic testing on medicines used by febrile children under five years at the population level, including stratification by malaria risk, transmission season, source of care, symptoms, and age. METHODS: Data were compiled from 12 Demographic and Health Surveys in 2010-2012 that reported fever prevalence, diagnostic test and medicine use, and socio-economic covariates (n=16,323 febrile under-fives taken to care). Mixed-effects logistic regression models quantified the influence of diagnostic testing on three outcomes (artemisinin combination therapy (ACT), any anti-malarial or any antibiotic use) after adjusting for data clustering and confounding covariates. For each outcome, interactions between diagnostic testing and the following covariates were separately tested: malaria risk, season, source of care, symptoms, and age. A multiple case study design was used to understand varying results across selected countries and sub-national groups, which drew on programme documents, published research and expert consultations. A descriptive typology of plausible explanations for quantitative results was derived from a cross-case synthesis. RESULTS: Significant variability was found in the effect of diagnostic testing on ACT use across countries (e.g., Uganda OR: 0.84, 95% CI: 0.66-1.06; Mozambique OR: 3.54, 95% CI: 2.33-5.39). Four main themes emerged to explain results: available diagnostics and medicines; quality of care; care-seeking behaviour; and, malaria epidemiology. CONCLUSIONS: Significant country variation was found in the effect of diagnostic testing on paediatric fever treatment at the population level, and qualitative results suggest the impact of diagnostic scale-up on treatment practices may not be straightforward in routine conditions given contextual factors (e.g., access to care, treatment-seeking behaviour or supply stock-outs). Despite limitations, quantitative results could help identify countries (e.g., Mozambique) or issues (e.g., malaria risk) where facility-based research or programme attention may be warranted. The mixed-methods approach triangulates different evidence to potentially provide a standard framework to assess routine programmes across countries or over time to fill critical evidence gaps.

Improving child survival through a district management strengthening and community empowerment intervention: early implementation experiences from Uganda.

BACKGROUND: The Community and District Empowerment for Scale-up (CODES) project pioneered the implementation of a comprehensive district management and community empowerment intervention in five districts in Uganda. In order to improve effective coverage and quality of child survival interventions CODES combines UNICEF tools designed to systematize priority setting, allocation of resources and problem solving with Community dialogues based on Citizen Report Cards and U-Reports used to engage and empower communities in monitoring health service provision and to demand for quality services. This paper presents early implementation experiences in five pilot districts and lessons learnt during the first 2 years of implementation. METHODS: This qualitative study was comprised of 38 in-depth interviews with members of the District Health Teams (DHTs) and two implementing partners. These were supplemented by observations during implementation and documents review. Thematic analysis was used to distill early implementation experiences and lessons learnt from the process. RESULTS: All five districts health teams with support from the implementing partners were able to adopt the UNICEF tools and to develop district health operational work plans that were evidence-based. Members of the DHTs described the approach introduced by the CODES project as a more systematic planning process and very much appreciated it. Districts were also able to implement some of the priority activities included in their work plans but limited financial resources and fiscal decision space constrained the implementation of some activities that were prioritized. Community dialogues based on Citizen Report Cards (CRC) increased community awareness of available health care services, their utilization and led to discussions on service delivery, barriers to service utilization and processes for improvement. Community dialogues were also instrumental in bringing together service users, providers and leaders to discuss problems and find solutions. The dialogues however are more likely to be sustainable if embedded in existing community structures and conducted by district based facilitators. U report as a community feedback mechanism registered a low response rate. CONCLUSION: The UNICEF tools were adopted at district level and generally well perceived by the DHTs. The limited resources and fiscal decision space however can hinder implementation of prioritized activities. Community dialogues based on CRCs can bring service providers and the community together but need to be embedded in existing community structures for sustainability.

Assessment of Childhood Stunting Prevalence over Time and Risk Factors of Stunting in the Healthy Village Programme Areas in Bangladesh.

Childhood stunting is a significant public health concern in Bangladesh. This study analysed the data from the Healthy Village programme, which aims to address childhood stunting in southern coastal Bangladesh. The aim was to assess childhood stunting prevalence over time and explore the risk factors in the programme areas. A cross-sectional, secondary data analysis was conducted for point-prevalence estimates of stunting from 2018 to 2021, including 132,038 anthropometric measurements of under-five children. Multivariate logistic regression analyses were conducted for risk factor analysis (n = 20,174). Stunting prevalence decreased from 51% in 2018 to 25% in 2021. The risk of stunting increased in hardcore poor (aOR: 1.46, 95% CI: 1.27, 1.68) and poor (aOR: 1.50, 95% CI: 1.33, 1.70) versus rich households, children with mothers who were illiterate (aOR: 1.25, 95% CI: 1.09, 1.44) and could read and write (aOR: 1.35, 95% CI: 1.16, 1.56) versus mothers with higher education, and children aged 1-2 years compared with children under one year (aOR: 1.32, 95% CI: 1.20, 1.45). The stunting rate was halved over three years in programme areas, which is faster than the national trend. We recommend addressing socioeconomic inequalities when tackling stunting and providing targeted interventions to mothers during the early weaning period.

The missing middle of childhood.

Middle childhood, between six and twelve years, is a critical bridge between earlier childhood and adolescence with rapid physical and psychological transitions. Most of the world's 2.6 billion young people, of which the middle childhood age group is a significant portion, live in low- and middle-income countries. Many live in environments that place them at high and growing risk for mental ill-health, injuries, and adoption of risky behaviours that often lead to non-communicable diseases in later years. Still, middle childhood, the 'missing middle,' is omitted from global health information systems, targeted policies, and strategies. The dearth of internationally comparable and standardised indicators on middle childhood in major international development agency databases hampers age-appropriate policy and programme development. Better understanding of the needs of this increasingly vulnerable population is critical. Middle childhood needs to be an explicit focus within child-focused research and implementation. Standardised, comprehensive, and relevant indicators are required to quantify the contribution of middle childhood to the global burden of disease and to facilitate interventions, monitoring, and evaluation, to ensure that all children flourish and thrive.

Mental health problems and service gaps experienced by pregnant adolescents and young women in Sub-Saharan Africa: A systematic review.

BACKGROUND: Pregnant adolescent girls and young women (AGYW, aged 12-24 years) are at high risk for mental health problems, particularly in the Sub-Saharan African (SSA) region. METHODS: We performed a systematic review of mental health studies among pregnant AGYW in SSA published between January 1, 2007 and December 31, 2020 in PubMed, Embase, CINAHL, PsycInfo, and Global Index Medicus following PRISMA guidelines (PROSPERO: CRD42021230980). We used Bronfenbrenner's bioecological model to frame and synthesize results from included studies. FINDINGS: Our search yielded 945 articles from which 18 studies were included (N = 8 quantitative, N = 9 qualitative, N = 1 case report). The most frequently studied mental health problem was depression (N = 9 studies); the most frequently utilized measurement tool was the Edinburgh Postnatal Depression Scale (N = 3). Studies reported life course factors, individual, microsystem, exosystem, macrosystem, and chronosystem-level factors associated with mental health problems. Gaps in mental health service delivery for pregnant AGYW included lack of confidentiality, judgmental healthcare worker attitudes, and lack of services tailored to their unique needs. INTERPRETATION: Gaps remain in research and services for mental health among pregnant AGYW in SSA. Integration of mental health services within school, community, and healthcare settings that are tailored to pregnant AGYW could strengthen health systems within SSA. FUNDING: Author contributions were supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (F31HD101149 to AL) and the Fogarty International Center (K43TW010716 to MK). The funding agencies had no role in the writing of the manuscript or the decision to submit it for publication. The project itself was not funded.

Child health and the implementation of Community and District-management Empowerment for Scale-up (CODES) in Uganda: a randomised controlled trial.

INTRODUCTION: Uganda's district-level administrative units buttress the public healthcare system. In many districts, however, local capacity is incommensurate with that required to plan and implement quality health interventions. This study investigates how a district management strategy informed by local data and community dialogue influences health services. METHODS: A 3-year randomised controlled trial (RCT) comprised of 16 Ugandan districts tested a management approach, Community and District-management Empowerment for Scale-up (CODES). Eight districts were randomly selected for each of the intervention and comparison areas. The approach relies on a customised set of data-driven diagnostic tools to identify and resolve health system bottlenecks. Using a difference-in-differences approach, the authors performed an intention-to-treat analysis of protective, preventive and curative practices for malaria, pneumonia and diarrhoea among children aged 5 and younger. RESULTS: Intervention districts reported significant net increases in the treatment of malaria (+23%), pneumonia (+19%) and diarrhoea (+13%) and improved stool disposal (+10%). Coverage rates for immunisation and vitamin A consumption saw similar improvements. By engaging communities and district managers in a common quest to solve local bottlenecks, CODES fostered demand for health services. However, limited fiscal space-constrained district managers' ability to implement solutions identified through CODES. CONCLUSION: Data-driven district management interventions can positively impact child health outcomes, with clinically significant improvements in the treatment of malaria, pneumonia and diarrhoea as well as stool disposal. The findings recommend the model's suitability for health systems strengthening in Uganda and other decentralised contexts. TRIAL REGISTRATION NUMBER: ISRCTN15705788.

Closing the know-do gap for child health: UNICEF's experiences from embedding implementation research in child health and nutrition programming.

UNICEF operates in 190 countries and territories, where it advocates for the protection of children's rights and helps meet children's basic needs to reach their full potential. Embedded implementation research (IR) is an approach to health systems strengthening in which (a) generation and use of research is led by decision-makers and implementers; (b) local context, priorities, and system complexity are taken into account; and (c) research is an integrated and systematic part of decision-making and implementation. By addressing research questions of direct relevance to programs, embedded IR increases the likelihood of evidence-informed policies and programs, with the ultimate goal of improving child health and nutrition.This paper presents UNICEF's embedded IR approach, describes its application to challenges and lessons learned, and considers implications for future work.From 2015, UNICEF has collaborated with global development partners (e.g. WHO, USAID), governments and research institutions to conduct embedded IR studies in over 25 high burden countries. These studies focused on a variety of programs, including immunization, prevention of mother-to-child transmission of HIV, birth registration, nutrition, and newborn and child health services in emergency settings. The studies also used a variety of methods, including quantitative, qualitative and mixed-methods.UNICEF has found that this systematically embedding research in programs to identify implementation barriers can address concerns of implementers in country programs and support action to improve implementation. In addition, it can be used to test innovations, in particular applicability of approaches for introduction and scaling of programs across different contexts (e.g., geographic, political, physical environment, social, economic, etc.). UNICEF aims to generate evidence as to what implementation strategies will lead to more effective programs and better outcomes for children, accounting for local context and complexity, and as prioritized by local service providers. The adaptation of implementation research theory and practice within a large, multi-sectoral program has shown positive results in UNICEF-supported programs for children and taking them to scale.

An embedded implementation research initiative to tackle service delivery bottlenecks in the expanded programme on immunisation in Pakistan: Overview and reflections.

BACKGROUND: Embedded implementation research (IR) can play a critical role in health systems strengthening by tackling systems and implementation bottlenecks of a program. To achieve this aim, with the financial support of GAVI, the Vaccine Alliance, in 2016, the Government of Pakistan, UNICEF and the Alliance for Health Policy and Systems Research (AHPSR) launched an Embedded IR for Immunisation Initiative (the Initiative) to explore health systems and implementation bottlenecks, and potential strategies to tackle such bottlenecks in the Expanded Programme on Immunisation (EPI) in Pakistan. In total, 10 research teams were involved in the Initiative, which was the first of its kind in the country. In this paper, we provided a brief overview of the Initiative's approach as well as the key learnings including challenges and successes of the research teams which could inform future embedded IR Initiatives. METHODS: Data were collected from members of the IR teams through an online survey. In addition, in-depth interviews were conducted via phone and in-person from IR team members to explore further the challenges they faced while conducting IR in Pakistan and recommendations for future IR initiatives. The qualitative information obtained from these sources was collated and categorized into themes reflecting some of the challenges, successes, and lessons learned, as well as teams' recommendations for future initiatives. RESULTS: The embedded IR Initiative in Pakistan followed several steps starting with a desk review to compile information on key implementation challenges of EPI and ended with a dissemination workshop where all the research teams shared their IR results with policymakers and implementers. Key factors that facilitated the successful and timely completion of the studies included appreciation by and leadership of implementers in generation and use of local knowledge, identification of research priorities jointly by EPI managers and researchers and provision of continuous and high-quality support from in-country research partners. Participants in the Initiative indicated that challenges included a lack of clarity on the role and responsibilities of each partner involved and need for further support to facilitate use and dissemination of research findings. CONCLUSIONS: The Initiative established that an immunisation programme in a lower middle-income country can use small and time-bound embedded IR, based on partnerships between programme managers and local researchers, to generate information and evidence that can inform decision-making. Future embedded IR initiatives should strive to ensure effective coordination and active participation of all key stakeholders, a clear research utilisation plan from the outset, and efforts to strengthen research teams' capacity to foster utilisation of research findings.

The perfect storm: Disruptions to institutional delivery care arising from the COVID-19 pandemic in Nepal.

BACKGROUND: The COVID-19 pandemic has led to system-wide disruption of health services globally. We assessed the effect of the pandemic on the disruption of institutional delivery care in Nepal. METHODS: We conducted a prospective cohort study among 52 356 women in nine hospitals to assess the disruption of institutional delivery care during the pandemic (comparing March to August in 2019 with the same months in 2020). We also conducted a nested follow up cohort study with 2022 women during the pandemic to assess their provision and experience of respectful care. We used linear regression models to assess the association between provision and experience of care with volume of hospital births and women's residence in a COVID-19 hotspot area. RESULTS: The mean institutional births during the pandemic across the nine hospitals was 24 563, an average decrease of 11.6% (P < 0.0001) in comparison to the same time-period in 2019. The institutional birth in high-medium volume hospitals declined on average by 20.8% (P < 0.0001) during the pandemic, whereas in low-volume hospital institutional birth increased on average by 7.9% (P = 0.001). Maternity services halted for a mean of 4.3 days during the pandemic and there was a redeployment staff to COVID-19 dedicated care. Respectful provision of care was better in hospitals with low-volume birth (ß = 0.446, P < 0.0001) in comparison to high-medium-volume hospitals. There was a positive association between women's residence in a COVID-19 hotspot area and respectful experience of care (ß = 0.076, P = 0.001). CONCLUSIONS: The COVID-19 pandemic has had differential effects on maternity services with changes varying by the volume of births per hospital with smaller volume facilities doing better. More research is needed to investigate the effects of the pandemic on where women give birth and their provision and experience of respectful maternity care to inform a "building-back-better" approach in post-pandemic period.

Mental Distress and Human Rights Violations During COVID-19: A Rapid Review of the Evidence Informing Rights, Mental Health Needs, and Public Policy Around Vulnerable Populations.

Background: COVID-19 prevention and mitigation efforts were abrupt and challenging for most countries with the protracted lockdown straining socioeconomic activities. Marginalized groups and individuals are particularly vulnerable to adverse effects of the pandemic such as human rights abuses and violations which can lead to psychological distress. In this review, we focus on mental distress and disturbances that have emanated due to human rights restrictions and violations amidst the pandemic. We underscore how mental health is both directly impacted by the force of pandemic and by prevention and mitigation structures put in place to combat the disease. Methods: We conducted a review of relevant studies examining human rights violations in COVID-19 response, with a focus on vulnerable populations, and its association with mental health and psychological well-being. We searched PubMed and Embase databases for studies between December 2019 to July 2020. Three reviewers evaluated the eligibility criteria and extracted data. Results: Twenty-four studies were included in the systematic inquiry reporting on distress due to human rights violations. Unanimously, the studies found vulnerable populations to be at a high risk for mental distress. Limited mobility rights disproportionately harmed psychiatric patients, low-income individuals, and minorities who were at higher risk for self-harm and worsening mental health. Healthcare workers suffered negative mental health consequences due to stigma and lack of personal protective equipment and stigma. Other vulnerable groups such as the elderly, children, and refugees also experienced negative consequences. Conclusions: This review emphasizes the need to uphold human rights and address long term mental health needs of populations that have suffered disproportionately during the pandemic. Countries can embed a proactive psychosocial response to medical management as well as in existing prevention strategies. International human rights guidelines are useful in this direction but an emphasis should be placed on strengthening rights informed psychosocial response with specific strategies to enhance mental health in the long-term. We underscore that various fundamental human rights are interdependent and therefore undermining one leads to a poor impact on the others. We strongly recommend global efforts toward focusing both on minimizing fatalities, protecting human rights, and promoting long term mental well-being.