Effects of the COVID-19 pandemic on general health and malaria control in Ghana: a qualitative study with mothers and health care professionals.

BACKGROUND: COVID-19 has severely impacted health systems and the management of non-COVID-19 diseases, including malaria, globally. The pandemic has hit sub-Saharan Africa less than expected; even considering large underreporting, the direct COVID-19 burden was minor compared to the Global North. However, the indirect effects of the pandemic, e.g. on socio-economic inequality and health care systems, may have been more disruptive. Following a quantitative analysis from northern Ghana, which showed significant reductions in overall outpatient department visits and malaria cases during the first year of COVID-19, this qualitative study aims to provide further explanations to those quantitative findings. METHODS: In the Northern Region of Ghana, 72 participants, consisting of 18 health care professionals (HCPs) and 54 mothers of children under the age of five, were recruited in urban and rural districts. Data were collected using focus group discussions with mothers and through key informant interviews with HCPs. RESULTS: Three main themes occurred. The first theme-general effects of the pandemic-includes impacts on finances, food security, health service provision as well as education and hygiene. Many women lost their jobs, which increased their dependance on males, children had to drop out of school, and families had to cope with food shortages and were considering migration. HCPs had problems reaching the communities, suffered stigmatisation and were often barely protected against the virus. The second theme-effects on health-seeking-includes fear of infection, lack of COVID-19 testing capacities, and reduced access to clinics and treatment. The third theme-effects on malaria-includes disruptions of malaria preventive measures. Clinical discrimination between malaria and COVID-19 symptoms was difficult and HCPs observed increases in severe malaria cases in health facilities due to late reporting. CONCLUSION: The COVID-19 pandemic has had large collateral impacts on mothers, children and HCPs. In addition to overall negative effects on families and communities, access to and quality of health services was severely impaired, including serious implications on malaria. This crisis has highlighted weaknesses of health care systems globally, including the malaria situation; a holistic analysis of the direct and indirect effects of this pandemic and an adapted strengthening of health care systems is essential to be prepared for the future.

Does EU and US paediatric legislation improve the authorization availability of medicines for children in other countries?

AIM: For over 15 years, the pharmaceutical industry has been engaged in developing medicines for children to comply with the European Union (EU) and the United States (US) regulatory requirements. We assessed the authorization availability of these medicines in countries without paediatric regulatory obligations. Special attention was given to the authorization availability of paediatric formulations. METHODS: Medicines for children were sampled from the US Food and Drug Administration and European Medicines Agency websites. We carried out systematic content analysis of product information and compared paediatric labelling in Australia, Brazil, Canada, Russia and South Africa with the EU or the US. The authorization availability of paediatric formulations in originator and generic medicines was reviewed. In Kenya, the authorization availability of sampled medicines and paediatric formulations was investigated. RESULTS: A total of 161 medicines authorized in the EU or the US were sampled. Whilst at least one paediatric indication was found in 70% of the medicines, the EU and US level of authorization was on average 38% in Australia, Brazil, Canada, Russia and South Africa. Paediatric formulations were authorized on average for 40% of originator and 36% of generic medicines. Kenya had the lowest authorization availability of medicines (40%) and formulations (26%). CONCLUSIONS: The authorization availability of novel medicines for children is lower in countries without paediatric regulatory obligations. Paediatric formulations often do not reach other countries if left unregulated, and their generic uptake is low. To increase authorization availability, submission of paediatric development results should become obligatory in each jurisdiction. Policy initiatives to stimulate the introduction of developed formulations should be encouraged.

'We Should Not Be Quiet but We Should Talk': Qualitative Accounts of Community-Based Communication of HIV Pre-Exposure Prophylaxis.

Community leaders play an important role in the acceptance of public health services, but little is known about their willingness to facilitate HIV pre-exposure prophylaxis (PrEP) roll-out in Eswatini. We conducted in-depth interviews (n = 25) with purposefully selected male and female community leaders in Eswatini. We analysed our data inductively using a thematic analysis approach. Community leaders feel they are important communicators of culturally appropriate PrEP messaging. Our participants described a complex social space within their communities influenced by religion, tradition, values, and HIV stigma. Community leaders use their position to provide leverage for unique, effective, and easily accessible messages and platforms to reach the community in a manner that ensures trust, relatability, familiarity, and shared faith. Community leaders feel that they are trusted and see trust manifesting in the conversations they are able to engage in, and have a reach that extends beyond formal health services. Existing PrEP programming should embed community leader participation in PrEP programming and engage the trust, knowledge, and potential of community leaders to support PrEP uptake and acceptance.

Impact of the COVID-19 pandemic on malaria cases in health facilities in northern Ghana: a retrospective analysis of routine surveillance data.

BACKGROUND: The COVID-19 pandemic and its collateral damage severely impact health systems globally and risk to worsen the malaria situation in endemic countries. Malaria is a leading cause of morbidity and mortality in Ghana. This study aims to describe the potential effects of the COVID-19 pandemic on malaria cases observed in health facilities in the Northern Region of Ghana. METHODS: Monthly routine data from the District Health Information Management System II (DHIMS2) of the Northern Region of Ghana were analysed. Overall outpatient department visits (OPD) and malaria case rates from the years 2015-2019 were compared to the corresponding data of the year 2020. RESULTS: Compared to the corresponding periods of the years 2015-2019, overall visits and malaria cases in paediatric and adult OPDs in northern Ghana decreased in March and April 2020, when major movement and social restrictions were implemented in response to the pandemic. Cases slightly rebounded afterwards in 2020, but stayed below the average of the previous years. Malaria data from inpatient departments showed a similar but more pronounced trend when compared to OPDs. In pregnant women, however, malaria cases in OPDs increased after the first COVID-19 wave. CONCLUSIONS: The findings from this study show that the COVID-19 pandemic affects the malaria burden in health facilities of northern Ghana, with declines in inpatient and outpatient rates except for pregnant women. They may have experienced reduced access to insecticide-treated nets and intermittent preventive malaria treatment in pregnancy, resulting in subsequent higher malaria morbidity. Further data, particularly from community-based studies and ideally complemented by qualitative research, are needed to fully determine the impact of the pandemic on the malaria situation in Africa.

Adherence to appointments for gestational diabetes testing and experiences with two-hour postprandial glucose test: a mixed-methods study in Ghana.

BACKGROUND: Failure to attend scheduled appointments is a common problem in healthcare. In obstetrics, diagnostic and treatment protocols for gestational diabetes mellitus (GDM) require client booking, test preparations, management and follow-up reviews. We identified the socio-demographic, obstetric and medical drivers influencing adherence to appointments for GDM testing and experiences of pregnant women's regarding performing oral glucose tolerance test (OGTT). METHODS: A convergent parallel mixed-methods study comprising a cross-sectional survey and an explorative qualitative descriptive design were used. We recruited 817 women in their first trimester of pregnancy from the antenatal clinics of primary, secondary and tertiary health facilities in Ghana. After obtaining their demographic and health history, we scheduled them for 2-h OGTT between 24 and 28 gestational weeks and estimated the odds of returning for the test. In the qualitative phase, we called 166 participants to ascertain why they failed to report. Also, we had in-depth and focused group discussions with 60 postpartum women who performed the OGTT to explore their experiences with the test. RESULTS: Out of 817 pregnant women scheduled, 490 (59.97%) reported of which 54.59, 54.33 and 53.24% completed fasting plasma glucose, 1-h and 2-h OGTT, respectively. Maternal age above 35 years (OR: 3.56, 95% CI:1.49-8.47), secondary education (OR: 3.21, 95% CI: 1.19-8.69), formal sector employment (OR: 2.02, 95% CI: 1.16-3.51) and having same-sex children (OR: 4.37, 95% CI: 1.98-9.66) increased odds of appointment adherence whereas healthcare in a tertiary hospital (OR:0.46, 95% CI:0.22-0.96), rural residence (OR: 0.53, 95% CI: 0.34-0.85) and being overweight (OR: 0.45, 95% CI: 0.25-0.78) decreased the likelihood. Experiences were thematized into feelings about test procedure, acceptability of test, skillfulness of the health workers and information on the test. Despite the apprehension and discomforts associated with the test, the desire to know one's disease status was the chief motivation. Empathy, reassurance and receiving ample information on the test procedures eased anxiety and improved test compliance. CONCLUSIONS: Although 40% of participants scheduled did not return, the test was generally acceptable. Socio-cultural underpinnings influenced the health-seeking behaviors, meaning that health worker interactions on test procedures need to be sensitive to the woman's situation.

Mind the gap: an analysis of core capacities of the international health regulations (2005) to respond to outbreaks in Yemen.

BACKGROUND: Yemen that has been devastated by war is facing various challenges to respond to the recent potential outbreaks and other public health emergencies due to lack of proper strategies and regulations, which are essential to public health security. The aim of this study is to assess the implementation of the International Health Regulations (IHR 2005) core capacities under the current ongoing conflict in Yemen. METHODS: The study simulated the World Health Organization (WHO) Joint External Evaluation (JEE) tool to assess the IHR core capacities in Yemen. Qualitative research methods were used, including desk reviews, in-depth interviews with key informants and analysis of the pooled data. RESULT: Based on the assessment of the three main functions of the IHR framework (prevention, detection, and response), Yemen showed a demonstrated or developed capacity to detect outbreaks, but nevertheless limited or no capacity to prevent and respond to outbreaks. CONCLUSION: This study shows that there has been poor implementation of IHR in Yemen. Therefore, urgent interventions are needed to strengthen the implementation of the IHR core capacities in Yemen. The study recommends 1) raising awareness among national and international health staff on the importance of IHR; 2) improving alignment of INGO programs with government health programs and aligning both towards better implementation of the IHR; 3) improving programmatic coordination, planning and implementation among health stakeholders; 4) increasing funding of the global health security agenda at country level; 5) using innovative approaches to analyze and address gaps in the disrupted health system, and; 6) addressing the root cause of the collapse of the health services and overall health system in Yemen by ending the protracted conflict situation.

COVID-19 in Ghana: challenges and countermeasures for maternal health service delivery in public health facilities.

We provide a situational update on COVID-19 in Ghana, the seventh African country reporting the most cases. Some modifications occurring within the health system to curtail the outbreak and its potential impact on the delivery of antenatal care services are also highlighted. With the discovery of the Delta variant in Ghana, the current attention is to prevent a third wave of infection, and also control and manage existing cases. Efforts to procure vaccines, vaccinate special populations and sensitize the public on the implications of vaccine hesitancy are ongoing. Amidst these activities, we suggest some innovations and countermeasures to safeguard primary healthcare services and potentially reinvest efforts towards achieving the sustainable development goal three within the context of maternal healthcare, citing examples specific to developing countries.

Principles of condom provision programs in prisons from the standpoint of European prison health experts: a qualitative study.

BACKGROUND: Condom provision is one of the most effective harm reduction interventions to control sexually transmitted infections (STIs) including HIV/AIDS and viral hepatitis in prisons. Yet, very few countries around the world provide prisoners with condoms. The present study aimed to elucidate principles of effective prison-based condom programs from the perspective of European public health and prison health experts. METHODS: As a part of the "Joint Action on HIV and Co-infection Prevention and Harm Reduction (HA-REACT)" twenty-one experts from the field of prison health from eight European countries were invited to discuss the principles of condom provision programs in prisons within two focus groups. The audio records were transcribed verbatim, coded, categorized, and analyzed using thematic analysis method. RESULTS: Six components emerged from the analysis as essential for successful condom programs in prisons: (1) highlighting the necessity of condom provision in prisons, (2) engagement of internal and external beneficiaries in all stages of designing and implementing the program, (3) conducting a pilot phase, (4) condom program in a comprehensive package of harm reduction interventions, (5) vending machine as the best method of condom distribution in prisons and (6) assuring the sustainability and quality of the intervention. CONCLUSION: Results of the present study can help prison health policy makers to design and conduct acceptable, accessible and high-quality prison-based condom provision programs, and consequently to mitigate the burden of STIs in prisons. Having access to high-quality healthcare services including condom provision programs is not only the right of prisoners to health, but also is a move towards achieving the sustainable development goal 3 of "leaving no one behind."

Availability, Accessibility, and Coverage of Needle and Syringe Programs in Prisons in the European Union.

Needle and syringe programs (NSPs) are among the most effective interventions for controlling the transmission of infection among people who inject drugs in prisons. We evaluated the availability, accessibility, and coverage of NSPs in prisons in European Union (EU) countries. In line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria, we systematically searched 4 databases of peer-reviewed publications (MEDLINE (PubMed), ISI Web of Science, EBSCO, and ScienceDirect) and 53 databases containing gray literature to collect data published from January 2008 to August 2018. A total of 23,969 documents (17,297 papers and 6,672 gray documents) were identified, of which 26 were included in the study. In 2018, imprisonment rates in 28 EU countries ranged between 51 per 100,000 population in Finland and 235 per 100,000 population in Lithuania. Only 4 countries were found to have NSPs in prisons: Germany (in 1 prison), Luxembourg (no coverage data were found), Romania (available in more than 50% of prisons), and Spain (in all prisons). Portugal stopped an NSP after a 6-month pilot phase. Despite the protective impact of prison-based NSPs on infection transmission, only 4 EU countries distribute sterile syringes among people who inject drugs in prisons, and coverage of the programs within these countries is very low. Since most prisoners will eventually return to the community, lack of NSPs in EU prisons not only is a threat to the health of prisoners but also endangers public health.

'It's far too complicated': why fragmentation persists in global health.

BACKGROUND: Despite many efforts to achieve better coordination, fragmentation is an enduring feature of the global health landscape that undermines the effectiveness of health programmes and threatens the attainment of the health-related Sustainable Development Goals. In this paper we identify and describe the multiple causes of fragmentation in development assistant for health at the global level. The study is of particular relevance since the emergence of new global health problems such as COVID-19 heightens the need for global health actors to work in coordinated ways. Our study is part of the Lancet Commission on Synergies between Universal Health Coverage, Health Security and Health Promotion. METHODS: We used a mixed methods approach. This consisted of a non-systematic literature review of published papers in scientific journals, reports, books and websites. We also carried out twenty semi-structured expert interviews with individuals from bilateral and multilateral organisations, governments and academic and research institutions between April 2019 and December 2019. RESULTS: We identified five distinct yet interconnected sets of factors causing fragmentation: proliferation of global health actors; problems of global leadership; divergent interests; problems of accountability; problems of power relations. We explain why global health actors struggle to harmonise their approaches and priorities, fail to align their work with low- and middle-income countries' needs and why they continue to embrace funding instruments that create fragmentation. CONCLUSIONS: Many global actors are genuinely committed to addressing the problems of fragmentation, despite their complexity and interconnected nature. This paper aims to raise awareness and understanding of the causes of fragmentation and to help guide actors' efforts in addressing the problems and moving to more synergistic approaches.

Assessment of electronic disease early warning system for improved disease surveillance and outbreak response in Yemen.

BACKGROUND: Diseases Surveillance is a continuous process of data collection, analysis interpretation and dissemination of information for swift public health action. Recent advances in health informatics have led to the implementation of electronic tools to facilitate such critical disease surveillance processes. This study aimed to assess the performance of the national electronic Disease Early Warning System in Yemen (eDEWS) using system attributes: data quality, timeliness, stability, simplicity, predictive value positive, sensitivity, acceptability, flexibility, and representativeness, based on the Centres for Disease Control & Prevention (US CDC) standard indicators. METHODS: We performed a mixed methods study that occurred in two stages: first, the quantitative data was collected from weekly epidemiological bulletins from 2013 to 2017, all alerts of 2016, and annual eDEWS reports, and then the qualitative method using in-depth interviews was carried out in a convergent strategy. The CDC guideline used to describe the following system attributes: data quality (reporting, and completeness), timeliness, stability, simplicity, predictive value positive, sensitivity, acceptability, flexibility and representativeness. RESULTS: The finding of this assessment showed that eDEWS is a resilient and reliable system, and despite the conflict in Yemen, the system is still functioning and expanding. The response timeliness remains a challenge, since only 21% of all eDEWS alerts were verified within the first 24 h of detection in 2016. However, identified gaps did not affect the system's ability to identify outbreaks in the current fragile situation. Findings show that eDEWS data is representative, since it covers the entire country. Although, eDEWS covers only 37% of all health facilities, this represents 83% of all functional health facilities in all 23 governorates and all 333 districts. CONCLUSION: The quality and timeliness of responses are major challenges to eDEWS' functionality, the eDEWS remains the only system that provides regular data on communicable diseases in Yemen. In particular, public health response timeliness needs improvement.

Prisoners should not be left behind in HCV research and policies.

With a worldwide prevalence of 15.4%, hepatitis C virus (HCV) has been estimated to be the most prevalent major infectious disease in prisons. The exceptionally high prevalence of HCV in prisons is attributable to common risk behaviors including sharing contaminated tattooing equipment and drug paraphernalia, as well as lack of HCV control interventions including needle and syringe programs. Despite the importance of attention to prisoners as a highly at-risk population to acquire and transmit HCV, the number of HCV research and policy documents ignoring prisoners is increasing. Highlighting this issue, the present manuscript discusses how excluding prisoners from HCV-related research and policies will jeopardize the global HCV elimination goals set forth by the global community.

Evaluation of e-learning for medical education in low- and middle-income countries: A systematic review.

In low- and middle-income countries (LMICs), e-learning for medical education may alleviate the burden of severe health worker shortages and deliver affordable access to high quality medical education. However, diverse challenges in infrastructure and adoption are encountered when implementing e-learning within medical education in particular. Understanding what constitutes successful e-learning is an important first step for determining its effectiveness. The objective of this study was to systematically review e-learning interventions for medical education in LMICs, focusing on their evaluation and assessment methods. Nine databases were searched for publications from January 2007 to June 2017. We included 52 studies with a total of 12,294 participants. Most e-learning interventions were pilot studies (73%), which mainly employed summative assessments of study participants (83%) and evaluated the e-learning intervention with questionnaires (45%). Study designs, evaluation and assessment methods showed considerable variation, as did the study quality, evaluation periods, outcome and effectiveness measures. Included studies mainly utilized subjective measures and custom-built evaluation frameworks, which resulted in both low comparability and poor validity. The majority of studies self-concluded that they had had an effective e-learning intervention, thus indicating potential benefits of e-learning for LMICs. However, MERSQI and NOS ratings revealed the low quality of the studies' evidence for comparability, evaluation instrument validity, study outcomes and participant blinding. Many e-learning interventions were small-scale and conducted as short-termed pilots. More rigorous evaluation methods for e-learning implementations in LMICs are needed to understand the strengths and shortcomings of e-learning for medical education in low-resource contexts. Valid and reliable evaluations are the foundation to guide and improve e-learning interventions, increase their sustainability, alleviate shortages in health care workers and improve the quality of medical care in LMICs.

Technology Acceptance and Information System Success of a Mobile Electronic Platform for Nonphysician Clinical Students in Zambia: Prospective, Nonrandomized Intervention Study.

BACKGROUND: Zambia is still experiencing a severe shortage of health workers, which is impacting the national health care system. Very few people are trained, educational infrastructure is inadequate, and senior human resources for training are not yet sufficient to produce the number of health care workers needed, especially for currently underserved rural areas. Therefore, to strengthen the medical education program of medical licentiates, we implemented a tablet-based electronic learning platform (e-platform) with a medical decision-support component. OBJECTIVE: As the primary objective, this study aimed to explore the acceptance and information system (IS) success of an e-platform focused on offline-based tablet usage for nonphysician clinical students in a low-resource context in Zambia, Africa. Furthermore, we aimed to evaluate student demographic factors and prior technological experience, as well as medical lecturers' acceptance of technology of the e-platform. METHODS: We collected data for the study before and after the intervention. Before the intervention, we collected student demographic data and prior technological experience using a questionnaire. After the intervention, we collected results of the questionnaire on technology acceptance of students and IS success of the e-platform, as well as technology acceptance of medical lecturers. We calculated statistical measures such as means, standard deviations, and correlations of investigated variables. The study report was compiled using the Consolidated Standards of Reporting Trials-Electronic Health checklist. RESULTS: Overall, questionnaire results of students and medical lecturers indicated acceptance of the e-platform and showed higher ratings for overall net benefits and information quality (students) and perceived ease of use and perceived usefulness (medical lecturers) as compared with ratings of other categories. The lowest scores were conveyed for system use and service quality (students) and attitude and behavioral intention (medical lecturers). CONCLUSIONS: Acceptance of the e-platform as a learning technology for strengthening medical education in a low-resource context in Zambia was generally high for students and medical lecturers, but shortcomings were also identified. Results indicated low overall usage of the e-platform as a learning and teaching tool. One hindering factor was the tablets' overall weak reliability with regard to its service life and battery life span, and another was the teachers' low engagement with the e-platform. Next steps may include other hardware and more technology-based training for medical lecturers. The evaluation results indicated that the e-platform may open new promise for further strengthening and expanding medical education in this context, especially with more affordable and viable technologies that are available.

E-Learning for Medical Education in Sub-Saharan Africa and Low-Resource Settings: Viewpoint.

E-learning has been heralded as a revolutionary force for medical education, especially for low-resource countries still suffering from a dire lack of health care workers. However, despite over two decades of e-learning endeavors and interventions across sub-Saharan Africa and other low- and middle-income countries, e-learning for medical education has not gained momentum and continues to fall short of the anticipated revolution. Many e-learning interventions have been cul-de-sac pilots that have not been scaled up but rather terminated after the pilot phase. This is usually a result of not adopting a system-wide approach, which leads to insufficient scope of training, insufficient technological maintenance and user support, unattainably high expectations, and unrealistic financial planning. Thus, a multitude of e-learning evaluations have failed to provide scientifically sound evidence of the effectiveness of e-learning for medical education in low-resource countries. Instead, it appears that technological development has overwhelmed rather than revolutionized medical education. The question of how to push e-learning into a higher gear in low-resource countries persists. Provision of e-learning as a technology is insufficient. E-learning needs to be vigorously and sustainably integrated into the local educational setting and aligned with national strategies and other national endeavors and interventions. Adhering to a standardized framework for the implementation and evaluation of e-learning endeavors is key, especially to bridge the gap in robust evidence that should also guide e-learning implementations. The primary objective of e-learning for medical education is to strengthen the health system in order to serve the population's health care needs and expectations. Currently, medical e-learning does not measure up to its potential or do justice to medical students in low-resource countries. Technology may help unfold the potential of e-learning, but an all-encompassing change is needed. This can only be achieved through a joint effort that follows a systematic and standardized framework, especially for implementation and evaluation.

Kenya's Health in All Policies strategy: a policy analysis using Kingdon's multiple streams.

BACKGROUND: Health in All Policies (HiAP) is an intersectoral approach that facilitates decision-making among policy-makers to maximise positive health impacts of other public policies. Kenya, as a member of WHO, has committed to adopting HiAP, which has been included in the Kenya Health Policy for the period 2014-2030. This study aims to assess the extent to which this commitment is being translated into the process of governmental policy-making and supported by international development partners as well as non-state actors. METHODS: To examine HiAP in Kenya, a qualitative case study was performed, including a review of relevant policy documents. Furthermore, 40 key informants with diverse backgrounds (government, UN agencies, development agencies, civil society) were interviewed. Analysis was carried out using the main dimensions of Kingdon's Multiple Streams Approach (problems, policy, politics). RESULTS: Kenya is facing major health challenges that are influenced by various social determinants, but the implementation of intersectoral action focusing on health promotion is still arbitrary. On the policy level, little is known about HiAP in other government ministries. Many health-related collaborations exist under the concept of intersectoral collaboration, which is prominent in the country's development framework - Vision 2030 - but with no specific reference to HiAP. Under the political stream, the study highlights that political commitment from the highest office would facilitate mainstreaming the HiAP strategy, e.g. by setting up a department under the President's Office. The budgeting process and planning for the Sustainable Development Goals were found to be potential windows of opportunity. CONCLUSION: While HiAP is being adopted as policy in Kenya, it is still perceived by many stakeholders as the business of the health sector, rather than a policy for the whole government and beyond. Kenya's Vision 2030 should use HiAP to foster progress in all sectors with health promotion as an explicit goal.

Germany's expanding role in global health.

Germany has become a visible actor in global health in the past 10 years. In this Series paper, we describe how this development complements a broad change in perspective in German foreign policy. Catalysts for this shift have been strong governmental leadership, opportunities through G7 and G20 presidencies, and Germany's involvement in managing the Ebola virus disease outbreak. German global health engagement has four main characteristics that are congruent with the health agenda of the Sustainable Development Goals; it is rooted in human rights, multilateralism, the Bismarck model of social protection, and a link between development and investment on the basis of its own development trajectory after World War 2. The combination of momentum and specific characteristics makes Germany well equipped to become a leader in global health, yet the country needs to accept additional financial responsibility for global health, expand its domestic global health competencies, reduce fragmentation of global health policy making, and solve major incoherencies in its policies both nationally and internationally.

Implementation of the redesigned Community Health Fund in the Dodoma region of Tanzania: A qualitative study of views from rural communities.

The need to understand how an intervention is received by the beneficiary community is well recognised and particularly neglected in the micro-health insurance (MHI) domain. This study explored the views and reactions of the beneficiary community of the redesigned Community Health Fund (CHF) implemented in the Dodoma region of Tanzania. We collected data from focus group discussions with 24 groups of villagers (CHF members and nonmembers) and in-depth interviews with 12 key informants (enrolment officers and health care workers). The transcribed material was analysed thematically. We found that participants highly appreciate the scheme, but to be resolved are the challenges posed by the implementation strategies adopted. The responses of the community were nested within a complex pathway relating to their interaction with the implementation strategies and their ongoing reflections regarding the benefits of the scheme. Community reactions ranged from accepting to rejecting the scheme, demanding the right to receive benefit packages once enrolled, and dropping out of the scheme when it failed to meet their expectations. Reported drivers of the responses included intensity of CHF communication activities, management of enrolment procedures, delivery of benefit packages, critical features of the scheme, and contextual factors (health system and socio-political context). This study highlights that scheme design and implementation strategies that address people's needs, voices, and values can improve uptake of MHI interventions. The study adds to the knowledge base on implementing MHI initiatives and could promote interests in assessing the response to interventions within the MHI domain and beyond.

Nutrient composition and dietary diversity of on-site lunch meals, and anthropometry of beneficiary children in private and public primary schools in Ghana.

BACKGROUND: On-site lunch provided through the Ghana School Feeding Programme is expected to be nutritionally adequate thereby contributing to reducing hunger and malnutrition. AIM: The aim of this study was to assess the dietary diversity and nutrient composition of on-site school lunch and estimate the extent to which it met the Food and Agriculture Organization Reference Nutrient Intakes for children aged 3-12 years. METHODS: In this cross-sectional food consumption survey, on-site lunch menus were reviewed, dietary diversity assessed and meal preparation/serving observed during a typical school week. Three randomly selected portion sizes were weighed and the average weight (grams) entered into the RIING nutrient software to estimate the nutrient composition. Anthropometry of participants enrolled in seven public (n = 113) and six private (n = 216) primary schools in Hohoe municipality, Ghana was analysed using World Health Organization Anthroplus software. RESULTS: The menu consisted largely of energy-dense staples, some vegetables and fish. Eggs, dairy and fruits were never served. Meals served in the public and private schools were statistically similar. Fat (23.8 vs. 27.7 g), iron (3.0 vs. 2.8 mg), vitamins A (417.3 vs. 280.8 µg retinol equivalent) and C (25.1 vs. 16.5 mg) requirements were fully met. Energy (420.6 vs. 462.2 kcal), protein (6.8 vs. 6.8 g), thiamin (0.18 vs. 0.17 mg) and zinc (1.3 vs. 1.2 mg) were 50-75% met. Calcium (62.6 vs. 61.4 mg), riboflavin (0.09 vs. 0.07 mg) and niacin (1.6 vs. 1.3 mg) were 26-37% met. Concerning nutritional status, prevalence of stunting (8.9% vs. 7.9%), underweight (3.6% vs. 5.7%), thinness (1.8% vs. 3.7%) and overweight/obesity (3.5% vs. 4.2%) were also statistically similar. CONCLUSION: Enhancing dietary diversity is crucial to achieving nutrient-dense school meals.