Community Control of Hypertension and Diabetes (CoCo-HD) program in the Indian states of Kerala and Tamil Nadu: a study protocol for a type 3 hybrid trial.

INTRODUCTION: India grapples with a formidable health challenge, with an estimated 315 million adults afflicted with hypertension and 100 million living with diabetes mellitus. Alarming statistics reveal rates for poor treatment and control of hypertension and diabetes. In response to these pressing needs, the Community Control of Hypertension and Diabetes (CoCo-HD) program aims to implement structured lifestyle interventions at scale in the southern Indian states of Kerala and Tamil Nadu. AIMS: This research is designed to evaluate the implementation outcomes of peer support programs and community mobilisation strategies in overcoming barriers and maximising enablers for effective diabetes and hypertension prevention and control. Furthermore, it will identify contextual factors that influence intervention scalability and it will also evaluate the program's value and return on investment through economic evaluation. METHODS: The CoCo-HD program is underpinned by a longstanding collaborative effort, engaging stakeholders to co-design comprehensive solutions that will be scalable in the two states. This entails equipping community health workers with tailored training and fostering community engagement, with a primary focus on leveraging peer supportat scale in these communities. The evaluation will undertake a hybrid type III trial in, Kerala and Tamil Nadu states, guided by the Institute for Health Improvement framework. The evaluation framework is underpinned by the application of three frameworks, RE-AIM, Normalisation Process Theory, and the Consolidated Framework for Implementation Research. Evaluation metrics include clinical outcomes: diabetes and hypertension control rates, as well as behavioural, physical, and biochemical measurements and treatment adherence. DISCUSSION: The anticipated outcomes of this study hold immense promise, offering important learnings into effective scaling up of lifestyle interventions for hypertension and diabetes control in low- and middle-income countries (LMICs). By identifying effective implementation strategies and contextual determinants, this research has the potential to lead to important changes in healthcare delivery systems. CONCLUSIONS: The project will provide valuable evidence for the scaling-up of structured lifestyle interventions within the healthcare systems of Kerala and Tamil Nadu, thus facilitating their future adaptation to diverse settings in India and other LMICs.

How can countries respond to the health and care workforce crisis? Insights from international evidence.

Future global health security requires a health and care workforce (HCWF) that can respond effectively to health crises as well as to changing health needs with ageing populations, a rise in chronic conditions and growing inequality. COVID-19 has drawn attention to an impending HCWF crisis with a large projected shortfall in numbers against need. Addressing this requires countries to move beyond a focus on numbers of doctors, nurses and midwives to consider what kinds of healthcare workers can deliver the services needed; are more likely to stay in country, in rural and remote areas, and in health sector jobs; and what support they need to deliver high-quality services. In this paper, which draws on a Policy Brief prepared for the World Health Organization (WHO) Fifth Global Forum on Human Resources for Health, we review the global evidence on best practices in organising, training, deploying, and managing the HCWF to highlight areas for strategic investments. These include (1). Increasing HCWF diversity to improve the skill-mix and provide culturally competent care; (2). Introducing multidisciplinary teams in primary care; (3). Transforming health professional education with greater interprofessional education; (4). Re-thinking employment and deployment systems to address HCWF shortages; (5). Improving HCWF retention by supporting healthcare workers and addressing migration through destination country policies that limit draining resources from countries with greatest need. These approaches are departures from current norms and hold substantial potential for building a sustainable and responsive HCWF.

Wealth-based inequality in the continuum of maternal health service utilisation in 16 sub-Saharan African countries.

BACKGROUND: Persistent inequalities in coverage of maternal health services in sub-Saharan Africa (SSA), a region home to two-thirds of global maternal deaths in 2017, poses a challenge for countries to achieve the Sustainable Development Goal (SDG) targets. This study assesses wealth-based inequalities in coverage of maternal continuum of care in 16 SSA countries with the objective of informing targeted policies to ensure maternal health equity in the region. METHODS: We conducted a secondary analysis of Demographic and Health Survey (DHS) data from 16 SSA countries (Angola, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, and Zambia). A total of 133,709 women aged 15-49 years who reported a live birth in the five years preceding the survey were included. We defined and measured completion of maternal continuum of care as having had at least one antenatal care (ANC) visit, birth in a health facility, and postnatal care (PNC) by a skilled provider within two days of birth. We used concentration index analysis to measure wealth-based inequality in maternal continuum of care and conducted decomposition analysis to estimate the contributions of sociodemographic and obstetric factors to the observed inequality. RESULTS: The percentage of women who had 1) at least one ANC visit was lowest in Ethiopia (62.3%) and highest in Burundi (99.2%), 2) birth in a health facility was less than 50% in Ethiopia and Nigeria, and 3) PNC within two days was less than 50% in eight countries (Angola, Burundi, Ethiopia, Gambia, Guinea, Malawi, Nigeria, and Tanzania). Completion of maternal continuum of care was highest in South Africa (81.4%) and below 50% in nine of the 16 countries (Angola, Burundi, Ethiopia, Guinea, Malawi, Mali, Nigeria, Tanzania, and Uganda), the lowest being in Ethiopia (12.5%). There was pro-rich wealth-based inequality in maternal continuum of care in all 16 countries, the lowest in South Africa and Liberia (concentration index = 0.04) and the highest in Nigeria (concentration index = 0.34). Our decomposition analysis showed that in 15 of the 16 countries, wealth index was the largest contributor to inequality in primary maternal continuum of care. In Malawi, geographical region was the largest contributor. CONCLUSIONS: Addressing the coverage gap in maternal continuum of care in SSA using multidimensional and people-centred approaches remains a key strategy needed to realise the SDG3. The pro-rich wealth-based inequalities observed show that bespoke pro-poor or population-wide approaches are needed.

'You say you are a TB doctor, but actually, you do not have any power': health worker (de)motivation in the context of integrated, hospital-based tuberculosis care in eastern China.

BACKGROUND: In China, tuberculosis (TB) care, traditionally provided through the Centre for Disease Control (CDC), has been integrated into 'designated' public hospitals at County level, with hospital staff taking on delivery of TB services supported by CDC staff. Little is known about the impact of this initiative on the hospital-based health workers who were delegated to manage TB. Drawing on a case study of two TB 'designated' hospitals in Zhejiang province, we explored factors influencing hospital-based health workers' motivation in the context of integrated TB service delivery. METHODS: We conducted 47 in-depth interviews with health officials, TB/hospital managers, clinicians, radiologists, laboratory staff and nurses involved in the integrated model of hospital-based TB care. Thematic analysis was used to develop and refine themes, code the data and assist in interpretation. RESULTS: Health workers tasked with TB care in 'designated' hospitals perceived their professional status to be low, related to their assessment of TB treatment as lacking need for professional skills, their limited opportunities for professional development, and the social stigma surrounding TB. In both sites, the integrated TB clinics were under-staffed: health workers providing TB care reported heavy workloads, and expressed dissatisfaction with a perceived gap in their salaries compared with other clinical staff. In both sites, health workers were concerned about poor infection control and weak risk management assessment systems. CONCLUSIONS: Inadequate attention to workforce issues for TB control in China, specifically the professional status, welfare, and development as well as incentivization of infectious disease control workers has contributed to dissatisfaction and consequently poor motivation to serve TB patients within the integrated model of TB care. It is important to address the failure to motivate health workers and maximize public good-oriented TB service provision through improved government funding and attention to the professional welfare of health workers providing TB care in hospitals.

What factors shape quality of life for women affected by gynaecological cancer in South, South East and East Asian countries? A critical review.

BACKGROUND: Gynaecological cancers are among the most prevalent cancers worldwide, with profound effects on the lives of women and their families. In this critical review, we explore the impacts of these cancers on quality of life (QOL) of women in Asian countries, and highlight areas for future inquiry. METHODS: A systematic search of the literature was conducted in six electronic databases: Web of Science, Scopus, Global Health (CAB Direct), PsycINFO (Ovid), EBMR (Ovid), and Medline (Ovid). Screening resulted in the inclusion of 53 relevant articles reporting on 48 studies. RESULTS: Most studies were conducted in high and upper-middle income countries in East Asia and used quantitative approaches. Women had predominantly been diagnosed with cervical or ovarian cancer, and most had completed treatment. Four key interrelated domains emerged as most relevant in shaping QOL of women affected by gynaecological cancer: support, including identified needs, sources and forms; mental health, covering psychological distress associated with cancer, risk and protective factors, and coping strategies; sexual function and sexuality, focused on physiological, emotional and relational changes caused by gynaecological cancers and treatments, and the impacts of these on women's identities; and physical health, covering the physical conditions associated with gynaecological cancers and their impacts on women's daily activities. CONCLUSION: QOL of women affected by gynaecological cancer is shaped by their mental and physical health, support, and changes in sexual function and sexuality. The limited number of studies from lower- and middle-income countries in South and Southeast Asia highlights important knowledge gaps requiring future research.

Multiple factors shape the quality of life of women affected by gynaecological cancers in Asian countries as elsewhere. We identified 53 articles reporting on 48 studies, most conducted in high- and upper-middle income East Asian countries, with much less attention to women in lower income countries in South and Southeast Asia. Most studies used quantitative research methods to gain an understanding of the impact on women diagnosed with cervical or ovarian cancer who had completed treatment. Women's quality of life was shaped by their mental and physical health, their support needs, and the changes they experienced in sexual function and sexuality.

Temporal trends and variation in out-of-pocket expenditures and patient cost sharing: evidence from a Chinese national survey 2011-2015.

OBJECTIVES: This study aims to examine: (1) temporal trends in the percentage of cost-sharing and amount of out-of-pocket expenditure (OOPE) from 2011 to 2015; (2) factors associated with cost-sharing and OOPE; and (3) the relationships between province-level economic development and cost-sharing and OOPE in China. SETTING: A total of 10,316 adults aged ≥45 years from China followed-up from 2011 to 2015 were included in the analysis. We measured two main outcome variables: (1) patient cost sharing, measured by the percentage of OOPE as total healthcare expenditure, and (2) absolute amount of OOPE. RESULTS: Based on self-reported data, we did not find substantial differences in the percentage of cost sharing, but a significant increase in the absolute amount of OOPE among the middle-aged and older Chinese between 2011 and 2015. The percentage of cost-sharing was considerably higher for outpatient than inpatient care, and the majority paid more than 80% of the total cost for prescription drugs. Provinces with higher GDP per capita tend to have lower cost-sharing and a higher OOPE than their counterparts, but the relationship for OOPE became insignificant after adjusting for individual factors. CONCLUSION: Reducing out-of-pocket expenditure and patient cost sharing is required to improve financial protection from illness, especially for those with those with chronic conditions and reside in less developed regions in China. Ongoing monitoring of financial protection using data from various sources is warranted.

Transforming UNICEF's approach to health system strengthening: what place can a blended learning course play?

BACKGROUND: The United Nations Children's Fund (UNICEF) published their Health Systems Strengthening (HSS) approach to meet its strategic goals of ending preventable maternal, newborn and child deaths and promoting the health and development of all children and reducing inequities in health in 2016. UNICEF commissioned the University of Melbourne's Nossal Institute for Global Health to develop and deliver a pilot blended HSS program, involving 60 hours of online learning and 2 weeks of face-to-face teaching over a 6-month period. To assess the extent to which the HSS program had built the first 83 UNICEF 2017 graduates' capabilities to apply HSS actions by 2017, UNICEF funded an independent evaluator from the University of Melbourne. METHODS: A mixed-methods assessment was conducted using: online surveys of graduates at: enrolment, completion, 6 months post-HSS program; nine focus groups with graduates at face-to-face workshops; and interviews with purposive samples of UNICEF graduates and graduate Senior Managers 12 months post-HSS program. RESULTS: The HSS program content, structure and mode of delivery was positively received. Graduates reported increased confidence taking HSS actions and multiple changes in work practices (e.g., increased systems thinking and using of health system-based approaches). Graduates' Senior Manager interviews revealed mixed impressions of graduates applying HSS actions, partly explained by the fit between the HSS program learnings and UNICEF's workplace environment. Key contextual factors influencing graduates applying HSS actions included: workload; limited opportunities to apply HSS actions; limited HSS examples; and variable support to apply HSS actions. Graduate and Senior Manager suggestions to optimise applying HSS actions included: linking HSS program content with UNICEF priorities; increasing opportunities for graduates to apply HSS actions; increasing access to HSS support. CONCLUSIONS: The paper concludes by presenting HSS program and assessment suggestions from the 2017 UNICEF Pilot HSS program assessment and actions taken for the 2018 UNICEF staff cohorts by HSS program developers, funders and beneficiaries.

The association between mental-physical multimorbidity and disability, work productivity, and social participation in China: a panel data analysis.

BACKGROUND: The co-occurrence of mental and physical chronic conditions (mental-physical multimorbidity) is a growing and largely unaddressed challenge for health systems and wider economies in low-and middle-income countries. This study investigated the independent and combined (additive or synergistic) effects of mental and physical chronic conditions on disability, work productivity, and social participation in China. METHODS: Panel data study design utilised two waves of the China Health and Retirement Longitudinal Study (2011, 2015), including 5616 participants aged ≥45 years, 12 physical chronic conditions and depression. We used a panel data approach of random-effects regression models to assess the relationships between mental-physical multimorbidity and outcomes. RESULTS: After adjusting for socio-economic and demographic factors, an increased number of physical chronic conditions was independently associated with a higher likelihood of disability (Adjusted odds ratio (AOR) = 1.39; 95% CI: 1.33, 1.45), early retirement (AOR = 1.37 [1.26, 1.49]) and increased sick leave days (1.25 days [1.16, 1.35]). Depression was independently associated with disability (AOR = 3.78 [3.30, 4.34]), increased sick leave days (2.18 days [1.72, 2.77]) and a lower likelihood of social participation (AOR = 0.57 [0.47, 0.70]), but not with early retirement (AOR = 1.24 [0.97, 1.58]). There were small and statistically insignificant interactions between physical chronic conditions and mental health on disability, work productivity and social participation, suggesting an additive effect of mental-physical multimorbidity on productivity loss. CONCLUSION: Mental-physical multimorbidity poses substantial negative health and economic effects on individuals, health systems, and societies. More research that addresses the challenges of mental-physical multimorbidity is needed to inform the development of interventions that can be applied to the workplace and the wider community in China.

Effect of multimorbidity on utilisation and out-of-pocket expenditure in Indonesia: quantile regression analysis.

BACKGROUND: Multimorbidity (the presence of two or more non-communicable diseases) is a major growing challenge for many low-income and middle-income countries (LMICs). Yet, its effects on health care costs and financial burden for patients have not been adequately studied. This study investigates the effect of multimorbidity across the different percentiles of healthcare utilisation and out-of-pocket expenditure (OOPE). METHODS: We conducted a secondary data analysis of the 2014/2015 Indonesian Family Life Survey (IFLS-5), which included 13,798 respondents aged ≥40 years. Poisson regression was used to assess the association between sociodemographic characteristics and the total number of non-communicable diseases (NCDs), while multivariate logistic regression and quantile regression analysis was used to estimate the associations between multimorbidity, health service use and OOPE. RESULTS: Overall, 20.8% of total participants had two or more NCDs in 2014/2015. The number of NCDs was associated with higher healthcare utilisation (coefficient 0.11, 95% CI 0.07-0.14 for outpatient care and coefficient 0.09 (95% CI 0.02-0.16 for inpatient care) and higher four-weekly OOPE (coefficient 27.0, 95% CI 11.4-42.7). The quantile regression results indicated that the marginal effect of having three or more NCDs on the absolute amount of four-weekly OOPE was smaller for the lower percentiles (at the 25th percentile, coefficient 1.0, 95% CI 0.5-1.5) but more pronounced for the higher percentile of out-of-pocket spending distribution (at the 90th percentile, coefficient 31.0, 95% CI 15.9-46.2). CONCLUSION: Multimorbidity is positively correlated with health service utilisation and OOPE and has a significant effect, especially among those in the upper tail of the utilisation/costs distribution. Health financing strategies are urgently required to meet the needs of patients with multimorbidity, particularly for vulnerable groups that have a higher level of health care utilisation.

The long-run effects of noncommunicable disease shocks.

The health shocks literature typically does not take into account the temporal patterns of loss since the time of the shock. This limits understanding of the long-run impact of health shocks and the capacity of individuals to cope over time. This study estimates the dynamic effects of a noncommunicable disease shock on the economic well-being of working-age individuals in China up to 6 years after onset. We find that after a period of temporal loss, individuals and their families can insure consumption against the average noncommunicable disease shock over the long-run. We observe significant heterogeneity according to the persistence of the disease, value of household wealth, and health insurance status. Individuals with consistent onset, with below median wealth, and without health insurance are least equipped to smooth consumption over the long-term.

Progress towards reducing sociodemographic disparities in breastfeeding outcomes in Indonesia: a trend analysis from 2002 to 2017.

BACKGROUND: Improving breastfeeding practice is important for reducing child health inequalities and achieving several Sustainable Development Goals. Indonesia has enacted legislation to promote optimal breastfeeding practices in recent years. We examined breastfeeding practices among Indonesian women from 2002 to 2017, comparing trends within and across sociodemographic subgroups. METHODS: Data from four waves of the Indonesia Demographic and Health Surveys were used to estimate changes in breastfeeding practices among women from selected sociodemographic groups over time. We examined three breastfeeding outcomes: (1) early initiation of breastfeeding; (2) exclusive breastfeeding; and (3) continued breastfeeding at 1 year. Multivariate logistic regression was used to assess changes in time trends of each outcome across population groups. RESULTS: The proportion of women reporting early initiation of breastfeeding and exclusive breastfeeding increased significantly between 2002 to 2017 (p < 0.05), with larger increases among women who: were from higher wealth quintiles; worked in professional sectors; and lived in Java and Bali. However, 42.7% of women reported not undertaking early initiation of breastfeeding, and 48.9% of women reported not undertaking exclusive breastfeeding in 2017. Women who were employees had lower exclusive breastfeeding prevalence, compared to unemployed or self-employed women. Women in Java and Bali had higher increase in early initiation of breastfeeding and exclusive breastfeeding compared to women in Sumatra. We did not find statistically significant decline in continued breastfeeding at 1 year over time for the overall population, except among women who: were from the second poorest wealth quintile; lived in rural areas; did not have a health facility birth; and lived in Kalimantan and Sulawesi (p < 0.05). CONCLUSIONS: There were considerable improvements in breastfeeding practices in Indonesia during a period of sustained policy reform to regulate breastfeeding and community support of breastfeeding, but these were not distributed uniformly across socioeconomic, occupation and geographic subgroups. Concerted efforts are needed to further reduce inequities in breastfeeding practice through both targeted and population-based strategies.

Strengthening routine immunization in Papua New Guinea: a cross-sectional provincial assessment of front-line services.

BACKGROUND: Routine immunization programs face many challenges in settings such as Papua New Guinea with dispersed rural populations, rugged geography and limited resources for transport and health. Low routine coverage contributes to disease outbreaks such as measles and the polio that re-appeared in 2018. We report on an in-depth local assessment that aimed to document immunization service provision so as to review a new national strategy, and consider how routine immunization could be better strengthened. METHODS: In East New Britain Province, over 2016 and 17, we carried out a cross-sectional assessment of 12 rural health facilities, staff and clients. The study was timed to follow implementation of a new national strategy for strengthening routine immunization. We used interview, structured observation, and records review, informed by theory-based evaluation, a World Health Organization quality checklist, and other health services research tools. RESULTS: We documented strengths and weaknesses across six categories of program performance relevant to national immunization strategy and global standards. We found an immunization service with an operational level of staff, equipment and procedures in place; but one that could reach only half to two thirds of its target population. Stronger routine services require improvement in: understanding of population catchments, tracking the unvaccinated, reach and efficiency of outreach visits, staff knowledge of vaccination at birth and beyond the first year of life, handling of multi-dose vials, and engagement of community members. Many local suggestions to enhance national plans, included more reliable on-demand services, integration of other family health services and increased involvement of men. CONCLUSIONS: The national strategy addresses most local gaps, but implementation and resourcing requires greater commitment. Long-term strengthening requires a major increase in centrally-allocated resources, however there are immediate locally feasible steps within current resources that could boost coverage and quality of routine immunization especially through better population-based local planning, and stronger community engagement. Our results also suggest areas where vaccination campaigns in PNG can contribute to routine immunization services.

Rural and urban differences in health system performance among older Chinese adults: cross-sectional analysis of a national sample.

BACKGROUND: Despite improvement in health outcomes over the past few decades, China still experiences striking rural-urban health inequalities. There is limited research on the rural-urban differences in health system performance in China. METHOD: We conducted a cross-sectional analysis to compare health system performance between rural and urban areas in five key domains of the health system: effectiveness, cost, access, patient-centredness and equity, using data from the WHO Study on Global AGEing and adult health (SAGE), China. Multiple logistic and linear regression models were used to assess the first four domains, adjusting for individual characteristics, and a relative index of inequality (RII) was used to measure the equity domain. FINDINGS: Compared to urban areas, rural areas had poorer performance in the management and control of hypertension and diabetes, with more than 50% lower odds of having breast (AOR = 0.44; 95% CI: 0.30, 0.64) and cervical cancer screening (AOR = 0.49; 95% CI: 0.29, 0.83). There was better performance in rural areas in the patient-centredness domain, with more than twice higher odds of getting prompt attention, respect, clarity of the communication with health provider and involvement in decision making of the treatment in inpatient care (AOR = 2.56, 2.15, 2.28, 2.28). Although rural residents incurred relatively less out-of-pocket expenditures (OOPE) for outpatient and inpatient services than urban residents, they were more likely to incur catastrophic expenditures on health (AOR = 1.30; 95% CI 1.16, 1.44). Wealth inequality was found in many indicators related to the effectiveness, costs and access domains in both rural and urban areas. Rural areas had greater inequalities in the management of hypertension and coverage of cervical cancer (RII = 7.45 vs 1.64). CONCLUSION: Our findings suggest that urban areas have achieved better prevention and management of non-communicable disease than rural areas, but access to healthcare was equivalent. A better understanding of the causes of the observed variations is needed to develop appropriate policy interventions which address these disparities.

The Joint Effect of Physical Multimorbidity and Mental Health Conditions Among Adults in Australia.

INTRODUCTION: The prevalence of chronic physical and mental health conditions is rising globally. Little evidence exists on the joint effect of physical and mental health conditions on health care use, work productivity, and health-related quality of life in Australia. METHODS: We analyzed data from the Household, Income and Labour Dynamics in Australia (HILDA) Survey, waves 9 (2009), 13 (2013), and 17 (2017). Economic effects associated with multimorbidity were measured through health service use, work productivity loss, and health-related quality of life. We used generalized estimating equations to assess the effect of the association between physical multimorbidity and mental health conditions and economic outcomes. RESULTS: From 2009 through 2017 the prevalence of physical multimorbidity increased from 15.1% to 16.2%, and the prevalence of mental health conditions increased from 11.2% to 17.3%. The number of physical health conditions was associated with the number of health services used (general practitioner visits, incidence rate ratio = 1.41), work productivity loss (labor force participation, adjusted odds ratio = 0.71), and reduced health-related quality of life (SF-6D score: Coefficient = -0.03). These effects were exacerbated by the presence of mental health conditions and low socioeconomic status. CONCLUSION: Having multiple physical health conditions (physical multimorbidity) creates substantial health and financial burdens on individuals, the health system, and society, including increased use of health services, loss of work productivity, and decreased health-related quality of life. The adverse effects of multimorbidity on health, quality of life, and economic well-being are exacerbated by the co-occurrence of mental health conditions and low socioeconomic status.

Oxygen systems to improve clinical care and outcomes for children and neonates: A stepped-wedge cluster-randomised trial in Nigeria.

BACKGROUND: Improving oxygen systems may improve clinical outcomes for hospitalised children with acute lower respiratory infection (ALRI). This paper reports the effects of an improved oxygen system on mortality and clinical practices in 12 general, paediatric, and maternity hospitals in southwest Nigeria. METHODS AND FINDINGS: We conducted an unblinded stepped-wedge cluster-randomised trial comparing three study periods: baseline (usual care), pulse oximetry introduction, and stepped introduction of a multifaceted oxygen system. We collected data from clinical records of all admitted neonates (<28 days old) and children (28 days to 14 years old). Primary analysis compared the full oxygen system period to the pulse oximetry period and evaluated odds of death for children, children with ALRI, neonates, and preterm neonates using mixed-effects logistic regression. Secondary analyses included the baseline period (enabling evaluation of pulse oximetry introduction) and evaluated mortality and practice outcomes on additional subgroups. Three hospitals received the oxygen system intervention at 4-month intervals. Primary analysis included 7,716 neonates and 17,143 children admitted during the 2-year stepped crossover period (November 2015 to October 2017). Compared to the pulse oximetry period, the full oxygen system had no association with death for children (adjusted odds ratio [aOR] 1.06; 95% confidence interval [CI] 0.77-1.46; p = 0.721) or children with ALRI (aOR 1.09; 95% CI 0.50-2.41; p = 0.824) and was associated with an increased risk of death for neonates overall (aOR 1.45; 95% CI 1.04-2.00; p = 0.026) but not preterm/low-birth-weight neonates (aOR 1.30; 95% CI 0.76-2.23; p = 0.366). Secondary analyses suggested that the introduction of pulse oximetry improved oxygen practices prior to implementation of the full oxygen system and was associated with lower odds of death for children with ALRI (aOR 0.33; 95% CI 0.12-0.92; p = 0.035) but not for children, preterm neonates, or neonates overall (aOR 0.97, 95% CI 0.60-1.58, p = 0.913; aOR 1.12, 95% CI 0.56-2.26, p = 0.762; aOR 0.90, 95% CI 0.57-1.43, p = 0.651). Limitations of our study are a lower-than-anticipated power to detect change in mortality outcomes (low event rates, low participant numbers, high intracluster correlation) and major contextual changes related to the 2016-2017 Nigerian economic recession that influenced care-seeking and hospital function during the study period, potentially confounding mortality outcomes. CONCLUSIONS: We observed no mortality benefit for children and a possible higher risk of neonatal death following the introduction of a multifaceted oxygen system compared to introducing pulse oximetry alone. Where some oxygen is available, pulse oximetry may improve oxygen usage and clinical outcomes for children with ALRI. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12617000341325.

Health workers' strikes in low-income countries: the available evidence.

OBJECTIVE: To analyse the characteristics, frequency, drivers, outcomes and stakeholders of health workers' strikes in low-income countries. METHODS: We reviewed the published and grey literature from online sources for the years 2009 to 2018. We used four search strategies: (i) exploration of main health and social sciences databases; (ii) use of specialized websites on human resources for health and development; (iii) customized Google search; and (iv) consultation with experts to validate findings. To analyse individual strike episodes, pre-existing conditions and influencing actors, we developed a conceptual framework from the literature. RESULTS: We identified 116 records reporting on 70 unique health workers' strikes in 23 low-income countries during the period, accounting for 875 days of strike. Year 2018 had the highest number of events (17), corresponding to 170 work days lost. Strikes involving more than one professional category was the frequent strike modality (32 events), followed by strikes by physicians only (22 events). The most commonly reported cause was complaints about remuneration (63 events), followed by protest against the sector's governance or policies (25 events) and safety of working conditions (10 events). Positive resolution was achieved more often when collective bargaining institutions and higher levels of government were involved in the negotiations. CONCLUSION: In low-income countries, some common features appear to exist in health sector strikes' occurrence and actors involved in such events. Future research should focus on both individual events and regional patterns, to form an evidence base for mechanisms to prevent and resolve strikes.

Never again? Challenges in transforming the health workforce landscape in post-Ebola West Africa.

BACKGROUND: The 2013-2014 West African Ebola outbreak highlighted how the world's weakest health systems threaten global health security and heralded huge support for their recovery. All three Ebola-affected countries had large shortfalls and maldistribution in their health workforce before the crisis, which were made worse by the epidemic. This paper analyzes the investment plans in Liberia, Sierra Leone, and Guinea to strengthen their health workforces and assesses their potential contribution to the re-establishment and strengthening of their health systems. The analysis calculates the plans' costs and compares those to likely fiscal space, to assess feasibility. METHODS: Public sector payroll data from 2015 from each country was used for the workforce analysis and does not include the private sector. Data were coded into the major cadres defined by the International Standard Classification of Occupations (ISCO-88). We estimated health worker training numbers and costs to meet international health worker density targets in the future and used sensitivity analysis to model hypothetical alternate estimates of attrition, drop-outs, and employment rates. RESULTS: Health worker-to-population density targets per 1000 population for doctors, nurses, and midwives are only specified in Liberia (1.12) and Guinea's (0.78) investment plans and fall far short of the regional average for Africa (1.33) or international benchmarks of 2.5 per 1000 population and 4.45 for universal health coverage. Even these modest targets translate into substantial scaling-up requirements with Liberia having to almost double, Guinea quadruple, and Sierra Leone having to increase its workforce by seven to tenfold to achieve Liberia and Guinea's targets. Costs per capita to meet the 2.5 per 1000 population density targets with 5% attrition, 10% drop-out, and 75% employment rate range from US$4.2 in Guinea to US$7.9 in Liberia in 2029, with projected fiscal space being adequate to accommodate the proposed scaling-up targets in both countries. CONCLUSIONS: Achieving even a modest scale-up of health workforce will require a steady growth in health budgets, a long-term horizon and substantial scale-up of current training institution capacity. Increasing value-for-money in health workforce investments will require more efficient geographical distribution of the health workforce and more consideration to the mix of cadres to be scaled-up.

What, why and how do health systems learn from one another? Insights from eight low- and middle-income country case studies.

BACKGROUND: All health systems struggle to meet health needs within constrained resources. This is especially true for low-income countries. It is critical that they can learn from wider contexts in order to improve their performance. This article examines policy transfer and evidence use linked to it in low- and middle-income settings. The objective was to inform international investments in improved learning across health systems. METHODS: The article uses a comparative case study design, drawing on case studies conducted in Bangladesh, Burkina Faso, Cambodia, Ethiopia, Georgia, Nepal, Rwanda and Solomon Islands. One or two recent health system reforms were selected in each case and 148 key informants were interviewed in total, using a semi-structured tool focused on different stages of the policy cycle. Interviewees were selected for their engagement in the policy process and represented political, technical, development partner, non-governmental, academic and civil society constituencies. Data analysis used a framework approach, allowing for new themes to be developed inductively, focusing initially on each case and then on patterns across cases. RESULTS: The selected policies demonstrated a range of influences of externally imposed, co-produced and home-grown solutions on the development of initial policy ideas. Eventual uptake of policy was strongly driven in most settings by local political economic considerations. Policy development post-adoption demonstrated some strong internal review, monitoring and sharing processes but there is a more contested view of the role of evaluation. In many cases, learning was facilitated by direct personal relationships with local development partner staff. While barriers and facilitators to evidence use included supply and demand factors, the most influential facilitators were incentives and capacity to use evidence. CONCLUSIONS: These findings emphasise the agency of local actors and the importance of developing national and sub-national institutions for gathering, filtering and sharing evidence. Developing demand for and capacity to use evidence appears more important than augmenting supply of evidence, although specific gaps in supply were identified. The findings also highlight the importance of the local political economy in setting parameters within which evidence is considered and the need for a conceptual framework for health system learning.

Managing the public-private mix to achieve universal health coverage.

The private sector has a large and growing role in health systems in low-income and middle-income countries. The goal of universal health coverage provides a renewed focus on taking a system perspective in designing policies to manage the private sector. This perspective requires choosing policies that will contribute to the performance of the system as a whole, rather than of any sector individually. Here we draw and extrapolate main messages from the papers in this Series and additional sources to inform policy and research agendas in the context of global and country level efforts to secure universal health coverage in low-income and middle-income countries. Recognising that private providers are highly heterogeneous in terms of their size, objectives, and quality, we explore the types of policy that might respond appropriately to the challenges and opportunities created by four stylised private provider types: the low-quality, underqualified sector that serves poor people in many countries; not-for-profit providers that operate on a range of scales; formally registered small-to-medium private practices; and the corporate commercial hospital sector, which is growing rapidly and about which little is known.

Providing oxygen to children in hospitals: a realist review.

OBJECTIVE: To identify and describe interventions to improve oxygen therapy in hospitals in low-resource settings, and to determine the factors that contribute to success and failure in different contexts. METHODS: Using realist review methods, we scanned the literature and contacted experts in the field to identify possible mechanistic theories of how interventions to improve oxygen therapy systems might work. Then we systematically searched online databases for evaluations of improved oxygen systems in hospitals in low- or middle-income countries. We extracted data on the effectiveness, processes and underlying theory of selected projects, and used these data to test the candidate theories and identify the features of successful projects. FINDINGS: We included 20 improved oxygen therapy projects (45 papers) from 15 countries. These used various approaches to improving oxygen therapy, and reported clinical, quality of care and technical outcomes. Four effectiveness studies demonstrated positive clinical outcomes for childhood pneumonia, with large variation between programmes and hospitals. We identified factors that help or hinder success, and proposed a practical framework depicting the key requirements for hospitals to effectively provide oxygen therapy to children. To improve clinical outcomes, oxygen improvement programmes must achieve good access to oxygen and good use of oxygen, which should be facilitated by a broad quality improvement capacity, by a strong managerial and policy support and multidisciplinary teamwork. CONCLUSION: Our findings can inform practitioners and policy-makers about how to improve oxygen therapy in low-resource settings, and may be relevant for other interventions involving the introduction of health technologies.