Documenting the development, adoption and pre-ebola implementation of Liberia's integrated disease surveillance and response (IDSR) strategy.

BACKGROUND: In the immediate aftermath of a 14-year civil conflict that disrupted the health system, Liberia adopted the internationally recommended integrated disease surveillance and response (IDSR) strategy in 2004. Despite this, Liberia was among the three West African countries ravaged by the worst Ebola epidemic in history from 2014 to 2016. This paper describes successes, failures, strengths, and weaknesses in the development, adoption, and implementation of IDSR following the civil war and up until the outbreak of Ebola, from 2004 to early 2014. METHODS: We reviewed 112 official Government documents and peer-reviewed articles and conducted 29 in-depth interviews with key informants from December 2021 to March 2022 to gain perspectives on IDSR in the post-conflict and pre-Ebola era in Liberia. We assessed the core and supportive functions of IDSR, such as notification of priority diseases, confirmation, reporting, analysis, investigation, response, feedback, monitoring, staff training, supervision, communication, and financial resources. Data were triangulated and presented via emerging themes and in-depth accounts to describe the context of IDSR introduction and implementation, and the barriers surrounding it. RESULTS: Despite the adoption of the IDSR framework, Liberia failed to secure the resources-human, logistical, and financial-to support effective implementation over the 10-year period. Documents and interview reports demonstrate numerous challenges prior to Ebola: the surveillance system lacked key components of IDSR including laboratory testing capacity, disease reporting, risk communication, community engagement, and staff supervision systems. Insufficient financial support and an abundance of vertical programs further impeded progress. In-depth accounts by donors and key governmental informants demonstrate that although the system had a role in detecting Ebola in Liberia, it could not respond effectively to control the disease. CONCLUSION: Our findings suggest that post-war, Liberia's health system intended to prioritize epidemic preparedness and response with the adoption of IDSR. However, insufficient investment and systems development meant IDSR was not well implemented, leaving the country vulnerable to the devastating impact of the Ebola epidemic.

Community-based delivery of intermittent preventive treatment of malaria in pregnancy in Burkina Faso: a qualitative study.

BACKGROUND: Burkina Faso is among ten countries with the highest rates of malaria cases and deaths in the world. Delivery and coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) is insufficient in Burkina Faso; In a 2016 survey, only 22% of eligible women had received their third dose of IPTp. It is also an extremely rural country and one with an established cadre of community healthcare workers (CHWs). To better meet the needs of pregnant women, an enhanced programme was established to facilitate distribution of IPTp at the community level by CHWs. METHODS: In order to assess the perceptions of CHWs and facility healthcare workers (HCWs) involved in this programme rollout, semi-structured interviews were conducted at three high malaria burden health districts in Burkina Faso. Interviews were conducted at baseline with 104 CHWs and 35 HCWs prior to the introduction of community based IPTp (c-IPTp) to assess capacity and any areas of concern. At endline, interviews were conducted with 29 CHWs and 21 HCWs to identify key facilitators and suggestions for further implementation of the c-IPTp programme. RESULTS: CHWs reported feeling capable of supporting c-IPTp delivery and facilitating linkage to antenatal care (ANC). They noted that the opportunity for enhanced training and close and ongoing connections with facility HCWs and supportive supervision were imperative. Both CHWs and HCWs perceived this approach as acceptable to community members and noted the importance of close community engagement, monthly meetings between CHWs and facility HCWs, and maintaining regular supplies of sulfadoxine-pyrimethamine (SP). Those interviewed noted that it was beneficial to have the involvement of both female and male CHWs. CONCLUSIONS: Community-based delivery of IPTp was feasible and acceptable to both facility HCWs and CHWs. This approach has the potential to strengthen delivery and uptake of IPTp and ANC both in Burkina Faso and across the region.

Access to primary healthcare Services in Conflict-Affected Fragile States: a subnational descriptive analysis of educational and wealth disparities in Cameroon, Democratic Republic of Congo, Mali, and Nigeria.

BACKGROUND: Measuring and improving equitable access to care is a necessity to achieve universal health coverage. Pre-pandemic estimates showed that most conflict-affected and fragile situations were off-track to meet the Sustainable Development Goals on health and equity by 2030. Yet, there is a paucity of studies examining health inequalities in these settings. This study addresses the literature gap by applying a conflict intensity lens to the analysis of disparities in access to essential Primary Health Care (PHC) services in four conflict-affected fragile states: Cameroon, Democratic Republic of Congo, Mali and Nigeria. METHODS: For each studied country, disparities in geographic and financial access to care were compared across education and wealth strata in areas with differing levels of conflict intensity. The Demographic Health Survey (DHS) and the Uppsala Conflict Data Program were the main sources of information on access to PHC and conflict events, respectively. To define conflict intensity, household clusters were linked to conflict events within a 50-km distance. A cut-off of more than two conflict-related deaths per 100,000 population was used to differentiate medium or high intensity conflict from no or low intensity conflict. We utilized three measures to assess inequalities: an absolute difference, a concentration index, and a multivariate logistic regression coefficient. Each disparity measure was compared based on the intensity of conflict the year the DHS data was collected. RESULTS: We found that PHC access varied across subnational regions in the four countries studied; with more prevalent financial than geographic barriers to care. The magnitude of both educational and wealth disparities in access to care was higher with geographic proximity to medium or high intensity conflict. A higher magnitude of wealth rather than educational disparities was also likely to be observed in the four studied contexts. Meanwhile, only Nigeria showed statistically significant interaction between conflict intensity and educational disparities in access to care. CONCLUSION: Both educational and wealth disparities in access to PHC services can be exacerbated by geographic proximity to organized violence. This paper provides additional evidence that, despite limitations, household surveys can contribute to healthcare assessment in conflict-affected and fragile settings.

Factors hindering health care delivery in nomadic communities: a cross-sectional study in Timbuktu, Mali.

BACKGROUND: In Mali, nomadic populations are spread over one third of the territory. Their lifestyle, characterized by constant mobility, excludes them from, or at best places them at the edge of, health delivery services. This study aimed to describe nomadic populations' characteristics, determine their perception on the current health services, and identify issues associated with community-based health interventions. METHODS: To develop a better health policy and strategic approaches adapted to nomadic populations, we conducted a cross-sectional study in the region of Timbuktu to describe the difficulties in accessing health services. The study consisted in administering questionnaires to community members in the communes of Ber and Gossi, in the Timbuktu region, to understand their perceptions of health services delivery in their settings. RESULTS: We interviewed 520 individuals, all members of the nomadic communities of the two study communes. Their median age was 38 years old with extremes ranging from 18 to 86 years old. Their main activities were livestock breeding (27%), housekeeping (26.4%), local trading (11%), farming (6%) and artisans (5.5%). The average distance to the local health center was 40.94 km and 23.19 km respectively in Gossi and Ber. In terms of barriers to access to health care, participants complained mainly about the transportation options (79.4%), the quality of provided services (39.2%) and the high cost of available health services (35.7%). Additionally, more than a quarter of our participants stated that they would not allow themselves to be examined by a health care worker of the opposite gender. CONCLUSION: This study shows that nomadic populations do not have access to community-based health interventions. A number of factors were revealed to be important barriers per these communities' perception including the quality of services, poverty, lifestyle, gender and current health policy strategies in the region. To be successful, future interventions should take these factors into account by adapting policies and methods.

A cluster randomized trial of delivery of intermittent preventive treatment of malaria in pregnancy at the community level in Burkina Faso.

BACKGROUND: Malaria in pregnancy is responsible for 8-14% of low birth weight and 20% of stillbirths in sub-Saharan Africa. To prevent these adverse consequences, the World Health Organization recommends intermittent preventive treatment of pregnant women (IPTp) with sulfadoxine-pyrimethamine be administered at each ANC visit starting as early as possible in the second trimester. Global IPTp coverage in targeted countries remains unacceptably low. Community delivery of IPTp was explored as a means to improve coverage. METHODS: A cluster randomized, controlled trial was conducted in 12 health facilities in a 1:1 ratio to either an intervention group (IPTp delivered by CHWs) or a control group (standard practice, with IPTp delivered at HFs) in three districts of Burkina Faso to assess the effect of IPTp administration by community health workers (CHWs) on the coverage of IPTp and antenatal care (ANC). The districts and facilities were purposively selected taking into account malaria epidemiology, IPTp coverage, and the presence of active CHWs. Pre- and post-intervention surveys were carried out in March 2017 and July-August 2018, respectively. A difference in differences (DiD) analysis was conducted to assess the change in coverage of IPTp and ANC over time, accounting for clustering at the health facility level. RESULTS: Altogether 374 and 360 women were included in the baseline and endline surveys, respectively. At baseline, women received a median of 2.1 doses; by endline, women received a median of 1.8 doses in the control group and 2.8 doses in the intervention group (p-value < 0.0001). There was a non-statistically significant increase in the proportion of women attending four ANC visits in the intervention compared to control group (DiD = 12.6%, p-value = 0.16). By the endline, administration of IPTp was higher in the intervention than control, with a DiD of 17.6% for IPTp3 (95% confidence interval (CI) - 16.3, 51.5; p-value 0.31) and 20.0% for IPTp4 (95% CI - 7.2, 47.3; p-value = 0.15). CONCLUSIONS: Community delivery of IPTp could potentially lead to a greater number of IPTp doses delivered, with no apparent decrease in ANC coverage.

Interactive Malaria Education Intervention and Its Effect on Community Participant Knowledge: The Malaria Awareness Program in Vhembe District, Limpopo, South Africa.

Malaria is preventable and treatable, yet remains the most prevalent parasitic endemic disease in Africa. This article analyzes prospective observational data from the Malaria Awareness Program (MAP), an interactive malaria education initiative led by home-based care workers to improve participant knowledge of malaria as a precursor to increased uptake of malaria control interventions in the Vhembe District, Limpopo, South Africa. Between 2012 and 2016, 1,330 individuals participated in MAP. MAP's effectiveness was measured through pre- and post-participation surveys assessing knowledge in malaria transmission, symptoms, prevention, and treatment. The primary analysis assessed differences in knowledge between individuals who completed MAP ( n = 499) and individuals who did not complete MAP ( n = 399). The adjusted odds of correct malaria knowledge score versus partially correct or incorrect score among MAP completers was 3.3 and 2.8 times greater for transmission and prevention, respectively ( p values<.001). A subanalysis assessed knowledge improvement among participants who completed both pre- and post-MAP intervention surveys ( n = 266). There was a 21.4% and 10.5% increase in the proportion of participants who cited correct malaria transmission and prevention methods, respectively. Future research should assess behavioral changes toward malaria prevention and treatment as a result of an intervention and examine incidence changes in the region.

Multicenter Pivotal Clinical Trial of Urine Malaria Test for Rapid Diagnosis of Plasmodium falciparum Malaria.

The need to expand malaria diagnosis capabilities alongside policy requirements for mandatory testing before treatment motivates exploration of noninvasive rapid diagnostic tests (RDTs). We report the outcome of the first cross-sectional, single-blind clinical performance evaluation of a urine malaria test (UMT) for diagnosis of Plasmodium falciparum malaria in febrile patients. Matched urine and finger-prick blood samples from participants ≥2 years of age with fever (axillary temperature of ≥37.5°C) or with a history of fever in the preceding 48 h were tested with UMT and microscopy (as the gold standard). BinaxNOW (Pf and Pan versions) blood RDTs were done to assess relative performance. Urinalysis and rheumatoid factor (RF) tests were conducted to evaluate possible interference. Diagnostic performance characteristics were computed at 95% confidence intervals (CIs). Of 1,800 participants screened, 1,691 were enrolled; of these 566 (34%) were febrile, and 1,125 (66%) were afebrile. Among enrolled participants, 341 (20%) tested positive by microscopy, 419 (25%) were positive by UMT, 676 (40%) were positive by BinaxNOW Pf, and 368 (22%) were positive by BinaxNow Pan. UMT sensitivity among febrile patients (for whom the test was indicated) was 85%, and specificity was 84%. Among febrile children ≤5 years of age, UMT sensitivity was 93%, and specificity was 83%. The area under the receiver-operator characteristic curve (AUC) of UMT (0.84) was not significantly different from that of BinaxNOW Pf (0.86) or of BinaxNOW Pan (0.87), indicating that the tests do not differ in overall performance. Gender, seasons, and RF did not impact UMT performance. Leukocytes, hematuria, and urobilinogen concentrations in urine were associated with lower UMT specificities. UMT performance was comparable to that of the BinaxNOW Pf/Pan tests, making UMT a promising tool to expand malaria testing in public and private health care settings where there are challenges to blood-based malaria diagnosis testing.

Determinants of Utilization and Community Experiences with Community Health Volunteers for Treatment of Childhood Illnesses in Rural Sierra Leone.

In 2010, at the same time as the national roll out of the Free Health Care Initiative (FHCI), which removed user fees for facility based health care, trained community health volunteers (CHVs) were deployed to provide integrated community case management of diarrhea, malaria and pneumonia to children under 5 years of age (U5) in Kambia and Pujehun districts, Sierra Leone. After 2 years of implementation and in the context of FHCI, CHV utilization rate was 14.0 %. In this study, we examine the factors associated with this level of CHV utilization. A cross-sectional household-cluster survey of 1590 caregivers of 2279 children U5 was conducted in 2012; with CHV utilization assessed using a multiple logistic regression model. Focus groups and in-depth interviews were also conducted to understand communities' experiences with CHVs. Children with diarrhea (OR = 3.17, 95 % CI: 1.17-8.60), from female-headed households (OR = 4.55, 95 % CI: 1.88-11.00), and whose caregivers reported poor quality of care as a barrier to facility care-seeking (OR = 8.53, 95 % CI: 3.13-23.16) were more likely to receive treatment from a CHV. Despite low utilization, caregivers were highly familiar and appreciative of CHVs, but were concerned about the lack of financial remuneration for CHVs. CHVs remained an important source of care for children from female-headed households and whose caregivers reported poor quality of care at health facilities. CHVs are an important strategy for certain populations even when facility utilization is high or when facility services are compromised, as has happened with the recent Ebola epidemic in Sierra Leone.

Providing Universal Health Insurance Coverage in Nigeria.

Despite a stated goal of achieving universal coverage, the National Health Insurance Scheme of Nigeria had achieved only 4% coverage 12 years after it was launched. This study assessed the plans of the National Health Insurance Scheme to achieve universal health insurance coverage in Nigeria by 2015 and discusses the challenges facing the scheme in achieving insurance coverage. In-depth interviews from various levels of the health-care system in the country, including providers, were conducted. The results of the analysis suggest that challenges to extending coverage include the difficulty in convincing autonomous state governments to buy into the scheme and an inadequate health workforce that might not be able to meet increased demand. Recommendations for increasing the scheme's coverage include increasing decentralization and strengthening human resources for health in the service delivery systems. Strong political will is needed as a catalyst to achieving these goals.

Informing a Behavior Change Communication Strategy: Formative Research Findings From the Scaling Up Nutrition Movement in Mozambique.

BACKGROUND: Nutrition interventions targeting the first 1000 days show promise to improve nutritional status, but they require effective implementation. Formative research is thus invaluable for developing such interventions, but there have been few detailed studies that describe this phase of work within the Scaling Up Nutrition (SUN) movement. OBJECTIVE: To inform a stunting prevention intervention in Cabo Delgado, Mozambique, by describing the sociocultural landscape and elucidating characteristics related to young child food, illness, and health. METHODS: This formative research utilized a rapid assessment procedures (RAP) approach with 3 iterative phases that explored local perceptions and behaviors around food and illness among the Macua, Mwani, and Maconde ethnic groups. Ethnographic methods, including in-depth interviews, direct observations, free lists, and pile sorts, were used to collect data from community leaders, caregivers, and children 6 to 23 months. Data were analyzed drawing from grounded theory and cultural domain analysis. RESULTS: Geographic differences drive sociocultural characteristics amid 3 ethnic groups that allow for segmentation of the population into 2 distinct audiences for behavior change communications. These 2 communities have similar classification systems for children's foods but different adult dietary patterns. Small-quantity lipid-based nutrient supplement did not fall into the existing food classification systems of either community, and participants preferred its promotion through community leader channels. Community members in both groups have little recognition of and perceived severity toward nutrition-related illnesses. CONCLUSION: Within Cabo Delgado, the cultural heterogeneity yields substantial differences related to food, illness, and health that are necessary to consider for developing an effective nutrition intervention.

Influence of community health volunteers on care seeking and treatment coverage for common childhood illnesses in the context of free health care in rural Sierra Leone.

OBJECTIVE: To examine whether community health volunteers induced significant changes in care seeking and treatment of ill children under five 2 years after their deployment in two underserved districts of Sierra Leone. METHODS: A pre-test-post-test study with intervention and comparison groups was used. A household cluster survey was conducted among caregivers of 5643 children at baseline and of 5259 children at endline. RESULTS: In the intervention districts, treatments provided by community health volunteers increased from 0 to 14.3% for all three conditions combined (P < 0.001). Care seeking from an appropriate provider was not statistically significant (OR = 1.50, 95% CI: 0.88-2.54) between intervention and comparison districts and coverage of appropriate treatment increased in both study groups for all three illnesses. However, the presence of community health volunteers was associated with a 105% increase in appropriate treatment for pneumonia (OR = 2.05, 95% CI: 1.22-3.42) and a 55% drop in traditional treatment for diarrhoea (OR = 0.45, 95% CI: 0.21-0.96). Community health volunteers were also associated with fewer facility treatments for malaria (OR = 0.21, 95% CI: 0.07-0.62). CONCLUSION: After implementing free care, coverage for treatment for all three illnesses in both study groups improved. Deployment of community health volunteers was associated with a reduced treatment burden at facilities and less reliance on traditional treatments.

Patterns and predictors of malaria care-seeking, diagnostic testing, and artemisinin-based combination therapy for children under five with fever in Northern Nigeria: a cross-sectional study.

BACKGROUND: Despite recent improvements in malaria prevention strategies, malaria case management remains a weakness in Northern Nigeria, which is underserved and suffers the country's highest rates of under-five child mortality. Understanding malaria care-seeking patterns and comparing case management outcomes to World Health Organization (WHO) and Nigeria's National Malaria Control Programme (NMCP) guidelines are necessary to identify where policy and programmatic strategies should focus to prevent malaria mortality and morbidity. METHODS: A cross-sectional survey based on lot quality assurance sampling was used to collect data on malaria care-seeking for children under five with fever in the last two weeks throughout Sokoto and Bauchi States. The survey assessed if the child received NMCP/WHO recommended case management: prompt treatment, a diagnostic blood test, and artemisinin-based combination therapy (ACT). Deviations from this pathway and location of treatment were also assessed. Lastly, logistic regression was used to assess predictors of seeking treatment. RESULTS: Overall, 76.7% of children were brought to treatment-45.5% to a patent medicine vendor and 43.8% to a health facility. Of children brought to treatment, 61.5% sought treatment promptly, but only 9.8% received a diagnostic blood test and 7.2% received a prompt ACT. When assessing adherence to the complete case management pathway, only 1.0% of children received NMCP/WHO recommended treatment. When compared to other treatment locations, health facilities provided the greatest proportion of children with NMCP/WHO recommended treatment. Lastly, children 7-59 months old were at 1.74 (p = 0.003) greater odds of receiving treatment than children ≤6 months. CONCLUSIONS: Northern Nigeria's coverage rates of NMCP/WHO standard malaria case management for children under five with fever fall short of the NMCP goal of 80% coverage by 2010 and universal coverage thereafter. Given the ability to treat a child with malaria differs greatly between treatment locations, policy and logistics planning should address the shortages of essential malaria supplies in recommended and frequently accessed treatment locations. Particular emphasis should be placed on integrating the private sector into standardized care and educating caregivers on the necessity for testing before treatment and the availability of free ACT in public health facilities for uncomplicated malaria.

Factors associated with underweight, overweight, stunting and wasting among primary school-going children participating in a school health initiative in South Africa.

BACKGROUND: The double burden of malnutrition among children remains a public health challenge in South Africa. In response, the government of South Africa developed the National Health Policy and Implementation Guidelines for school-going children in 2003. This policy was subsequently upgraded to 'The Integrated School Health Programme' in 2012. An element of the programme is the provision of a meal to school-going children on school days. However, evidence suggests that one-third of school-going children continue to have nutritional deficiencies. This study investigated the sociodemographic as well as the nutritional characteristics of school-going children participating in a school health initiative in KwaZulu-Natal Province, South Africa. METHODS: This was a retrospective descriptive cross-sectional study involving 1,275 children (50.3% females and 49.7% males) aged 3 to 15 years. Epidemiological data on the screening of the children's nutritional characteristics by school health nurses and school health nutritionists under the integrated school health programme (ISHP) was reviewed and analysed for the study. RESULTS: Nearly half (50.3%) and 49.7% of the population were females and males, respectively. The average age of participants was 8.4 years old. 'Underweight' (p = 0.000), 'overweight' (p = 0.000), 'at risk of overweight' (p = 0.000),'stunting' (p = 0.000),'severe stunting' (p = 0.005), 'wasting' (p = 0.010), and 'obesity' (p = 0.037) were associated with the 'schools that children attended'. School-going children' living conditions were significantly associated with 'normal weight' (p = 0.000), 'underweight' (p = 0.000), and 'underweight' (p = 0.028). However, the social grant to parents/guardians had some positive effects on the percentage of children who reported 'normal weight' (55.4%), 'wasting' (1.0%), 'underweight' (4.0%), and 'at risk of overweight' (20.2%). CONCLUSION: Chronic nutritional deficiencies persist among children. Therefore, ISHP implementation must retarget specific regions of the country to ensure that national goals and gains on school-going children nutrition, are met and maintained. Indeed, considering the positive impact of the government's social grant programme on the nutritional status of the children in this study, we recommend policy reforms that will increase parents' and carers' access to means of subsistence in order to meet the health and nutritional needs of children in the study communities.

Community Health Worker programmes' integration into national health systems: Scoping review.

BACKGROUND: Community health worker (CHW) programmes, when adequately integrated into mainstream health systems, can provide a viable, affordable and sustainable path to strengthened health systems that better meets demands for improved child health, especially in resource-constrained settings. However, studies that report on how CHW programmes are integrated into respective health systems in sub-Saharan Africa (SSA) are missing. AIM: This review presents evidence on CHW programmes' integration into National Health Systems for improved health outcomes in SSA. SETTING: Sub-Saharan Africa. METHOD: Six CHW programmes representing three sub-Saharan regions (West, East, and Southern Africa) were purposively selected based on their deemed integration into respective National Health Systems. A database search of literature limited to the identified programmes was then conducted. Screening and literature selection was guided a scoping review framework. Abstracted data were synthesised and presented in a narrative form. RESULTS: A total of 42 publications met the inclusion criteria. Reviewed papers had an even focus on all six CHW programmes integration components. Although some similarities were observed, evidence of integration on most CHW programme integration components varied across countries. The linkage of CHW programmes to respective health systems runs across all reviewed countries. Some CHW programme components such as CHW recruitment, education and certification, service delivery, supervision, information management, and equipment and supplies are integrated into the health systems differently across the region. CONCLUSION: Different approaches to the integration of all the components depict complexity in the field of CHW programme integration in the region.Contribution: The study presents synthesized evidence on CHW programmes integration into national health systems in SSA.

Characteristics of persons who complied with and failed to comply with annual ivermectin treatment.

OBJECTIVE: To assess individual compliance with annual ivermectin treatment in onchocerciasis-endemic villages. METHODS: Multi-site study in eight APOC-sponsored projects in Cameroon, Nigeria and Uganda to identify the socio-demographic correlates of compliance with ivermectin treatment. A structured questionnaire was administered on 2305 persons aged 10 years and above. Two categories of respondents were purposively selected to obtain both high and low compliers: people who took ivermectin 6-8 times and 0-2 times previously. Simple descriptive statistics were employed in characterizing the respondents into high and low compliers, while some socio-demographic and key perceptual factors were employed in regression models constructed to explain levels of compliance among the respondents. RESULTS: Some demographic and perceptual factors associated with compliance were identified. Compliance was more common among men (54.4%) (P < 0.001). Adults (54.6%) had greater rates of high compliance (P < 0.001. The mean age of high compliers (41.5 years) was significantly older (35.8 years) (t = 8.46, P < 0.001). Perception of onchocerciasis and effectiveness of ivermectin influenced compliance. 81.4% of respondents saw benefits in annual ivermectin treatment, high compliance among those who saw benefits was 59.3% compared to 13.3% of those who did not (P < 0.001). CONCLUSION: Efforts to increase compliance with ivermectin treatment should focus on providing health education to youth and women. Health education should also highlight the benefits of taking ivermectin.

Primary Healthcare Quality in Conflict and Fragility: a subnational analysis of disparities using Population Health surveys.

BACKGROUND: Recent global reports highlighted the importance of addressing the quality of care in all settings including fragile and conflict-affected situations (FCS), as a central strategy for the attainment of sustainable development goals and universal health coverage. Increased mortality burden in FCS reflects the inability to provide routine services of good quality. There is also paucity of research documenting the impact of conflict on the quality of care within fragile states including disparities in service delivery. This study addresses this measurement gap by examining disparities in the quality of primary healthcare services in four conflict-affected fragile states using proxy indicators. METHODS: A secondary analysis of publicly available data sources was performed in four conflict-affected fragile states: Cameroon, the Democratic Republic of Congo, Mali, and Nigeria. Two main databases were utilized: the Demographic Health Survey and the Uppsala Conflict Data Program for information on components of care and conflict events, respectively. Three equity measures were computed for each country: absolute difference, concentration index, and coefficients of mixed-effects logistic regression. Each computed measure was then compared according to the intensity of organized violence events at the neighborhood level. RESULTS: Overall, the four studied countries had poor quality of PHC services, with considerable subnational variation in the quality index. Poor quality of PHC services was not only limited to neighborhoods where medium or high intensity conflict was recorded but was also likely to be observed in neighborhoods with no or low intensity conflict. Both economic and educational disparities were observed in individual quality components in both categories of conflict intensity. CONCLUSION: Each of the four conflict-affected countries had an overall poor quality of PHC services with both economic and educational disparities in the individual components of the quality index, regardless of conflict intensity. Multi-sectoral efforts are needed to improve the quality of care and disparities in these settings, without a limited focus on sub-national areas where medium or high intensity conflict is recorded.

Health systems strengthening through policy-level integration of community health worker programs into national health systems for improved health outcomes - scorecard metrics validation: A bifactor structural equation model approach.

Background: Subsequent to the demonstrated potential of community health workers (CHWs) in strengthening health systems to improve health outcomes, recent literature has defined context and guidelines for integrating CHW programs into mainstream health systems. However, quantitative measures for assessing the extent of CHW program integration into national health systems need to be developed. The purpose of this study was to validate a newly developed scale, Community Health Worker Program Integration Scorecard Metrics (CHWP-ISM), for assessing the degree of integration of CHW programs into national health systems in Sub-Saharan Africa (SSA). Methods: Data obtained through a pilot study involving a purposively selected sample of 41 participants selected from populations involved in CHW programs work in selected countries of SSA formed the basis of a 31-item bifactor model. Data were collected between June and December 2019. By applying a latent variable approach implemented with structural equation modeling, data analysis was mainly done using the R statistical environment, applying factor analysis procedures. Results: Dimensionality, construct validity, and the CHWP-ISM scale's internal consistency were assessed. Confirmatory factor analysis of the CHW-ISM bifactor model supported a co-occurring CHW integration general factor and six unique domain-specific factors. Both the comparative fit index (CFI) and Tucker-Lewis Index (TLI) fit indices were above 0.9, while the root mean square of the residuals (RMSR) was 0.02. Cronbach's alpha (α), Guttman 6 (Lambda 6), and Omega total (ωt) were above 0.8, indicating good scale reliability. Conclusion: Statistical significance of the bifactor model suggests that CHW integration has to be examined using factors that reflect a single common underlying integration construct, as well as factors that reflect unique variances for the identified six subject-specific domains. The validated CHWP-ISM could be useful to inform policy advisers, health systems, donors, non-governmental organizations, and other CHW program stakeholders with guidance on how to quantitatively assess the integration status of different components of CHW programs into respective critical functions of the health system. Improved integration could increase CHW program functionality, which could in turn strengthen the healthcare systems to improve health outcomes in the region.

Preventing malaria in pregnancy through community-directed interventions: evidence from Akwa Ibom State, Nigeria.

BACKGROUND: Despite massive anti-malaria campaigns across the subcontinent, effective access to intermittent preventive treatment (IPTp) and insecticide-treated nets (ITNs) among pregnant women remain low in large parts of sub-Saharan Africa. The slow uptake of malaria prevention products appears to reflect lack of knowledge and resistance to behavioural change, as well as poor access to resources, and limited support of programmes by local communities and authorities. METHODS: A recent community-based programme in Akwa Ibom State, Nigeria, is analysed to determine the degree to which community-directed interventions can improve access to malaria prevention in pregnancy. Six local government areas in Southern Nigeria were selected for a malaria in pregnancy prevention intervention. Three of these local government areas were selected for a complementary community-directed intervention (CDI) programme. Under the CDI programme, volunteer community-directed distributors (CDDs) were appointed by each village and kindred in the treatment areas and trained to deliver ITNs and IPTp drugs as well as basic counseling services to pregnant women. FINDINGS: Relative to women in the control area, an additional 7.4 percent of women slept under a net during pregnancy in the treatment areas (95% CI [0.035, 0.115], p-value < 0.01), and an additional 8.5 percent of women slept under an ITN after delivery and prior to the interview (95% CI [0.045, 0.122], p-value < 0.001). The effects of the CDI programme were largest for IPTp adherence, increasing the fraction of pregnant women taking at least two SP doses during pregnancy by 35.3 percentage points [95% CI: 0.280, 0.425], p-value < 0.001) relative to the control group. No effects on antenatal care attendance were found. CONCLUSION: The presented results suggest that the inclusion of community-based programmes can substantially increase effective access to malaria prevention, and also increase access to formal health care access in general, and antenatal care attendance in particular in combination with supply side interventions. Given the relatively modest financial commitments they require, community-directed programmes appear to be a cost-effective way to improve malaria prevention; the participatory approach underlying CDI programmes also promises to strengthen ties between the formal health sector and local communities.

Scorecard metrics for assessing the extent of integration of community health worker programmes into national health systems.

BACKGROUND: The effectiveness of community health workers (CHWs) in delivering community-based preventive services is often curtailed by inadequate or complete lack of integration of the CHW programmes into national health systems. Although literature has defined the context and guidelines for integrating CHW programmes into health systems, indicators to quantitatively assess the extent of integration are inadequately addressed. AIM: This article presents an integration scale - CHW Programme Integration Scorecard Metrics (CHWP-ISM) - for measuring the extent of CHW programme integration into national health systems. SETTING: Literature review and policy documents were focused on sub-Saharan Africa, while interview participants were drawn from six African countries. METHODS: A deductive-inductive approach to item and measurement scale development was employed. Information obtained from a combination of diverse literature sources, subject matter expert (SME) interviews and documentary abstraction from publicly available policy documents advised item generation for the proposed CHWP-ISM. The study qualitatively captured the sectoral CHW integration, thematically analysed the data and culminated in the quantitative integration metrics. RESULTS: Analysis of the responses from six SMEs and abstraction from policy documents resulted in the compilation of metrics with a total of 100 indicators for the CHWP-ISM scale that could be used to assess the level of CHW programmes integration into national health systems. The indicators were categorised along the six World Health Organization's (WHO) health systems building blocks. Subject matter expert responses corresponded well with abstracted results from the 18 country CHW programmes, indicating content validity. CONCLUSION: The proposed scorecard metrics can be used to quantitatively rate the extent of CHW programmes integration into health systems, in an attempt to strengthen health systems to improve health outcomes.

Association of Plasmodium falciparum kelch13 R561H genotypes with delayed parasite clearance in Rwanda: an open-label, single-arm, multicentre, therapeutic efficacy study.

BACKGROUND: Partial artemisinin resistance is suspected if delayed parasite clearance (ie, persistence of parasitaemia on day 3 after treatment initiation) is observed. Validated markers of artemisinin partial resistance in southeast Asia, Plasmodium falciparum kelch13 (Pfkelch13) R561H and P574L, have been reported in Rwanda but no association with parasite clearance has been observed. We aimed to establish the efficacy of artemether-lumefantrine and genetic characterisation of Pfkelch13 alleles and their association with treatment outcomes. METHODS: This open-label, single-arm, multicentre, therapeutic efficacy study was done in 2018 in three Rwandan sites: Masaka, Rukara, and Bugarama. Children aged 6-59 months with P falciparum monoinfection and fever were eligible and treated with a 3-day course of artemether-lumefantrine. Treatment response was monitored for 28 days using weekly microscopy screenings of blood samples for P falciparum. Mutations in Pfkelch13 and P falciparum multidrug resistance-1 (Pfmdr1) genes were characterised in parasites collected from enrolled participants. Analysis of flanking microsatellites surrounding Pfkelch13 was done to define the origins of the R561H mutations. The primary endpoint was PCR-corrected parasitological cure on day 28, as per WHO protocol. FINDINGS: 228 participants were enrolled and 224 (98·2%) reached the study endpoint. PCR-corrected efficacies were 97·0% (95% CI 88-100) in Masaka, 93·8% (85-98) in Rukara, and 97·2% (91-100) in Bugarama. Pfkelch13 R561H mutations were present in 28 (13%) of 218 pre-treatment samples and P574L mutations were present in two (1%) pre-treatment samples. 217 (90%) of the 240 Pfmdr1 haplotypes observed in the pretreatment samples, had either the NFD (N86Y, Y184F, D1246Y) or NYD haplotype. Eight (16%) of 51 participants in Masaka and 12 (15%) of 82 participants in Rukara were microscopically positive 3 days after treatment initiation, which was associated with pre-treatment presence of Pfkelch13 R561H in Masaka (p=0·0005). Genetic analysis of Pfkelch13 R561H mutations suggest their common ancestry and local origin in Rwanda. INTERPRETATION: We confirm evidence of emerging artemisinin partial resistance in Rwanda. Although artemether-lumefantrine remains efficacious, vigilance for decreasing efficacy, further characterisation of artemisinin partial resistance, and evaluation of additional antimalarials in Rwanda should be considered. FUNDING: The US President's Malaria Initiative. TRANSLATION: For the French translation of the abstract see Supplementary Materials section.