Search

Global health initiatives are multistakeholder partnerships that mobilize and disburse resources to address global health challenges, often by supporting implementation of health programmes in low-and middle-income countries. (1) These initiatives [...]

Background The Coronavirus Disease 2019 (COVID-19) pandemic has had wide-reaching direct and indirect impacts on population health. In low- and middle-income countries, these impacts can halt progress toward reducing maternal and child mortality. This study estimates changes in health services utilization during the pandemic and the associated consequences for maternal, neonatal, and child mortality. Methods and findings Data on service utilization from January 2018 to June 2021 were extracted from health management information systems of 18 low- and lower-middle-income countries (Afghanistan, Bangladesh, Cameroon, Democratic Republic of the Congo (DRC), Ethiopia, Ghana, Guinea, Haiti, Kenya, Liberia, Madagascar, Malawi, Mali, Nigeria, Senegal, Sierra Leone, Somalia, and Uganda). An interrupted time-series design was used to estimate the percent change in the volumes of outpatient consultations and maternal and child health services delivered during the pandemic compared to projected volumes based on prepandemic trends. The Lives Saved Tool mathematical model was used to project the impact of the service utilization disruptions on child and maternal mortality. In addition, the estimated monthly disruptions were also correlated to the monthly number of COVID-19 deaths officially reported, time since the start of the pandemic, and relative severity of mobility restrictions. Across the 18 countries, we estimate an average decline in OPD volume of 13.1% and average declines of 2.6% to 4.6% for maternal and child services. We projected that decreases in essential health service utilization between March 2020 and June 2021 were associated with 113,962 excess deaths (110,686 children under 5, and 3,276 mothers), representing 3.6% and 1.5% increases in child and maternal mortality, respectively. This excess mortality is associated with the decline in utilization of the essential health services included in the analysis, but the utilization shortfalls vary substantially between countries, health services, and over time. The largest disruptions, associated with 27.5% of the excess deaths, occurred during the second quarter of 2020, regardless of whether countries reported the highest rate of COVID-19-related mortality during the same months. There is a significant relationship between the magnitude of service disruptions and the stringency of mobility restrictions. The study is limited by the extent to which administrative data, which varies in quality across countries, can accurately capture the changes in service coverage in the population. Conclusions Declines in healthcare utilization during the COVID-19 pandemic amplified the pandemic's harmful impacts on health outcomes and threaten to reverse gains in reducing maternal and child mortality. As efforts and resource allocation toward prevention and treatment of COVID-19 continue, essential health services must be maintained, particularly in low- and middle-income countries., Author(s): Tashrik Ahmed 1,*, Timothy Roberton 2, Petra Vergeer 1, Peter M. Hansen 1, Michael A. Peters 3, Anthony Adofo Ofosu 4, Charles Mwansambo 5, Charles Nzelu 6, Chea Sanford [...]

Objective To estimate the economic impact likely to be achieved by efforts to vaccinate against 10 vaccine-preventable diseases between 2001 and 2020 in 73 low- and middle-income countries largely supported by Gavi, the Vaccine Alliance. Methods We used health impact models to estimate the economic impact of achieving forecasted coverages for vaccination against Haemophilus influenzae type b, hepatitis B, human papillomavirus, Japanese encephalitis, measles, Neisseria meningitidis serogroup A, rotavirus, rubella, Streptococcus pneumoniae and yellow fever. In comparison with no vaccination, we modelled the costs --expressed in 2010 United States dollars (US$)--of averted treatment, transportation costs, productivity losses of caregivers and productivity losses due to disability and death. We used the value-of-a-life-year method to estimate the broader economic and social value of living longer, in better health, as a result of immunization. Findings We estimated that, in the 73 countries, vaccinations given between 2001 and 2020 will avert over 20 million deaths and save US$ 350 billion in cost of illness. The deaths and disability prevented by vaccinations given during the two decades will result in estimated lifelong productivity gains totalling US$330 billion and US$9 billion, respectively. Over the lifetimes of the vaccinated cohorts, the same vaccinations will save an estimated US$ 5 billion in treatment costs. The broader economic and social value of these vaccinations is estimated at US$820 billion. Conclusion By preventing significant costs and potentially increasing economic productivity among some of the world's poorest countries, the impact of immunization goes well beyond health. Objectif Estimer l'impact economique qui pourrait decouler des efforts de vaccination contre 10 maladies a prevention vaccinale deployes entre 2001 et 2020 dans 73 pays a revenu faible et intermediaire, et largement soutenus par Gavi, I'Alliance du Vaccin. Methodes Nous avons utilise des modeles devaluation de l'impact sur la sante pour estimer l'impact economique qui decoulerait, si le taux de couverture prevu est atteint, des vaccinations contre Haemophilus influenzae type B, l'hepatite B, le papillomavirus humaln, l'encephalite japonaise, la rougeole, Neisseria meningitidis serogroupe A, le rotavirus, la rubeole, Streptococcus pneumoniae et la fievre jaune. Pour etablir une comparaison avec l'absence de vaccination, nous avons modelise les couts--exprimes en dollars des Etats-Unis 2010 (USD)--des traitements evites, les couts de transport, les pertes de productivite des soignants non professionnels et les pertes de productivite pour cause d'invalidite ou de deces. Nous avons utilise une methode permettant d'evaluer la valeur d'une annee de vie pour estimer la valeur economique et sociale au sens large d'une vie plus longue et en meilleure sante grace a la vaccination. Resultats D'apres nos estimations, les vaccinations pratiquees entre 2001 et 2020 dans les 73 pays permettront d'eviter plus de 20 millions de deces et d'economiser 350 milliards de dollars des Etats-Unis en couts sanitaires. Les cas de deces et d'invalidite evites grace a la vaccination pratiquee au cours de ees deux decennies entraineront des gains de productivite permanents respectivement estimes a 330 milliards de dollars des Etats-Unis et 9 milliards de dollars des Etats-Unis. On estime qu'au cours de la vie des cohortes vaccinees, les memes vaccinations permettront d'economiser 5 milliards de dollars des Etats-Unis en couts de traitement. La valeur economique et sociale au sens large de ees vaccinations est estimee a 820 milliards de dollars des Etats-Unis. Conclusion L'impact de la vaccination depasse le domaine de la sante, car il permet d'eviter d'importants couts et une augmentation potentielle de la productivite economique de certains des pays les plus pauvres du monde. Objetivo Estimarei impacto economico que probablemente se logaria con los esfuerzos de vacunar frente a 10 enfermedades evitables mediante la vacunacion entre 2001 y 2020 en 73 paises con ingresos bajos y medios ampliamente respaldados por la Gavi, la Vaccine Alliance. Metodos Se utilizaron modelos de impacto sanitario para estimar el impacto economico de lograr las coberturas previstas de vacunacion frente a Haemophilus influenzae tipo b, hepatitis B, virus del papiloma humano, encefalitis japonesa, sarampion, Neisseria meningitidis serogrupo A, rotavirus, rubeola, Streptococcus pneumoniae y fiebre amarilla. En comparacion con la no vacunacion, se modelaron los costes (expresados en dolares estadounidenses, USD, de 2010) de los tratamientos evitados, los costes de transporte, las perdidas de productividad de los proveedores de salud y las perdidas de productividad debido a la discapacidad y la muerte. Se utilizo el metodo de valor de vida anual para estimar de forma mas amplia el valor economico y social del hecho de vivir mas, con una mejor salud, como resultado de la inmunizacion. Resultados Se estimo que, en los 73 paises, las vacunas suministradas entre 2001 y 2020 evitaran mas de 20 millones de muertes y ahorraran 350 000 millones de USD en costes de enfermedades. Las muertes y las discapacidades evitadas gracias a las vacunas suministradas durante las dos decadas tendran como resultado unas ganancias permanentes estimadas en la productividad de un total de 330 000 millones de USD y 9 000 millones de USD, respectivamente. Durante la vida de las cohortes vacunadas, se estima que las mismas vacunaciones ahorraran 5 000 millones de USD en costes de tratamientos. El valor economico y social mas amplio de estas vacunas se estima en 820 000 millones de USD. Conclusion El impacto de las vacunas es positivo mas alla de la salud, ya que se evitan costes significativos y se aumenta potencialmente la productividad economica entre algunos de los paises mas pobres., Introduction While vaccination is generally regarded to be one of the most cost-effective interventions in public health, the introduction and sustained use of any new vaccine needs to be supported [...]

Equity monitoring is a priority for Gavi, the Vaccine Alliance, and for those implementing The2030agenda for sustainable development. For its new phase of operations, Gavi reassessed its approach to monitoring equity in vaccination coverage. To help inform this effort, we made a systematic analysis of inequalities in vaccination coverage across 45 Gavi-supported countries and compared results from different measurement approaches. Based on our findings, we formulated recommendations for Gavi's equity monitoring approach. The approach involved defining the vulnerable populations, choosing appropriate measures to quantify inequalities, and defining equity benchmarks that reflect the ambitions of the sustainable development agenda. In this article, we explain the rationale for the recommendations and for the development of an Improved equity monitoring tool. Gavi's previous approach to measuring equity was the difference in vaccination coverage between a country's richest and poorest wealth quintiles. In addition to the wealth index, we recommend monitoring other dimensions of vulnerability (maternal education, place of residence, child sex and the multidimensional poverty index). For dimensions with multiple subgroups, measures of inequality that consider information on all subgroups should be used. We also recommend that both absolute and relative measures of inequality be tracked over time. Finally, we propose that equity benchmarks target complete elimination of inequalities. To facilitate equity monitoring, we recommend the use of a data display tool--the equity dashboard--to support decision-making in the sustainable development period. We highlight its key advantages using data from Cote d'Ivoire and Haiti. Le suivi de l'equite est une priorite pour Gavi, l'Alliance du Vaccin et pour ceux qui mettent en oeuvre le Programme de developpement durable a l'horizon 2030. Dans le cadre de sa nouvelle phase d'operations, Gavi a repense son approche relative au suivi de l'equite en matiere de couverture vaccinale. Afin de contribuer a cet effort, nous avons realise une analyse systematique des inegalites en matiere de couverture vaccinale dans 45 pays soutenus par Gavi et compare les resultats obtenus a partir de differentes methodes de mesure. Nous nous sommes appuyes sur nos conclusions pour formuler des recommandations concernant l'approche adoptee par Gavi pour suivre l'equite. Cette approche impliquait de definir les populations vulnerables, de choisir des mesures appropriees pour quantifier les inegalites et d'etablir des criteres en matiere d'equite qui refletent les ambitions du programme de developpement durable. Dans le present article, nous expliquons la raison d'etre de nos recommandations et le but de l'elaboration d'un meilleur outil de suivi de l'equite. L'approche precedemment utilisee par Gavi pour mesurer l'equite consistait a calculer la difference en matiere de couverture vaccinale entre les quintiles de richesse les plus eleves et les plus bas d'un pays. Nous recommandons de suivre des dimensions de la vulnerabilite (education maternelle, lieu de residence, sexe des enfants et indice de pauvrete multidimensionnelle) autres que l'indice de richesse. Lorsqu'une dimension inclut divers sous-groupes, il convient d'utiliser des mesures de l'inegalite prenant en compte les informations relatives a tous les sous-groupes. Nous conseillons egalement de suivre les mesures absolues mais aussi relatives d'inegalite au fil du temps. Enfin, nous suggerons que les criteres en matiere d'equite visent l'elimination complete des inegalites. Afin de faciliter le suivi de l'equite, nous recommandons l'utilisation d'un outil d'affichage de donnees--le tableau de bord de l'equite--pour favoriser la prise de decision dans le cadre du programme de developpement durable. Nous mettons en avant les principaux avantages de cet outil a l'aide de donnees provenant de Cote d'ivoire et d'Haiti. La supervision de la equidad es una prioridad para la Gavi, la Vaccine Alliance y para los que implementan la Agenda 2030 para el Desarrollo Sostenible. Para su nueva fase de operaciones, la Gavi reevaluo su enfoque para supervisar la equidad en la cobertura de vacunacion. Para ayudar a informar este esfuerzo, se realizo un analisis sistematico de desigualdades en la cobertura de vacunacion en 45 paises apoyados por la Gavi y se compararon los resultados desde distintos enfoques de medicion. En base a los resultados, se formularon recomendaciones para el enfoque de supervision de equidad de la Gavi. El enfoque implico la definicion de las poblaciones vulnerables, la seleccion de las medidas adecuadas para cuantificar las desigualdades y la definicion de las referencias de equidad que reflejan las ambiciones de la agencia de desarrollo sostenible. En este articulo, se explican los motivos de las recomendaciones y el desarrollo de una herramienta mejorada de supervision de la equidad. El anterior enfoque de la Gavi para la medicion de la equidad era la diferencia de la cobertura de vacunacion entre los sectores demograficos mas ricos y mas pobres de un pais. Ademas del indice patrimonial, se recomienda supervisar otras dimensiones de vulnerabilidad (educacion de la madre, lugar de residencia, sexo de los ninos y el indice de pobreza multidimensional). Para las dimensiones con multiples subgrupos, deberian utilizarse medidas de desigualdad que tienen en cuenta informacion acerca de todos los subgrupos.Tambien se recomienda que, con el paso del tiempo, se haga un seguimiento tanto de la medida de desigualdad absoluta como relativa. Por ultimo, se propone que las referencias de equidad tengan como objetivo la eliminacion completa de la desigualdad. Para facilitar la supervision de la equidad, se recomienda utilizar una herramienta de indicacion de datos (el tablero de equidad) para apoyar la toma de decisiones durante el periodo de desarrollo sostenible. Se destacan sus ventajas basicas utilizando datos de Cote d'ivoire y de Haiti., Introduction The 2030 agenda for sustainable development calls upon the international community to prioritize the needs and rights of the most vulnerable, so that no one is left behind. (1) [...]

Objective To examine historical estimates of infant and under-five mortality in Afghanistan, provide estimates for rural areas from current population-based data, and discuss the methodological challenges that undermine data quality and hinder retrospective estimations of mortality. Methods Indirect methods of estimation were used to calculate infant and under-five mortality from a household survey conducted in 2006. Sex-specific differences in underreporting of births anal deaths were examined and sensitivity analyses were conducted to assess the effect of underreporting on infant and under-five mortality. Findings For 2004, rural unadjusted infant and under-five mortality rates were estimated to be 129 and 191 deaths per 1000 live births, respectively, with some evidence indicating underreporting of female deaths. If adjustment for underreporting is made (i.e. by assuming 50% of the unreported girls are dead), mortality estimates go up to 140 and 209, respectively. Conclusion Commonly used estimates of infant and under-five mortality in Afghanistan are outdated; they do not reflect changes that have occurred in the past 15 years or recent intensive investments in health services development, such as the implementation of the Basic Package of Health Services. The sociocultural aspects of mortality anal their effect on the reporting of births anal deaths in Afghanistan need to be investigated further. Objectif Examiner l'historique des estimations sur la mortalite des nourrissons et des enfants de moins de 5 ans en Afghanistan, fournir des estimations pour les zones rurales a partir des donnees actuelles sur la population et debattre des problemes methodologiques qui portent prejudice a la qualite des donnees et entravent les estimations retrospectives de la mortalite. Methodes Des methodes indirectes d'estimation ont ete utilisees pour calculer la mortalite chez tes nourrissons et les enfants de moins de cinq ans a partir d'une enquete aupres de menages conduite en 2006. Les differences sexospecifiques relatives a la sous-declaration des naissances et des deces ont ete examinees et des analyses de sensibilite ont ete realisees pour evaluer l'effet de la sous-declaration de la mortalite chez les nourrissons et les enfants de moins de cinq ans. Resultats Pour 2004, les taux non corriges de mortalite rurale pour les nourrissons et les enfants de moins de cinq ans ont ete estimes respectivement entre 129 et 191 morts pour 1 000 naissances envie, avec quelques elements indiquant une sous-declaration des deces des enfants de sexe feminin. Si l'on procede a un ajustement de la sous-declaration (en assumant par ex. que 50 % des filies sous-declarees sont decedees), les estimations de mortalite s'elevent respectivement a 140 et 209. Conclusion Les estimations couramment utilisees pour la mortalite chez les nourrissons et les enfants de moins de cinq ans en Afghanistan sont depassees; elles ne refletent pas les changements qui se sont produits Iors des 15 dernieres annees ni les importants investissements recents pour le developpement des services de sante, comme la mise en place de l'ensemble des services sanitaires de base. Les aspects socioculturels de la mortalite et leurs effets sur la declaration des naissances et des deces en Afghanistan necessitent des investigations supplementaires. Objetivo Estudiar las estimaciones historicas de la mortalidad en lactantes y ninos menores de cinco anos en Afganistan, proporcionar estimaciones para las zonas rurales a partir de los datos basados en la pobiacion actual y analizar las dificultades metodologicas que menoscaban la calidad de los datos y dificultan las estimaciones retrospectivas de la mortalidad. Metodos Para calcular la mortalidad en lactantes y en ninos menores de cinco anos se emplearon metodos indirectos de estimacion a partir de una encuesta a domicilio realizada en 2006. Se estudiaron las diferencias especificas segun el sexo en los subregistros de nacimientos y fallecimientos, y se llevaron a cabo analisis de la sensibilidad para valorar el erecto de la informacion incompleta de dicha mortalidad. Resultados Se estimaron los indices no ajustados de mortalidad en lactantes y en ninos menores de cinco anos en las zonas rurales para 2004, registrandose 129 y 191 muertes por cada 1000 recien nacidos vivos respectivamente, y se obtuvieron datos que indicaban un subregistro de los fallecimientos de mujeres. Si se realiza el ajuste de los datos incompletos (es decir, asumiendo que el 50% de las ninas de subregistros habian fallecido), las estimaciones de la mortalidad ascienden hasta 140 y 209, respectivamente. Conclusion Las estimaciones de la mortalidad en lactantes y ninos menores de cinco anos que se suelen emplear en Nganistan estan anticuadas, no reflejan los cambies que se han producido en los ultimos 15 anos ni las fuertes inversiones llevadas a cabo recientemente en la mejora de los servicios sanitarios, como la aplicacion del Paquete basico de servicios sanitarios. Se deben investigar mas a rondo los aspectos socioculturales de la mortalidad y su erecto sobre la notificacion de los nacimientos y los fallecimientos producidos en Afganistan., Introduction According to the State of the world's children, Afghanistan's under-five mortality rate of 257 deaths per 1000 live births is the third highest in the world, surpassed only by [...]

Objective To study trends in the quality of the healthcare provided to children aged less than 5 years in Afghanistan between 2004 and 2006. In particular, to determine the effect on such quality of a basic package of health services (BPHS), including Integrated Management of Childhood Illness (IMCI), introduced in 2003. Methods In each year of the study, 500-600 health facilities providing the BPHS were selected by stratified random sampling in 29 provinces of Afghanistan. We observed consultations for children aged less than 5 years, interviewed their caretakers, interviewed health-care providers and measured adherence to case management standards for assessment and counselling in a random sample. Findings The quality of the assessment and counselling provided to sick children aged less than 5 years improved significantly between 2004 and 2006. A 43.4% increase in the assessment index and a 28.7% increase in the counselling index (P< 0.001) were noted. Assessment quality improved significantly every year and was statistically associated with certain characteristics of the provider (being a doctor, having a higher knowledge score, being trained in IMCI, being part of a "contracting-in" mechanism and providing a longer consultation time) and the child (being younger and having a female caretaker). Counselling quality was also significantly associated with these characteristics, except for provider cadre and child age. The presence of clinical guidelines and the frequency of supervision were significantly associated with improved quality scores in 2006 (P < 0.05 and< 0.01, respectively). Conclusion Quality of care improved over the study period, but performance remained suboptimal in some areas. Continued investments in Afghanistan&apos;s health system capacity are needed. Objectif Etudier les tendances de la qualite des soins de sante delivres aux enfants de moins de 5 ans en Afghanistan entre 2004 et 2006. Determiner en particulier les offets sur cette qualite d&apos;un ensemble de services de sante essentiels (BPHS), incluant ia Prise en charge integree des maladies de l&apos;enfant (PCIME), introduite en 2003. Methodes Pour chaque annee d&apos;etude, 500 a 600 etablissements de soins delivrant le BPHS ont ete seiectionnes par sondage aleatoire stratifie dans 29 provinces d&apos;Afghanistan. Nous avons observe ies consultations dont ont benoficie les enfants de moins de 5 ans, interroge les personnes s&apos;occupant de ces enfants et les prestateurs de soins et mesure sur un echantillon aleatoire l&apos;observance des normes de prise en charge des cas pour ce qui concerne l&apos;evaluation et les conseils. Resultats La qualite de l&apos;evaluation et des conseils delivres aux enfants maiades de moins de 5 ans s&apos;est amelioree significativement entre 2004 et 2006. On a ainsi note une augmentation de 43,4 % de l&apos;indice d&apos;evaluation de l&apos;evaluation medicale et de 28,7 % de l&apos;indice d&apos;evaluation des conseils (p < 0,001). La qualite de l&apos;evaluation a progresse significativement chaque annee et etait statistiquement associee a certaines caracteristiques du prestateur (etre medecin, obtenir un score de connaissances plus eleve, etre formee a la PCIME, travailler sous contrat pour le gouvernement et assurer une consultation plus longue) et de l&apos;enfant (jeune age et prise en charge par une femme dans la vie courante). La qualite des conseils presentait egalement une association statistique avec ces caracteristiques, excepte le niveau de qualification du prestateur et l&apos;age de l&apos;enfant. L&apos;existence de directives cliniques et la frequence de la supervision etaient significativement associees a une amelioration des scores de qualite en 2006 (p < 0,05 et p < 0,01, respectivement). Conclusion La qualite des soins s&apos;est amelioree sur la periode etudiee, mais les performances sont restees sous-optimales dans certaines zones. Il faut continuer a investir dans le renforcement des capacites du systeme de sante afghan. Objetivo Estudiar las tendencias de la calidad de la atencion sanitaria proporcionada a los menores de cinco anos en Afganistan entre 2004 y 2006. En particular, determinar el ofecto de la calidad de un paquete basico de servicios de salud (PBSS) que incluia la atencion Integrada a las Enfermedades Prevalentes de la Infancia (AIEPI), introducida en 2003. Metodos Mediante muestreo aleatorio estratificado, cada ano dei estudio se seleccionaron 500-600 centros de salud que empleaban el PBSS en 29 provincias de Afganistan. Observamos las consultas de atencion a menores de cinco anos, entrevistamos a sus cuidadores y a los profesionales que los atendieron, y medimos su cumplimiento de las normas de manejo de casos para evaluacion y asesoramiento en una muestra aleatoria. Resultados La calidad de la evaluacion y de los consejos proporcionados para los ninos enfermos de menos de 5 anos de edad mejoro significativamente entre 2004 y 2006. Se observo un aumento del 43,4% del indice de evaluacion y un aumento dei 28,7% del indice de asesoramiento (p < 0,001). La calidad de la evaluacion mejoro considerablemente cada ano y demostro estar relacionada de forma significativa con determinadas caracteristicas del proveedor (condicion de medico, mayor puntuacion de sus conocimientos, capacitacion en la AIEPI, participacion en un mecanismo de contratacion de la Administracion, y mayor duracion de la consulta) y dei nino (una menor edad, y el hecho de tener a una mujer como cuidadora). Se observo que la calidad del asesoramiento tambien estaba asociada significativamente a esos factores, exceptuando la profesion del trabajador sanitario y la edad dei nino. La existencia de directrices clinicas y la frecuencia de la supervision se asociaron significativamente a mejores puntuaciones de la calidad en 2006 (p < 0,05 y p < 0,01, respectivamente). Conclusion La calidad de la atencion mejoro a lo largo del periodo de estudio, pero el desempeno seguia siendo suboptimo en algunas zonas. Es preciso seguir invirtiendo de forma continuada en la capacidad del sistema de salud de Afganistan., Une traduction en francais de ce resume figure a la fin de l'article. Al final del articulo se facilita una traduccion al espanol. Introduction Afghanistan has some of the poorest [...]

Objectives. We sought to identify characteristics associated with use of skilled birth attendants where health services exist in Afghanistan. Methods. We conducted a cross-sectional study in all 33 provinces in 2004, yielding data from 617 health facilities and 9917 women who lived near the facilities and had given birth in the past 2 years. Results. Only 13% of respondents had used skilled birth attendants. Women from the wealthiest quintile (vs the poorest quintile) had higher odds of use (odds ratio [OR] = 6.3; 95% confidence interval [CI] = 4.4, 8.9). Literacy was strongly associated with use (OR = 2.5; 95% CI = 2.0, 3.2), as was living less than 60 minutes from the facility (OR = 1.5; 95% CI = 1.1, 2.0) and residing near a facility with a female midwife or doctor (OR = 1.4; 95% CI = 1.1, 1.8). Women living near facilities that charged user fees (OR = 0.8; 95% CI = 0.6, 1.0) and that had male community health workers (OR = 0.6; 95% CI = 0.5, 0.9) had lower odds of use. Conclusions. In Afghanistan, the rate of use of safe delivery care must be improved. The financial barriers of poor and uneducated women should be reduced and culturally acceptable alternatives must be considered.

Abstract The Ministry of Public Health (MOPH) in Afghanistan has developed a balanced scorecard (BSC) to regularly monitor the progress of its strategy to deliver a basic package of health services. Although frequently used in other health-care settings, this represents the first time that the BSC has been employed in a developing country. The BSC was designed via a collaborative process focusing on translating the vision and mission of the MOPH into 29 core indicators and benchmarks representing six different domains of health services, together with two composite measures of performance. In the absence of a routine health information system, the 2004 BSC for Afghanistan was derived from a stratified random sample of 617 health facilities, 5719 observations of patient-provider interactions, and interviews with 5597 patients, 1553 health workers, and t3 843 households. Nationally, health services were found to be reaching more of the poor than the less-poor population, and providing for more women than men, both key concerns of the government. However, serious deficiencies were found in five domains, and particularly in counselling patients, providing delivery care during childbirth, monitoring tuberculosis treatment, placing staff and equipment, and establishing functional village health councils. The BSC also identified wide variations in performance across provinces; no province performed better than the others across all domains. The innovative adaptation of the BSC in Afghanistan has provided a useful tool to summarize the multidimensional nature of health-services performance, and is enabling managers to benchmark performance and identify strengths and weaknesses in the Afghan context. Bulletin of the World Health Organization 2007;85:146-151. Resume Le Ministere de la sante publique d&apos;Afghanistan a mis au point une carte de pointage equilibree (BSC) pour surveiller regulierement les progres de sa strategie de delivrance d&apos;un ensemble de services sanitaires de base. Bien que ce systeme soit souvent utilise dans le domaine de la sante, il s&apos;agit de sa premiere mise en oeuvre dans un pays en developpement. La BSC afghane est le resultat d&apos;un processus collaboratif visant principalement a traduire la strategie et la mission du Ministere de la sante sous forme de vingt-neuf indicateurs et indices de reference cles, representant six domaines differents des services de sante, et de deux mesures composites de performances associees. En l&apos;absence de systeme d&apos;information sanitaire systematique, la BSC 2004 pour l&apos;Afghanistan a ete mise au point a partir d&apos;un echantillon stratifie et randomise, constitue partir de 617 etablissements de sante, de 5719 observations d&apos;interactions prestateur/patient et d&apos;entretiens avec 5597 patients, 1553 agents de sante et 13843 menages. A l&apos;echelle nationale, la BSC a revele que les services de sante atteignaient davantage les populations les plus pauvres que celles moins desheritees et beneficiaient plus aux femmes qu&apos;aux hommes, deux preoccupations importantes pour les pouvoirs publics. Des insuffisances graves ont toutefois ete relevees dans cinq domaines, notamment les conseils aux patients, les soins obstetricaux pendant l&apos;accouchement, la surveillance des traitements antituberculeux et la raise en place de personnel, d&apos;equipements et de conseils sanitaires operationnels dans les villages. La BSC a egalement permis de mettre en evidence de fortes differences de performances entre les provinces, aucune d&apos;entre elles n&apos;obtenant des resultats systematiquement meilleurs que les autres dans tous les domaines. L&apos;adaptation de la BSC au systeme de sante Afghan fournit un outil novateur et interessant pour evaluer de maniere synthetique les performances multidimensionnelles des services sanitaires et permet aux gestionnaires un << benchmarking >> des performances et d&apos;identifier les points forts et les faiblesses des services sanitaires en Afghanistan. Resumen El Ministerio de Salud Publica (MSP) del Afganistan ha elaborado un cuadro de mando (CM) para vigilar periodicamente los progresos de la estrategia que ha disenado para suministrar un conjunto basico de servicios de salud. Aunque utilizado frecuentemente en otros entornos asistenciales, es la primera vez que este tipo de sistema se emplea en un pais en desarrollo. El CM se diseno mediante un proceso de colaboracion centrado en traducir la vision y la mision del MSP en 29 indicadores y criterios de referencia basicos representativos de seis dominios de los servicios de salud, junto con dos indicadores combinados del desempeno. A falta de un sistema de informacion sanitaria sistematica, el CM de 2004 empleado para el Afganistan se elaboro a partir de una muestra aleatoria estratificada de 617 centros de salud, 5719 observaciones de interacciones paciente-proveedor, y entrevistas con 5597 pacientes, 1553 agentes de salud y 13 843 hogares. A nivel nacional, se observo que los servicios de salud Ilegaban mas a la poblacio pobre que a la poblacion menos pobre, y a las mujeres que a los hombres, por ser esos objetivos prioritarios del Gobierno. Sin embargo, se detectaron graves deficiencias en cinco dominios, sobre todo en lo que respecta al asesoramiento a los pacientes, la prestacion de asistencia al parto, la vigilancia del tratamiento de la tuberculosis, la ubicacion del personal y el equipo, y el establecimiento de consejos de salud de aldea operativos. El CM permitio identificar tambien amplias diferencias de desempeno entre las distintas provincias; ninguna provincia funcionaba mejor que las otras en todos los dominios. La novedosa adaptacion del CM realizada en el Afganistan se ha revelado como un valioso instrumento para sintetizar el caracter multidimensional del desempeno de los servicios de salud, y esta permitiendo a los administradores comparar el desempeno e identificar los puntos fuertes y las deficiencias en el contexto de ese pais., Une traduction en francais de ce resume figure a la fin d l'article. Al final del articulo se facilita una traduccion al espanol. Introduction Decades of conflict in Afghanistan have [...]

The components that are known to physically contribute to an object's observed redshift are reviewed. Then, using a postulated galactic ejection model for quasars, and previously derived results from electromagnetic [...]