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Background: Antenatal period is an opportunity for reaching pregnant women with vital interventions. In fact, antenatal care (ANC) coverage was an indicator for assessing progress towards the Millennium Development Goals. This paper applies a novel index of service coverage using ANC, which accounts for every ANC visit. An index of service coverage gap is also proposed. These indices are additively decomposable by population groups and they are sensitive to the receipt of more ANC visits below a defined threshold. These indices have also been generalised to account for the quality of services. Methods: Data from recent rounds of the Demographic and Health Survey (DHS) are used to reassess ANC service coverage in 35 sub-Saharan African countries. An index of ANC coverage was estimated. These countries were ranked, and their ranks are compared with those based on attaining at least four ANC visits (ANC4+). Findings: The index of ANC coverage reflected the level of service coverage in countries. Further, disparities exist in country ranking as some countries, e.g. Cameroon, Benin Republic and Nigeria are ranked better using the ANC4+ indicator but poorly using the proposed index. Also, Rwanda and Malawi are ranked better using the proposed index. Conclusion: The proposed ANC index allows for the assessment of progressive realisation, rooted in the move towards universal health coverage. In fact, the index reflects progress that countries make in increasing service coverage. This is because every ANC visit counts. Beyond ANC coverage, the proposed index is applicable to assessing service coverage generally including quality education. [ABSTRACT FROM AUTHOR]

Objective: To characterize the impact of widespread inventory management policies on stock-outs of essential drugs in Zambia’s health clinics and develop related recommendations. Methods: Daily clinic storeroom stock levels of artemether-lumefantrine (AL) products in 2009–2010 were captured in 145 facilities through photography and manual transcription of paper forms, then used to determine historical stock-out levels and estimate demand patterns. Delivery lead-times and estimates of monthly facility accessibility were obtained through worker surveys. A simulation model was constructed and validated for predictive accuracy against historical stock-outs, then used to evaluate various changes potentially affecting product availability. Findings: While almost no stock-outs of AL products were observed during Q4 2009 consistent with primary analysis, up to 30% of surveyed facilities stocked out of some AL product during Q1 2010 despite ample inventory being simultaneously available at the national warehouse. Simulation experiments closely reproduced these results and linked them to the use of average past monthly issues and failure to capture lead-time variability in current inventory control policies. Several inventory policy enhancements currently recommended by USAID | DELIVER were found to have limited impact on product availability. Conclusions: Inventory control policies widely recommended and used for distributing medicines in sub-Saharan Africa directly account for a substantial fraction of stock-outs observed in common situations involving demand seasonality and facility access interruptions. Developing central capabilities in peripheral demand forecasting and inventory control is critical. More rigorous independent peer-reviewed research on pharmaceutical supply chain management in low-income countries is needed. [ABSTRACT FROM AUTHOR]

Background: The prevalence of hypertension is highest in the African Region with 46% of adults aged 25 and above diagnosed with hypertension, while the lowest prevalence of 35% is found in the Americas. There is sparse evidence on the approaches used to prevent hypertension in Sub-Saharan Africa and the effectiveness of these approaches. It is therefore imperative that a systematic review; which synthesises all the available evidence on the approaches and their impact is conducted to inform public health policy and practice. Objective: To synthesise evidence on the interventions used for the primary prevention of hypertension in Sub-Saharan Africa and to evaluate the effectiveness of these interventions in reducing blood pressure, hypertension prevalence and the risk factors for hypertension. Methods and results: This systematic review was reported per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Bibliographic databases were searched on the 4th-17th of January 2018 from 1970 to January 2018 and on the 5th of May 2019 from 1970 to May 2019, for studies focusing on the primary prevention of hypertension in communities in Sub-Saharan Africa. A narrative synthesis was conducted based on study interventions and outcomes. Also, a meta-analysis was carried out using pooled mean differences; using a random effects model of generic inverse variance option in RevMan. A total of 854 studies were identified after deduplication, with thirteen studies meeting the inclusion criteria. Six studies with varying interventions and methodologies observed a significant pooled reduction in systolic blood pressure of -3.3mmHg (95%CI -4.64 to -1.96) and a reduction of -2.26mmHg (95%CI -6.36 to 1.85) in diastolic blood pressure, which was not statistically significant (p = 0.28). Also, moderate to significant heterogeneity was observed (I2 = 68% and 99%) for the systolic and diastolic blood pressure respectively. Intervention and study design accounted for 100% heterogeneity for both systolic and diastolic blood pressure (r2 = 100%). Conclusion: Health promotion and interventions targeting various risk factors of hypertension and, salt consumption restriction interventions have been employed in Sub-Saharan Africa with varying levels of success. We recommend that higher quality studies and a meta-analysis are needed to evaluate the impact of these interventions and to inform public health policy and practice. [ABSTRACT FROM AUTHOR]

Background: Long acting reversible and permanent contraception (LARPs) offer promising opportunities for addressing the high and growing unmet need for modern contraception and helps to reduce unintended pregnancies and abortion rates in sub-Saharan Africa (SSA). This study examines the contextual factors that influence the use of long acting reversible and permanent contraception among married and fecund women in Ethiopia. Method: We use data from the 2016 Ethiopian Demographic and Health Survey to examine the contextual factors that influence choice of long acting reversible and permanent contraception among married, non-pregnant and fecund women. The DHS collects detailed information on individual and household characteristics, contraception, and related reproductive behaviors from women of reproductive age. In addition, we created cluster level variables by aggregating individual level data to the cluster level. Analysis was done using a two-level multilevel logistic regression with data from 6994 married (weighted = 7352) women residing in 642 clusters (communities). Results: In 2016, 12% of married, non-pregnant and ‘fecund’ women were using long-acting reversible and permanent methods of contraception in Ethiopia. A higher proportion of women with secondary and above education (17.6%), urban residents (19.7%), in the richest wealth quintile (18.3%) and in paid employment (18.3%) were using LARP methods compared to their counterparts. Regression analysis showed that community level variables such as women’s empowerment, access to family planning information and services, region of residence and knowledge of methods were significantly associated with use of LARP methods. Age, wealth status, employment status and women’s fertility preferences were among the individual and household level variables associated with choice of LARP methods. With regards to age, the odds of using LARP methods was significantly lower among adolescents (OR, 0.53; 95% CI, 0.32–0.85) and women over the age of 40 (OR, 0.63; 95% CI, 0.44–0.90) compared to women in their 20’s. Conclusion: The findings of this study indicate that the demand for long-acting reversible and permanent contraception is influenced not only by women’s individual and household characteristics but also by the community’s level of women’s empowerment, socio-economic development, as well as access and exposure to family planning information and services. Thus, improving knowledge of long-acting reversible and permanent methods, improving women’s decision making autonomy and upgrading the capacity and skills of health workers particularly the midlevel providers and community health extension workers on the provision of LARP methods and rights-based approach is important to improve the uptake of LARP methods. [ABSTRACT FROM AUTHOR]

Background: Although the large majority of persons with diabetes and other non-communicable diseases (NCDs) lives and dies in low- and middle-income countries, the prevention and treatment of diabetes and other NCDs is widely neglected in these areas. A contributing reason may be that, unlike the impacts of acute and communicable diseases, the demands on resources imposed by diabetes is not superficially obvious, and studies capable of detecting these impacts have not be done. Methods: To ascertain recent use of medical services and medicines and other information about the impact of ill-health, we in 2008–2009 conducted structured, personal interviews with 1,780 persons with diagnosed diabetes (DMs) and 1,770 matched comparison subjects (MCs) without diabetes in Cameroon, Mali, Tanzania and South Africa. We sampled DMs from diabetes registries and, in Cameroon and South Africa, from attendees at outpatient diabetes clinics. To recruit MCs, we asked subjects with diabetes to identify five persons living nearest to them who were of the same sex and approximate age. We estimated diabetes impact on medical services use by calculating ratios and differences between DMs and MCs, testing for statistical significance using two-stage multivariable hurdle models. Findings: DMs consumed 12.95 times more days of inpatient treatment, 7.54 times more outpatient visits, and 5.61 times more medications than MCs (all p<0.001). DMs used an estimated 3.44 inpatient days per person per year, made 10.72 outpatient visits per person per year (excluding traditional healers), and were taking an average of 2.49 prescribed medicines when interviewed. Conclusions: In Sub-Saharan Africa, the relative incremental use of medical care and medicines associated with diagnosed diabetes is much greater than in industrialized countries and in China. Published calculations of the health-system impact of diabetes in Africa are dramatic underestimates. Although non-communicable diseases like diabetes are commonly thought to be minor problems for health systems and patients in Africa, our data demonstrate the opposite. [ABSTRACT FROM AUTHOR]