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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 [...]

Background: Vaccine hesitancy remains a critical barrier in mitigating the effects of the ongoing COVID-19 pandemic. The willingness of health care workers (HCWs) to be vaccinated, and, in turn, recommend the COVID-19 vaccine for their patient population is an important strategy. This study aims to understand the uptake of COVID-19 vaccines and the reasoning for vaccine hesitancy among facility-based health care workers (HCWs) in LMICs. Methods: We conducted nationally representative phone-based rapid-cycle surveys across facilities in six LMICs to better understand COVID-19 vaccine hesitancy. We gathered data on vaccine uptake among facility managers, their perceptions of vaccine uptake and hesitancy among the HCWs operating in their facilities, and their perception of vaccine hesitancy among the patient population served by the facility. Results: 1,148 unique public health facilities participated in the study, with vaccines being almost universally offered to facility-based respondents across five out of six countries. Among facility respondents who have been offered the vaccine, more than 9 in 10 survey respondents had already been vaccinated at the time of data collection. Vaccine uptake among other HCWs at the facility was similarly high. Over 90% of facilities in Bangladesh, Liberia, Malawi, and Nigeria reported that all or most staff had already received the COVID-19 vaccine when the survey was conducted. Concerns about side effects predominantly drive vaccine hesitancy in both HCWs and the patient population. Conclusion: Our findings indicate that the opportunity to get vaccinated in participating public facilities is almost universal. We find vaccine hesitancy among facility-based HCWs, as reported by respondents, to be very low. This suggests that a potentially effective effort to increase vaccine uptake equitably would be to channel promotional activities through health facilities and HCWs.However, reasons for hesitancy, even if limited, are far from uniform across countries, highlighting the need for audience-specific messaging. [ABSTRACT FROM AUTHOR]

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 [...]

The article examines the factors that need to consider to modify the organizational evaluation process to enhance health equity initiatives world wide. Topics mentioned include the importance of investing in several forms of evidence generation and use and independent evaluation, the issues pertaining to health equity, and the role of evaluation in decision making and capacity building.

This paper presents the findings of a study to assess the effectiveness and sustainability of a GAVI (Global Alliance of Vaccines and Immunization) sponsored, time-limited Injection Safety (INS) support. The support came in two forms: 1) in-kind, in the form of AD syringes and safety boxes, and 2) in cash, for those countries that already had a secure, multi-year source of AD syringes and safety boxes, but proposed to use INS support to strengthen their injection safety activities. In total, GAVI gave INS support for a three-year period to 58 countries: 46 with commodities and 12 with cash support. To identify variables that might be associated with financial sustainability, frequencies and cross-tabulations were run against various programmatic and socio-economic variables in the 58 countries. All but two of the 46 commodity-recipient countries were able to replace and sustain the use of AD syringes and safety boxes after the end of their GAVI INS support despite the fact that standard disposable syringes are less costly than ADs (10-15 percent differential). In addition, all 12 cash- recipient countries continued to use AD syringes and safety boxes in their immunization programs in the years following GAVI INS assistance. At the same time, countries were often not prepared for the increased waste management requirements associated with the use of the syringes, suggesting the importance of anticipating challenges with the introduction of new technologies. The sustained use of AD syringes in countries receiving injection safety support from GAVI, in a majority of cases through government financing, following the completion of three years of time-limited support, represents an early indication of how GHPs can contribute to improved health outcomes in immunization safety in the world's poorest countries in a sustainable way. [ABSTRACT FROM AUTHOR]

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 and 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 and their effect on the reporting of births and deaths in Afghanistan need to be investigated further. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: From August to December 2011, a multidisciplinary group with expertise in mathematical modeling was constituted by the GAVI Alliance and the Bill & Melinda Gates Foundation to estimate the impact of vaccination in 73 countries supported by the GAVI Alliance. Methods: The number of deaths averted in persons projected to be vaccinated during 2011–2020 was estimated for ten antigens: hepatitis B, yellow fever, Haemophilus influenzae type B (Hib), Streptococcus pneumoniae, rotavirus, Neisseria meningitidis serogroup A, Japanese encephalitis, human papillomavirus, measles, and rubella. Impact was calculated as the difference in the number of deaths expected over the lifetime of vaccinated cohorts compared to the number of deaths expected in those cohorts with no vaccination. Numbers of persons vaccinated were based on 2011 GAVI Strategic Demand Forecasts with projected dates of vaccine introductions, vaccination coverage, and target population size in each country. Results: By 2020, nearly all GAVI-supported countries with endemic disease are projected to have introduced hepatitis B, Hib, pneumococcal, rotavirus, rubella, yellow fever, N. meningitidis serogroup A, and Japanese encephalitis-containing vaccines; 55 (75 percent) countries are projected to have introduced human papillomavirus vaccine. Projected use of these vaccines during 2011–2020 is expected to avert an estimated 9.9 million deaths. Routine and supplementary immunization activities with measles vaccine are expected to avert an additional 13.4 million deaths. Estimated numbers of deaths averted per 1000 persons vaccinated were highest for first-dose measles (16.5), human papillomavirus (15.1), and hepatitis B (8.3) vaccination. Approximately 52 percent of the expected deaths averted will be in Africa, 27 percent in Southeast Asia, and 13 percent in the Eastern Mediterranean. Conclusion: Vaccination of persons during 2011–2020 in 73 GAVI-eligible countries is expected to have substantial public health impact, particularly in Africa and Southeast Asia, two regions with high mortality. The actual impact of vaccination in these countries may be higher than our estimates because several widely used antigens were not included in the analysis. The quality of our estimates is limited by lack of data on underlying disease burden and vaccine effectiveness against fatal disease outcomes in developing countries. We plan to update the estimates annually to reflect updated demand forecasts, to refine model assumptions based on results of new information, and to extend the analysis to include morbidity and economic benefits. [Copyright &y& Elsevier]

Introduction: The SARS-CoV-2 (COVID-19) pandemic overwhelmed some primary health care (PHC) systems, while others adapted and recovered. In Nigeria, large, within-state variations existed in the ability to maintain PHC service volumes. Identifying characteristics of high-performing local government areas (LGAs) can improve understanding of subnational health systems resilience., Methods: Employing a sequential explanatory mixed-methods design, we quantitatively identified 'positive deviant' LGAs based on their speed of recovery of outpatient and antenatal care services to prepandemic levels using service volume data from Nigeria's health management information system and matched them to comparators with similar baseline characteristics and slower recoveries. 70 semistructured interviews were conducted with LGA officials, facility officers and community leaders in sampled LGAs to analyse comparisons based on Kruk's resilience framework., Results: A total of 57 LGAs were identified as positive deviants out of 490 eligible LGAs that experienced a temporary decrease in PHC-level outpatient and antenatal care service volumes. Positive deviants had an average of 8.6% higher outpatient service volume than expected, and comparators had 27.1% lower outpatient volume than expected after the initial disruption to services. Informants in 12 positive deviants described health systems that were more integrated, aware and self-regulating than comparator LGAs. Positive deviants were more likely to employ demand-side adaptations, whereas comparators primarily focused on supply-side adaptations. Barriers included long-standing financing and PHC workforce gaps., Conclusion: Sufficient flexible financing, adequate PHC staffing and local leadership enabled health systems to recover service volumes during COVID-19. Resilient PHC requires simultaneous attention to bottom-up and top-down capabilities connected by strong leadership., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: During and after the SARS-CoV-2 (COVID-19) pandemic, many countries experienced declines in immunization that have not fully recovered to pre-pandemic levels. This study uses routine health facility immunization data to estimate variability between and within countries in post-pandemic immunization service recovery for BCG, DPT1, and DPT3., Methods: After adjusting for data reporting completeness and outliers, interrupted time series regression was used to estimate the expected immunization service volume for each subnational unit, using an interruption point of March 2020. We assessed and compared the percent deviation of observed immunizations from the expected service volume for March 2020 between and within countries., Results: Six countries experienced significant service volume declines for at least one vaccine as of October 2022. The shortfall in BCG service volume was ~6% (95% CI -1.2%, -9.8%) in Guinea and ~19% (95% CI -16%, 22%) in Liberia. Significant cumulative shortfalls in DPT1 service volume are observed in Afghanistan (-4%, 95% CI -1%, -7%), Ghana (-3%, 95% CI -1%, -5%), Haiti (-7%, 95% CI -1%, -12%), and Kenya (-3%, 95% CI -1%, -4%). Afghanistan has the highest percentage of subnational units reporting a shortfall of 5% or higher in DPT1 service volume (85% in 2021 Q1 and 79% in 2020 Q4), followed by Bangladesh (2020 Q1, 83%), Haiti (80% in 2020 Q2), and Ghana (2022 Q2, 75%). All subnational units in Bangladesh experienced a 5% or higher shortfall in DPT3 service volume in the second quarter of 2020. In Haiti, 80% of the subnational units experienced a 5% or higher reduction in DPT3 service volume in the second quarter of 2020 and the third quarter of 2022., Conclusions: At least one region in every country has a significantly lower-than-expected post-pandemic cumulative volume for at least one of the three vaccines. Subnational monitoring of immunization service volumes using disaggregated routine health facility information data should be conducted routinely to target the limited vaccination resources to subnational units with the highest inequities.

Responsive primary health-care facilities are the foundation of resilient health systems, yet little is known about facility-level processes that contribute to the continuity of essential services during a crisis. This paper describes the aspects of primary health-care facility resilience to coronavirus disease 2019 (COVID-19) in eight countries. Rapid-cycle phone surveys were conducted with health facility managers in Bangladesh, Burkina Faso, Chad, Guatemala, Guinea, Liberia, Malawi and Nigeria between August 2020 and December 2021. Responses were mapped to a validated health facility resilience framework and coded as binary variables for whether a facility demonstrated capacity in eight areas: removing barriers to accessing services, infection control, workforce, surge capacity, financing, critical infrastructure, risk communications, and medical supplies and equipment. These self-reported capacities were summarized nationally and validated with the ministries of health. The analysis of service volume data determined the outcome: maintenance of essential health services. Of primary health-care facilities, 1,453 were surveyed. Facilities maintained between 84% and 97% of the expected outpatient services, except for Bangladesh, where 69% of the expected outpatient consultations were conducted between March 2020 and December 2021. For Burkina Faso, Chad, Guatemala, Guinea and Nigeria, critical infrastructure was the largest constraint in resilience capabilities (47%, 14%, 51%, 9% and 29% of facilities demonstrated capacity, respectively). Medical supplies and equipment were the largest constraints for Liberia and Malawi (15% and 48% of facilities demonstrating capacity, respectively). In Bangladesh, the largest constraint was workforce and staffing, where 44% of facilities experienced moderate to severe challenges with human resources during the pandemic. The largest constraints in facility resilience during COVID-19 were related to health systems building blocks. These challenges likely existed before the pandemic, suggesting the need for strategic investments and reforms in core capacities of comprehensive primary health-care systems to improve resilience to future shocks., (© The Author(s) 2023. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

With conventional Doppler ultrasound it is not possible to estimate direction and velocity of blood flow, when the angle of insonation exceeds 60-70°. Transverse oscillation is an angle independent vector velocity technique which is now implemented on a conventional ultrasound scanner. In this paper a few of the possibilities with transverse oscillation are demonstrated.

A randomized controlled trial of four interventions was conducted using tubewells (n=2,486), liquid sodium hypochlorite ('Clorin') distributed with an improved water vessel (n=2,305), hygiene promotion (n=1,877), and a combination of the three (n=2,040) to create an evidence-base for water policy in Afghanistan. A fifth group served as a control (n=2,377). Interventions were randomized across 32 villages in Wardak province. Outcomes were measured through two household surveys separated by one year and twice-weekly household surveillance conducted over 16 months. The households receiving all three interventions showed reduction in diarrhoea compared with the control group, through both longitudinal surveillance data (IRR [95% CI]=0.61 [0.47-0.81]) and cross-sectional survey data (AOR [95% CI]=0.53 [0.30-0.93]). This reduction was significant when all household members were included, but did not reach significance when only children under five were considered. These results suggest multi-barrier methods are necessary where there are many opportunities for water contamination. Surveillance data suggested a greater impact of interventions on reducing diarrhoeal diseases than data from the surveys. Higher economic status as measured through household assets was associated with lower rates of diarrhoea and greater intervention uptake, excepting Clorin. Use of soap was also associated with lower prevalence of diarrhoea.