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Competing Interests: Competing interests: The authors completed the ICMJE Declaration of Interest Form (available upon request from the corresponding author), and declare no conflicts of interest.

Implementation of innovative strategies to improve coverage of evidence-based interventions, especially in the most marginalised populations, is a key focus of policy makers and planners aiming to improve child survival, health, and nutrition. We present a three-step approach to improvement of the effective coverage of essential interventions. First, we identify four different intervention delivery channels--ie, clinical or curative, outreach, community-based preventive or promotional, and legislative or mass media. Second, we classify which interventions' deliveries can be improved or changed within their channel or by switching to another channel. Finally, we do a meta-review of both published and unpublished reviews to examine the evidence for a range of strategies designed to overcome supply and demand bottlenecks to effective coverage of interventions that improve child survival, health, and nutrition. Although knowledge gaps exist, several strategies show promise for improving coverage of effective interventions-and, in some cases, health outcomes in children-including expanded roles for lay health workers, task shifting, reduction of financial barriers, increases in human-resource availability and geographical access, and use of the private sector. Policy makers and planners should be informed of this evidence as they choose strategies in which to invest their scarce resources., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Progress on child mortality and undernutrition has seen widening inequities and a concentration of child deaths and undernutrition in the most deprived communities, threatening the achievement of the Millennium Development Goals. Conversely, a series of recent process and technological innovations have provided effective and efficient options to reach the most deprived populations. These trends raise the possibility that the perceived trade-off between equity and efficiency no longer applies for child health--that prioritising services for the poorest and most marginalised is now more effective and cost effective than mainstream approaches. We tested this hypothesis with a mathematical-modelling approach by comparing the cost-effectiveness in terms of child deaths and stunting events averted between two approaches (from 2011-15 in 14 countries and one province): an equity-focused approach that prioritises the most deprived communities, and a mainstream approach that is representative of current strategies. We combined some existing models, notably the Marginal Budgeting for Bottlenecks Toolkit and the Lives Saved Tool, to do our analysis. We showed that, with the same level of investment, disproportionately higher effects are possible by prioritising the poorest and most marginalised populations, for averting both child mortality and stunting. Our results suggest that an equity-focused approach could result in sharper decreases in child mortality and stunting and higher cost-effectiveness than mainstream approaches, while reducing inequities in effective intervention coverage, health outcomes, and out-of-pocket spending between the most and least deprived groups and geographic areas within countries. Our findings should be interpreted with caution due to uncertainties around some of the model parameters and baseline data. Further research is needed to address some of these gaps in the evidence base. Strategies for improving child nutrition and survival, however, should account for an increasing prioritisation of the most deprived communities and the increased use of community-based interventions., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

The purpose of this study was to examine care-seeking during fatal infant illnesses in under-resourced South African settings to inform potential strategies for reducing infant mortality. We interviewed 22 caregivers of deceased infants in a rural community and 28 in an urban township. We also interviewed seven local leaders and 12 health providers to ascertain opinions about factors contributing to infant death. Despite the availability of free public health services in these settings, many caregivers utilized multiple sources of care including allopathic, indigenous and home treatments. Urban caregivers reported up to eight points of care while rural caregivers reported up to four points of care. The specific pathways taken and combinations of care varied, but many caregivers used other types of care shortly after presenting at public services, indicating dissatisfaction with the care they received. Many infants died despite caregivers' considerable efforts, pointing to critical deficiencies in the system of care serving these families. Initiatives that aim to improve assessment, management and referral practices by both allopathic and traditional providers (for example, through training and improved collaboration), and caregiver recognition of infant danger signs may reduce the high rate of infant death in these settings., (Copyright © 2011 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.)

This study employs data from rural South Africa to determine whether there were socioeconomic differences in the profile of HIV-infected persons living in the community and HIV-infected patients presenting for hospital-based outpatient HIV/AIDS care and related services. There were 776 HIV-infected persons aged 18-35 years in Limpopo Province, South Africa who were included in the study, including 534 consecutive patients who presented for care at a hospital-based outpatient HIV clinic, and 242 persons living in the community. Persons seen in clinic had a higher overall socioeconomic profile compared to the community sample. They were more likely to have completed matric or tertiary education (P=0.04), less likely to be unemployed (P<0.001), and more likely to live in households with access to a private tap water supply (P<0.001). These differences persisted after multivariable adjustment. Our findings demonstrate that important socioeconomic differences in uptake of hospital-based HIV/AIDS care were identified among HIV-infected adults living in a rural region of South Africa. This suggests an important limitation in hospital-based HIV/AIDS care and underscores the need to monitor the equity implications of highly active antiretroviral therapy scale-up in resource-limited settings.

This community situational analysis determined factors impacting the utilization of maternal health services in South Africa. Quantitative and qualitative research methods were used, including semistructured household interviews, case studies of women with no antenatal care and/or home birth, and verbal/social autopsies of maternal and infant deaths, conducted in three diverse sites across the country. Data analysis used quantitative statistics for the semistructured interviews and a qualitative thematic content approach for the case studies and verbal/social autopsies. Each component was analyzed separately and then triangulated. The following themes emerged: 1) transport and distance to care were the biggest problems, particularly in rural areas; 2) providers' communication with families was very poor; 3) health-seeking behavior was better than anticipated; 4) treatment by health providers and quality of care showed mixed results; 5) HIV/AIDS is a major issue; however, basic maternity and neonatal service quality cannot be overlooked; and 6) families and communities are an untapped resource for improving maternal and neonatal health. Implications for maternal and infant health care in developing countries are discussed, with a particular focus on barriers to utilization and involvement of communities and families in maternity care.

The health inequalities in South Africa are rapidly worsening. Since 1994, the new democratic government has initiated a number of large-scale policies and programs with explicit pro-equity objectives that have improved access to health care and other social resources. However, these policies and programs have been constrained by macroeconomic policies that dictate fiscal restraint and give priority to technical rather than developmental considerations. We propose an approach to improving health for all that focuses on equity in the allocation of health resources. The implementation of pro-equity policies requires, in addition to technically efficacious interventions, both advocacy initiatives and communication with, and the involvement of, affected communities. The Cape Town Equity Gauge project is presented as one example of a response to the challenge of inequity.

Objectives: To assess the extent of inequalities in availability and utilisation of HIV services across South Africa., Design: Cross-sectional descriptive study., Setting: Three districts reflecting different socio-economic conditions, but with similar levels of HIV infection, were purposively sampled., Outcome Measures: Availability and utilisation of HIV services and management and support structures for programmes were assessed through the collection of secondary data supplemented by site visits., Results: There were marked inequalities in service delivery between the three sites. Compared with two poorer sites, clinics at the urban site had greater availability of HIV services, including voluntary counselling and testing (100% v. 52% and 24% respectively), better uptake of this service (59 v. 9 and 5.5 clients per 1000 adults respectively) and greater distribution of condoms (15.6 v. 8.2 condoms per adult male per year). Extra counsellors had also been employed at the urban site in contrast to the other 2 sites. The urban site also had far more intensive management support and monitoring, with 1 manager per 12 health facilities compared with 1 manager per more than 90 health facilities at the other 2 sites., Conclusion: The process of scaling up of HIV services seems to be accentuating inequalities. The urban site in this study was better able to utilise the extra resources. In contrast, the poorer sites have thus far been unable to scale up the response to HIV even with the availability of extra resources. Unless policy makers pay more attention to equity, efficacious interventions may prove to be of limited effectiveness.

Background Due to ongoing insecurity, the government of Afghanistan delivers health care to the country's population by contracting out service delivery to non-governmental organization service providers (SPs). In 2018, major changes to SP contracts were introduced, resulting in a new pay-for-performance service delivery model. This model, called "Sehatmandi", pays SPs based on the volume of 11 key services they provide. Methods A narrative review of Sehatmandi's key features is presented, as well as lessons learned during implementation. Counterfactual comparisons of service delivery data for 10 payment-related service indicators are made. The first comparison is between the rate of change in the volume of services delivered from 2018 to 2019 (ie, the first year of Sehatmandi implementation) relative to the rate change from 2017 to 2018 (ie, prior to the program). The second comparison is between the rate of change in the volume of services delivered in provinces under the pay-for-performance mechanism relative to provinces which were not financed using pay-for-performance. Time trends in non-payment service indicators and service quality are also examined. Results The increase in service volume in Sehatmandi provinces from 2018 to 2019 was higher than the increase from 2017 to 2018 for 8 out of 10 indicators. The median increase in the rate of change was 10 percentage points. Similar results were obtained when comparing pay-for-performance provinces to those not financed using pay-for-performance. Improvements were also observed for services that were not directly compensated by the pay-for-performance approach. Payment for service volume was not associated with reduced service quality. The narrative review suggests that the pay-for-performance system has stimulated more effective oversight of SPs by the government of Afghanistan and has incentivized innovative service delivery strategies by SPs. Sehatmandi may benefit from re-structuring its financial incentives to stimulate improved service quality and accelerate delivery of lagging services. Conclusions The available evidence - though subject to some limitations - suggests that the introduction of a pay-for-performance system was associated with an expanded volume of service delivery in Afghanistan. This approach may be beneficial in other conflict-affected countries. [ABSTRACT FROM AUTHOR]

The article discusses the inequities of ethnicity- and gender-based bias and discrimination in global immunization coverage as of February 2020. Topics covered include data quality improvement, use of traditional surveys, electronic health information systems, machine learning, satellite imagery, and better data visualization, and building of national and local capacity for data use and service expansion. Also noted are the challenges of vertical programmes and underserved children.

The article focuses on research which examined the effects of policy options for human resources for health by analyzing systematic reviews. Researchers examined and searched Medline and Embase fro 1979 to 2006, the Cochrane Library, and the Human Resources for Health Global Resource Center database. They determined that there is a need for more systematic reviews on the effects of policy options to improve human resources for health in countries with low and middle incomes. They also determined that there was a need for assessments of policy makers to introduce, plan and manage human resources for health.

Background: Life expectancy initially improves rapidly with economic development but then tails off. Yet, at any level of economic development, some countries do better, and some worse, than expected – they either punch above or below their weight. Why this is the case has been previously researched but no full explanation of the complexity of this phenomenon is available. New research network: In order to advance understanding, the newly formed Punching Above Their Weight Research Network has developed a model to frame future research. It provides for consideration of the following influences within a country: political and institutional context and history; economic and social policies; scope for democratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles and power dynamics; the extent of civil society activity and disease burdens. Conclusion: Further research using this framework has considerable potential to advance effective policies to advance health and equity. [ABSTRACT FROM AUTHOR]

This article discusses research into health outcomes in countries that have focussed on primary care since the 1978 Alma-Ata, Kazakhstan conference established universal health care as an international goal. The countries assessed have made the most dramatic changes in their child mortality rates since 1978. These countries are then analysed in terms of the relationship between their health outcomes and their per capita gross national income. Successful countries improved their life expectancy statistics faster than their GNI grew. Issues of governance, violence and political stability are cited as explanations for the different performances of different countries. INSETS: Panel 1: Thailand's progress in primary health care and...;Panel 2: Composite lessons learned from countries that are....

This article discusses the failure to implement the goals of the 1978 Alma-Ata, Kazakhstan Declaration on public health services accessibility and the 2000 United Nations Millennium Project goals. The role that primary health care services will play in the eventual achievement of these goals is addressed. The goals are described in terms of their larger ideals, such as health for all, and their quantifiable aims, such as measurable reductions in child mortality. Challenges related to the integration of primary health care within the public health infrastructures of developing countries are addressed. administration and the development of meaningful community participation in health care are described as two issues relating to the implementation of public health goals. INSETS: Panel 1: Research priorities for primary health care based on...;Panel 2: Actions to increase commitment and resources for....

This article discusses public health interventions designed to cope with the chronic disease burdens faced by developing countries and impoverished regions. The ageing of populations in these countries and the proliferation of chronic diseases such as AIDS are assessed as challenges facing public health administration. efforts to improve health risk assessment, diagnostic, and early intervention strategies for the treatment of chronic illness are described. The authors encourage the integration of this treatment method within existing primary medical care systems directed toward high risk populations. INSETS: Key messages;Panel 1: Chronic diseases and global mental health;Panel 2: Scaling-up of HIV treatment;Panel 3: Mexico's Veracruz initiative for diabetes awareness...

This article presents a systematic review of research into the administration and financing of public health interventions in developing countries and impoverished regions. The development of financing programs for primary care systems is assessed in terms of the implementation of user fees and the use of financial incentives to encourage health outcomes. The importance of task shifting, and emphasis on the devolution of primary care from professional doctors and nurses onto allied health personnel is emphasised. The importance of small scale interventions in the development of public health resources for the administration INSETS: Key messages;Panel 1: Taxonomy of governance, financial, and delivery...;Panel 2: Assessing the applicability to low-income and...;Panel 3: Key messages from systematic reviews of implementation..

This article assesses the implementation of health care reforms proposed by the Alma-Ata, Kazakhstan Declaration on health services accessibility in 1978. These principles included equal access to treatment, social justice, and health care for all. Changes in the provision of primary care are analysed in terms of the changing contexts in which public health services are administered. Issues arising from the development of integrated health systems and an increasing focus on evidence-based approaches to medicine are considered. The increasing importance of community participation in medical care is noted. The importance of increased access to medical technology in the developing world is encouraged. INSETS: Panel 1: Declaration of Alma-Ata International Conference on...;Panel 3: Summary of the main programmes and tasks within the....

The authors explore the reasons for the failure to prevent diarrhoea in children and recommend a seven-point plan for comprehensive diarrhoea control. They present an overview of the report "Diarrhoea: Why Children Are Still Dying and What Can Be Done." They cite the development of innovative delivery strategies to expand access to zinc and low-osmolarity oral rehydration salts. The authors also emphasize the need to include families, communities and governments in the fight against diarrhoea.