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Background The Millennium Villages Project facilitated technology-based health interventions in rural under-resourced areas of sub-Saharan Africa. Our study examined whether data entry using SMS compared with paper forms by community health workers (CHWs) led to higher proportion of timely follow-up visits for malnutrition screening in under-5 children in Ghana, Rwanda, Senegal, and Uganda. Methods Children under 5 years were screened for malnutrition every 90 days by CHWs using mid-upper arm circumference (MUAC) readings. CHWs used either SMS texts or paper forms to enter MUAC data. Reminder texts were sent at 15 days before follow-up was needed. Chi-square tests assessed proportion of timely follow-up visits within 90 days between SMS and paper groups. Logistic regression analysis was conducted in a step-wise multivariate model. Post-hoc power calculations were conducted to verify strength of associations. Results SMS data entry was associated with a higher proportion of timely malnutrition follow-up visits compared with paper forms across all sites. The association was strongest with consistent SMS use over consecutive visits. SMS use at the first of 2 consecutive visits was most effective, highlighting the importance of SMS reminder alerts. Conclusions SMS technology with reminders increased timely CHW malnutrition screening visits for under-5 children in Ghana, Rwanda, Senegal, and Uganda, highlighting the importance of such technology for improving health worker behavior in low-resource settings.

The sustainable development goals (SDGs) and updated Global strategy for women's, children's and adolescents' health (2016-2030) call upon countries and the global community to transform health systems and society. (1,2) Additional investments in women's, children's and adolescents' health are essential to achieve the ambitious agenda that has been set. Support for nationally-identified reproductive, maternal, newborn and child health priorities needs to be better coordinated and new mechanisms, such as the Global Financing Facility, need to be used to expand domestic financing and attract additional resources. (3,4) The relevant global frameworks have to be translated into actions at the country level and, for this, the lessons learnt from previous engagement with individual countries may give useful guidance. The Reproductive, Maternal, Newborn and Child Health Fund was established in 2013 to support countries with the highest burden of preventable maternal and child deaths and help direct such countries towards millennium development goals (MDGs) 4 and 5 (to reduce child mortality and to improve maternal health by 2015). The fund's main aims were to provide catalytic resources to fill the critical gaps identified by countries and facilitate greater integration of financing and intervention programmes. At the time of the fund's launch, integration was complicated by the proliferation of multiple new initiatives under the Every Woman Every Child umbrella--e.g. A Promised Renewed, Family Planning 2020 and the United Nations (UN) Commission on Life-Saving Commodities, etc. (5) In 2013, under the stewardship of heath ministries and with the support of the H4+ partnership, UN agencies and partners, a country engagement process was outlined to identify implementation gaps across the reproductive, maternal, newborn and child health spectrum. The objectives were to improve the alignment and integration of partners and programmes and to provide catalytic support for prioritized gaps. Using the latest relevant national and subnational data, a situation analysis was conducted to evaluate progress and identify key bottlenecks. Demand for reproductive, maternal, newborn and child health was then evaluated so that the interventions and strategies needed to achieve MDGs 4 and 5 could be determined. In many cases, the priorities identified had already appeared in existing national plans. In-country dialogues with key stakeholders then identified opportunities to strengthen national coordination and alignment. Forward-looking resource mapping was used to assess the financial resources that were--or might become--available to support reproductive, maternal, newborn and child health from domestic and external sources. Finally, prioritized gaps were identified against which further resource alignment could take place and new funding--e.g. from the Reproductive, Maternal, Newborn and Child Health Fund--mobilized. The country perspectives that we present in this article (Table 1) come from the health ministries, civil society organizations and partner agencies from 16 countries in sub-Saharan Africa that collectively received over 180 million United States dollars from the Reproductive, Maternal, Newborn and Child Health Fund (Box 1 and Box 2). These perspectives were generated from a synthesis of facilitated group discussions that took place, among representatives from all 16 focus countries, during a week-long workshop in October 2015. (6) By 2016, a range of lessons had been learnt from this country engagement process. There was a lack of enabling environment. At country level, there was persistent confusion around the multitude of global and regional initiatives on reproductive, maternal, newborn and child health. This resulted in high transaction costs for ministries and duplication and fragmentation in financing and programming. Although there was a compelling global discourse and commitment to improving alignment, this was not always mirrored by actions on the ground. …

Background During the last 15 years, Malawi has made remarkable progress in reducing child mortality. However, maternal and newborn mortality remains persistently high. To help address these entrenched challenges, the Reproductive, Maternal, Newborn and Child Health (RMNCH) Trust Fund provided short-term catalytic financing of $11.5 million (2013-2016) to support country plans to advance the RMNCH and commodity agenda. Objectives (1) To document how Malawi (ministries, partners, working groups) used evidence to inform decision-making and RMNCH investments, (2) To identify barriers to utilizing information and evidence in the planning and prioritization process at national and sub-national levels, and (3) To assess the utility of the RMNCH Landscape Synthesis, which uses existing information to review life-saving RMNCH commodities and services. Methods This was a qualitative case study utilizing a Rapid Appraisal (RA) approach, where semi-structured interviews were conducted with staff members from UN agencies, development partners and the Ministry of Health (MoH) at national and district level. The analysis enlists a framework approach for manual qualitative content analysis. Results Led by the MoH, the RMNCH Trust Fund grant proposal utilized an evidence-based and equity-focused process for prioritization of investments. Data-informed decision-making permeates similar commodity-focused working groups. However, common health information system (HIS) weaknesses, such as data quality and collection burden, persist and are more prevalent at district-level. The collation of evidence in the RMNCH Landscape Synthesis was a useful and sustainable tool to support planning. Conclusions The evidence-based, equity-focused decision-making process for the RMNCH Trust Fund proposal provides an effective model for inter-agency investment prioritization. Strengthening data-informed decision-making will require financial and political commitments to HIS and capacity building for data use, particularly at the district-level. New initiatives (e.g. Health Data Collaborative and QED Network to Improve Quality of Care) provide opportunities to further improve evidence-informed decision-making.

Introduction : Ziehl-Neelsen (ZN) bright-field microscopy is time-consuming, with poor sensitivity, even under optimal conditions. Introduction of Primo Star iLED fluorescent microscopy (FM) may improve TB case finding at referral hospitals in Rwanda. The study aimed to determine the acceptability and effectiveness of iLED in a low resource setting. Methods : Between June 2009 and May 2010, the Rwandan TB Program and National Reference Laboratory carried out demonstration studies with iLED at a referral hospital in the capital, Kigali, and a rural district hospital in Nyamata, taking conventional FM as Gold Standard. Results : Agreement between the iLED and rechecking at the Reference Laboratory were deemed “almost perfect” (kappa = 0.81-1.00) across three of four site-phase combinations. The exception was Nyamata District Hospital during the validation phase, which was deemed “substantial” agreement (kappa = 0.61-0.80). However, the 100% concordance at both demonstration sites during the continuation phase shows technicians' rapid command of the new iLED microscope in a relatively short time. The lower overall positivity rate obtained in the rural clinic is not related to the performance of the microscope (or technicians), but is attributable to a significant increase in total number of patients and samples screened through active case finding. Conclusion : Laboratory technicians demonstrated high acceptance of iLED. Additionally, fluorescent microscopy reduces the time necessary for examination by more than half. The high level of agreement between iLED and FM during implementation in both sites provides initial evidence for iLED to replace current methods.

Background: In sub-Saharan Africa, ;40% of children ,5 y old are stunted, with levels that have remained largely unchanged over the past 2 decades. Although the complex determinants of undernutrition are well recognized, few studies have evaluated strategies that combine nutrition-specific, health-based approaches with food system‐ and livelihood-based interventions. Objective: We examined changes in childhood stunting and its determinants after 3 y of exposure to an integrated, multisector intervention and compared these changes with national trends. Design: A prospective observational trial was conducted across rural sites in 9 sub-Saharan African countries with baseline levels of childhood stunting .20%. A stratified random sample of households and resident children ,2 y old from villages exposed to the program were enrolled in the study. Main outcome measures included principal determinants of undernutrition and childhood stunting, which was defined as a height-for-age z score less than 22. National trends in stunting were generated from demographic and health surveys. Results: Three years after the start of the program in 2005‐2006, consistent improvements were observed in household food security and diet diversity, whereas coverage with child care and diseasecontrol interventions improved for most outcomes. The prevalence of stunting in children ,2 y old at year 3 of the program (2008‐ 2009) was 43% lower (adjusted OR: 0.57; 95% CI: 0.38, 0.83) than at baseline. The average national stunting prevalence for the countries included in the study had remained largely unchanged over the past 2 decades. Conclusion: These findings provide encouraging evidence that a package of multisector interventions has the potential to produce reductions in childhood stunting. Am J Clin Nutr doi: 10. 3945/ajcn.111.020099.

In Africa, older adults aged 50 and older are still sexually active and play a critical role as caregivers, yet little is known about their attitudes towards HIV and awareness of services. In this study, surveys were con- ducted in nine African sites. A multilevel model was fitted to evaluate the relationship between age and outcome variables. The study reveals that people aged 50 years and older have lower levels of HIV-related knowledge and awareness than those aged 25-49. Older adults were less likely to have been tested for HIV and women aged 50 and older showed particularly low levels of awareness.

Stronger governance and leadership is needed to implement and maintain integrated reporting systems, say Theresa Diaz and colleagues

The field of mHealth has made significant advances in a short period of time, demanding a more thorough and scientific approach to understanding and evaluating its progress. A recent review of mHealth literature identified two primary research needs in order for mHealth to strengthen health systems and promote healthy behaviors, namely health outcomes and cost-benefits (Mechael et al., 2010 ). In direct response to the gaps identified in mHealth research, the aim of this paper is to present the study design and highlight key observations and next steps from an evaluation of the mHealth activities within the electronic health (eHealth) architecture implemented by the Millennium Villages Project (MVP) by leveraging data generated through mobile technology itself alongside complementary qualitative research and costing assessments. The study, funded by the International Development and Research Centre (IDRC) as part of the Open Architecture Standards and Information Systems research project (OASIS II) (Sinha, 2009 ), is being implemented on data generated by 14 MVP sites in 10 Sub-Saharan African countries including more in-depth research in Ghana, Rwanda, Tanzania, and Uganda. Specific components of the study include rigorous quantitative case-control analyses and other epidemiological approaches (such as survival analysis) supplemented by in-depth qualitative interviews spread out over 18 months, as well as a costing study to assess the impact of mHealth on health outcomes, service delivery, and efficiency.

This paper describes the process of implementing a low-cost 'real-time' vital registration and verbal autopsy system integrated within an electronic medical record within the Millennium Village cluster in rural Ghana. Using MGV-Net, an open source health information architecture built around the OpenMRS platform, a total of 2378 births were registered between January 2007 and June 2009. The percentage of births registered in the health facility under supervision of a skilled attendant increased substantially over the course of the project from median of 35% in 2007 to 64% in 2008 and 85% midway through 2009. Building additional clinics to reduce distance to facility and using the CHEWs to refer women for delivery in the clinics are possible explanations for the success in the vital registration. The integration of vital registration and verbal autopsies with the MGV-Net information system makes it possible for rapid assessment of effectiveness and provides important feedback to local providers and the Millennium Villages Project.