June 2018 | Volume 6 | Number 2
- Can Universal Health Coverage prioritize health impact?
- Are long-lasting insecticidal nets for malaria control sufficient and sustainable?
- How can we keep up the momentum to eliminate mother-to-child transmission of HIV by 2030?
- How can observation uncover issues critical to ensuring health interventions succeed?
- What elements are essential to improving voluntary contraception use among married youth?
- How can high-risk advanced maternal age and high parity pregnancies be averted?
Read the June 2018 issue of GHSP to find answers to these questions and more. View a list of all articles by article type below or online.
Visit the GHSP website to read and comment on the articles, and subscribe to receive alerts when new articles and issues are published.
TABLE OF CONTENTS
EDITORIALS
Five years after launching Global Health: Science and Practice, we are seeing signs that we are helping to fill an important gap in program-related evidence. Looking forward, we seek to offer better coverage for topics that are relatively neglected in the global health literature and to publish more papers by authors based in low- and middle-income countries. We invite authors to submit manuscripts on global health programs grounded in evidence from research, evaluation, monitoring data, or experiential knowledge, and encourage readers to access and share our free articles to find scalable approaches and important lessons to inform programs and policy.
Sadly, we face a vast sea of health problems in global health. Universal health coverage programming should prioritize interventions with the most health impact, but instead largely succumbs to emphasizing less impactful clinical curative services. In contrast, DCP3 provides an evidence-based template that prioritizes impact. Yet even the most basic and realistic DCP3 package comes at a formidable price.
While having saved many lives over the past decade, continued dependence on mass distribution of free long-lasting insecticidal nets (LLINs) is not sufficient and may not be sustainable. Programs must be enabled with flexible policy and technical options to place LLINs within a larger context of multisectoral partnerships and integrated vector management, avoiding what happened in the DDT era, where there was overreliance implementing a uniform solution to a complex problem.
Newly emerging low-cost molecular assays and improved visual tests for cervical cancer screening call into question the role of visual inspection with acetic acid (VIA). VIA-based screening continues to offer a low-cost, single-visit approach for screening. However, VIA is highly rater-dependent and has problematic accuracy. RNA, DNA, and protein tests are now available. They offer greater accuracy and the option for self-sampling, but the testing kits are expensive. As these new options continue to improve, the time to move beyond VIA is fast approaching.
Policy makers and program managers are better enabled to draw relevant lessons from implementation research and program experience elsewhere when there is richer documentation on what was done and what key contextual factors may have influenced outcomes. Newly developed Program Reporting Standards from WHO provide helpful guidance on what is needed for optimally useful documentation.
VIEWPOINTS
To keep up momentum in preventing mother-to-child transmission we propose: (1) advocating for greater political and financial commitment; (2) targeting high-risk populations such as adolescent girls and young women; (3) implementing novel service delivery models such as community treatment groups; (4) performing regular viral load monitoring during pregnancy and postpartum to ensure suppression before delivery and during breastfeeding; and (5) harnessing technology in monitoring and evaluation and HIV diagnostics.
COMMENTARIES
WHO has recently published program reporting standards to guide the type of information that reproductive, maternal, newborn, child, and related health programs should document to promote cross-program learning. We strongly encourage our partners and key stakeholders to make use of the new standards as part of their routine program reporting.
ORIGINAL ARTICLES
Even within the fairly homogenous context of francophone Africa, among 18 options presented to experts on how to proceed toward universal health coverage (UHC), consensus was reached on only 1 with respect to effectiveness and another with respect to feasibility. The complexity and challenges of UHC as well as the weak evidence base likely contribute to this uncertainty.
Three years following a mass bed net distribution campaign, the addition of school-based distribution to antenatal care (ANC) distribution in Cross River State, Nigeria, increased household ownership of any net to nearly 80%, whereas ownership in the comparison area was below 50%. School distribution was nearly equitable among rich and poor, and very few households obtained nets from both ANC and schools, suggesting complementary reach.
Four case studies show how observation can uncover issues critical to making a health intervention succeed or, sometimes, reveal reasons why it is likely to fail. Observation can be particularly valuable for interventions that depend on mechanical or clinical skills; service delivery processes; effects of the built environment; and habitual tasks that practitioners find difficult to articulate.
The single-visit approach was implemented with strong attention to systems in 14 health facilities. In the 2 largest facilities, nearly 14,000 women screened for cervical cancer over 4 years. Of approximately 9% who screened positive, about 66% received same-day cryotherapy. Attention is needed to ensure local technicians can repair cryotherapy equipment, supplies are consistently in stock, and user fees are not to accessing care.
Men in the study generally supported couples' use of contraception, especially citing socioeconomic reasons. Some had reservations stemming from perceptions that family planning could facilitate infidelity and promiscuity. They also thought family planning decisions should be made jointly. All men expressed interest in learning more about family planning, preferring dissemination from community health workers, trusted men, and current family planning users.
Critical program elements to improving voluntary contraceptive use among married youth included: (1) use of a socioecological intervention model of behavior change; (2) engaging both women and men; and (3) calibrating interventions to different moments in the life cycle of adolescents and youth. Trade-offs between intensive NGO-led models and less intensive government-led models occurred in effectiveness, scale of interventions, and sustained behavior changes.
In Ghana, Rwanda, Senegal, and Uganda, we found positive association between community health workers (CHWs) using SMS data entry with reminder alerts and timely follow-up for childhood malnutrition screening visits compared with paper forms. This association was strongest when CHWs used SMS data entry consecutively over multiple visits than when they switched between SMS and paper forms.
The majority of countries with mandatory grain fortification requirements document the technical specifications for grain fortification, such as allowable food vehicles and fortification levels required. Most document systems for monitoring. However, detailed protocols, descriptions of roles and responsibilities, means to support the cost of regulation, enforcement strategies, and methods for reporting monitoring results to stakeholders are generally lacking.
FIELD ACTION REPORTS
Harmful social norms and lack of knowledge contribute to risky pregnancies in older and high-parity women in low- and middle-income countries. A social and behavior change communication resource combining technical guidance with tangible client and provider materials was designed to address and prevent such pregnancies in Niger and Togo.
SHORT REPORTS
In 3 regions of Myanmar, village malaria workers (VMWs) and mobile teams tested a higher number of people than strategically placed fixed screening points at border crossings, but VMWs and screening points yielded higher malaria positive rates. We recommend using a combination of these approaches in the Greater Mekong Subregion for such populations depending on the strategic approach of the program.
METHODOLOGIES
As demand for family planning has increasingly been satisfied, disparities between groups within a country have also generally declined but persist. To monitor disparity across countries and over time, we recommend comparing met demand by wealth quintile because it is most comparable to interpret and highly correlated with disparity by education, residence, and region. Within country, comparing disparity in met demand across geographic region can identify populations with greater need for programmatic purposes.
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