PARTNER CONTENT
Countdown to 2015 country case studies
Countdown to 2015 was a multi-institution consortium tracking progress towards Millennium Development Goals (MDGs) 4 and 5. Case studies to explore factors contributing to progress (or lack of progres...
Countdown to 2015 country case studies: what have we learned about processes and progress towards MDGs 4 and 5?
Countdown to 2015 was a multi-institution consortium tracking progress towards Millennium Development Goals (MDGs) 4 and 5. Case studies to explore factors contributing to progress (or lack of progress) in reproductive, maternal, newborn and child health (RMNCH) were undertaken in: Afghanistan, Bangladesh, China,
Ethiopia, Kenya, Malawi, Niger, Pakistan, Peru, and Tanzania. This paper aims to identify cross-cutting themes on how and why these countries achieved or did not achieve MDG progress. Further, applying a standard evaluation framework, analyses of impact, coverage and equity were undertaken, including a mixed methods analysis of how these were influenced by national context and coverage determinants (including health systems, policies and financing).
Authors
Corrina Moucheraud, Helen Owen, Neha S.Singh, Courtney Kuonin Ng, Jennifer Requejo, Joy E. Lawn, Peter Berman and the Countdown Case Study Collaboration Group
Institutional Affiliation(s)
University of California
PARTNER CONTENT
Acting on the Call...Maternal Deaths Report
Working together over the last three decades, we have expanded coverage of voluntary family planning, dramatically improved access to new vaccines, integrated nutrition and hygiene into global health,...
Acting on the Call: Ending Preventable Child and Maternal Deaths Report (2014)
Working together over the last three decades, we have expanded coverage of voluntary family planning, dramatically improved access to new vaccines, integrated nutrition and hygiene into global health, and launched innovative public-private partnerships to extend our reach. Since 2010, the Helping Babies Breathe partnership has trained and equipped 130,000 health workers in 60 countries to provide life-saving resuscitation for newborns with asphyxia, with results in Tanzania showing a 47% reduction in early newborn mortality. From 1990 to 2012, the world achieved a 72% reduction in the risk of a child dying from pneumonia or diarrhea, thanks in part to the introduction of vaccines against rotavirus and pneumococcus and improvements in treatment — both advances supported by diverse public and private organizations, including USAID. Together with its partners, the President’s Malaria Initiative contributed to the significant reduction in malaria mortality rates in children under five in Africa by an estimated 54% between 2000 and 2012.
Institutional Affiliation(s)
USAID
PARTNER CONTENT
Acting on the Call...A Focus on Equity
For USAID, Acting on the Call (AOTC) is a continuous improvement process in the Agency’s drive to end preventable child and maternal deaths (EPCMD). Starting in 2012 with the Call to Action, USA...
Acting on the Call: Ending Preventable Child and Maternal deaths: A Focus on Equity (2016)
For USAID, Acting on the Call (AOTC) is a continuous improvement process in the Agency’s drive to end preventable child and maternal deaths (EPCMD). Starting in 2012 with the Call to Action, USAID embraced strategic programming shifts and a bold endgame to help USAID priority countries reach parity with more developed countries in child mortality. In 2012 we estimated that to reach this goal, EPCMD countries would need to achieve an average annual rate of reduction (ARR) of under-5 deaths of 4.1 percent. Between 2012 and 2015, we have achieved an ARR in our countries of 3.6 percent, indicating a need for further progress. Despite the need for additional work, some countries are on track to meet these expectations. Based on country specific target ARRs, Bangladesh, India, Indonesia, Malawi, Nepal, Rwanda, Senegal, Tanzania, and Uganda are on track to achieve the SDGs under-5 mortality target of 25 child deaths per 1,000 live births by 2030.
Institutional Affiliation(s)
USAID
PARTNER CONTENT
Using implementation research...
Under-5 mortality decreased significantly worldwide between 2000 and 2015, but there is still progress to be made, particularly in lower- and middle-income countries. This supplement shares the work o...
Using implementation research to understand lessons in reducing child mortality
Under-5 mortality decreased significantly worldwide between 2000 and 2015, but there is still progress to be made, particularly in lower- and middle-income countries. This supplement shares the work over the last four years on a project to understand how six countries (Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal) were more successful in decreasing child mortality than many of their regional and economic peers. The use of implementation research across these countries identifies common implementation strategies and contextual factors that can facilitate or impede successful implementation of an evidence-based intervention and explores a common pathway to implementation. The work highlights how the use of implementation research to understand the “how” and the “why” behind countries’ success provides important actionable knowledge and lessons to country-level decision-makers, donors, and implementers as we arrive at the midpoint of the Sustainable Development Goal era.
Authors
Agnes Binagwaho and Lisa R. Hirschhorn
Institutional Affiliation(s)
University of Global Health Equity, Northwestern University Feinberg School of Medicine
PARTNER CONTENT
Understanding rapid implementation from..
Rwanda was the first low-income African country to implement the rotavirus vaccine (RTV) and also adopted Option B+ for effective prevention of mother-to-child transmission (PMTCT) before the World He...
Understanding rapid implementation from discovery to scale: Rwanda’s implementation of rotavirus vaccines and PMTCT in the quest to reduce under-5 mortality
Rwanda was the first low-income African country to implement the rotavirus vaccine (RTV) and also adopted Option B+ for effective prevention of mother-to-child transmission (PMTCT) before the World Health Organization’s (WHO) recommendation. This study uses implementation research to identify contextual factors and strategies associated with Rwanda’s rapid uptake of these two EBIs developed or adapted during the study period. The team found several cross-cutting strategies that supported the rapid uptake and implementation of PMTCT, RTV. Key implementation strategies included community and stakeholder involvement and education, leveraging of in-country research capacity to drive adoption and adaptation, coordination of donors and implementing partners, data audit and feedback of coverage, a focus on equity, and integration into pre-existing systems, including community health workers and primary care. The availability of donor funding, culture of evidence-based decision-making, preexisting accountability systems, and rapid adoption of innovation were facilitating contextual factors.
Authors
Felix Sayinzoga, Lisa R Hirschhorn, Jovial Thomas Ntawukuriryayo, Caroline Beyer, Kateri Donahoe, Agnes Binagwaho
Institutional Affiliation(s)
Rwanda Biomedical Center, University of Global Health Equity, Northwestern University Feinberg School of Medicine
PARTNER CONTENT
Integrated Management of Childhood...
Nepal has been a leader in dropping U5M including through adopting EBIs such as integrated management of childhood illness (IMCI). The team conducted a mixed methods case study using an implementation...
Integrated Management of Childhood Illness Implementation in Nepal: Understanding Strategies, Context, and Outcomes
Nepal has been a leader in dropping U5M including through adopting EBIs such as integrated management of childhood illness (IMCI). The team conducted a mixed methods case study using an implementation research framework developed to understand how Nepal outperformed its peers between 2000–2015 in implementing health system-delivered EBIs known to reduce amenable U5M. Strategies chosen and adapted to meet Nepal’s specific context included leveraging local research to inform national decision-makers, pilot testing, partner engagement, and building on and integrating with the existing community health system. These cross-cutting strategies benefited from facilitating factors included community health system and structure, culture of data use, and local research capacity. Geography was a critical barrier and while substantial drops in U5M were seen in both the highest and lowest wealth quintiles, substantial geographic inequities remained.
Authors
Raj Kumar Subedi, Amelia VanderZanden, Kriti Adhikari, Sasmrita Bastola, Lisa R Hirschhorn, Agnes Binagwaho, Mahesh Maskey
Institutional Affiliation(s)
Nepal Public Health Foundation, University of Global Health Equity, Northwestern University Feinberg School of Medicine
PARTNER CONTENT
Examining the implementation of...
Bangladesh significantly reduced under-5 mortality (U5M) between 2000 and 2015, and this study aims to understand how Bangladesh was able to achieve this success. The team studied key implementation ...
Examining the implementation of facility-based integrated management of childhood illness and insecticide treated nets in Bangladesh: lessons learned through implementation research
Bangladesh significantly reduced under-5 mortality (U5M) between 2000 and 2015, and this study aims to understand how Bangladesh was able to achieve this success. The team studied key implementation strategies and associated implementation outcomes for selected EBIs (facility-based integrated management of childhood illnesses and insecticide treated nets) and contextual factors which facilitated or hindered this work. Strategies which contributed to the successful implementation and wide coverage of the selected EBIs included community engagement, data use, and small-scale testing, important to achieving implementation outcomes such as effectiveness, reach and fidelity, although gaps persisted including in quality of care. Key contextual factors including a strong community-based health system, accountable leadership, and female empowerment facilitated implementation of these EBIs. Challenges included human resources for health, dependence on donor funding and poor service quality in the private sector.
Authors
Fauzia Akhter Huda, Kedest Mathewos, Hassan Rushekh Mahmood, Omar Faruk, Lisa R Hirschhorn, Agnes Binagwaho
Institutional Affiliation(s)
International Centre for Diarrhoeal Disease Research Bangladesh, University of Global Health Equity, Northwestern University Feinberg School of Medicine
PARTNER CONTENT
Reducing the equity gap in under-5...
The Ethiopian government implemented a national community health program, the Health Extension Program (HEP), to provide community-based health services to address persisting access-related barriers t...
Reducing the equity gap in under-5 mortality through an innovative community health program in Ethiopia: An implementation research study
The Ethiopian government implemented a national community health program, the Health Extension Program (HEP), to provide community-based health services to address persisting access-related barriers to care using health extension workers (HEWs). The team used implementation research to understand how Ethiopia leveraged the HEP to widely implement specific evidence-based interventions (EBIs) (implementation of pneumococcal conjugate vaccine (PCV-10) and integrated community case management (iCCM)) known to reduce under-5 mortality (U5M) and address health inequities. By 2014/15, estimated coverage of three doses of PCV-10 was at 76%, with high acceptability (nearly 100%) of vaccines in the community. Between 2000 and 2015, the team found evidence of improved care-seeking; coverage of oral rehydration solution for treatment of diarrhea, a service included in iCCM, doubled over this period. HEWs made health services more accessible to rural and pastoralist communities, which account for over 80% of the population, with previously low access, a contextual factor that had been a barrier to high coverage of interventions.
Authors
Laura Drown, Alemayehu Amberbir, Alula M. Teklu, Meseret Zelalem, Abreham Tariku, Yared Tadesse, Solomon Gebeyehu, Yirdachew Semu, Jovial Thomas Ntawukuriryayo, Amelia VanderZanden, Agnes Binagwaho, Lisa R. Hirschhorn
Institutional Affiliation(s)
Brigham and Women’s Hospital Division of Global Health Equity, University of Global Health Equity, MERQ Consultancy PLC, Minstry of Health Ethiopia, Northwestern University Feinberg School of Medicine
PARTNER CONTENT
Lessons from Peru to reduce under-5 ...
This case study in Peru used implementation research to explore the contextual factors and strategies that contributed to the successful implementation of key evidence-based interventions (EBIs) for r...
Lessons from Peru to reduce under-5 mortality: understanding program implementation and context
This case study in Peru used implementation research to explore the contextual factors and strategies that contributed to the successful implementation of key evidence-based interventions (EBIs) for reductions in U5M. Three EBIs were selected and evaluated: antenatal care visits (ANC), facility-based deliveries, and infant vaccination, all of which increased greatly between 2000–2015. Key informants noted that economic growth, financial reforms, strong national commitment to reduce poverty in Peru, and national prioritization of maternal and child health, were important contextual factors that contributed to the successful reduction of U5M. They noted key strategies that helped achieve success during the implementation of EBIs, including utilization of data for decision-making, adaptation driven by cultural sensitivity to address gaps in coverage, and a focus on equity and anti-poverty initiatives with the participation of government, civil society, and political parties to assure continuity of policies.
Authors
Patricia J. García, Anna Larson Williams, Marco H. Carcamo, Amelia VanderZanden, Agnes Binagwaho
Institutional Affiliation(s)
Cayetano Heredia University (UPCH) School of Public Health, University of Global Health Equity
PARTNER CONTENT
Cross-Country Analysis of Contextual...
The Exemplars in Under-5 Mortality (U5M) investigated how six low- and middle-income countries (LMICs), Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal, implemented health system-delivered evid...
Cross-Country Analysis of Contextual Factors and Implementation Strategies in Under-5 Mortality Reduction in Six Low- and Middle-Income Countries 2000-2015
The Exemplars in Under-5 Mortality (U5M) investigated how six low- and middle-income countries (LMICs), Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal, implemented health system-delivered evidence-based interventions (EBIs) to reduce U5M between 2000 and 2015 more effectively than others in their regions or with similar economic growth. Using implementation research, the team conducted a cross-country analysis to compare decision-making pathways for how these countries chose, implemented, and adapted strategies for health system-delivered EBIs that mitigated or leveraged contextual factors to improve implementation outcomes in reducing amenable U5M. Results found that the six countries implemented many of the same EBIs, often using similar strategies with adaptations to local context and disease burden. Common implementation strategies included use of data by decision-makers to identify problems and prioritize EBIs, determine implementation strategies and their adaptation, and measure outcomes; leveraging existing primary healthcare systems; and community and stakeholder engagement. The team also found common facilitators included culture of donor and partner coordination and culture and capacity of data use, while common barriers included geography and culture and beliefs.
Authors
Agnes Binagwaho, Amelia VanderZanden, Patricia J. Garcia, Fauzia Akhter Huda, Mahesh Maskey, Mohamadou Sall, Felix Sayinzoga, Raj Kumar Subedi, Alula M. Teklu, Kateri Donahoe, Miriam Frisch, Jovial Thomas Ntawukuriryayo, Kelechi Udoh, Lisa R Hirschhorn
Institutional Affiliation(s)
University of Global Health Equity, Cayetano Heredia University School of Public Health, University of Washington Global Health Department, International Centre for Diarrhoeal Disease Research Bangladesh, Nepal Public Health Foundation, The Cheikh Anta Diop University, Rwanda Biomedical Center, MERQ Consultancy PLC, Northwestern University Feinberg School of Medicine
PARTNER CONTENT
Inequity in the face of success...
Building on mixed methods multi-case studies of six LMICs leading in U5M reduction from 2000-2015, the team describes geographic and wealth-based equity in facility-based delivery, a critical evidence...
Inequity in the face of success: Understanding geographic and wealth-based equity in success of facility-based delivery for under-5 mortality reduction in six countries
Building on mixed methods multi-case studies of six LMICs leading in U5M reduction from 2000-2015, the team describes geographic and wealth-based equity in facility-based delivery, a critical evidence-based intervention (EBI) to reduce neonatal mortality which requires a trusted and functional health system, and compare the implementation strategies and contextual factors which influenced success or challenges within and across the countries. The absolute geographic and wealth-based equity gaps decreased in three countries, with greatest drops in Rwanda. The largest increases were seen in Bangladesh and in Ethiopia. Facilitators to reducing equity gaps across the six countries included leadership commitment and culture of data use; in some countries, community or maternal and child health insurance was also an important factor. Barriers across all the countries included geography, while country-specific barriers included low female empowerment subnationally and cultural beliefs. Successful strategies included building on community health worker (CHW) programs, with country-specific adaptation of pre-existing CHW programs and cultural adaptation of delivery protocols.
Authors
Jovial Thomas Ntawukuriryayo, Amelia VanderZanden, Alemayehu Amberbir, Alula Teklu, Fauzia Akhter Huda, Mahesh Maskey, Mohamadou Sall, Patricia J Garcia, Raj Kumar Subedi, Sayinzoga Felix, Lisa R Hirschhorn, Agnes Binagwaho
Institutional Affiliation(s)
University of Global Health Equity, MERQ Consultancy PLC, International Centre for Diarrhoeal Disease Research Bangladesh, Nepal Public Health Foundation, The Cheikh Anta Diop University, Cayetano Heredia University School of Public Health, Rwanda Biomedical Center, Northwestern University Feinberg School of Medicine
PARTNER CONTENT
Drivers of success: Improving...
Understanding how context influences implementation of evidence-based interventions is a promising strategy for enhancing child survival initiatives. Spreading approaches that are identified as driver...
Drivers of success: Improving implementation research tools for better health outcomes.
Understanding how context influences implementation of evidence-based interventions is a promising strategy for enhancing child survival initiatives. Spreading approaches that are identified as drivers of successful reduction in under-five mortality from ‘exemplar’ countries could be pivotal in leading to reductions in other LMIC settings facing stagnant mortality rates. Yet there remains a lack of robust analytic methods to accurately assess mortality and describe the drivers of interventions’ implementation success at both national and subnational levels. The field of implementation science and its defining targets and tools is well positioned to address this knowledge gap by integrating qualitative and quantitative research methods into an adaptable evaluation framework that can be tailored to meet the specific needs across varying country contexts. This commentary aims to emphasize the role of implementation research in understanding how exemplar countries achieved significant improvements in child survival and in identifying replicable lessons for other settings.
Authors
Quinhas Fernandes, Orvalho Augusto, Kenneth Sherr
Institutional Affiliation(s)
Ministry of Health Mozambique, National Directorate of Public Health, Eduardo Mondlane University School of Medicine Community Health Department, University of Washington Department of Global Health, Department of Industrial & Systems Engineering, and Department of Epidemiology
PARTNER CONTENT
Embedded Implementation Research...
This supplement examines six countries that have reduced under-five mortality faster than other countries, taking an implementation research approach, with country case studies done with local researc...
Embedded Implementation Research in Programming at Scale – the New Normal to be!
This supplement examines six countries that have reduced under-five mortality faster than other countries, taking an implementation research approach, with country case studies done with local researchers and local institutions. Key generalizable learnings are to choose and adapt implementation strategies to context, design strategies to target the most vulnerable, systematically learn from implementation experience, and to leverage non-health-sector contributions. Embedding implementation research in programming has the potential to greatly improve and accelerate the contextualization and implementation of evidence-based child survival interventions to improve equity in coverage and overall effectiveness in reducing under-five mortality. It is now time to build such capacity in local institutions at scale, and incentives for concerned stakeholders to make this the new normal. Regional institutions should now take the lead in making this happen, not just in individual institutions and countries, but across entire regions, supported by global partners.
Authors
Stefan Swartling Peterson
Institutional Affiliation(s)
Karolinska Institutet and Uppsala University, Makerere University
PARTNER CONTENT
Mitigating the impact of COVID-19 on...
The COVID-19 pandemic posed unprecedented challenges and threats to health systems, particularly affecting delivery of evidence-based interventions (EBIs) to reduce under-5 mortality (U5M) in resource...
Mitigating the impact of COVID-19 on primary healthcare interventions for the reduction of under-5 mortality in Bangladesh: Lessons learned through implementation research
The COVID-19 pandemic posed unprecedented challenges and threats to health systems, particularly affecting delivery of evidence-based interventions (EBIs) to reduce under-5 mortality (U5M) in resource-limited settings such as Bangladesh. The team explored the level of disruption of these EBIs, strategies and contextual factors associated with preventing or mitigating service disruptions, and how previous efforts supported the work to maintain EBIs during the pandemic. Bangladesh had an initial drop in U5M-oriented EBIs during the early phase of the pandemic, which began recovering in June 2020. Barriers such as lockdown and movement restrictions, difficulties accessing medical care, and redirection of the health system’s focus to the COVID-19 pandemic, resulted in reduced health-seeking behavior and service utilization. Strategies to prevent and respond to disruptions included data use for decision-making, use of digital platforms, and leveraging community-based healthcare delivery. Transferable lessons included collaboration and coordination of activities and community and civil society engagement, and investing in health system quality.
Authors
Alemayehu Amberbir, Fauzia A. Huda, Amelia VanderZanden, Kedest Mathewos, Jovial Thomas Ntawukuriryayo, Agnes Binagwaho, Lisa R. Hirschhorn
Institutional Affiliation(s)
University of Global Health Equity, International Centre for Diarrhoeal Disease Research Bangladesh, Northwestern University Feinberg School of Medicine
PARTNER CONTENT
Development and application of ...
This article describes the development and testing of a hybrid implementation research (IR) framework to understand the pathways, successes, and challenges in addressing amenable under-5 mortality (U5...
Development and application of a hybrid implementation research framework to understand success in reducing under-5 mortality in Rwanda
This article describes the development and testing of a hybrid implementation research (IR) framework to understand the pathways, successes, and challenges in addressing amenable under-5 mortality (U5M) – deaths preventable through health system-delivered evidence-based interventions (EBIs) – in low- and middle-income countries (LMICs). The team reviewed existing IR frameworks to develop a hybrid framework, then conducted a mixed-methods case study of Rwanda using the framework to explore its utility in understanding the steps the country took in EBI-related decision-making and implementation between 2000-2015, key contextual factors which hindered or facilitated success, and to extract actionable knowledge for other countries working to reduce U5M. While relevant frameworks were identified, none individually covered the scope needed to understand Rwanda’s actions and success. Building on these frameworks, the teamcombined and adapted relevant frameworks to capture exploration, planning, implementation, contextual factors in LMICs such as Rwanda, and outcomes beyond effectiveness and coverage. Utilizing their hybrid framework in Rwanda, they studied multiple EBIs and identified a common pathway and cross-cutting strategies and contextual factors that supported the country’s success in reducing U5M through the health system EBIs.
Authors
Lisa R. Hirschhorn, Miriam Frisch, Jovial Thomas Ntawukuriryayo, Amelia VanderZanden, Kateri Donahoe, Kedest Mathewos, Felix Sayinzoga, Agnes Binagwaho
Institutional Affiliation(s)
Department of Medical Social Sciences Northwestern University Feinberg School of Medicine, University of Global Health Equity, Maternal, Child, and Community Health Division Rwanda Biomedical Center
