John Grove

Declines in HIV prevalence can be associated with changing sexual behaviour in Uganda, urban Kenya, Zimbabwe, and urban Haiti

Objective: To determine whether observed changes in HIV prevalence in countries with generalised HIV epidemics are associated with changes in sexual risk behaviour. Methods: A mathematical model was developed to explore the relation between prevalence recorded at antenatal clinics (ANCs) and the pattern of incidence of infection throughout the population. To create a null model a range of assumptions about sexual behaviour, natural history of infection, and sampling biases in ANC populations were explored to determine which factors maximised declines in prevalence in the absence of behaviour change. Modelled prevalence, where possible based on locally collected behavioural data, was compared with the observed prevalence data in urban Haiti, urban Kenya, urban Cote d’Ivoire, Malawi, Zimbabwe, Rwanda, Uganda, and urban Ethiopia. Results: Recent downturns in prevalence observed in urban Kenya, Zimbabwe, and urban Haiti, like Uganda before them, could only be replicated in the model through reductions in risk associated with changes in behaviour. In contrast, prevalence trends in urban Cote d’Ivoire, Malawi, urban Ethiopia, and Rwanda show no signs of changed sexual behaviour. Conclusions: Changes in patterns of HIV prevalence in urban Kenya, Zimbabwe, and urban Haiti are quite recent and caution is required because of doubts over the accuracy and representativeness of these estimates. Nonetheless, the observed changes are consistent with behaviour change and not the natural course of the HIV epidemic.

Count every newborn; A measurement improvement roadmap for coverage data

BackgroundThe Every Newborn Action Plan (ENAP), launched in 2014, aims to end preventable newborn deaths and stillbirths, with national targets of ≤12 neonatal deaths per 1000 live births and ≤12 stillbirths per 1000 total births by 2030. This requires ambitious improvement of the data on care at birth and of small and sick newborns, particularly to track coverage, quality and equity.MethodsIn a multistage process, a matrix of 70 indicators were assessed by the Every Newborn steering group. Indicators were graded based on their availability and importance to ENAP, resulting in 10 core and 10 additional indicators. A consultation process was undertaken to assess the status of each ENAP core indicator definition, data availability and measurement feasibility. Coverage indicators for the specific ENAP treatment interventions were assigned task teams and given priority as they were identified as requiring the most technical work. Consultations were held throughout.ResultsENAP published 10 core indicators plus 10 additional indicators. Three core impact indicators (neonatal mortality rate, maternal mortality ratio, stillbirth rate) are well defined, with future efforts needed to focus on improving data quantity and quality. Three core indicators on coverage of care for all mothers and newborns (intrapartum/skilled birth attendance, early postnatal care, essential newborn care) have defined contact points, but gaps exist in measuring content and quality of the interventions. Four core (antenatal corticosteroids, neonatal resuscitation, treatment of serious neonatal infections, kangaroo mother care) and one additional coverage indicator for newborns at risk or with complications (chlorhexidine cord cleansing) lack indicator definitions or data, especially for denominators (population in need). To address these gaps, feasible coverage indicator definitions are presented for validity testing. Measurable process indicators to help monitor health service readiness are also presented. A major measurement gap exists to monitor care of small and sick babies, yet signal functions could be tracked similarly to emergency obstetric care.ConclusionsThe ENAP Measurement Improvement Roadmap (2015-2020) outlines tools to be developed (e.g., improved birth and death registration, audit, and minimum perinatal dataset) and actions to test, validate and institutionalise proposed coverage indicators. The roadmap presents a unique opportunity to strengthen routine health information systems, crosslinking these data with civil registration and vital statistics and population-based surveys. Real measurement change requires intentional transfer of leadership to countries with the greatest disease burden and will be achieved by working with centres of excellence and existing networks.

Guidelines for Accurate and Transparent Health Estimates Reporting: the GATHER statement

Measurements of health indicators are rarely available for every population and period of interest, and available data may not be comparable. The Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) define best reporting practices for studies that calculate health estimates for multiple populations (in time or space) using multiple information sources. Health estimates that fall within the scope of GATHER include all quantitative population-level estimates (including global, regional, national, or subnational estimates) of health indicators, including indicators of health status, incidence and prevalence of diseases, injuries, and disability and functioning; and indicators of health determinants, including health behaviours and health exposures. GATHER comprises a checklist of 18 items that are essential for best reporting practice. A more detailed explanation and elaboration document, describing the interpretation and rationale of each reporting item along with examples of good reporting, is available on the GATHER website.

Deconstructing the differences: a comparison of GBD 2010 and CHERG's approach to estimating the mortality burden of diarrhea, pneumonia, and their etiologies

BackgroundPneumonia and diarrhea are leading causes of death for children under five (U5). It is challenging to estimate the total number of deaths and cause-specific mortality fractions. Two major efforts, one led by the Institute for Health Metrics and Evaluation (IHME) and the other led by the World Health Organization (WHO)/Child Health Epidemiology Reference Group (CHERG) created estimates for the burden of disease due to these two syndromes, yet their estimates differed greatly for 2010.MethodsThis paper discusses three main drivers of the differences: data sources, data processing, and covariates used for modelling. The paper discusses differences in the model assumptions for etiology-specific estimates and presents recommendations for improving future models.ResultsIHME’s Global Burden of Disease (GBD) 2010 study estimated 6.8 million U5 deaths compared to 7.6 million U5 deaths from CHERG. The proportional differences between the pneumonia and diarrhea burden estimates from the two groups are much larger; GBD 2010 estimated 0.847 million and CHERG estimated 1.396 million due to pneumonia. Compared to CHERG, GBD 2010 used broader inclusion criteria for verbal autopsy and vital registration data. GBD 2010 and CHERG used different data processing procedures and therefore attributed the causes of neonatal death differently. The major difference in pneumonia etiologies modeling approach was the inclusion of observational study data; GBD 2010 included observational studies. CHERG relied on vaccine efficacy studies.DiscussionGreater transparency in modeling methods and more timely access to data sources are needed. In October 2013, the Bill & Melinda Gates Foundation (BMGF) hosted an expert meeting to examine possible approaches for better estimation. The group recommended examining the impact of data by systematically excluding sources in their models. GBD 2.0 will use a counterfactual approach for estimating mortality from pathogens due to specific etiologies to overcome bias of the methods used in GBD 2010 going forward.

Maternal, newborn, and child health and the Sustainable Development Goals--a call for sustained and improved measurement.

Immunisation is one of the great global health successes of th e past century, with millions of lives saved. Ensuring vaccination of millions of children is complex, but is made possible by one fundamental task: systematic counting at multiple levels and at frequent intervals. From charts in thousands of rural health posts, to databases in ministries of health, to standardised surveys and global reports from WHO, UNICEF, and GAVI, the Vaccine Alliance, a robust interconnected system of data collection and use enables health workers, programme managers, and global actors to track who is vaccinated and make course corrections as needed to improve performance, policies, and programmes. Similar large-scale and long-term gains have been made against malaria by way of highly aligned and coordinated global measurement strategies linked to programmes. These characteristics were also a prominent feature of the successful global diarrhoeal disease control programme of the 1980s and early 1990s. “The Three Ones” (ie, one action framework, one national coordinating authority, and one countrylevel monitoring and evaluation system) for HIV promoted harmonised measurement plans that were made possible by an aggressive global capacity-building eff ort. In maternal, newborn, and child health, the counting is more diffi cult than in some other parts of global health, but has never been more crucial. The Sustainable Development Goals (SDGs) call for major reductions in maternal, neonatal, and child mortality and universal access to sexual and reproductive health services by 2030. These aims require further expansion in coverage, quality, and measurement of eff ective interventions. Although the Millennium Development Goals (MDGs) sparked an increase in data collection, most countries still do not have timely data about how many of the women, adolescents, children, and newborns who need eff ective interventions are receiving them. This is unacceptable, and the global health community can do better. Great progress has been made through household survey programmes such as Demographic and Health Surveys and the Multiple Indicator Cluster Surveys, the Countdown to 2015 for Maternal, Newborn and Child Survival (Countdown) eff ort, and the investment and visibility promoted by the Commission on Information and Accountability for Women’s and Children’s Health and its independent Expert Review Group. Yet challenges remain, such as the need for improved standardised data collection and use at the facility level and innovation to address fundamental technical issues. A more robust data system to measure the coverage of interventions known to be eff ective in reducing maternal, newborn, and child mortality—similar to those that currently exist for vaccines and malaria—will be essential to enhance services, improve health, and achieve long-term goals in mortality reduction. Building on, extending, and refi ning this system for measuring maternal, newborn, and child health is an urgent task for the global community, as well as national and local governments. For the DHS Program: Demographic and Health Surveys see http://dhsprogram. com

Methods for evaluating the impact of vertical programs on health systems: protocol for a study on the impact of the global polio eradication initiative on strengthening routine immunization and primary health care

BackgroundThe impact of vertical programs on health systems is a much-debated topic, and more evidence on this complex relationship is needed. This article describes a research protocol developed to assess the relationship between the Global Polio Eradication Initiative, routine immunization, and primary health care in multiple settings.Methods/DesignThis protocol was designed as a combination of quantitative and qualitative research methods, making use of comparative ethnographies. The study evaluates the impact of the Global Polio Eradication Initiative on routine immunization and primary health care by: (a) combining quantitative and qualitative work into one coherent study design; (b) using purposively selected qualitative case studies to systematically evaluate the impact of key contextual variables; and (c) making extensive use of the method of participant observation to create comparative ethnographies of the impact of a single vertical program administered in varied contexts.DiscussionThe study design has four major benefits: (1) the careful selection of a range of qualitative case studies allowed for systematic comparison; (2) the use of participant observation yielded important insights on how policy is put into practice; (3) results from our quantitative analysis could be explained by results from qualitative work; and (4) this research protocol can inform the creation of actionable recommendations. Here, recommendations for how to overcome potential challenges in carrying out such research are presented. This study illustrates the utility of mixed-methods research designs in which qualitative data are not just used to embellish quantitative results, but are an integral component of the analysis.

Improved measurement for mothers, newborns and children in the era of the Sustainable Development Goals

Background An urgent priority in maternal, newborn and child health is to accelerate the scale–up of cost–effective essential interventions, especially during labor, the immediate postnatal period and for the treatment of serious infectious diseases and acute malnutrition.  Tracking intervention coverage is a key activity to support scale–up and in this paper we examine priorities in coverage measurement, distinguishing between essential interventions that can be measured now and those that require methodological development. Methods We conceptualized a typology of indicators related to intervention coverage that distinguishes access to care from receipt of an intervention by the population in need.  We then built on documented evidence on coverage measurement to determine the status of indicators for essential interventions and to identify areas for development. Results Contact indicators from pregnancy to childhood were identified as current indicators for immediate use, but indicators reflecting the quality of care provided during these contacts need development. At each contact point, some essential interventions can be measured now, but the need for development of indicators predominates around interventions at the time of birth and interventions to treat infections. Addressing this need requires improvements in routine facility based data capture, methods for linking provider and community–based data, and improved guidance for effective coverage measurement that reflects the provision of high–quality care. Conclusion Coverage indicators for some essential interventions can be measured accurately through household surveys and be used to track progress in maternal, newborn and child health.  Other essential interventions currently rely on contact indicators as proxies for coverage but urgent attention is needed to identify new measurement approaches that directly and reliably measure their effective coverage.

Making the most of common impact metrics: promising approaches that need further study

We applaud the effort to develop common metrics of avertable burden to inform decision making. It is an important effort for the health metrics community to explore. Arriving at a set of methods and measures that balance scientific rigor pragmatism and the urgent need for better data at the local level is no small undertaking but the journey has just begun. Investments in methodological innovation and improved capacity to manage data “at the source” are now more important than ever before. From a technical perspective more validation studies are needed before modeled impacts can be considered as credible evidence of attributable or actual impact and the wholesale use of modeled outputs alone in such an evaluative manner seems to us premature. For example before we can be confident in the impact estimates generated we must be confident they are good at overcoming the most vexing problem in global monitoring and evaluation: accurately assessing or estimating intervention coverage. While a good measure or approximation of intervention coverage is essential to estimating impact the data needed to support coverage indicators are often difficult to collect through observational techniques and operational definitions of key terms (e.g. “delivery with a skilled birth attendant”) often vary by country or program. Moving forward donors and partners need to continue to integrate efforts and prioritize common metrics whenever possible. Pushing for innovation in method and efficiencies would improve our assessment tools and processes -- as well as our decision making -- even further. Data sharing transparency and peer review are critical in this new context. (Excerpt)

Aiming for Utility in ‘Systems-based Evaluation’: A Research-based Framework for Practitioners

System dynamics modelling (SDM) was used and process researched as a case to investigate its utility as a systems‐based evaluation (SBE) approach. A system dynamics (SD) model was developed to evaluate the potential requirements and implications on the health systems of the ambitious antiretroviral therapy (ART) scale‐up strategy in Lusaka, Zambia. Research on SDM for strategic evaluation provided insights and principles for future application of SBE. The SD diagrams readily inspired new insights while practical constraints limited use of the model for action planning. Research suggests that utility of SBE begins with engaging stakeholders to share and align their views on a representation of the system and progresses to their reinterpretations of the system that they inhabit, ultimately moving towards transformative change. Evaluators must balance two purposes in managing for utility of SBE approaches: producing a defensible representation of the system(s) and facilitating transformative change appropriately with and for system stakeholders.

ON THE PRESENT STATE OF THE MEDICAL REFORM QUESTION.

dical sense, to continue to be three countries, or to be, in fact as well as in name, one united kingdom of Great Britain and Ireland; and whether or not we are to be subjected to vexatious iterations of the process of examination, serving no useful purpose, merely because we choose to shift our quarters from one part of the Queens dominions to another. As respects medical incorporations, it is the question whether they will best consult their interests and their respectability by continuing to have a little preserve for each of them, and by prosecuting as poachers those who intrude upon it, or by exercising in common certain great functions for the benefit of the entire community of Great Britain and Ireland. And as re-