Table of Contents
EDITORIALS
- ARVs: The Next Generation. Going Boldly Together to New Frontiers of HIV Treatment
New antiretrovirals (ARVs), particularly the potentially “game-changing” ARV dolutegravir, offer major potential to meet the compelling need for simpler and better HIV treatment for tens of millions of people in the coming decade. Advantages include substantially lower manufacturing cost, fewer side effects, and less risk of resistance. But key obstacles must be addressed in order to develop and introduce new ARVs in specific combinations optimized for the needs of low- and middle-income countries. Strong leadership will be essential from the global health community to nurture more focused collaboration between the private and public sectors.
- Stunning Popularity of LARCs With Good Access and Quality: A Major Opportunity to Meet Family Planning Needs
Given true choice, a very high proportion of women, perhaps most, would select one of the long-acting reversible contraceptives (LARCs)—implants or IUDs—for contraception. If implemented on a wide scale, it would not only drastically alter the current method mix but also serve client needs much better and prevent unintended pregnancy more successfully.
ORIGINAL ARTICLES
- Delivering High-Quality Family Planning Services in Crisis-Affected Settings I: Program Implementation
Extending access to a wide variety of contraceptive methods, including long-acting reversible methods, is feasible in crisis-affected countries by focusing on best practices such as competency-based training, supply chain support, systematic supervision, and community mobilization. Prudent use of data helps drive program improvements.
- Delivering High-Quality Family Planning Services in Crisis-Affected Settings II: Results
A family planning program in 5 crisis-affected settings reached more than 52,000 new contraceptive users in just 2.5 years. Long-acting reversible contraceptives (LARCs) made up 61% of the method mix, with implants predominating in most countries. IUD use also increased over time as the program intensified its efforts to improve provider skills and user awareness. These findings demonstrate the strong popularity of LARCs and the feasibility of providing them in fragile settings even though they require more training and infrastructure support than short-acting methods.
- Trends in the Contraceptive Method Mix in Low- and Middle-Income Countries: Analysis Using a New “Average Deviation” Measure
Applying a standard measure of the method mix evenness suggests 4 patterns among 15 countries moving toward a more balanced mix: (1) rise of one previously underrepresented or new method, (2) replacement of traditional with modern methods, (3) continued but declining domination by a single method, and (4) general movement toward a balanced mix. Improving availability of underutilized or new methods can improve the method mix, although better implementation of more popular methods might increase contraceptive use more expeditiously.
- A Resource Planning Analysis of District Hospital Surgical Services in the Democratic Republic of the Congo
District hospitals in the DRC, on average, could not provide 21% of lifesaving surgical interventions due to deficiencies in basic infrastructure and essential surgical equipment and supplies. Surgery's important health impact and proportionally low service delivery budget argue for greater emphasis on surgical interventions, including for obstetric care.
- Successful Proof of Concept of Family Planning and Immunization Integration in Liberia
Mobilizing vaccinators to provide mothers key family planning information and referrals to co-located, same-day family planning services was feasible in resource-limited areas of Liberia, leading to substantial increases in contraceptive use. Conversely, impact on immunization rates was less clear, but at a minimum there was no decrease in doses administered.
- Predictors of Workforce Retention Among Malawian Nurse Graduates of a Scholarship Program: A Mixed-Methods Study
Several non-remuneration strategies may help improve retention of public-sector nurses: availability of supplies, adequate housing, advancement opportunities, and a positive work environment. A scholarship program with close follow-up of graduates may also help improve retention.
- Female Health Workers at the Doorstep: A Pilot of Community-Based Maternal, Newborn, and Child Health Service Delivery in Northern Nigeria
Deployment of resident female Community Health Extension Workers (CHEWs) to a remote rural community led to major and sustained increases in service utilization, including antenatal care and facility-based deliveries. Key components to success: (1) providing an additional rural residence allowance to help recruit and retain CHEWs; (2) posting the female CHEWs in pairs to avoid isolation and provide mutual support; (3) ensuring supplies and transportation means for home visits; and (4) allowing CHEWs to perform deliveries.
FIELD ACTION REPORTS
- Barriers to Health Care in Rural Mozambique: A Rapid Ethnographic Assessment of Planned Mobile Health Clinics for ART
Mobile health clinics can markedly decrease clients' transportation time and cost to access antiretroviral therapy (ART) and other health services in rural areas, potentially improving use. Close coordination with community leaders and regularly scheduled visits by the mobile clinics are critical.
- Engaging Communities With a Simple Tool to Help Increase Immunization Coverage
Use of a simple, publicly placed tool that monitors vaccination coverage in a community has potential to broaden program coverage by keeping both the community and the health system informed about every infant's vaccination status.
TUTORIALS
- Patient Flow Analysis in Resource-Limited Settings: A Practical Tutorial and Case Study
Patient flow analysis (PFA), a simple quality improvement tool to identify patient flow patterns, can be used in resource-limited settings to inform service delivery improvements. A PFA at a Ghanaian hospital found that personnel constraints and a mismatch between staffing and patient arrival surges led to long wait and total attendance times. The median time from arrival to first-provider contact was 4.6 hours.
INNOVATIONS
- Biometric Fingerprint System to Enable Rapid and Accurate Identification of Beneficiaries
Inability to uniquely identify clients impedes access to services and contributes to inefficiencies. Using a pocket-sized fingerprint scanner that wirelessly syncs with a health worker's smartphone, the SimPrints biometric system can link individuals' fingerprints to their health records. A pilot in Bangladesh will assess its potential.
TAKING EXCEPTION
- A False Dichotomy: RCTs and Their Contributions to Evidence-Based Public Health
Global public health should rely on those research methods that best answer the pressing questions at hand. Randomized controlled trials (RCTs) and other rigorous impact evaluation methods have a critical role to play in public health.
- Response to “A False Dichotomy: RCTs and Their Contributions to Evidence-Based Public Health”
While randomized controlled trials (RCTs) can and do make valuable contributions, they also have severe limitations, including in answering the basic question of “Does it work?” and, even more so, in steering how to proceed with complex public health programming at scale. They deserve no exalted position in the pantheon of methodologies for evidence-based public health.
