More articles from EDITORIAL
- Effective LARC Providers: Moving Beyond Training
Effective and productive providers are the key to successful provision of long-acting reversible contraceptives (LARCs). But LARCs demand more of providers than short-acting resupply methods. In addition to sound training, key elements to developing highly productive providers of LARCs include a thorough understanding of the service delivery system context; selecting providers with the most potential, especially from mid-level cadres; strong mentoring and supportive supervision; and attention to the supply chain and to demand-side support.
- Sustaining Gains Made in Voluntary Medical Male Circumcision
Introducing early infant male circumcision (EIMC) can sustain voluntary medical male circumcision (VMMC) programs. This Global Health: Science and Practice supplement presents lessons learned, research findings on demand creation, and cost comparisons of various models of EIMC introduction.
- A Convenient Truth: Cost of Medications Need Not Be a Barrier to Hepatitis B Treatment
Drugs that are inexpensive to manufacture and simple to administer greatly expand the potential to help tens of millions of people who need treatment for chronic hepatitis B virus (HBV) infection. Key program implementation challenges include identifying who would benefit from antiviral medication and ensuring long-term and consistent treatment to people who feel well. The best opportunities are where health systems are advanced enough to effectively address these challenges and in settings where HIV service platforms can be leveraged. Research, innovation, and collaboration are critical to implement services most efficiently and to realize economies of scale to drive down costs of health care services, drugs, and diagnostics.
- Leading With LARCs in Nigeria: The Stars Are Aligned to Expand Effective Family Planning Services Decisively
Despite years of family planning effort in Nigeria, the modern contraceptive prevalence (mCPR) has reached only 10%. Yet a few recent seminal, well-executed programs have been outstandingly successful providing long-acting reversible contraceptives (LARCs)—both in the public and private sector, and in the North and South. Remarkably, the LARCs they provided were equivalent to 2% mCPR in 2015 alone.
Accordingly, we advocate markedly increased support for: (1) private-sector approaches such as social franchising, particularly in the South, (2) mobile outreach, and (3) support to public clinical facilities, including expanding access through community health extension workers (CHEWs), particularly in the North. Success will require system support, quality, and concerted engagement from a variety of partners including the Government of Nigeria.
Without significant progress in Nigeria, the global FP2020 goal appears unattainable. Fortunately, leading with LARCs along with wide choice of other methods provides a clear avenue for success.
- Birthing Centers Staffed by Skilled Birth Attendants: Can They Be Effective … at Scale?
Peripheral-level birthing centers may be appropriate and effective in some circumstances if crucial systems requirements can be met. But promising models don’t necessarily scale well, so policy makers and program managers need to consider what requirements can and cannot be met feasibly at scale. Apparently successful components of the birthing center model, such as engagement of traditional birth attendants and use of frontline staff who speak the local language, appear conducive to use in other similar settings.
- Abbreviating the Wealth Index to Measure Equity in Health Programs More Easily
Efforts to simplify the construction of the DHS wealth index are encouraged (while recognizing it is constructed differently in each country), but attempts to assess equity in health programs should bear in mind that it is not sufficient to calculate the wealth index just for the participants in the program. The quintile distributions can vary dramatically within sub-populations. Assessments of equity require knowledge of the distribution of potential participants as well as actual participants.
- Reduced Effectiveness of Contraceptive Implants for Women Taking the Antiretroviral Efavirenz (EFV): Still Good Enough and for How Long?
EFV clearly reduces effectiveness of implants. However, the reduced effectiveness still appears better compared with short-acting methods overall, at least for the initial period of implant use, and may be acceptable to many women. We need better data on effectiveness, especially over the long term and on whether ENG implants (Implanon) might be more effective than LNG implants (Jadelle). Communicating the risk of pregnancy to clients under these circumstances is very challenging. In the longer term, providing an alternative to EFV, such as dolutegravir, might solve this problem.
- Pre-eclampsia as Underlying Cause for Perinatal Deaths: Time for Action
Pre-eclampsia is a major underlying cause of late fetal and early neonatal death, accounting for somewhere between 1 in 10 and 1 in 4 perinatal deaths; it warrants greater efforts from the maternal-newborn community.
- Behavior Change Fast and Slow: Changing Multiple Key Behaviors a Long-Term Proposition?
An intensive radio campaign in rural areas of Burkina Faso addressed multiple key behaviors to reduce child mortality, using a randomized cluster design. After 20 months, despite innovative approaches and high reported listenership, only modest reported change in behavior was found, mainly related to care seeking rather than habitual behavior such as hand washing. Various methodologic difficulties may have obscured a true greater impact. Analysis of the intervention after its full 35-month duration may reveal more impact, including on actual child mortality. Improving a number of key behaviors is essential to child survival efforts, and much of it may require strong and sustained efforts.
- Women’s Groups to Improve Maternal and Child Health Outcomes: Different Evidence Paradigms Toward Impact at Scale
The Care Group model, with relatively intensive international NGO implementation at moderate scale, appears successful in a wide variety of settings, as assessed by high-quality evaluation with rich program learning. Another women’s group approach—Participatory Women’s Groups—has also been implemented across various settings but at smaller scale and assessed using rigorous RCT methodology under controlled—but less naturalistic—conditions with generally, although not uniformly, positive results. Neither approach, as implemented to date, is directly applicable to large-scale integration into current public programs. Our challenge is to distill the elements of success across these approaches that empower women with knowledge, motivation, and increased self-efficacy—and to apply them in real-world programs at scale.