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Background: The elimination of mother-to-child HIV transmission requires access to HIV testing services (HTS) for pregnant women. In Akwa Ibom, Nigeria, 76% of pregnant women receive antenatal care from traditional birth attendants and may not have access to HIV testing. Objectives: This study examines the contribution of traditional birth attendants and other healthcare workers in community birth centres in improving access to HTS among pregnant women and their HIV-exposed infants. Design: A retrospective cross-sectional study of previously collected programme data at two points in time to evaluate the prevention of mother-to-child transmission (PMTCT) programme. Methods: We assessed programme records before and after introducing an intervention that engaged traditional birth attendants and other healthcare workers in community birth centres to expand access to HTS among pregnant women and their HIV-exposed infants in Akwa Ibom State, Nigeria. Data were abstracted from the programme database for the preintervention period (April 2019 to September 2020) and the intervention period (October 2020 to March 2022). Data abstracted include the number of pregnant women tested for HIV, those diagnosed with HIV, the number of HIV-exposed infants who had samples collected for early infant diagnosis and those diagnosed with HIV. The data were analysed descriptively and inferentially. Results: Before the intervention, 39,305 pregnant women and 2248 HIV-exposed infants were tested for HIV. After the intervention, the number of pregnant women tested increased to 127,005 and the number of HIV-exposed infants tested increased to 2490. Among pregnant women, the postintervention testing increased by 3.2-fold, with community birth centres reporting 63% of all tests. The intervention also resulted in an 11% increase in HIV-exposed infants benefitting from early infant diagnosis with community birth centres reporting 5% of all tests. Of those diagnosed with HIV, 24% of pregnant women and 12% of infants were diagnosed at community birth centres. Conclusion: Community-based HIV testing for pregnant women can reduce mother-to-child transmission and improve early diagnosis and treatment of exposed infants. Collaboration with birth attendants is crucial to ensure testing opportunities are not missed. Prospective research is needed to understand the clinical outcomes of intervention programmes in the community.

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BACKGROUND: Several trials of community-based HIV self-testing (HIVST) provide evidence on the acceptability and feasibility of campaign-style distribution to reach first-time testers, men and adolescents. However, we do not know how many remain unaware of HIVST after distribution campaigns, and who these individuals are. Here we look at factors associated with never having heard of HIVST after community-based campaign-style HIVST distribution in rural Zimbabwe between September 2016 and July 2017. METHODS: Analysis of representative population-based trial survey data collected from 7146 individuals following community-based HIVST distribution to households was conducted. Factors associated with having never heard of HIVST were determined using multivariable mixed-effects logistic regression adjusted for clustered design. RESULTS: Among survey participants, 1308 (18.3%) self-reported having never heard of HIVST. Individuals who were between 20 and 60 years old {20-29 years: [aOR = 0.74, 95% CI (0.58-0.95)], 30-39 years: [aOR = 0.56, 95% CI (0.42-0.74)], 40-49 years: [aOR = 0.50, 95% CI (0.36-0.68)], 50-59 years [aOR = 0.58, 95% CI (0.42-0.82)]}, who had attained at least ordinary level education [aOR = 0.51, 95% CI (0.34-0.76)], and who had an HIV test before [aOR = 0.30, 95% CI (0.25-0.37)] were less likely to have never heard of HIVST compared with individuals who were between 16 and 19 years old, who had a lower educational level and who had never tested for HIV before, respectively. In addition, non-household heads or household head representatives [aOR = 1.21, 95% CI (1.01-1.45)] were more likely to report never having heard of HIVST compared to household head and representatives. CONCLUSIONS: Around one fifth of survey participants remain unaware of HIVST even after an intensive community-based door-to-door HIVST distribution. Of note, those least likely to have heard of self-testing were younger, less educated and less likely to have tested previously. Household heads appear to play an important role in granting or denying access to self-testing to other household members during door-to-door distribution. Differentiated distribution models are needed to ensure access to all. Trial registration PACTR, PACTR201607001701788. Registered 29 June 2016, https://pactr.samrc.ac.za/ PACTR201607001701788.

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In the late 1990s, an estimated 75% of pregnant women in Nepal were anaemic. Although iron and folic acid (IFA) supplements were available free of charge, coverage among pregnant women was very low. In response, the Government of Nepal launched the Iron Intensification Programme (IIP) in 2003 to improve the coverage of IFA supplementation and anthelminthic treatment during pregnancy, as well as promote the utilization of antenatal care. This review examined how the IIP programme contributed to Nepal's success in increasing the consumption of IFA supplements during pregnancy. Nepal's cadre of Female Community Health Volunteers were engaged in the IIP to support the community-based distribution of IFA supplements to pregnant women and complement IFA distribution through health facilities and outreach services. As a result, the country achieved a fourfold increase in the proportion of women who took IFA supplements during pregnancy between 2001 and 2016 (from 23% to 91%) and a 12-fold increase in the proportion who took IFA supplements for at least 90 days during pregnancy (from 6% to 71%). The increase in coverage of IFA supplements accompanied an increase in the coverage of antenatal care during the same period. By 2016, the prevalence of anaemia in pregnant women decreased to 46%, highlighting the need to tackle other causes of anaemia and improve haemoglobin concentration before pregnancy, while maintaining the successful efforts to reach pregnant women with IFA supplements at the community level.

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BACKGROUND: Clients must recall information from contraceptive counseling sessions to properly use their chosen method. Client recall in community-based settings is challenging given the public nature of these events and the presence of many potential distractions. Understanding the factors that influence client recall during community-based distribution events can guide future training of providers to improve proper use of contraceptive methods and client satisfaction. METHODS: This cross-sectional study employed a convenience sample of 957 women ages 15-49 old who sought contraceptive services from community-based contraceptive distribution events in Kinshasa, Democratic Republic of the Congo, known as Lelo PF. Recall scores were developed by matching direct observations with client exit interviews. The association between recall and client characteristics, provider characteristics and an index for the quality of the provider-client interaction were tested using multivariate linear regression. RESULTS: The average recall score was 67.6%. Recall scores were higher among clients who accepted methods with simpler administration procedures, such as CycleBeads (81.3%), compared to methods requiring more medically advanced administration procedures, such as DMPA-SC (56.6%) and Implanon-NXT (62.1%). This relationship held even after controlling for amount of information each client received. Status as a first-time user was associated with a 5.8 percentage point decrease in recall score (p = 0.002). Time since the provider's initial family planning training and clients' perception of the provider-client interaction were associated with higher client recall scores. CONCLUSION: Results of this study suggest that to improve client recall at Lelo PF events, future provider training should focus on how to deliver clear, specific information to clients, making sure clients feel at ease during the counseling session, and treating clients with respect. First-time family planning users and clients who select methods with more medically advanced administration procedures may require extra attention during the consultation to ensure they are able understand and remember the information. Results suggest that providers who have been offering services longer may be more effective in conveying information in a way that clients can remember. Program managers should consider requesting input from experienced providers to improve training sessions.

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BACKGROUND: The significant contribution of community-based distribution (CBD) of family planning services and contraceptives to the uptake of contraceptives in hard-to-reach communities has resulted in the scaling-up of this approach in many Sub-Saharan countries. However, contextual factors need to be taken into consideration. For example, social network influence (e.g. spouse/partner, in-laws, and parents) on fertility decisions in many African and Asian societies is inevitable because of the social organisational structures. Hence the need to adapt CBD strategies to the social network context of a given society. METHODS: Data collection involved structured interviews from August 2018 to March 2019. Randomly selected respondents (n = 149) were recruited from four purposively selected health facilities in Lusaka district, Zambia. Respondents were screened for age (> 15 yrs.) and marital status. A mix of categorical and qualitative data was generated. The Statistical Package for Social Sciences (SPSS®24) was used to carry out descriptive analysis and tests of association (Fisher's exact) while Nvivo®12 was used to analyse the qualitative data using a deductive thematic approach. RESULTS: The results indicate that pre-marriage counselling (pre-MC) influences key elements of the husband-wife relationship (p > 0.005), namely; sexual relationship, inter-personal communication, assignation of roles and responsibilities, leadership and authority. These elements of the husband-wife relationship also affect how spouses/partners interact when making fertility decisions. More importantly, the majority (86%) of the respondents indicated having a continuing relationship with their marriage counsellors because of the need to consult them on marital issues. CONCLUSION: Marriage counsellors, though hardly reported in fertility studies, are important 'constituents' of the social network in the Zambian society. This is because marriage counsellors are trusted sources of information about marital issues and often consulted about family planning but perceived not to have the correct information about modern contraceptives. In this context, pre-MC offers a readily available, sustainable and culturally appropriate platform for disseminating accurate information about modern contraceptives provided in a private and personal manner. Therefore, the CBD strategy in Zambia can harness marriage counsellors by recruiting and training them as community agents.

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This report aims to provide practical advice about the implementation of a public health monitoring system using both geographic information system technology and mobile health, a term used for healthcare delivery via mobile devices. application amongst household residents and community stakeholders in the limited resource community. A public health monitoring system was implemented in a semi-rural district in Thailand. The challenges encountered during implementation were documented qualitatively in a series of monthly focus group discussions, several community hearings, and many targeted interviews. In addition, lessons learned from the expansion of the program to 75 other districts throughout Thailand were also considered. All challenges proved solvable yielding several key pieces of advice for future project implementation teams. Specifically, communication between team members, anticipating technological challenges, and involvement of community members are critical. The problems encountered in our project were mainly related to the capabilities of the data collectors and technical issues of mobile devices, internet coverage, and the GIS application itself. During the implementation phase, progressive changes needed to be made to the system promptly, in parallel with community team building in order to get the highest public health impact.

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BACKGROUND: The use of implants has steadily increased in Kinshasa since 2013 but clinic-based access to this family planning method is limited due to distance and costs barriers. The objective of this study was to examine the feasibility and acceptability of providing Implanon NXT at the community level using medical and nursing students (M/N) as distributors, as part of a strategy to improve contraceptive uptake in the Democratic Republic of Congo. METHODS: A cohort of 531 women who chose to receive Implanon NXT from a M/N student during community-based campaign days participated in three rounds of a quantitative survey administered at the time of insertion of the method, and at 6 and 12 months later. We conducted descriptive analysis to assess the feasibility and acceptability of providing the method through M/N students in terms of method choice, user profiles, contraceptive history, experience with insertion and side effects, continuation / discontinuation of the method, and overall satisfaction with FP services as well as students' preparedness and capacity to safely offer the method, and their satisfaction with the experience.. RESULTS: The study demonstrated the feasibility of training students for community-based provision of Implanon NXT and 95% of them were satisfied with their experience. Acceptability of both the method and the service delivery strategy was high among participants, including among young and first-time contraceptive users. Out of the 441 women with a known outcome at 12 months, 92% still had Implanon NXT inserted, despite some of them reporting experiencing side effects. The vast majority (79%) would "strongly recommend" obtaining NXT from a M/N student if a friend wanted to avoid pregnancies. CONCLUSIONS: The provision of Implanon NXT at the community-level is a promising solution to address some of the barriers to accessing this method for women living in Kinshasa. However, strengthening pre-insertion counseling, particularly on expected side-effects and the possibility of early removal, is necessary to increase informed choice for the women and potentially limit method discontinuation.

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BACKGROUND: Efforts to expand access to family planning in rural Africa often focus on the deployment of community health agents (CHAs). METHODS: This paper reports on results of the impact of a randomized cluster trial of CHA deployment on contraceptive uptake among 3078 baseline and 2551 endline women of reproductive age residing in 50 intervention and 51 comparison villages in Tanzania. Qualitative data were collected to broaden understanding of method preference, reasons for choice, and factors that explain non-use. RESULTS: Regression difference-in-differences results show that doorstep provision of oral contraceptive pills and condoms was associated with a null effect on modern contraceptive uptake [p = 0.822; CI 0.857; 1.229]. Discussions suggest that expanding geographic access without efforts to improve spousal and social support, respect preference for injectable contraceptives, and address perceived risk of side-effects offset the benefits of adopting contraceptives provided by community-based services. CONCLUSIONS: The results of this study demonstrate that increasing access to services does not necessarily catalyze contraceptive use as method choice and spousal dynamics are key components of demand for contraception. Findings attest to the importance of strategies that respond to the climate of demand. TRIAL REGISTRATION: Controlled-Trial.com ISRCTN96819844. Retrospectively registered on 29.03.2012.

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BACKGROUND: Following the successful pilot of the community-based distribution of injectable contraceptives (CBDIC) by community health extension workers (CHEWs) in Gombe, northern Nigeria in 2010, there was a policy decision to scale-up the innovation to other parts of the country. However, there is limited understanding of health system factors that may facilitate or impede the successful scale-up of this innovation beyond the pilot site. Thus, this study assessed the health system readiness to deliver CBDIC in Nigeria and how this may influence the scale-up process. METHODS: This study was conducted in two Local Government Areas in Gombe State in September 2016. Seven key informant interviews were held with purposively sampled senior officials of the ministries of health at the federal and state levels as well as NGO program managers. Also, 10 in-depth interviews were carried out with health workers. All transcripts were analyzed using the thematic framework analysis approach. RESULT: The availability of a policy framework that supports task-shifting and task-sharing, as well as application of evidence from the pilot programme and capacity building programmes for health workers provided a favourable environment for scale-up. Health system challenges for the scale-up process included insufficient community health workers, resistance to the task-shifting policy from professional health groups (who should support the CHEWs), limited funding and poor logistics management which affected commodity distribution and availability. However, there were also a number of health worker innovations which kept the scale-up going. Health workers sometimes used personal resources to make up for logistics failures and poor funding. They often modify the process in order to adapt to the realities on the ground. CONCLUSION: This study shows health system weaknesses that may undermine scale-up of CBDIC. The study also highlights what happens when scale-up is narrowly focused on the intervention without considering system context, capacity and readiness. However, agency and discretionary decision-making among frontline health workers facilitated the process of scaling up, although the sustainability of this is questionable. Benefits observed during the pilot may not be realised on a larger scale if health system challenges are not addressed.

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INTRODUCTION: Community distribution of misoprostol to pregnant women in advance of labor is one of the compelling strategies for preventing postpartum hemorrhage. Concerns have been reported that misoprostol distribution could reduce facility delivery or lead to misuse of the medication. This scoping review was conducted to synthesize the evidence on the effect of community-based misoprostol distribution on rates of facility delivery, and to assess the frequency of mothers taking distributed misoprostol before delivery, and any harmful outcomes of such misuse. METHODS: We included peer-reviewed articles on misoprostol implementation from PubMed, Cochrane Review Library, Popline, and Google Scholars. Narrative synthesis was used to analyze and interpret the findings, in which quantitative and qualitative syntheses are integrated. RESULTS: Three qualitative studies, seven observational studies, and four experimental or quasi-experimental studies were included in this study. All before-after household surveys reported increased delivery coverage after the intervention: ranging from 4 to 46 percentage points at the end of the intervention when compared to the baseline. The pooled analysis of experimental and quasi-experimental studies involving 7564 women from four studies revealed that there was no significant difference in rates of facility delivery among the misoprostol and control groups [OR 1.011; 95% CI: 0.906-1.129]. A qualitative study among health professionals also indicated that community distribution of misoprostol for the prevention of postpartum hemorrhage is acceptable to community members and stakeholders and it is a feasible interim solution until access to facility birth increases. In the community-based distribution of misoprostol programs, self-administration of misoprostol by pregnant women before delivery was reported in less than 2% of women, among seven studies involving 11,108 mothers. Evidence also shows that most women who used misoprostol pills, used them as instructed. No adverse outcomes from misuse in either of the studies reviewed. CONCLUSIONS: The claim that community-based distribution of misoprostol would divert women who would have otherwise had institutional deliveries to have home deliveries and promote misuse of the medication are not supported with evidence. Therefore, community-based distribution of misoprostol can be an appropriate strategy for reducing maternal deaths which occur due to postpartum hemorrhages, especially in resource-limited settings.

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BACKGROUND: Studies have shown that social networks influence health behaviors, including the adoption of health innovations. This study explored the potential for early adopters of community health worker-delivered injectable contraceptives (CHWDIC) to influence the uptake of this innovation by women in their social networks. METHODS: This Social Network Analysis (SNA) study was conducted in Gombe, Nigeria. Twenty women who were early adopters of the CHWDIC were recruited. Each participant (ego) listed ten women of reproductive age (alters) with whom they related. An interviewer-administered questionnaire was used to collect from each ego, data about the nature of her relationship with each alter (ego-alter relationship), whether she talked about CHWDIC with each alter, and whether her listed alters talked to each other about CHWDIC (alter-alter relationship). Data were also collected on age, marital status and education level for each ego and alter. Data were analyzed with UCINET social network analysis software. Variables of interest include homophilia (similarity), density (number of ties as a proportion of possible ties), degree (popularity) and betweeness (frequency of connecting actor pairs who otherwise might not communicate). RESULTS: There were 20 egos and 200 alters. Between two thirds (alters) and three quarters (egos) of the women were 30 years or older. All of the egos and 196 (98%) of alters were married. Most of the networks had similar (homophilic) actors according to certain sociodemographic characteristics - ethnicity, age, education and type of marriage. More than 90% of the networks had density greater than 50%, suggesting high cohesion in most networks. The majority of actors in these networks used injectable contraceptives. In some of the networks, few actors with the highest prominence (betweeness centrality) were not users of injectable contraceptives. CONCLUSION: The study illustrates the application and feasibility of ego SNA in identifying champions and opinion leaders among women of reproductive age group. It also shows the influence of social networks on the diffusion of community-based injectable contraceptives, and how homophilic and dense networks may have positive health externality. The interrelatedness of network members' decision to adopt a health innovation was also demonstrated by the findings of this study.

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RATIONALE: Although many sub-Saharan African countries have scaled-up pilot projects of community-based distribution (CBD) of family planning services, the effects of the scaled-up CBDs on contraceptive use remain unclear. OBJECTIVE: We leveraged a national scale-up of Malawi's Learning and Innovation Population and Family Planning pilot to evaluate the effects of a scale-up of CBDs on contraceptive use. We also investigated whether education and income, two important determinants of contraceptive use behaviors, moderate the effects of the scaled-up CBDs. METHOD: We used the 2000/2004 and 2010/2016 Malawi Demographic and Health Surveys (N = 57,978) and difference-in-differences analyses to estimate the effects of the 2005 national scale-up of CBDs on modern contraceptive use. We used rural and urban communities as the intervention and comparison groups because the national CBDs were implemented only in rural communities. Contraceptive use is defined as the current use of any modern contraceptive method (e.g., pills) and was modelled using multilevel logistic regression. RESULTS: Prior to the implementation of the national scale CBDs (2000/2004), the probability of using contraceptives was 21.5% in rural communities and 26.3% in urban communities. After the scale-up (2010/2016), the probability of using contraceptives increased in both rural and urban communities but was greater in rural communities (44.9% vs. 42.9%). The effect attributable to the national scale CBDs was 6.8 percentage points (95% CI [3.3, 9.7]). The effects of the national CBDs were greater among uneducated and low-income women. CONCLUSIONS: These findings suggest that national CBDs increase overall contraceptive use, particularly in rural communities, and that poor and uneducated women benefit more from family planning interventions that reduce communication and financial barriers.

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OBJECTIVES: The subcutaneous depot medroxyprogesterone acetate (DMPA-SC) injectable contraceptive was introduced in South West Nigeria in 2015 through private sector channels. The introduction included community-based distribution and was supported by a social marketing approach. From program monitoring and evaluation, aimed at understanding performance, market reach and other process measures, we identify lessons learned to inform future scale-up efforts. METHODS: We synthesized the findings from a core set of key performance indicators collected through different methods: (1) implementer performance indicators, (2) phone survey of DMPA-SC users (n=541) with a follow-up after 3 months (n=342) and (3) in-depth interviews with 57 providers and 42 users of DMPA-SC. RESULTS: Distribution of DMPA-SC to private providers was concentrated in states with large urban populations. A shift toward focusing on high-volume family planning facilities coincided with a rapid increase in distribution in late 2016. Users reached in the phone survey were generally older and married with children; few were under age 25. Users and providers reported favorable opinions of DMPA-SC. Many users reported choosing DMPA-SC due to recommendations from providers and friends, and the hope of experiencing reduced side effects compared to other methods. While users reported positive experiences interacting with community-based distributors, the delivery model encountered a number of challenges - high turnover, low motivation, lack of an appropriate compensation package and logistical costs - and was ultimately disbanded. CONCLUSIONS: In the DMPA-SC introductory program in Nigeria, distribution was amplified when focused on high-volume contraceptive providers. Although community-based distribution can be one effective service delivery model for reaching underserved populations, more consideration for balancing cost recovery and public health goals through private sector approaches are needed in the context of South West Nigeria. Additional communications and outreach efforts are needed to reach younger, unmarried users with contraceptive services.

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OBJECTIVE: The aim of this study was to examine continuation of subcutaneous and intramuscular depot medroxyprogesterone acetate (DMPA-SC and DMPA-IM) when administered by facility-based health workers in Burkina Faso and Village Health Teams (VHTs) in Uganda. STUDY DESIGN: Participants were family planning clients of health centers (Burkina Faso) or VHTs (Uganda) who had decided to initiate injectable use. Women selected DMPA-SC or DMPA-IM and study staff followed them for up to four injections (providing 12 months of pregnancy protection) to determine contraceptive continuation. Study staff interviewed women at their first injection (baseline), second injection, fourth injection and if they discontinued either product. RESULTS: Twelve-month continuation in Burkina Faso was 50% for DMPA-SC and 47.4% for DMPA-IM (p=.41, N=990, 492 DMPA-SC and 498 DMPA-IM). Twelve-month continuation in Uganda was 77.8% for DMPA-SC and 77.4% for DMPA-IM (p=.85, N=1224, 609 DMPA-SC and 615 DMPA-IM). Reasons for discontinuation of DMPA across groups in Burkina Faso included side effects (90/492, 18.3%), being late for injection (68/492, 13.8%) and refusal of spouse (51/492, 10.4%). Reasons for discontinuation in Uganda included being late for injection (65/229, 28.4%), received from non-VHT (50/229, 21.8%) and side effects (34/229, 14.8%). Increased age (adjusted hazard ratio=0.98, p=.01) and partner acceptance of family planning (adjusted hazard ratio=0.48, p<.001) had protective effects against discontinuation in Burkina Faso; we did not find statistically significant variables in Uganda. CONCLUSIONS: There is no difference in 12-month continuation (through four injections) between DMPA-SC and DMPA-IM whether from facility-based health workers in Burkina Faso or VHTs in Uganda. Continuation was higher through community-based distribution in Uganda than health facilities in Burkina Faso. IMPLICATIONS: The subcutaneous formulation of depot medroxyprogesterone acetate (DMPA-SC) is increasingly available in Family Planning 2020 countries. Use of DMPA-SC does not appear to change continuation relative to traditional intramuscular DMPA. Growing evidence of DMPA-SC's suitability for community-based distribution and self-injection may yield indirect benefits for contraceptive continuation and help reach new users.

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OBJECTIVE: To evaluate the 12-month total direct costs (medical and nonmedical) of delivering subcutaneous depot medroxyprogesterone acetate (DMPA-SC) under three strategies - facility-based administration, community-based administration and self-injection - compared to the costs of delivering intramuscular DMPA (DMPA-IM) via facility- and community-based administration. STUDY DESIGN: We conducted four cross-sectional microcosting studies in three countries from December 2015 to January 2017. We estimated direct medical costs (i.e., costs to health systems) using primary data collected from 95 health facilities on the resources used for injectable contraceptive service delivery. For self-injection, we included both costs of the actual research intervention and adjusted programmatic costs reflecting a lower-cost training aid. Direct nonmedical costs (i.e., client travel and time costs) came from client interviews conducted during injectable continuation studies. All costs were estimated for one couple year of protection. One-way sensitivity analyses identified the largest cost drivers. RESULTS: Total costs were lowest for community-based distribution of DMPA-SC (US$7.69) and DMPA-IM ($7.71) in Uganda. Total costs for self-injection before adjustment of the training aid were $9.73 (Uganda) and $10.28 (Senegal). After adjustment, costs decreased to $7.83 (Uganda) and $8.38 (Senegal) and were lower than the costs of facility-based administration of DMPA-IM ($10.12 Uganda, $9.46 Senegal). Costs were highest for facility-based administration of DMPA-SC ($12.14) and DMPA-IM ($11.60) in Burkina Faso. Across all studies, direct nonmedical costs were lowest for self-injecting women. CONCLUSIONS: Community-based distribution and self-injection may be promising channels for reducing injectable contraception delivery costs. We observed no major differences in costs when administering DMPA-SC and DMPA-IM under the same strategy. IMPLICATIONS: Designing interventions to bring contraceptive service delivery closer to women may reduce barriers to contraceptive access. Community-based distribution of injectable contraception reduces direct costs of service delivery. Compared to facility-based health worker administration, self-injection brings economic benefits for women and health systems, especially with a lower-cost client training aid.

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BACKGROUND: Previous estimates of global palliative care development have not been based on official country data. AIM: The World Health Organization Noncommunicable Disease Country Capacity Survey of World Health Organization member state officials monitors countries' capacities for the prevention and control of noncommunicable diseases. In 2015, for the first time, questions were included on a number of palliative care development metrics to generate baseline data for monitoring global palliative care development. DESIGN: Participants were given instructions, a glossary of terms, and 3 months to complete this closed, non-randomized, online survey. Questions were developed through a consultative process with relevant technical World Health Organization departments. SETTING/PARTICIPANTS: Health ministry officials serving as noncommunicable disease focal points from 177 out of 194 (91%) of World Health Organization Member States completed the voluntary survey. RESULTS: This survey reveals that (a) a minority (37%) of countries have an operational national policy for noncommunicable diseases that includes palliative care, (b) palliative care is least likely to have funding available compared with other core noncommunicable disease services, and (c) there is a large country-income gradient for palliative care funding, oral morphine availability, and integration of palliative care services at the primary levels of the health system. CONCLUSION: Palliative care for noncommunicable disease patients must be strengthened in a majority of countries. These data provide a baseline for trend measurement of official country-level and global palliative care development. A repeat assessment is taking place in the first half of 2017.

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OBJECTIVE: The present literature review aimed to review the evidence for community-based distribution (CBD) of iron-folic acid (IFA) supplementation as a feasible approach to improve anaemia rates in low- and middle-income countries. DESIGN: The literature review included peer-reviewed studies and grey literature from PubMed, Cochrane Library, LILAC and Scopus databases. SETTING: Low- and middle-income countries. SUBJECTS: Non-pregnant women, pregnant women, and girls. RESULTS: CBD programmes had moderate success with midwives and community health workers (CHW) who counselled on health benefits and compliance with IFA supplementation. CHW were more likely to identify and reach a greater number of women earlier in pregnancy, as women tended to present late to antenatal care. CBD channels had greater consistency in terms of adequate supplies of IFA in comparison to clinics and vendors, who faced stock outages. Targeting women of reproductive age through school and community settings showed high compliance and demonstrated reductions in anaemia. CONCLUSIONS: CBD of IFA supplementation can be a valuable platform for improving knowledge about anaemia, addressing compliance and temporary side-effects of IFA supplements, and increasing access and coverage of IFA supplementation. Programmatic efforts focusing on community-based platforms should complement services and information provided at the health facility level. Provision of training and supportive supervision for CHW on how to counsel women on benefits, side-effects, and when, why, and how to take IFA supplements, as part of behaviour change communication, can be strengthened, alongside logistics and supply systems to ensure consistent supplies of IFA tablets at both the facility and community levels.

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OBJECTIVES: The objectives were to assess acceptors' attitudes toward Sayana® Press as a method and toward the mechanism of community-based distribution by medical and nursing (M/N) students, known locally as "DBCs," in Kinshasa, Democratic Republic of the Congo, and to evaluate the experience of these DBCs. STUDY DESIGN: In 2015, surveys were conducted among (1) acceptors of Sayana® Press on the day of the initial injection, (2) these same acceptors 3 months later and (3) the DBCs providing community-based services. The analysis was descriptive and involved no significance testing. RESULTS: Acceptors of Sayana® Press expressed high levels of satisfaction with the method, despite some pain experienced at injection and subsequent side effects. Although most were satisfied with the counseling and services received from the DBCs, less than one third realized that the providers were M/N students. The DBCs expressed satisfaction in serving as community-based distributors; more than 95% would recommend it to others. Their primary complaints were lack of remuneration, stockouts and need for greater supervision. CONCLUSIONS: Consistent with results from previous pilot introductions of Sayana® Press in three African countries, clients were highly satisfied with Sayana® Press as a method. The reported preference for resupply at health centers may reflect a lack of client awareness that the DBCs administering methods near the health center were not in fact staff from the health center. The pilot served to gain acceptance for the use of M/N students in community-based distribution, paving the way for additional task-shifting pilots in Kinshasa. IMPLICATIONS: Sayana® Press represents a promising new method for increasing access to modern contraception in low-income countries. The Kinshasa experience is the first to test the use of medical and nursing students as providers at the community level. The study reports high levels of satisfaction on three counts: acceptors of the contraceptive method, acceptors of the mode of service delivery, and DBCs in their role as providers of contraception at the community level. However, many clients were not aware that the DBCs were students. The study represents an important contribution to the literature on task-shifting, especially in a country with chronic shortages of healthcare personnel.

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BACKGROUND: The rising demand for chronic disease treatment and the barriers to accessing these medicines have led to the development of novel models for distributing medicines in South Africa's public sector, including distribution away from health centres, known as community-based distribution (CBD). In this article, we provide a typology of CBD models and outline perceived facilitators and barriers to their implementation using an adapted health systems framework with a view to analysing how future policy decisions on CBD could impact existing models and the health system as a whole. METHODS: A qualitative exploratory study comprising in-depth interviews and non-participant observations was conducted between 2012 and 2014 in one province. Study participants consisted of frontline healthcare providers (HCPs) in the public sector and a few policy, supply chain and public health experts. Observations of processes occurred at two CBD sites. We conducted deductive analysis guided by the adapted framework. RESULTS: Models varied in typology ranging from formal (approved by the Department of Health) to informal (demand-driven) and with or without user-fees. Processes and structures also differed, as did HCPs' perceptions of what is appropriate. HCPs perceived that CBD models were largely acceptable to patients and accommodating of their needs. Affordability of services linked to charging of user-fees was a contested issue, requiring further exploration. CBD models operated in the absence of formal policy to guide implementation, and this, coupled with the involvement of non-health professionals, issues regarding medicines handling and storage; and limited patient counselling raised concerns about the quality of pharmaceutical services being delivered. Policy decisions on each of the health system elements will likely affect other elements and ultimately influence the structure and operational modalities of models. In anticipation of a future CBD policy, stakeholders cited the need for a context specific lens in order to harmonise with current implementation efforts. CONCLUSION: A formal policy on CBD is required in an effort to standardise services for quality assurance purposes. Frontline HCPs should be involved in the development of such policy to ensure that existing arrangements already working well are not undermined. Further research will seek to contribute towards evidence-based development of policy and service delivery guidelines for CBD activities in South Africa.

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OBJECTIVE: The ambitious '90-90-90' treatment targets require innovative models of care to support quality antiretroviral therapy (ART) delivery. While evidence for differentiated models of ART delivery is growing, there are few data on the feasibility of scale-up. We describe the implementation of the Adherence Club (AC) model across the Cape Metro health district in Cape Town, South Africa, between January 2011 and March 2015. METHODS: Using data from monthly aggregate AC monitoring reports and electronic monitoring systems for the district cohort, we report on the number of facilities offering ACs and the number of patients receiving ART care in the AC model. RESULTS: Between January 2011 and March 2015, the AC programme expanded to reach 32 425 patients in 1308 ACs at 55 facilities. The proportion of the total ART cohort retained in an AC increased from 7.3% at the end of 2011 to 25.2% by March 2015. The number of facilities offering ACs also increased and by the end of the study period, 92.3% of patients were receiving ART at a facility that offered ACs. During this time, the overall ART cohort doubled from 66 616 to 128 697 patients. The implementation of the AC programme offset this increase by 51%. CONCLUSIONS: ACs now provide ART care to more than 30 000 patients. Further expansion of the model will require additional resources and support. More research is necessary to determine the outcomes and quality of care provided in ACs and other differentiated models of ART delivery, especially when implemented at scale.

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