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BACKGROUND: The National TB elimination programme (NTEP) is facilitating sub-national certification of "TB Free" status with benchmarks at every 20% reduction in incidence from the baseline of 2015. Drug consumption/sale is essential criteria to claim for the award. During the certification process in 10 districts of Madhya Pradesh in 2022, it was found that Nikshay Aushadhi (a web-based supply chain management portal) entries were incomplete or vacant in most of the districts and it was observed that quarterly drug requests were not sent using Nikshay Aushadhi. Hence, present study was planned to explore the perceived challenges and suggested solutions from provider perspective, pertaining to Nikshay Aushadhi portal. METHODS: A descriptive qualitative study with two distinct but interrelated phases. Free listing to identify the perceived challenges and suggested solutions pertaining to Nikshay Aushadhi followed with key informant interviews to explore in detail. Finally, the findings obtained were triangulated to increase the heterogeneity and validity of the results. RESULT: Major perceived challenges identified were i) interrupted internet accessibility ii) frequent changes in portal iii) inadequate testing of portal before deployment/updates iii) excess, unutilized field in the portal iv & v) lack of frequent and effective training vi) quarterly drug request is not felt need vii) increased workload viii) lack of lack of human resource ix) lack of job actualization, and x) lack of digital literacy. Four major themes for suggested solutions were: i) improve the internet accessibility ii) frequent and effective training iii) job actualization and iv) improve the portal interface. CONCLUSION: If the internet and portal related issues are sorted out, the health care workers should be able to run this portal smoothly. Capacity building of the NTEP staff is of utmost importance.

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INTRODUCTION: The HIV Prevention 2025 Roadmap, developed by UNAIDS, recommends the adoption of a precision prevention approach focused on priority populations and geographies. With reduction in new HIV acquisitions in many countries, designing a differentiated HIV prevention response, using a Programme Science approach, based on the understanding of the epidemic and transmission dynamics at a sub-national level, is critical. METHODS: To support strategic planning, an epidemic appraisal at the sub-national level across 47 counties, with the 2019 population ranging from 0.14 million in Lamu to 4.40 million in Nairobi City, was conducted in Kenya using several existing data sources. Using 2021 Spectrum/EPP/Naomi model estimates of national and sub-national HIV incidence and prevalence, counties with high HIV incidence and prevalence were identified for geographic prioritization. The size of local key population (KP) networks and HIV prevalence in key and general populations were used to define epidemic typology and prioritize populations for HIV prevention programmes. Analysis of routine programme monitoring data for 2021 was used to assess coverage gaps in HIV prevention programmes, including prevention of vertical transmission, anti-retroviral therapy, KP programmes, adolescent girls and young women programme, and voluntary male medical circumcision programme. RESULTS: Ten counties with more than 1000 incident acquisitions in 2021 accounted for 57% of new acquisitions. Twenty-four counties were grouped into the concentrated epidemic type-due to their low prevalence in the general population, high prevalence in KPs and relatively higher density of female sex workers and men who have sex with men populations. Four counties reflected a generalized epidemic, where HIV prevalence was more than 10% and 30%, respectively, among the general and key populations. The remaining 19 counties were classified as having mixed epidemics. Gaps in programmes were identified and counties where these gaps need to be addressed were also prioritized. CONCLUSIONS: The HIV burden in Kenya is unevenly distributed and hence the mix of prevention strategies may vary according to the epidemic typology of the county. Prioritization of programmes based not only on disease burden and epidemic typology, but also on the prevailing gaps in coverage for reducing inequities is a key aspect of this appraisal.

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Equity and efficiency in health financing are intermediate universal health coverage (UHC) objectives. While there is growing attention to monitoring these goals at the national level, subnational assessment is also needed to uncover potential divergences across subnational units. We assessed whether health funds were allocated or contributed equitably and spent efficiently across 26 regions in Tanzania in 2017/18 for four sources of funding. Government and donor health basket fund (HBF) expenditure data were obtained from government authorities. Household contributions to health insurance and out-of-pocket payments were obtained from the national household budget survey. We used the Kakwani index (KI) to measure regional funding equity, whereby regional GDP per capita measured regional economic status. Efficiency analysis included four financing inputs and two UHC outputs (maternal health service coverage and financial protection indices). Data envelopment analysis estimated efficiency scores. There was substantial variation in per capita regional funding, especially in insurance contributions (TZS 473-13,520), and service coverage performance (49-86.3%). There was less variation in per capita HBF spending (TZS 1294-2394) and financial protection (93.5-99.4%). Government spending (KI: -0.047, p = 0.348) was proportional to regional economic status; but HBF spending (KI: -0.195, p < 0.001) was significantly progressive (equitably distributed), being targeted to regions with high economic need (poor). The burden of contributing to social health insurance (NHIF) was proportional (KI: 0.058, p = 0.613), while the burden of paying for community-based insurance (CHF, KI: -0.152, p=0.012) and out-of-pocket payments (KI: -0.187, p=0.005) was higher among the poor (regressive). The average efficiency score across regions was 90%, indicating that 90% of financial resources were used optimally, while 10% were wasted or underutilised. Tanzania should continue mobilising domestic resources for health towards UHC, and reduce reliance on inequitable out-of-pocket payments and community-based health insurance. Policymakers must enhance resource allocation formulas, public financial management, and sub-national resource tracking to improve equity and efficiency in resource use.

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Recent studies have established the key individual-level risk factors of COVID-19 mortality such as age, gender, ethnicity, and socio-economic status. However, the spread of infectious diseases is a spatial and temporal process implying that COVID-19 mortality and its determinants may vary sub-nationally and over time. We investigate the spatial patterns of age-standardised death rates due to COVID-19 and their correlates across local authority districts in England, Wales, and Scotland across three waves of infection. Using a Spatial Durbin model, we explore within- and between-country variation and account for spatial dependency. Areas with a higher share of ethnic minorities and higher levels of deprivation had higher rates of COVID-19 mortality. However, the share of ethnic minorities and population density in an area were more important predictors of COVID-19 mortality in earlier waves of the pandemic than in later waves, whereas area-level deprivation has become a more important predictor over time. Second, during the first wave of the pandemic, population density had a significant spillover effect on COVID-19 mortality, indicating that the pandemic spread from big cities to neighbouring areas. Third, after accounting for differences in ethnic composition, deprivation, and population density, initial cross-country differences in COVID-19 mortality almost disappeared. COVID-19 mortality remained higher in Scotland than in England and Wales in the third wave when COVID-19 mortality was relatively low in all three countries. Interpreting these results in the context of higher overall (long-term) non-COVID-19 mortality in Scotland suggests that Scotland may have performed better than expected during the first two waves. Our study highlights that accounting for both spatial and temporal factors is essential for understanding social and demographic risk factors of mortality during pandemics.

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BACKGROUND: Primary healthcare systems require adequate staffing to meet the needs of their local population. Guidelines typically use population ratio targets for healthcare workers, such as Ethiopia's goal of two health extension workers for every five thousand people. However, fixed ratios do not reflect local demographics, fertility rates, disease burden (e.g., malaria endemicity), or trends in these values. Recognizing this, we set out to estimate the clinical workload to meet the primary healthcare needs in Ethiopia by region. METHODS: We utilize the open-source R package PACE-HRH for our analysis, which is a stochastic Monte Carlo simulation model that estimates workload for a specified service package and population. Assumptions and data inputs for region-specific fertility, mortality, disease burden were drawn from literature, DHS, and WorldPop. We project workload until 2035 for seven regions and two charted cities of Ethiopia. RESULTS: All regions and charted cities are expected to experience increased workload between 2021 and 2035 for a starting catchment of five thousand people. The expected (mean) annual clinical workload varied from 2,930 h (Addis) to 3,752 h (Gambela) and increased by 19-28% over fifteen years. This results from a decline in per capita workload (due to declines in fertility and infectious diseases), overpowered by total population growth. Pregnancy, non-communicable diseases, sick child care, and nutrition remain the largest service categories, but their priority shifts substantially in some regions by 2035. Sensitivity analysis shows that fertility assumptions have major implications for workload. We incorporate seasonality and estimate monthly variation of up to 8.9% (Somali), though most services with high variability are declining. CONCLUSIONS: Regional variation in demographics, fertility, seasonality, and disease trends all affect the workload estimates. This results in differences in expected clinical workload, the level of uncertainty in those estimates, and relative priorities between service categories. By showing these differences, we demonstrate the inadequacy of a fixed population ratio for staffing allocation. Policy-makers and regulators need to consider these factors in designing their healthcare systems, or they risk sub-optimally allocating workforce and creating inequitable access to care.

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BACKGROUND: Performance based financing was introduced to Kilifi county in Kenya in 2015. This study investigates how and why political and bureaucratic actors at the local level in Kilifi county influenced the extent to which PBF was politically prioritised at the sub-national level. METHODS: The study employed a single-case study design. The Shiffman and Smith political priority setting framework with adaptations proposed by Walt and Gilson was applied. Data was collected through document review (n=19) and in-depth interviews (n=8). Framework analysis was used to analyse data and generate findings. RESULTS: In the period 2015-2018, the political prioritisation of PBF at the county level in Kilifi was influenced by contextual features including the devolution of power to sub-national actors and rigid public financial management structures. It was further influenced by interpretations of the idea of 'pay-for-performance', its framing as 'additional funding', as well as contestation between actors at the sub national level about key PBF design features. Ultimately PBF ceased at the end of 2018 after donor funding stopped. CONCLUSION: Health reformers must be cognisant of the power and interests of national and sub national actors in all phases of the policy process, including both bureaucratic and political actors in health and non-health sectors. This is particularly important in devolved public governance contexts where reforms require sustained attention and budgetary commitment at the sub national level. There is also need for early involvement of critical actors to develop shared understandings of the ideas on which interventions are premised, as well as problems and solutions.

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Background: Avoidable mortality, including both treatable and preventable deaths, is frequently used as an indicator of health system performance. Whilst the term treatable mortality refers to deaths that might be averted by medical interventions, preventable mortality generally reflects the impact of system-wide health policies. The concept of preventable mortality has not been evaluated extensively in the Russian Federation, particularly at the regional or sub-national (oblast) level. Methods: We calculated total preventable mortality as well as individual rates for males and females in each oblast using data from the Russian Fertility and Mortality Database (RusFMD) and computed the contributions of specific preventable causes of death to the overall rates. We also evaluated the relationship between preventable mortality and its main correlates during the years 2014-2018 using panel fixed effects modelling with variables that reflected both, behavioural risk factors and access to health care. Findings: Overall preventable mortality in the Russian Federation has been on a downward trend. Whilst 548 preventable deaths per 100,000 person-years were reported in the year 2000, only 301 per 100,000 person-years were reported in 2018. Whilst mortality due to cancer, cardiovascular, and alcohol-related diseases has declined (albeit unevenly) amongst both males and females, deaths resulting from complications of diabetes and human immunodeficiency virus infection have increased. Our findings also revealed significant heterogeneity in preventable mortality at the oblast level. For example, in 2018, deaths due to preventable causes were concentrated primarily in Siberia and the Far East. Smoking and the availability of nurses were identified as significant correlates of preventable mortality at the oblast level. Interpretations: Efforts designed to strengthen the current health care system, notably those serving the rural and less densely populated oblasts, might reduce the rate of preventable mortality in Russia. These efforts might be coupled with an ongoing focus on programs designed to reduce smoking. Funding: None.

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Green production is one of the major debates as environmental degradation poses threats globally. The paper attempts to explore the relationship between green production and environmental quality by using Economic Fitness approach. We develop a Green Complexity Index (GCI) dataset consisting of 290 traded green-labeled products and Economic Fitness Index (EFI) for the US states between 2002 and 2018. We analyze the environmental performance of green production using the GCI and EFI data at the sub-national level. Findings indicate that exporting more complex green products has insignificant effects on local (i.e., sulfur dioxide, particulate Matter 10) and global polluters such as carbon dioxide, even accounting for per capita income. Yet, economic fitness has a significant negative impact on the emission levels implying that sophisticated production significantly improves environmental quality in the USA. The insignificant impact of GCI on environmental degradation suggests that green product classifications should incorporate the production and end-use stages of goods to limit the adverse environmental effects of green-labeled products.

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BACKGROUND: In malaria endemic countries, seasonal malaria chemoprevention (SMC) interventions are performed during the high malaria transmission in accordance with epidemiological surveillance data. In this study we propose a predictive approach for tailoring the timing and number of cycles of SMC in all health districts of Mali based on sub-national epidemiological surveillance and rainfall data. Our primary objective was to select the best of two approaches for predicting the onset of the high transmission season at the operational scale. Our secondary objective was to evaluate the number of malaria cases, hospitalisations and deaths in children under 5 years of age that would be prevented annually and the additional cost that would be incurred using the best approach. METHODS: For each of the 75 health districts of Mali over the study period (2014-2019), we determined (1) the onset of the rainy season period based on weekly rainfall data; (ii) the onset and duration of the high transmission season using change point analysis of weekly incidence data; and (iii) the lag between the onset of the rainy season and the onset of the high transmission. Two approaches for predicting the onset of the high transmission season in 2019 were evaluated. RESULTS: In the study period (2014-2019), the onset of the rainy season ranged from week (W) 17 (W17; April) to W34 (August). The onset of the high transmission season ranged from W25 (June) to W40 (September). The lag between these two events ranged from 5 to 12 weeks. The duration of the high transmission season ranged from 3 to 6 months. The best of the two approaches predicted the onset of the high transmission season in 2019 to be in June in two districts, in July in 46 districts, in August in 21 districts and in September in six districts. Using our proposed approach would prevent 43,819 cases, 1943 hospitalisations and 70 deaths in children under 5 years of age annually for a minimal additional cost. Our analysis shows that the number of cycles of SMC should be changed in 36 health districts. CONCLUSION: Adapting the timing of SMC interventions using our proposed approach could improve the prevention of malaria cases and decrease hospitalisations and deaths. Future studies should be conducted to validate this approach.

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Against the backdrop of universal healthcare coverage and pre-existing policies on antimicrobial use, China has adopted a state-governed, multi-level, top-down policy governance approach around an antimicrobial resistance (AMR) national action plan (NAP). The Plan relies on tightening control over antimicrobial prescription and use in human and animal sectors. At the same time, medical doctors and veterinarians operate in an environment of high rates of infectious diseases, multi-drug resistance and poor livestock husbandry. In exploring the way that policy responsibilities are distributed, this study aims to describe how Guangdong as a province adopts national AMR policies in a tightly controlled public policy system and an economy with high disparity. We draw on an analysis of 225 AMR-relevant Chinese policy documents at the national and sub-national levels. We adopt a multi-level governance perspective and apply a temporal sequence framework to identify and analyse documents. To identify policy detail, we conducted keyword analysis using the Consolidated Framework for Implementation Research (CFIR) on policies that conserve antimicrobials. We also identify pre-existing medical and public policies associated with AMR. Our findings highlight the emphasis and policies around antimicrobial use regulation to address AMR in China.

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BACKGROUND: Recent global reports highlighted the importance of addressing the quality of care in all settings including fragile and conflict-affected situations (FCS), as a central strategy for the attainment of sustainable development goals and universal health coverage. Increased mortality burden in FCS reflects the inability to provide routine services of good quality. There is also paucity of research documenting the impact of conflict on the quality of care within fragile states including disparities in service delivery. This study addresses this measurement gap by examining disparities in the quality of primary healthcare services in four conflict-affected fragile states using proxy indicators. METHODS: A secondary analysis of publicly available data sources was performed in four conflict-affected fragile states: Cameroon, the Democratic Republic of Congo, Mali, and Nigeria. Two main databases were utilized: the Demographic Health Survey and the Uppsala Conflict Data Program for information on components of care and conflict events, respectively. Three equity measures were computed for each country: absolute difference, concentration index, and coefficients of mixed-effects logistic regression. Each computed measure was then compared according to the intensity of organized violence events at the neighborhood level. RESULTS: Overall, the four studied countries had poor quality of PHC services, with considerable subnational variation in the quality index. Poor quality of PHC services was not only limited to neighborhoods where medium or high intensity conflict was recorded but was also likely to be observed in neighborhoods with no or low intensity conflict. Both economic and educational disparities were observed in individual quality components in both categories of conflict intensity. CONCLUSION: Each of the four conflict-affected countries had an overall poor quality of PHC services with both economic and educational disparities in the individual components of the quality index, regardless of conflict intensity. Multi-sectoral efforts are needed to improve the quality of care and disparities in these settings, without a limited focus on sub-national areas where medium or high intensity conflict is recorded.

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BACKGROUND: This article reports an evaluation of the Immunization Training Challenge Hackathons (ITCH), invented by The Geneva Learning Foundation (TGLF) for national and sub-national immunization staff who strive to develop the knowledge and capacity of others to improve immunization program performance. ITCH, a fully-digital program focused on networked collaborative problem-solving between peers, provided an "opt-in" activity for learners in the Teach to Reach (T2R) Accelerator Program designed to improve training effectiveness in the immunization sphere. METHODS: Conducted by a team from the University of Georgia, this mixed method evaluation consisted of thematic analysis of recorded sessions and open-ended comments; and statistical analyses of application and follow-up survey data. The evaluation focused on what was learned and how ITCH participants implemented what they learned. Key stakeholder interviews provided supplemental data about program intent and results. ITCH consisted of 17 30-min sessions held in 2020, in English and French, with 581 participating at least once out of 1,454 enrolled in the overall program. Challenge owners and respondents came from 15 African and Asian countries and spanned different roles with differing scope. RESULTS: Over 85% [n = 154] of survey respondents [n = 181, a 31% response rate] indicated they were able to implement what they learned from the ITCH sessions. A majority [n = 139, 76.7%] reported finding the sessions useful. Issues with poor connectivity and the timing of the live meetings impeded some in their ability to participate, a problem compounded by consequences of the pandemic. The ITCH process constituted of learning or coming to consciousness simultaneously of four types of learning - participants realizing how much they could learn from each other (peer learning), experiencing the power of defying distance to solve problems together (remote learning), and feeling a growing sense of belonging to a community (social learning), emergent across country borders and health system levels (networked learning). CONCLUSIONS: Based on evaluation findings, it was concluded that ITCH demonstrated an effective scalable, informal, non-didactic, experience-led, fast-paced, peer learning design. A focus on community engagement and developing brokering skills was recommended.

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Developing effective strategies to alleviate increasing water stress in China requires an understanding of how consumption and production drive water stress footprints (WSF) at a high resolution and multiple spatial and temporal scales. However, current Chinese multi-regional input-output (CMRIO) models have limited resolution. Here, we build a high-resolution international MRIO model covering 31 Chinese provinces, 163 sectors, to address this issue, and then analyze the impact of changes in China's interprovincial and international trade patterns on the WSF from 2012 to 2017. We find that China's water stress embodied in inter-provincial trade has increased year after year, to 5606 km3 H2O-eq in 2017, exceeding 50 % of the total domestic footprint. Domestic water stress transfer is most apparent in the outsourcing of water stress from eastern coastal regions to Central and Western regions, with the top interregional supply chain paths mainly associated with the demand of processed rice and tobacco products. China has transformed into a net exporter of water stress in 2017, with water stress exports to developing countries accounting for 54 % of total exports, up from 51 % in 2012. With deepening globalization, trade between China and developing countries has boosted bilateral economic development, while also exacerbating water stress in China. In addition to agricultural cultivation, industrial products such as plastics and steel exported to meet international industries further contribute to water stress in Northern China. Further identify hotspots of water stress consumption is needed to prioritize actions to relieve regional water stress in a more effective manner, and our study can provide key information.

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The current study investigates whether tournament incentives motivate chief executive officer(s) (CEOs) to be socially responsible. Furthermore, it explores the role of sub-national institutional contingencies [i.e., state-owned enterprises (SOE) vs. non-SOEs, foreign-owned entities (FOE) vs. non-FOEs, cross-listed vs. non-cross-listed, developed region] in CEO tournament incentives and the corporate social responsibility performance (CSRP) relationship. Data were collected from all A-shared companies listed in the stock exchanges of China from 2014 to 2019. The study uses the baseline methodology of ordinary least squares (OLS) and cluster OLS regression. Moreover, firm-fixed effects regression, two-stage least squares regression, and propensity score matching deal with the endogeneity problem and check the robustness of the results. The results provide reliable evidence that tournament incentives motivate CEOs to be more socially responsible. On the other hand, sub-national institutional contingencies positively affect the association between CEO tournament incentives and CSRP. The findings have important implications for companies and regulators who wish to enhance CSP by providing incentives to top managers.

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BACKGROUND: Devolution of healthcare services in Kenya resulted in a large number of newly recruited tuberculosis (TB) coordinators. We describe a unique collaboration between a national tuberculosis program (NTP), a local, and an international non-governmental organization to build human resource capacity in TB care and prevention. METHODS: From 2016 to 2021, the Kenya Division of National Tuberculosis, Leprosy and Lung Disease Program, Centre for Health Solutions-Kenya, and the International Union Against Tuberculosis and Lung Disease developed and conducted a series of 7-day training courses. A key focus of training was the introduction of TBData4Action, an approach involving the local use of routinely available data to strengthen decision-making and support supervision. RESULTS: Implementation outcomes included training 331 (96%) coordinators out of 344, representing all 47 counties, 37 national officers and 21 other stakeholders using the country-tailored curriculum, including hands-on group work by county teams and field practicals. Thirty-five national facilitators were identified and mentored as local faculty. Training costs were reduced by 75% compared with international alternatives. CONCLUSION: The collaboration resulted in the training of the majority of the coordinators in a standardized approach to TB care. A sustainable approach to capacity building in local data use was found feasible; the model could be adapted by other NTPs.

CONTEXTE: La décentralisation des services de santé au Kenya a conduit au recrutement d'un grand nombre de nouveaux coordinateurs TB. Nous décrivons une collaboration unique entre un programme national de lutte contre la TB (NTP), une organisation non gouvernementale locale et une organisation non gouvernementale internationale visant à renforcer les capacités humaines en matière de prévention et de soins de la TB. MÉTHODES: De 2016 à 2021, la division kényane du programme national de lutte contre la tuberculose, la lèpre et les maladies respiratoires, le Centre for Health Solutions-Kenya et l'Union internationale contre la tuberculose et les maladies respiratoires ont développé et dispensé une série de formations en 7 jours. La formation mettait l'accent sur l'introduction de l'approche TBData4Action, qui promeut une utilisation locale des données disponibles en routine afin de renforcer la prise de décision et d'épauler les activités de supervision. RÉSULTATS: Les résultats de la mise en place de cette formation comprenaient la formation de 331 (96%) coordinateurs sur 344, représentant l'ensemble des 47 pays, 37 administrateurs nationaux et 21 autres acteurs formés à l'aide du programme adapté aux besoins du pays concerné (dont travail de groupe pratique par les équipes nationales et travaux pratiques sur le terrain). Trente-cinq facilitateurs nationaux ont été identifiés et formés comme enseignants locaux. Les coûts de la formation ont été réduits de 75% par rapport aux alternatives internationales. CONCLUSION: La collaboration a permis de former la majorité des coordinateurs à l'aide d'une approche standardisée de soins de la TB. Une approche durable de renforcement des capacités en matière d'utilisation des données locales s'est avérée réalisable. Ce modèle peut être adapté à d'autres NTP.

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BACKGROUND: District management is emerging as a lynchpin for primary healthcare system performance. However, delivery of district-level interventions at scale is challenging, and overlooks the potential role of management at other subnational levels. From 2015-2019, Ethiopia's Primary Healthcare Transformation Initiative (PTI), aimed to build a culture of performance management and accountability at the zonal level. This paper aims to evaluate the longitudinal change in management practice and performance in the 19 zones participating in PTI, which included 315 districts and 1617 health centers. METHODS: Using data from PTI intervention (2018 to 2019), we employed quantitative measures of management capacity at health center, district, and zonal levels, and quantified primary healthcare service performance using a summary score based on antenatal care coverage, contraception use, skilled birth attendance, infant immunization, and availability of essential medications. We used multiple generalized linear regression models accounting for clustering of health centers within zones to quantify (1) change in management and performance during the two-year intervention, (2) associations between the changes in management capacity at the zonal, district, and health facility level. RESULTS: Adherence to management standards at the zonal, district, and health facility level improved significantly over two years (37%, P<.001; 18%, P<.001; 18%, P<.001; respectively), as did the performance summary score (14%, P<.001). Adherence at the zonal level in year one was associated with district level adherence in year one (P=.04), and, over the two-year period (P=.002), and district management mediated the relationship between management practice at zonal and health center levels (P<.001). CONCLUSION: Improvements in zonal-level management practice were associated with significant improvements in district-level management and performance in PTI sites. Investments in managerial practices at the zonal level may provide an immediate way to energize primary healthcare system performance at scale in low-income country settings.

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BACKGROUND: In many places, health workers at the sub-national level are on the frontlines of disseminating information about coronavirus (COVID-19) to communities. To ensure communities are receiving timely and accurate information, it is vital health workers are kept abreast of the most recent recommendations, and guidance. METHODS: An electronic survey was implemented to provide insights about the dissemination and utilisation of information and evidence related to the COVID-19 pandemic by health workers engaged at sub-national levels of the Ugandan health system. The aim of this survey was to provide insights about the dissemination and utilisation of information and evidence related to the coronavirus (COVID-19) pandemic by individuals engaged at sub-national levels of the health system. RESULTS: Mass media and public health campaigns and outreach activities were deemed the most suitable means to reach communities with COVID-19 information. Given the reported disruption to public outreach campaigns, this is a particularly important consideration for the provision of information to communities. All materials should be adapted to the local context. The need for information on homecare of COVID-19 patients was highlighted, along with the need for updated local statistics as to COVID-19 cases to be relayed for health workers at sub-national levels. CONCLUSIONS: Understanding the sources of information used by health workers can facilitate the transfer of relevant and timely information, which in turn increases the use of such information by the Ugandan population. It is vital that these issues are continued to be monitored, and communication modes and content are actively responsive to the time- and place-specific needs of health workers and community members.

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BACKGROUND: Poor access to health care providers was among the contributing factors to less prompt and ineffective malaria treatment. This limitation could cause severe diseases in remote areas. This study examined the sub-national disparities and predictors in accessing anti-malarial drug treatment among adults in Eastern Indonesia. METHODS: The study analyzed a subset of the 2018 National Basic Health Survey conducted in all 34 provinces in Indonesia. We extracted socio-demographic data of 4655 adult respondents diagnosed with malaria in the past 12 months in five provinces in Eastern Indonesia. The association between socio-demographic factors and the access to anti-malarial drug treatment was assessed using logistic regression. RESULTS: Over 20% of respondents diagnosed with malaria within last 12 months admitted that they did not receive anti-malarial drug treatment (range 12-29.9%). The proportion of untreated cases was 12.0% in East Nusa Tenggara, 29.9% in Maluku, 23.1% in North Maluku, 12.7% in West Papua, and 15.6% in Papua. The likelihood of receiving anti-malarial drug treatment was statistically lower in Maluku (adjusted OR = 0.258; 95% CI 0.161-0.143) and North Maluku (adjusted OR = 0.473; 95% CI 0.266-0.840) than those in Eastern Nusa Tenggara (reference). Urban respondents were less likely to receive malaria treatment than rural (adjusted OR = 0.545; 95% CI 0.431-0.689). CONCLUSIONS: This study found that there were sub-national disparities in accessing anti-malarial drug treatment in Eastern Indonesia, with a high proportion of untreated malaria cases across the areas. Findings from this study could be used as baseline information to improve access to anti-malarial drug treatment and better target malaria intervention in Eastern Indonesia.

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BACKGROUND: During the millennium development goals period, reduction in under-five mortality (U5M) and increases in child health intervention coverage were characterised by sub-national disparities and inequities across Kenya. The contribution of changing risk factors and intervention coverage on the sub-national changes in U5M remains poorly defined. METHODS: Sub-national county-level data on U5M and 43 factors known to be associated with U5M spanning 1993 and 2014 were assembled. Using a Bayesian ecological mixed-effects regression model, the relationships between U5M and significant intervention and infection risk ecological factors were quantified across 47 sub-national counties. The coefficients generated were used within a counterfactual framework to estimate U5M and under-five deaths averted (U5-DA) for every county and year (1993-2014) associated with changes in the coverage of interventions and disease infection prevalence relative to 1993. RESULTS: Nationally, the stagnation and increase in U5M in the 1990s were associated with rising human immunodeficiency virus (HIV) prevalence and reduced maternal autonomy while improvements after 2006 were associated with a decline in the prevalence of HIV and malaria, increase in access to better sanitation, fever treatment-seeking rates and maternal autonomy. Reduced stunting and increased coverage of early breastfeeding and institutional deliveries were associated with a smaller number of U5-DA compared to other factors while a reduction in high parity and fully immunised children were associated with under-five lives lost. Most of the U5-DA occurred after 2006 and varied spatially across counties. The highest number of U5-DA was recorded in western and coastal Kenya while northern Kenya recorded a lower number of U5-DA than western. Central Kenya had the lowest U5-DA. The deaths averted across the different regions were associated with a unique set of factors. CONCLUSION: Contributions of interventions and risk factors to changing U5M vary sub-nationally. This has important implications for targeting future interventions within decentralised health systems such as those operated in Kenya. Targeting specific factors where U5M has been high and intervention coverage poor would lead to the highest likelihood of sub-national attainment of sustainable development goal (SDG) 3.2 on U5M in Kenya.

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BACKGROUND: Persisting within-country disparities in maternal health service access are significant barriers to attaining the Sustainable Development Goals aimed at reducing inequalities and ensuring good health for all. Sub-national decision-makers mandated to deliver health services play a central role in advancing equity but require appropriate evidence to craft effective responses. We use spatial analyses to identify locally-relevant barriers to access using sub-national data from rural areas in Jimma Zone, Ethiopia. METHODS: Cross-sectional data from 3727 households, in three districts, collected at baseline in a cluster randomized controlled trial were analysed using geographically-weighted regressions. These models help to quantify associations within women's proximal contexts by generating local parameter estimates. Data subsets, representing an empirically-identified scale for neighbourhood, were used. Local associations between outcomes (antenatal, delivery, and postnatal care use) and potential explanatory factors at individual-level (ex: health information source), interpersonal-level (ex: companion support availability) and health service-levels (ex: nearby health facility type) were modelled. Statistically significant local odds ratios were mapped to demonstrate how relevance and magnitude of associations between various explanatory factors and service outcomes change depending on locality. RESULTS: Significant spatial variability in relationships between all services and their explanatory factors (p < 0.001) was detected, apart from the association between delivery care and women's decision-making involvement (p = 0.124). Local models helped to pinpoint factors, such as danger sign awareness, that were relevant for some localities but not others. Among factors with more widespread influence, such as that of prior service use, variation in estimate magnitudes between localities was uncovered. Prominence of factors also differed between services; companion support, for example, had wider influence for delivery than postnatal care. No significant local associations with postnatal care use were detected for some factors, including wealth and decision involvement, at the selected neighbourhood scale. CONCLUSIONS: Spatial variability in service use associations means that the relative importance of explanatory factors changes with locality. These differences have important implications for the design of equity-oriented and responsive health systems. Reductions in within-country disparities are also unlikely if uniform solutions are applied to heterogeneous contexts. Multi-scale models, accommodating factor-specific neighbourhood scaling, may help to improve estimated local associations.

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