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Background From 1990 to 2015, the number of maternal deaths globally has dropped by 43%. Despite this, progress in attaining MDG 5 is not remarkable in LMICs. Only 52% of pregnant women in LMICs obtain WHO recommended minimum of four antenatal consultations and the coverage of postnatal care is relatively poor. In recent years, the increased cellphone penetration has brought the potential for mHealth to improve preventive maternal healthcare services. The objective of this review is to assess the effectiveness of mHealth solutions on a range of maternal health outcomes by categorizing the interventions according to the types of mHealth applications. Methods Three international online electronic databases were searched between January 1, 2000 and January 25, 2016 to identify studies exploring the role of mHealth solutions in improving preventive maternal healthcare services. Of 1262 titles screened after duplication, 69 potentially relevant abstracts were obtained. Out of 69 abstracts, 42 abstracts were shortlisted. Full text of 42 articles was reviewed using data extraction sheet. A total of 14 full text studies were included in the final analysis. Results The 14 final studies were categorized in to five mHealth applications defined in the conceptual framework. Based on our analysis, the most reported use of mHealth was for client education and behavior change communication, such as SMS and voice reminders [ n  = 9, 65%]. The categorization provided the understanding that much work have been done on client education and behavior change communication. Most of the studies showed that mHealth interventions have proven to be effective to improve antenatal care and postnatal care services, especially those that are aimed at changing behavior of pregnant women and women in postnatal period. However, little evidence exists on other type of mHealth applications. Conclusion This review suggests that mHealth solutions targeted at pregnant women and women in postnatal period can improve preventive maternal healthcare services. However, there is a need to conduct more controlled-trials and quasi-experimental studies to strengthen the literature in this research area. The review recommends that mHealth researchers, sponsors, and publishers should prioritize the transparent reporting of interventions to allow effective interpretation of extracted data.

Background Since the advent of democracy, the South African government has been putting charters, policies, strategies and plans in place in an effort to strengthen public health system performance and enhance service delivery. However, public health programme performance and outcomes remained poor while the burden of disease increased. This was also the case in the Free State Province, where major public health system challenges occurred around 2012. Assessment was necessary in order to inform health system strengthening. Methods The study entailed a multi-method situation appraisal utilising information collated in 44 reports generated in 2013 through presentations by unit managers, subdistrict assessments by district clinical specialist teams, and group discussions with district managers, clinic supervisors, primary health care managers and chief executive and clinical officers of hospitals. These data were validated through community and provincial health indabas including non-governmental organisations, councils and academics, as well as unannounced facility visits involving discussions with a wide range of functionaries and patients. The reports were reviewed using the World Health Organization health system building blocks as a priori themes with subsequent identification of emerging subthemes. Data from the different methods employed were triangulated in a causal loop diagram showing the complex interactions between the components of an (in) effective health system. Results The major subthemes or challenges that emerged under each a priori theme included: firstly, under the ‘ service delivery ’ a priori theme, ‘ fragmentation of health services ’ (42 reports); secondly, under the ‘ health workforce ’ a priori theme, ‘ staff shortages ’ (39 reports); thirdly, under the ‘ health financing ’ a priori theme, ‘ financial/cash-flow problems ’ (39 reports); fourthly, under the ‘ leadership and governance ’ a priori theme, ‘ risk to patient care ’ (38 reports); fifthly, under the ‘ medical products/technologies ’ a priori theme, ‘ dysfunctional communication technology ’ (27 reports); and, sixthly, under the ‘ information ’ a priori theme, ‘ poor information management ’ (26 reports). Conclusion The major overall public health system challenges reported by stakeholders involved fragmentation of services, staff shortages and financial/cash-flow problems. In order to effect health systems strengthening there was particularly a need to improve integration and address human and financial deficiencies in this setting.

Background Out-of-hospital emergency care (OHEC), also known as prehospital care, has been shown to reduce morbidity and mortality from serious illness. We sought to summarize literature for low and low-middle income countries to identify barriers to and key interventions for OHEC delivery. Methods We performed a systematic review of the peer reviewed literature from January 2005 to March 2015 in PubMed, Embase, Cochrane, and Web of Science. All articles referencing research from low and low-middle income countries addressing OHEC, emergency medical services, or transport/transfer of patients were included. We identified themes in the literature to form six categories of OHEC barriers. Data were collected using an electronic form and results were aggregated to produce a descriptive summary. Results A total 1927 titles were identified, 31 of which met inclusion criteria. Barriers to OHEC were divided into six categories that included: culture/community, infrastructure, communication/coordination, transport, equipment and personnel. Lack of transportation was a common problem, with 55% (17/31) of articles reporting this as a hindrance to OHEC. Ambulances were the most commonly mentioned (71%, 22/31) mode of transporting patients. However, many patients still relied on alternative means of transportation such as hired cars, and animal drawn carts. Sixty-one percent (19/31) of articles identified a lack of skilled personnel as a key barrier, with 32% (10/31) of OHEC being delivered by laypersons without formal training. Forty percent (12/31) of the systems identified in the review described a uniform access phone number for emergency medical service activation. Conclusions Policy makers and researchers seeking to improve OHEC in low and low-middle income countries should focus on increasing the availability of transport and trained providers while improving patient access to the OHEC system. The review yielded articles with a primary focus in Africa, highlighting a need for future research in diverse geographic areas.

Background Children with disabilities (CwDs) make up around 150 million of the billion people with disabilities in the world. The Sub-Saharan African countries have a large number of CwDs who have limited access to healthcare and rehabilitation care. This, combined with chronic poverty, low education, and inadequately trained healthcare professionals, substantially lowers these children’s quality of life. The main objective of this scoping review was to discover the barriers and facilitators to healthcare access for CwDs in selected low to middle income Sub-Saharan African countries. As African countries significantly vary in socioeconomic status, we only focused on countries in Sub-Saharan Africa who allocated less than $50/person to healthcare. Methods A broad and iterative search strategy using multiple sources and databases including CINAHL, Medline, Global Health, and Embase were utilized. Using a comprehensive search strategy, 704 articles were generated. After removal of the duplicates, 466 of them were screened based on the study inclusion and exclusion criteria. After iterative reading and screening of these articles, a final 15 articles were included in this review. Results This scoping review shows that CwDs in the selected Sub-Saharan African countries face major barriers including stigma and negative attitudes, poverty and insufficient resources, inadequate policy implementations, physical inaccessibility, lack of transportation, lack of privacy, and inadequately trained healthcare professionals to deal with disability. Emotional and social support, including peer support for CwDs and caregivers, were identified as facilitators for better access to health services. Conclusions There is limited access to healthcare services in the low and middle income Sub-Saharan African countries due to poverty, low education, inadequate healthcare systems, and shortage of healthcare professionals. It is evident that there are socioeconomic, cultural, and physical related impediments that affect CwDs’ and their caregivers’ access to the required healthcare services. Policy development, improved physical accessibility, public disability awareness, and parental support are some of the key facilitators to access healthcare services. The study highlights the importance of revisions to childhood disability and healthcare provisions policy and practice as well as sustainable rehabilitation programs. Further research is required to explore ways to improve experience of accessing health services.

Background The COVID-19 pandemic has posed unprecedented challenges and threats to the health care system, particularly affecting the effective delivery of essential health services in resource-poor countries such as Nepal. This study aimed to explore community perceptions of COVID-19 and their experiences towards health services utilization during the pandemic in Province-2 of Nepal. Methods The semi-structured qualitative interviews were conducted among purposively selected participants ( n  = 41) from a mix of rural and urban settings in all districts ( n  = 8) of the Province 2 of Nepal. Virtual interviews were conducted between July and August 2020 in local languages. The data were analyzed using thematic network analysis in NVivo 12 Pro. Results The findings of this research are categorized into four global themes: i) Community and stakeholders’ perceptions towards COVID-19; ii) Impact of COVID-19 and lockdown on health services delivery; iii) Community perceptions and experiences of health services during COVID-19; and iv) COVID-19: testing, isolation, and quarantine services. Most participants shared their experience of being worried and anxious about COVID-19 and reported a lack of awareness, misinformation, and stigma as major factors contributing to the spread of COVID-19. Maternity services, immunization, and supply of essential medicine were found to be the most affected areas of health care delivery during the lockdown. Participants reported that the interruptions in health services were mostly due to the closure of health services at local health care facilities, limited affordability, and involvement of private health sectors during the pandemic, fears of COVID-19 transmission among health care workers and within health centers, and disruption of transportation services. In addition, the participants expressed frustrations on poor testing, isolation, and quarantine services related to COVID-19, and poor accountability from the government at all levels towards health services continuation/management during the COVID-19 pandemic. Conclusions This study found that essential health services were severely affected during the COVID-19 pandemic in all districts of Province-2. It is critical to expand and continue the service coverage, and its quality (even more during pandemics), as well as increase public-private sector engagement to ensure the essential health services are available for the population.

Background Routine health information systems (RHISs) support resource allocation and management decisions at all levels of the health system, as well as strategy development and policy-making in many low- and middle-income countries (LMICs). Although RHIS data represent a rich source of information, such data are currently underused for research purposes, largely due to concerns over data quality. Given that substantial investments have been made in strengthening RHISs in LMICs in recent years, and that there is a growing demand for more real-time data from researchers, this systematic review builds upon the existing literature to summarize the extent to which RHIS data have been used in peer-reviewed research publications. Methods Using terms ‘routine health information system’, ‘health information system’, or ‘health management information system’ and a list of LMICs, four electronic peer-review literature databases were searched from inception to February 202,019: PubMed, Scopus, EMBASE, and EconLit. Articles were assessed for inclusion based on pre-determined eligibility criteria and study characteristics were extracted from included articles using a piloted data extraction form. Results We identified 132 studies that met our inclusion criteria, originating in 37 different countries. Overall, the majority of the studies identified were from Sub-Saharan Africa and were published within the last 5 years. Malaria and maternal health were the most commonly studied health conditions, although a number of other health conditions and health services were also explored. Conclusions Our study identified an increasing use of RHIS data for research purposes, with many studies applying rigorous study designs and analytic methods to advance program evaluation, monitoring and assessing services, and epidemiological studies in LMICs. RHIS data represent an underused source of data and should be made more available and further embraced by the research community in LMIC health systems.

This study aimed to estimate both direct medical and indirect costs of treating the Coronavirus disease 2019 (COVID-19) from a societal perspective in the patients at a referral hospital in Fars province as well as the economic burden of COVID-19 in Iran in 2020. Methods This study is a partial economic evaluation and a cross-sectional cost-description study conducted based on the data of the COVID-19 patients referred to a referral university hospital in Fars province between March and July 2020. The data were collected by examining the patients’ records and accounting information systems. The subjects included all the inpatients with COVID-19 (477 individuals) who admitted to the medical centre during the 4 months. Bottom-up costing (also called micro-costing approach), incidence-based and income-based human capital approaches were used as the main methodological features of this study. Results The direct medical costs were estimated to be 28,240,025,968 Rials ($ 1,791,172) in total with mean cost of 59,203,409 Rials ($ 3755) per person (SD = 4684 $/ 73,855,161 Rials) in which significant part (41%) was that of intensive and general care beds (11,596,217,487 Rials equal to $ 735,510 (M = 24,310,728 Rials or $ 1542, SD = 34,184,949 Rials or $ 2168(. The second to which were the costs of medicines and medical consumables (28%). The mean indirect costs, including income loss due to premature death, economic production loss due to hospitalization and job absenteeism during recovery course were estimated to be 129,870,974 Rials ($ 11,634) per person. Furthermore, the economic burden of the disease in the country for inpatient cases with the definitive diagnosis was 22,688,925,933,095 Rials equal to $ 1,439,083,784. Conclusion The results of this study showed that the severe status of the disease would bring about the extremely high cost of illness in this case. It is estimated that the high prevalence rate of COVID-19 has been imposing a heavy economic burden on the country and health system directly that may result in rationing or painful cost-control approaches.

Background The 2014 Ebola Virus Disease epidemic evolved in alarming ways in Sierra Leone spreading to all districts. The country struggled to control it against a backdrop of a health system that was already over-burdened. Health workers play an important role during epidemics but there is limited research on how they cope during health epidemics in fragile states. This paper explores the challenges faced by health workers and their coping strategies during the Ebola outbreak in four districts – Bonthe, Kenema, Koinadugu and Western Area - of Sierra Leone. Methods We used a qualitative study design: key informant interviews ( n  = 19) with members of the District Health Management Teams and local councils, health facility managers and international partners; and in depth interviews with health workers ( n  = 25) working in public health facilities and international health workers involved with the treatment of Ebola patients. Results There were several important coping strategies including those that drew upon existing mechanisms: being sustained by religion, a sense of serving their country and community, and peer and family support. Externally derived strategies included: training which built health worker confidence in providing care; provision of equipment to do their job safely; a social media platform which helped health workers deal with challenges; workshops that provided ways to deal with the stigma associated with being a health worker; and the risk allowance, which motivated staff to work in facilities and provided an additional income source. Conclusions Supportive supervision, peer support networks and better use of communication technology should be pursued, alongside a programme for rebuilding trusting relations with community structures. The challenge is building these mechanisms into routine systems, pre-empting shocks, rather than waiting to respond belatedly to crises.

Background Maternal mortality has remained a challenge in many low-income countries, especially in Africa and in Nigeria in particular. This study examines the geographical and socioeconomic inequalities in maternal healthcare utilization in Nigeria over the period between 2003 and 2017. Methods The study used four rounds of Nigeria Demographic Health Surveys (DHS, 2003, 2008, 2013, and 2018) for women aged 15–49 years old. The rate ratios and differences (RR and RD) were used to measure differences between urban and rural areas in terms of the utilization of the three maternal healthcare services including antenatal care (ANC), facility-based delivery (FBD), and skilled-birth attendance (SBA). The Theil index (T), between-group variance (BGV) were used to measure relative and absolute inequalities in the utilization of maternal healthcare across the six geopolitical zones in Nigeria. The relative and absolute concentration index (RC and AC) were used to measure education-and wealth-related inequalities in the utilization of maternal healthcare services. Results The RD shows that the gap in the utilization of FBD between urban and rural areas significantly increased by 0.3% per year over the study period. The Theil index suggests a decline in relative inequalities in ANC and FBD across the six geopolitical zones by 7, and 1.8% per year, respectively. The BGV results do not suggest any changes in absolute inequalities in ANC, FBD, and SBA utilization across the geopolitical zones over time. The results of the RC and the AC suggest a persistently higher concentration of maternal healthcare use among well-educated and wealthier mothers in Nigeria over the study period. Conclusion We found that the utilization of maternal healthcare is lower among poorer and less-educated women, as well as those living in rural areas and North West and North East geopolitical zones. Thus, the focus should be on implementing strategies that increase the uptake of maternal healthcare services among these groups.

Background Many low- and middle-income countries (LMIC) are moving towards enforcing prescription-only access to antibiotics. This systematic literature review aims to assess the interventions used to enforce existing legislation prohibiting over-the-counter (OTC) sales of antibiotics in LMICs, their impact and examine the methods chosen for impact measurement including their strengths and weaknesses. Methods Both PubMed and Embase were systematically searched for studies reporting on impact measurement in moving towards prescription only access to antibiotics in LMICs. The PRISMA methodological review framework was used to ensure systematic data collection and analysis of literature. Narrative data synthesis was used due to heterogeneity of study designs. Results In total, 15 studies were included that assessed policy impact in 10 different countries. Strategies employed to enforce regulations prohibiting OTC sales of systemic antibiotics included retention of prescriptions for antibiotics by pharmacies, government inspections, engaging pharmacists in the design of interventions, media campaigns for the general public and educational activities for health care workers. A variety of outcomes was used to assess the policy impact; changes in antimicrobial resistance rates, changes in levels of antibiotic use, changes in trends of antibiotic use, changes in OTC supply of antibiotics, and changes in reported practices and knowledge of pharmacists, medicine sellers and the general public. Differences in methodological approaches and outcome assessment made it difficult to compare the effectiveness of law enforcement activities. Most effective appeared to be multifaceted approaches that involved all stakeholders. Monitoring of the impact on total sales of antibiotics by means of an interrupted time series (ITS) analysis and analysis of pharmacies selling antibiotics OTC using mystery clients were the methodologically strongest designs used. Conclusions The published literature describing activities to enforce prescription-only access to antibiotics in LMICs is sparse and offers limited guidance. Most likely to be effective are comprehensive multifaceted interventions targeting all stakeholders with regular reinforcement of messages. Policy evaluation should be planned as part of implementation to assess the impact and effectiveness of intervention strategies and to identify targets for further activities. Robust study designs such as ITS analyses and mystery client surveys should be used to monitor policy impact.