Lars Åke Persson

Effective coverage measurement has emerged as a tool to help understand health system performance for the provision of high-quality health care. Using a cascade approach that combines data on demand- and supply-side steps, effective coverage measures highlight where gaps in the health system exist and how improvements might be made so that more people benefit from the potential of the health services available to them. In practice, however, there are challenges in making this work. This analysis paper aimed to highlight those challenges in calculating effective coverage in Ethiopia, using antenatal care as a test case, and propose a solution. In Ethiopia, government leaders are committed to taking a data-informed approach to improving health care quality. To support this, an effective coverage technical working group was formed of individuals with experience of effective coverage analysis in Ethiopia to share knowledge and create learning for a way forward. Through methods analysis of one common indicator, the effective coverage of antenatal care, four key challenges were identified by the group: (1) features of the data sources used, (2) the number of cascade steps included in the effective coverage calculations, (3) the data elements included within cascade steps and (4) the methods applied to generate composite indicators. Multiple small differences were observed to have an influence on the usability of effective coverage measures for decision-making. The group concluded that greater transparency in reporting effective coverage measures was urgently needed and proposed and discussed the use of a reporting checklist for this purpose.

Objective: Our objective was to assess the feasibility of using the routine health information system data source, District Health Information System (DHIS2) to measure the effective coverage of selected health service indicators in Ethiopia and to explore stakeholder perceptions of those measures. Design: We conducted a mixed-methods study. We mapped the availability of data elements in DHIS2 between July 2022 and June 2023 for five indicators (four or more antenatal care visits (ANC4+), skilled birth attendance, postnatal care, sick child care and child nutrition care). We defined effective coverage cascade steps for each indicator, assessed data quality and analysed data using STATA V.17. Finally, qualitative interviews were conducted with 15 key stakeholders, and the data were analysed thematically for reflections on the DHIS2 output. Setting: The data were captured from all public health facilities of 11 regions and 2 administrative cities in Ethiopia. Results: There was better availability of data elements for maternal healthcare than for child healthcare. It was possible to estimate the intervention-adjusted coverage of ANC4+ (16% nationally) and the process-quality-adjusted coverage of skilled birth attendance (19% nationally). Postnatal care, sick child care and child nutrition indicators lacked data across multiple cascade steps. The quality of data for effective coverage measurement differed by region. The key informants expressed concerns about the adequacy and appropriateness of DHIS2 data for this analysis. While all acknowledged its potential for decision-making, respondents emphasised the need for standardised methods and data sources to enhance comparability and acceptability of the findings. Conclusions: The findings underscore the need for system-level improvement of data availability and quality, and adoption of a standardised approach to calculating effective coverage using DHIS2. There was a concern that the findings may not be accepted by policymakers; however, the local level granularity made possible through DHIS2 was appreciated.

Equitable partnerships in global health research can counteract power imbalances in this field. Theoretical perspectives have been provided on equitable global health partnerships, but there are few reports from researchers actively engaged in such partnerships. This article departs from the experiences of four long-term global health research partnerships, two in Africa and two in Asia. It describes the challenges in enhancing an equitable research partnership and how these were addressed. The examples illustrate that funders can play a pivotal role in counteracting power imbalances by assigning leadership roles and directing primary funding to institutions where the research occurs. Such a transition requires adaptations and a new mindset on both sides. Embedded research capacity enhancement, part of all four partnership examples, is essential in correcting power imbalances. Capacity enhancement should preferably include enhancing the broader research ecosystem within the partner university, across academic institutions in the country or beyond. The development of mutual trust and respect takes time and requires long-term engagement, transparency in budgeting, project planning and all steps of the research process. Reciprocity in learning is important for all partners. It may include twinning of research students, joint degrees and efforts to bring research findings into policy and practice in all partner contexts. The partnership examples illustrate the achievements and challenges in bringing new research evidence into policy and practice, where early involvement and continuous buy-in by policymakers are crucial.

Introduction: This programme effectiveness study responds to the need for evidence of the effect on birth weight of switching from iron-folic acid supplementation to multiple micronutrient supplementation as part of routine antenatal care in Ethiopia. A 2019 meta-analysis reported a mean increase of 35 g in birth weight among newborns of women who took multiple micronutrient supplements in pregnancy compared with those who took iron-folic acid. Responding to that evidence, the government of Ethiopia decided to implement a 21 district pilot of the use of multiple micronutrient supplementation in routine antenatal care and requested an evaluation of implementation outcomes, including on birth weight. Methods and analysis: A pragmatic, facility-based, randomised trial is being conducted in 42 districts over five regions of Ethiopia between January 2023 and December 2024. Districts have been randomised to one of the two arms, either to retain iron-folic acid supplementation as part of routine antenatal care or switch to multiple micronutrient supplementation. During the study period, the birth weights of all eligible babies born in enrolled health facilities in these 42 districts are continuously recorded alongside data on maternal receipt and use of either multiple micronutrient or iron-folic acid supplementation. We hypothesise that newborns of women resident in the 21 multiple micronutrient supplementation districts will have higher mean birth weight than newborns of women resident in the 21 iron-folic acid supplementation districts. Facility surveys involving pregnant women and healthcare workers at baseline, midline and endline contribute to a process evaluation and cost and cost-effectiveness evaluation. Ethics and dissemination: The study received ethical approval from the review boards at the Ethiopian Public Health Institute (EPHI-IRB-455-2022) and the London School of Hygiene & Tropical Medicine (LSHTM ref 28021). Results from this pragmatic trial will be used by the government of Ethiopia in assessing success of the multiple-micronutrient supplements pilot and for decision making about subsequent scale-up. Dissemination of findings will also inform global decision making, particularly in settings where a transition from iron-folic acid to multiple micronutrient supplementation is being contemplated at scale. Trial registration number: NCT05708183 .

Objectives To assess the geographical equity in Ethiopian infants’ exclusive breastfeeding at 5 months and dietary diversity at 12 months and whether social factors explained the spatial inequities. Design Secondary analysis of a birth cohort study. Setting Analysis of data from the Ethiopian Performance Monitoring for Action panel study conducted from July 2020 to August 2021 in five regions (ie, Oromia, Amhara, Afar and Southern Nations, Nationalities and Peoples regions and the Addis Ababa City administration). We analysed geographical autocorrelation to assess geographical variations in exclusive breastfeeding and dietary diversity. Areas with higher and lower coverage of appropriate infant feeding outcomes were analysed using hotspot analyses. We performed geographically weighted regression to investigate whether sociodemographic factors explained the geographical feeding differences. Participants 1850 infants were prospectively followed from birth to 12 months. Outcome measures Exclusive breastfeeding at 5 months and minimum-level dietary diversity at 12 months. Results Sixty-nine percent (95% CI 67 to 71) of infants were exclusively breastfed at 5 months, while at 12 months, only 16% (95% CI 13 to 19) had complementary feeding from five or more food groups. There were geographical variations in the coverage of exclusive breastfeeding and minimum dietary diversity. Higher proportions of infants were exclusively breastfed at 5 months in northern areas, and more 12-month-old infants in central parts of the country had complementary feeding from at least five food groups. Sociodemographic factors explained a quarter of the geographical variation in dietary diversity. Conclusion Most Ethiopian infants were exclusively breastfed, which was in line with global recommendations but with some geographical differences. There was prominent geographical variation in dietary diversity, partly explained by social factors, but overall, very few 12-month-old infants were fed from at least five food groups. This low dietary quality could impair Ethiopian children’s physical growth, development and health.

Post-term birth is birth at a gestation of ≥42 weeks [1–3]. It has been associated with increased perinatal morbidity and mortality [4–7]. The estimated global prevalence of post-term births ranges from 1–10% of all deliveries [8–10]. The occurrence differs within and between countries [11], partly depending on assessments by reported last menstrual period (LMP) dates […]

Background Use of local data for health system planning and decision-making in maternal, newborn and child health services is limited in low-income and middle-income countries, despite decentralisation and advances in data gathering. An improved culture of data-sharing and collaborative planning is needed. The Data-Informed Platform for Health is a system-strengthening strategy which promotes structured decision-making by district health officials using local data. Here, we describe implementation including process evaluation at district level in Ethiopia, and evaluation through a cluster-randomised trial. Methods We supported district health teams in 4-month cycles of data-driven decision-making by: (a) defining problems using a health system framework; (b) reviewing data; (c) considering possible solutions; (d) value-based prioritising; and (e) a consultative process to develop, commit to and follow up on action plans. 12 districts were randomly selected from 24 in the North Shewa zone of Ethiopia between October 2020 and June 2022. The remaining districts formed the trial’s comparison arm. Outcomes included health information system performance and governance of data-driven decision-making. Analysis was conducted using difference-in-differences. Results 58 4-month cycles were implemented, four or five in each district. Each focused on a health service delivery challenge at district level. Administrators’ practice of, and competence in, data-driven decision-making showed a net increase of 77% (95% CI: 40%, 114%) in the regularity of monthly reviews of service performance, and 48% (95% CI: 9%, 87%) in data-based feedback to health facilities. Statistically significant improvement was also found in administrators’ use of information to appraise services. Qualitative findings also suggested that district health staff reported enhanced data use and collaborative decision-making. Conclusions This study generated robust evidence that 20 months’ implementation of the Data-Informed Platform for Health strengthened health management through better data use and appraisal practices, systemised problem analysis to follow up on action points and improved stakeholder engagement. Trial registration number NCT05310682.

Introduction A history of preterm birth reportedly increases the risk of subsequent preterm birth. This association has primarily been studied in high-income countries and not in low-income settings in transition with rapidly descending preterm birth figures. We evaluated the population-based trends of preterm births and recurrent preterm births and the risk of preterm birth recurrence in the second pregnancy based on prospectively studied pregnancy cohorts over three decades in Matlab, Bangladesh. Methods A population-based cohort included 72 160 live births from 1990 to 2019. We calculated preterm birth and recurrent preterm birth trends. We assessed the odds of preterm birth recurrence based on a subsample of 14 567 women with live-born singletons in their first and second pregnancies. We used logistic regression and presented the associations by OR with a 95% CI. Results The proportion of preterm births decreased from 25% in 1990 to 13% in 2019. The recurrent preterm births had a similar, falling pattern from 7.4% to 3.1% across the same period, contributing 27% of the total number of preterm births in the population. The odds of second pregnancy preterm birth were doubled (OR 2.18; 95% CI 1.96 to 2.43) in women with preterm birth compared with the women with term birth in their first pregnancies, remaining similar over the study period. The lower the gestational age at the first birth, the higher the odds of preterm birth in the subsequent pregnancy (test for trend pConclusion In this rural Bangladeshi setting, recurrent preterm births contributed a sizeable proportion of the total number of preterm births at the population level. The increased risk of recurrence remained similar across three decades when the total proportion of preterm births was reduced from 25% to 13%.

Background: Due to low care utilization, a complex intervention was done for two years to optimize the Ethiopian Health Extension Program. Improved quality of the integrated community case management services was an intermediate outcome of this intervention through community education and...