Building health systems in fragile states: the instructive example of Afghanistan.

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The effect of maternal iron status and intake during pregnancy on cardiovascular disease risk in the offspring

Iron is an important micronutrient essential in carrying oxygen and maintaining the function of many body enzymes. It is of particular importance during gestation as body demands increase leading to iron deficiency in women with inadequate iron stores at the start of pregnancy. Animal studies have shown that iron deficiency in pregnancy leads to offspring with adverse cardiovascular risk profiles compared to offspring of iron replete mothers. This thesis aimed to examine the association of maternal iron intake and status in pregnancy with short and long term birth outcomes that are considered cardiovascular risk indicators later in life. Analysis of data from three cohorts and one Mendelian randomisation study was included in this thesis. Total maternal iron intake in early, but not late, pregnancy was positively associated with birth size. There was no evidence of association between taking iron-containing supplements in pregnancy and size at birth. However, taking multivitamin-mineral supplements, which contain iron, in late pregnancy was associated with an increased risk of preterm birth. Also taking iron supplements up to 32 weeks gestation was associated with lower offspring systolic blood pressure at 10 years. Maternal iron deficiency and anaemia in early pregnancy were associated with an increased risk of giving birth to a SGA baby. Infant brachio-femoral PWV measured at 2-6 weeks of age was found to be higher in women who were anaemic in early pregnancy, but not in those who were only iron deficient. Finally, using a Mendelian randomisation design, maternal iron status measured by serum ferritin with C282Y mutation as an instrumental variable, was not found to be associated with adult offspring BP and adiposity. In conclusion, maternal iron intake and status in early pregnancy seem to be associated with short term birth outcomes like size at birth, while associations with long term offspring cardiovascular indicators were not detected in this thesis

Monitoring and evaluating the implementation of essential packages of health services

Essential packages of health services (EPHS) are a critical tool for achieving universal health coverage, especially in low-income and lower middle-income countries. However, there is a lack of guidance and standards for monitoring and evaluation (M&E) of EPHS implementation. This paper is the final in a series of papers reviewing experiences using evidence from the Disease Control Priorities, third edition publications in EPHS reforms in seven countries. We assess current approaches to EPHS M&E, including case studies of M&E approaches in Ethiopia and Pakistan. We propose a step-by-step process for developing a national EPHS M&E framework. Such a framework would start with a theory of change that links to the specific health system reforms the EPHS is trying to accomplish, including explicit statements about the 'what' and 'for whom' of M&E efforts. Monitoring frameworks need to consider the additional demands that could be placed on weak and already overstretched data systems, and they must ensure that processes are put in place to act quickly on emergent implementation challenges. Evaluation frameworks could learn from the field of implementation science; for example, by adapting the Reach, Effectiveness, Adoption, Implementation and Maintenance framework to policy implementation. While each country will need to develop its own locally relevant M&E indicators, we encourage all countries to include a set of core indicators that are aligned with the Sustainable Development Goal 3 targets and indicators. Our paper concludes with a call to reprioritise M&E more generally and to use the EPHS process as an opportunity for strengthening national health information systems. We call for an international learning network on EPHS M&E to generate new evidence and exchange best practices

Lessons from the development process of the Afghanistan integrated package of essential health services

In 2017, in the middle of the armed conflict with the Taliban, the Ministry of Public Health decided that the Afghan health system needed a well-defined priority package of health services taking into account the increasing burden of non-communicable diseases and injuries and benefiting from the latest evidence published by DCP3. This leads to a 2-year process involving data analysis, modelling and national consultations, which produce this Integrated Package of Essential health Services (IPEHS). The IPEHS was finalised just before the takeover by the Taliban and could not be implemented. The Afghanistan experience has highlighted the need to address not only the content of a more comprehensive benefit package, but also its implementation and financing. The IPEHS could be used as a basis to help professionals and the new authorities to define their priorities

Country readiness and prerequisites for successful design and transition to implementation of essential packages of health services: Experience from six countries

This paper reviews the experience of six low- and lower middle-income countries in setting their own essential packages of health services (EPHS), with the purpose of identifying the key requirements for the successful design and transition to implementation of the packages in the context of accelerating progress towards universal health coverage (UHC). The analysis is based on input from three meetings of a knowledge network established by the Disease Control Priorities 3 Country Translation Project and working groups, supplemented by a survey of participating countries. All countries endorsed the sustainable development goals target 3.8 on UHC for achievement by 2030. The assessment of country experiences found that health system strengthening and mobilising and sustaining health financing are major challenges. EPHS implementation is more likely when health system gaps are addressed and when there are realistic and sustainable financing prospects. However, health system assessments were inadequate and the government planning and finance sectors were not consistently engaged in setting the EPHS in most of the countries studied. There was also a need for greater engagement with community and civil society representatives, academia, and the private sector in package design. Leadership and reinforcement of technical and managerial capacity are critical in the transition from EPHS design to sustained implementation, as are strong human resources and country ownership of the process. Political commitment beyond the health sector is key, particularly commitment from parliamentarians and policymakers in the planning and finance sectors. National ownership, institutionalisation of technical and managerial capacity, and reinforcing human resources are critical for success. The review concludes that four prerequisites are crucial for a successful EPHS: (1) sustained high-level commitment, (2) sustainable financing, (3) health system readiness, and (4) institutionalisation

Protecting essential health services in low-income and middle-income countries and humanitarian settings while responding to the COVID-19 pandemic.

In health outcomes terms, the poorest countries stand to lose the most from these disruptions. In this paper, we make the case for a rational approach to public sector health spending and decision making during and in the early recovery phase of the COVID-19 pandemic. Based on ethics and equity principles, it is crucial to ensure that patients not infected by COVID-19 continue to get access to healthcare and that the services they need continue to be resourced. We present a list of 120 essential non-COVID-19 health interventions that were adapted from the model health benefit packages developed by the Disease Control Priorities project