Percentage of DHMT/providers who identified each health system component as a barrier, by geography.

Percentage of DHMT/providers who identified each health system component as a barrier, by geography.</p

MNCHN assets of interest.

Inequitable coverage of evidence-based MNCHN interventions is particularly pronounced in low and middle income countries where access and delivery of these interventions can vary dramatically at the subnational level. We conducted health system assessments in nine subnational geographies in five countries (Burkina Faso, Ethiopia, India, Kenya and Nigeria) to explore progress toward scale of 14 evidence-based MNCHN interventions (iron-folic acid, oxytocin, magnesium sulfate, misoprostol; 7.1% chlorhexidine for umbilical cord care, neonatal resuscitation, kangaroo mother care, community regimen for the treatment of possible severe bacterial infection; amoxicillin dispersible tablets, multiple micronutrient supplements, balanced energy protein supplementation, early and exclusive breastfeeding, feeding of small and sick newborns, and management of severe and moderate acute malnutrition in children less than five years old). Between March and October 2021, we conducted key informant interviews with a purposive sample of 275 healthcare providers and 94 district health management (DHMT) staff to better understand bottlenecks, facilitators and uptake of the interventions across varied subnational settings. Across all interventions and geographies, providers and DHMT staff perceived lack of robust HMIS data as the most significant barrier to scale followed by weak facility infrastructure. DHMT staff viewed limited budget allocation and training as a much larger barrier than healthcare providers, most likely given their purview as subnational managers. Healthcare providers were focused on supply chain and staffing, which affect workflows and service provision. Understanding provider and health facility management views of why interventions do or do not advance towards effective coverage can assist in creating enabling environments for the scale of best practices. These types of data are most helpful when collected at the subnational level, which allows for comparisons both within and between countries to show health disparities. Importantly, this strategic data collection can provide a starting point for improvement efforts to address existing health system gaps.</div

Provider/DHMT awareness, experience, and routine use of assets across geographies.

Note: Denominators for experience and routine use of assets are the number of providers who have heard of the asset. Routine use data were collected for providers only. 7.1% chlorhexidine data from India have been excluded due to a lack of national policy. MMS data from India, Kenya and Nigeria have been excluded due to widespread confusion with iron-folic acid and micronutrient powders. ADT = amoxicillin dispersible tablets; BEP = balanced energy protein supplementation; CHX = 7.1% chlorhexidine for umbilical cord care; EEBF = early initiation and exclusive breastfeeding; FSSN = feeding of the small and sick newborn; IFA = iron-folic acid; KMC = kangaroo mother care; MgSO4 = magnesium sulfate; MISO = misoprostol; MMS = multiple micronutrient supplements; NRE = neonatal/newborn resuscitation; OXY = oxytocin; PSBI = possible severe bacterial infection.</p

Routine use of select assets as reported by providers, by subnational geography.

Note: 7.1% chlorhexidine data from India have been excluded due to a lack of national policy. MMS data from India, Kenya, and Nigeria have been excluded due to widespread confusion with iron-folic acid and micronutrient powders.</p

Perception of overall barriers to scale for any asset by respondent category.

HIMS = Health Management Information System; DHMT = District Health Management Team.</p

Six stage framework of the pathway to effective coverage.

HCW = health care worker; HMIS = health management information system; LMIS = logistics management information system; SRA = stringent regulatory authority; WHO = World Health Organization.</p

Map of selected subnational geographies within countries.

Map of selected subnational geographies within countries.</p

Distribution of sites and respondents, by geography.

Distribution of sites and respondents, by geography.</p

ODA as a percentage of gross national income (GNI) in (2013).

<p>Source: OECD. Development Co-operation Report 2014: Mobilising Resources for Sustainable Development. Paris: OECD Publishing; 2014. Available at <a href="http://observ-ocd.org/sites/observ-ocd.org/files/publicacion/docs/informe_coop.desen_._2014_ocde.pdf" target="_blank">http://observ-ocd.org/sites/observ-ocd.org/files/publicacion/docs/informe_coop.desen_._2014_ocde.pdf</a>. Accessed January 14, 2016.</p

Development Assistance Committee (DAC) members' official development assistance (ODA) in 2013.

<p>Source: OECD. Development Co-operation Report 2014: Mobilising Resources for Sustainable Development. Paris: OECD Publishing; 2014. Available at <a href="http://observ-ocd.org/sites/observ-ocd.org/files/publicacion/docs/informe_coop.desen_._2014_ocde.pdf" target="_blank">http://observ-ocd.org/sites/observ-ocd.org/files/publicacion/docs/informe_coop.desen_._2014_ocde.pdf</a>. Accessed January 14, 2016.</p