Who gives birth in private facilities in Asia? A look at six countries.

Over the past two decades, multilateral organizations have encouraged increased engagement with private healthcare providers in developing countries. As these efforts progress, there are concerns regarding how private delivery care may effect maternal health outcomes. Currently available data do not allow for an in-depth study of the direct effect of increasing private sector use on maternal health across countries. As a first step, however, we use demographic and health surveys (DHS) data to (1) examine trends in growth of delivery care provided by private facilities and (2) describe who is using the private sector within the healthcare system. As Asia has shown strong increases in institutional coverage of delivery care in the last decade, we will examine trends in six Asian countries. We hypothesize that if the private sector competes for clients based on perceived quality, their clientele will be wealthier, more educated and live in an area where there are enough health facilities to allow for competition. We test this hypothesis by examining factors of socio-demographic, economic and physical access and actual/perceived need related to a mother's choice to deliver in a health facility and then, among women delivering in a facility, their use of a private provider. Results show a significant trend towards greater use of private sector delivery care over the last decade. Wealth and education are related to private sector delivery care in about half of our countries, but are not as universally related to use as we would expect. A previous private facility birth predicted repeat private facility use across nearly all countries. In two countries (Cambodia and India), primiparity also predicted private facility use. More in-depth work is needed to truly understand the behaviour of the private sector in these countries; these results warn against making generalizations about private sector delivery care.

Effectiveness of scaling up the 'three pillars' approach to accelerating MDG 4 progress in Ethiopia.

This paper describes the integrated approach taken by the Government of Ethiopia with support from the Essential Services for Health in Ethiopia (ESHE) Project and assesses its effect on the coverage of six child health practices associated with reducing child mortality. The ESHE Project was designed to contribute to reducing high child mortality rates at scale among 14.5 million people through the 'three pillars' approach. This approach aimed to (i) strengthen health systems, (ii) improve health workers' performance, and (iii) engage the community. The intervention was designed with national and subnational stakeholders' input. To measure the Project's effect on the coverage of child health practices, we used a quasi-experimental design, with representative household survey data from the three most populous regions of Ethiopia, collected at the 2003-2004 baseline and 2008 endline surveys of the Project. Adifference-in-differences analysis model detected an absolute effect of the ESHE intervention of 8.4% points for DTP3 coverage (p=0.007), 12.9% points for measles vaccination coverage (p<0.001), 12.6% points for latrines (p=0.002), and 9.8% points for vitamin A supplementation (p<0.001) across the ESHE-intervention districts (woredas) compared to all non-ESHE districts of the same three regions. Improvements in the use of modern family planning methods and exclusive breastfeeding were not significant. Important regional variations are discussed. ESHE was one of several partners of the Ministry of Health whose combined efforts led to accelerated progress in the coverage of child health practices.

Factors affecting availability of essential medicines among community health workers in Ethiopia, Malawi, and Rwanda: solving the last mile puzzle.

To understand how supply chain factors affect product availability at the community level, the Improving Supply Chains for Community Case Management of Pneumonia and Other Common Diseases of Childhood Project developed a theory of change (TOC) framework for gathering, organizing, and interpreting evidence about supply constraints to community case management (CCM). Baseline assessments in Ethiopia, Malawi, and Rwanda conducted in 2010 provided information on the strengths and weaknesses of existing CCM supply chains for five main products: antibiotics for pneumonia, oral rehydration solution, ready to use therapeutic food, zinc, and artemether/lumefantrine. The assessments tested the strength and validity of causal pathways identified in the TOC that were believed to influence availability of CCM products among community health workers (CHWs) for treating common childhood illnesses. Results of the assessments showed product availability to be weak in each country, with more than half of CHWs stocked out of at least one tracer product on the day of the assessment. This report will focus on the findings related to three key preconditions of the TOC and how these were used to inform the design of the CCM supply chain improvement strategy in each country. The three key preconditions include product availability at CHW resupply points, supply chain knowledge and capacity among CHWs and their supervisors, and availability of appropriate transportation.