Characterising the performance measurement and management system in the primary health care systems of Malawi.

BACKGROUND:  Performance Measurement and Management (PMM) systems are levers that support key management functions in health care systems. Just like many low- and middle-income countries (LMICs), Malawi strives to improve performance via evidence-based decision making and a suitable performance culture. AIM:  This study sought to describe PMM practices at all levels of primary health care (PHC) in Malawi. SETTING:  This study targeted three levels of PHC, namely the district health centres (DHCs), the zones, and the ministry headquarters. METHODS:  This was a qualitative exploratory research study where decision-makers at each level of PHC were engaged using key-informant interviews (KII) and focus group discussions (FGDs). RESULTS:  We found that there is a weak link among levels of PHC in supporting PMM practices leading to poor dissemination of priorities and goals. There is also failure to appropriately institute good PMM practices, and the use of performance information was found to be limited among decision-makers. CONCLUSION:  Though PMM is acknowledged to be key in supporting health service delivery systems, Malawi's PHC system has not fully embarked on making this a priority. Some challenges include unsupportive culture and inadequate capacity for PMM.Contribution: This study contributes to the understanding of the PMM processes in Malawi and further highlights the salient challenges in the use of information for performance management. While the presence of policies on PMM is acknowledged, implementation studies that deal with challenges are urgent and imperative.

Characterizing the implementation of performance management interventions in a primary health care system: a case study of the Salud Mesoamerica Initiative in El Salvador.

Performance management (PM) reforms have been introduced in health systems worldwide to improve accountability, transparency and learning. However, gaps in evidence exist regarding the ways in which PM contributes to organizational-level outcomes. Between 2015 and 2017, the government of El Salvador and the Salud Mesoamerica Initiative (SMI) introduced team-based PM interventions in the country's primary health care (PHC) system including target setting, performance measurement, provision of feedback and in-kind incentives. The programme's evaluation showed widespread improvements in performance for community outreach and service timeliness, quality and utilization. The current study characterizes how the implementation of team-based PM interventions by SMI implementers contributed to PHC system performance improvements. We used a descriptive, single-case study design informed by a programme theory (PT). Data sources included qualitative in-depth interviews and SMI programme documents. We interviewed the members of four PHC teams (n = 13), Ministry of Health (MOH) decision makers (n = 8) and SMI officials (n = 6). Coded data were summarized, and thematic analysis was employed to identify broader categories and patterns. The outcomes chain in the PT was refined based on empirical findings that revealed the convergence of two processes: (1) increased social interactions and relationships among implementers that enhanced communication and created opportunities for social learning and (2) cyclical performance monitoring that generated novel flows of information. These processes contributed to emergent outcomes including the uptake of performance information, altruistic behaviours in service delivery and organizational learning. Through time, the cyclical nature of PM appears to have led to the spread of these behaviours beyond the teams studied here, thus contributing to system-wide effects. Findings illustrate the social nature of implementation processes and describe plausible pathways through which lower-order implementation programme effects can contribute to higher-order changes in system performance.

The role of social norms on adolescent family planning in rural Kilifi county, Kenya.

PURPOSE: Despite Kenya's encouraging progress in increasing access to modern contraception among youth, several barriers remain preventing large-scale efforts to reduce demand-side unmet need for family planning. Shifting social norms around the use and acceptability of modern contraception may represent a potent target for future interventions. However, the structure of normative influence on individual modern contraceptive use among youth needs to be determined. Therefore, our aim was to estimate the influence of individual and group-level normative influence on modern contraceptive use among adolescents from two villages in rural Kenya. METHODS: Trained enumerators collected data from individuals aged 15-24 who provided oral informed consent, or parental informed consent, in two villages in rural Kilifi county. Participants completed a questionnaire related to modern contraceptive use and were asked to nominate one to five people (referents) with whom they spend free time. The enumerators photographed each individual who nominated at least one referent using Android phones and matched them with their nominated referents. Using this social network data, we estimated group-level normative influence by taking an average of referents' modern contraception use. We then explored associations between descriptive norms, injunctive norms, and network modern contraceptive use on individual modern contraceptive use, controlling for known confounders using logistic regression models. We also conducted sensitivity analyses to test a pattern of differential referent influence on individual modern contraceptive use. RESULTS: There was a positive association between pro-modern contraception descriptive and injunctive norms and individual modern contraception use (adjusted Odds Ratio (aOR) = 1.29, 95% confidence interval (CI) = 1.05-1.6, and aOR = 1.31, CI = 1.06-1.62, respectively). Network modern contraceptive use was associated with individual use in the bivariate model (aOR = 2.57, CI = 1.6-4.12), but not in the multivariable model (aOR = 1.67, CI = 0.98-2.87). When stratified by sex and marital status, network modern contraceptive use was associated with individual modern contraceptive use among female participants (aOR = 2.9, CI = 1.31-6.42), and unmarried female participants (aOR = 5.26, CI = 1.34-20.69), but not among males. No interactive effects between norms variables were detected. Sensitivity analyses with a different estimate of network modern contraceptive use showed similar results. CONCLUSIONS: Social norms are multilevel phenomena that influence youth modern contraceptive use, especially among young women in rural Kenya. Unmarried women with modern contraceptive users in their social network may feel less stigma to use contraception themselves. This may reflect gendered differences in norms and social influence effects for modern contraceptive use. Future research should investigate group-level normative influence in relation to family planning behaviors.

Characterising performance information use in the primary healthcare systems of El Salvador, Lebanon and Malawi: multiple qualitative case study protocol.

INTRODUCTION: Governments in low-income and middle-income countries (LMICs) and official development assistance agencies use a variety of performance measurement and management approaches to improve the performance of healthcare systems. The effectiveness of such approaches is contingent on the extent to which managers and care providers use performance information. To date, major knowledge gaps exist about the contextual factors that contribute, or not, to performance information use by primary healthcare (PHC) decision-makers in LMICs. This study will address three research questions: (1) How do decision-makers use performance information, and for what purposes? (2) What are the contextual factors that influence the use or non-use of performance information? and (3) What are the proximal outcomes reported by PHC decision-makers from performance information use? METHODS AND ANALYSIS: We present the protocol of a theory-driven, qualitative study with a multiple case study design to be conducted in El Salvador, Lebanon and Malawi.Data sources include semi structured in-depth interviews and document review. Interviews will be conducted with approximately 60 respondents including PHC system decision-makers and providers. We follow an interdisciplinary theoretical framework that draws on health policy and systems research, public administration, organisational science and health service research. Data will be analysed using thematic analysis to explore how respondents use performance information or not, and for what purposes as well as barriers and facilitators of use. ETHICS AND DISSEMINATION: The ethical boards of the participating universities approved the protocol presented here. Study results will be disseminated through peer-reviewed journals and global health conferences.

Using Trellis software to enhance high-quality large-scale network data collection in the field.

Trellis is a mobile platform created by the Human Nature Lab at the Yale Institute for Network Science to collect high-quality, location-aware, off-line/online, multi-lingual, multi-relational social network and behavior data in hard-to-reach communities. Respondents use Trellis to identify their social contacts by name and photograph, a procedure especially useful in low-literacy populations or in contexts where names may be similar or confusing. We use social network data collected from 1,969 adult respondents in two villages in Kenya to demonstrate Trellis' ability to provide unprecedented metadata to monitor and report on the data collection process including artifactual variability based on surveyors, time of day, or location.

Does the Belief That Contraceptive Use Causes Infertility Actually Affect Use? Findings from a Social Network Study in Kenya.

The belief that contraceptive use causes infertility has been documented across sub-Saharan Africa, but its quantitative association with actual contraceptive use has not been examined. We collected and analyzed sociocentric network data covering 74 percent of the population in two villages in rural Kenya. We asked respondents to nominate people from their village (their network), and then we matched their network (alters) to the individual participant (ego) to understand how their beliefs and behaviors differ. We asked about contraceptive use and level of agreement with a statement about contraceptive use causing infertility. We calculated the average nominated network contraceptive use score and the average nominated network belief score. Holding the individual belief that contraceptive use causes infertility was associated with lower odds of using contraceptive (AOR = 0.82, p = < 0.01); however, when one's own nominated network connections held this belief, the odds of using contraceptive were even lower (AOR = 0.75, p <0.01). Our findings show that this belief is associated with lower odds of contraceptive use and highlights the role that other people in one's network play in reinforcing it. Sexual and reproductive health programs should address this misperception at the individual and social network level.

Performance management in complex adaptive systems: a conceptual framework for health systems.

Existing performance management approaches in health systems in low-income and middle-income countries are generally ineffective at driving organisational-level and population-level outcomes. They are largely directive: they try to control behaviour using targets, performance monitoring, incentives and answerability to hierarchies. In contrast, enabling approaches aim to leverage intrinsic motivation, foster collective responsibility, and empower teams to self-organise and use data for shared sensemaking and decision-making.The current evidence base is too limited to guide reforms to strengthen performance management in a particular context. Further, existing conceptual frameworks are undertheorised and do not consider the complexity of dynamic, multilevel health systems. As a result, they are not able to guide reforms, particularly on the contextually appropriate balance between directive and enabling approaches. This paper presents a framework that attempts to situate performance management within complex adaptive systems. Building on theoretical and empirical literature across disciplines, it identifies interdependencies between organisational performance management, organisational culture and software, system-level performance management, and the system-derived enabling environment. It uses these interdependencies to identify when more directive or enabling approaches may be more appropriate. The framework is intended to help those working to strengthen performance management to achieve greater effectiveness in organisational and system performance. The paper provides insights from the literature and examples of pitfalls and successes to aid this thinking. The complexity of the framework and the interdependencies it describes reinforce that there is no one-size-fits-all blueprint for performance management, and interventions must be carefully calibrated to the health system context.

Impact of the Ananya program on reproductive, maternal, newborn and child health and nutrition in Bihar, India: early results from a quasi-experimental study.

BACKGROUND: The Government of Bihar (GoB) in India, the Bill and Melinda Gates Foundation and several non-governmental organisations launched the Ananya program aimed to support the GoB to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) statewide. Here we summarise changes in indicators attained during the initial two-year pilot phase (2012-2013) of implementation in eight focus districts of approximately 28 million population, aimed to inform subsequent scale-up. METHODS: The quasi-experimental impact evaluation included statewide household surveys at two time points during the pilot phase: January-April 2012 ("baseline") including an initial cohort of beneficiaries and January-April 2014 ("midline") with a new cohort. The two arms were: 1) eight intervention districts, and 2) a comparison arm comprised of the remaining 30 districts in Bihar where Ananya interventions were not implemented. We analysed changes in indicators across the RMNCHN continuum of care from baseline to midline in intervention and comparison districts using a difference-in-difference analysis. RESULTS: Indicators in the two arms were similar at baseline. Overall, 40% of indicators (20 of 51) changed significantly from baseline to midline in the comparison districts unrelated to Ananya; two-thirds (n = 13) of secular indicator changes were in a direction expected to promote health. Statistically significant impact attributable to the Ananya program was found for 10% (five of 51) of RMNCHN indicators. Positive impacts were most prominent for mother's behaviours in contraceptive utilisation. CONCLUSIONS: The Ananya program had limited impact in improving health-related outcomes during the first two-year period covered by this evaluation. The program's theories of change and action were not powered to observe statistically significant differences in RMNCHN indicators within two years, but rather aimed to help inform program improvements and scale-up. Evaluation of large-scale programs such as Ananya using theory-informed, equity-sensitive (including gender), mixed-methods approaches can help elucidate causality and better explain pathways through which supply- and demand-side interventions contribute to changes in behaviour among the actors involved in the production of population-level health outcomes. Evidence from Bihar indicates that deep structural constraints in health system organisation and delivery of interventions pose substantial limitations on behaviour change among health care providers and beneficiaries. STUDY REGISTRATION: ClinicalTrials.gov number NCT02726230.

Improving primary health care delivery in Bihar, India: Learning from piloting and statewide scale-up of Ananya.

In 2010, the Bill and Melinda Gates Foundation (BMGF) partnered with the Government of Bihar (GoB), India to launch the Ananya program to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) outcomes. The program sought to address supply- and demand-side barriers to the adoption, coverage, quality, equity and health impact of select RMNCHN interventions. Approaches included strengthening frontline worker service delivery; social and behavior change communications; layering of health, nutrition and sanitation into women's self-help groups (SHGs); and quality improvement in maternal and newborn care at primary health care facilities. Ananya program interventions were piloted in approximately 28 million population in eight innovation districts from 2011-2013, and then beginning in 2014, were scaled up by the GoB across the rest of the state's population of 104 million. A Bihar Technical Support Program provided techno-managerial support to governmental Health as well as Integrated Child Development Services, and the JEEViKA Technical Support Program supported health layering and scale-up of the GoB's SHG program. The level of support at the block level during statewide scale-up in 2014 onwards was approximately one-fourth that provided in the pilot phase of Ananya in 2011-2013. This paper - the first manuscript in an 11-manuscript and 2-viewpoint collection on Learning from Ananya: Lessons for primary health care performance improvement - seeks to provide a broad description of Ananya and subsequent statewide adaptation and scale-up, and capture the background and context, key objectives, interventions, delivery approaches and evaluation methods of this expansive program. Subsequent papers in this collection focus on specific intervention delivery platforms. For the analyses in this series, Stanford University held key informant interviews and worked with the technical support and evaluation grantees of the Ananya program, as well as leadership from the India Country Office of the BMGF, to analyse and synthesise data from multiple sources. Capturing lessons from the Ananya pilot program and statewide scale-up will assist program managers and policymakers to more effectively design and implement RMNCHN programs at scale through technical assistance to governments.

'Our village is dependent on us. That's why we can't leave our work'. Characterizing mechanisms of motivation to perform among Accredited Social Health Activists (ASHA) in Bihar.

Community health workers (CHWs) play major roles in delivering primary healthcare services, linking communities to the formal health system and addressing the social determinants of health. Available evidence suggests that the performance of CHW programmes in low- and middle-income countries can be influenced by context-dependent causal mechanisms such as motivation to perform. There are gaps regarding what these mechanisms are, and what their contribution is to CHW performance. We used a theory-driven case study to characterize motivational mechanisms among Accredited Social Health Activists (ASHAs) in Bihar, India. Data were collected through semi-structured interviews with CHWs and focus group discussions with beneficiary women. Data were coded using a combined deductive and inductive approach. We found that ASHAs were motivated by a sense of autonomy and self-empowerment; a sense of competence, connection and community service; satisfaction of basic financial needs; social recognition; and feedback and answerability. Findings highlight the potential of ASHAs' intrinsic motivation to increase their commitment to communities and identification with the health system and of programme implementation and management challenges as sources of work dissatisfaction. Efforts to nurture and sustain ASHAs' intrinsic motivation while addressing these challenges are necessary for improving the performance of Bihar's ASHA programme. Further research is needed to characterize the dynamic interactions between ASHAs' motivation, commitment, job satisfaction and overall performance; also, to understand how work motivation is sustained or lost through time. This can inform policy and managerial reforms to improve ASHA programme's performance.

Effects of team-based goals and non-monetary incentives on front-line health worker performance and maternal health behaviours: a cluster randomised controlled trial in Bihar, India.

INTRODUCTION: We evaluated the impact of a 'Team-Based Goals and Incentives' (TBGI) intervention in Bihar, India, designed to improve front-line (community health) worker (FLW) performance and health-promoting behaviours related to reproductive, maternal, newborn and child health and nutrition. METHODS: This study used a cluster randomised controlled trial design and difference-in-difference analyses of improvements in maternal health-related behaviours related to the intervention's team-based goals (primary), and interactions of FLWs with each other and with maternal beneficiaries (secondary). Evaluation participants included approximately 1300 FLWs and 3600 mothers at baseline (May to June 2012) and after 2.5 years of implementation (November to December 2014) who had delivered an infant in the previous year. RESULTS: The TBGI intervention resulted in significant increases in the frequency of antenatal home visits (15 absolute percentage points (PP), p=0.03) and receipt of iron-folic acid (IFA) tablets (7 PP, p=0.02), but non-significant changes in other health behaviours related to the trial's goals. Improvements were seen in selected attitudes related to coordination and teamwork among FLWs, and in the provision of advice to beneficiaries (ranging from 8 to 14 PP) related to IFA, cord care, breast feeding, complementary feeding and family planning. CONCLUSION: Results suggest that combining an integrated set of team-based coverage goals and targets, small non-cash incentives for teams who meet targets and team building to motivate FLWs resulted in improvements in FLW coordination and teamwork, and in the quality and quantity of FLW-beneficiary interactions. These improvements represent programmatically meaningful steps towards improving health behaviours and outcomes. TRIAL REGISTRATION NUMBER: NCT03406221.

Evidence gap map of performance measurement and management in primary healthcare systems in low-income and middle-income countries.

INTRODUCTION: We mapped available evidence on performance measurement and management (PMM) strategies in primary healthcare (PHC) systems of low-income and middle-income countries (LMICs). Widely used, their effectiveness remains inconclusive. This evidence gap map characterises existing research and evidence gaps. METHODS: Systematic mapping of performance measurement and management research in LMICs from 2000 to mid-2018; literature searches of seven academic databases and institutional repositories of impact evaluations and systematic reviews. Using a combination of manual screening and machine learning, four reviewers appraised 38 088 titles and abstracts, and extracted metadata from 137 impact evaluations and 18 systematic reviews that met the inclusion criteria. The resulting visual representation of the evidence base was uploaded to a web-based platform. RESULTS: Since 2000, the number of studies has increased; the first systematic reviews were completed in 2010. Two-thirds of the studies were conducted in sub-Saharan Africa and South Asia. Randomised controlled trials were the most frequently used study design. The evidence is concentrated in two types of PMM strategies: implementation strategies (in-service training, continuing education, supervision) and performance-based financing. Major gaps exist in accountability arrangements particularly the use of audit and feedback. The least studied types of outcomes were unintended effects, harm and social equity. CONCLUSIONS: The evidence is clustered around interventions that are unlikely to achieve transformational change in health outcomes. The gaps identified suggest that routinely used PMM strategies are implemented without sufficient knowledge of their effects. Future efforts at redesigning PHC systems need to be informed by evidence on the most effective approaches for using PMM strategies.

"They Destroy the Reproductive System": Exploring the Belief that Modern Contraceptive Use Causes Infertility.

A common reason for nonuse of modern contraceptives is concern about side effects and health complications. This article provides a detailed characterization of the belief that modern contraceptives cause infertility, and an examination of how this belief arises and spreads, and why it is so salient. We conducted focus group discussions and key informant interviews in three rural communities along Kenya's eastern coast, and identified the following themes: (1) the belief that using modern contraception at a young age or before childbirth can make women infertile is widespread; (2) according to this belief, the most commonly used methods in the community were linked to infertility; (3) when women observe other women who cannot get pregnant after using modern contraceptives, they attribute the infertility to the use of contraception; (4) within the communities, the primary goal of marriage is childbirth and thus community approval is rigidly tied to childbearing; and, therefore (5) the social consequences of infertility are devastating. These findings may help inform the design of programs to address this belief and reduce unmet need.

Understanding modern contraception uptake in one Ethiopian community: a case study.

BACKGROUND: In the last decade, the proportion of Ethiopian women using contraceptive methods has increased substantially (from 14% in 2005 to 35% in 2016 among married women). Numerous factors have contributed to the increased uptake. An important one is the implementation of the Health Extension Program, a government-led health service delivery strategy that has deployed more than 38,000 health extension workers (HEWs) throughout the country. Key mechanisms underlying the success of this program are not well understood. Using a case study approach, the goal of this study is to describe how key features of local contexts, community perceptions, and messaging by HEWs have contributed to the increased use of modern contraception in one community in Ethiopia. METHODS: We conducted focus groups and individual interviews with men, women, adolescents, and key informants, including (HEWs), in Oromia, Ethiopia. We used a random sampling protocol to recruit all participants except key informants, with whom purposive sampling was used to ensure participants were knowledgeable on family planning in the village. Interviews were audio recorded, translated, transcribed, and then analyzed using applied thematic analysis and NVivo v.11 qualitative research software. RESULTS: We identified four themes that may explain uptake of contraception: (1) HEWs are seen as trusted and valued community members who raised awareness about family planning; (2) the HEW messaging that contraception is useful to space pregnancies among married women was effective; (3) the message that spacing is healthy for mother and child was also effective; and (4) communicating to the entire community (including men, women, adolescents, and religious leaders), contributed to changing attitudes around contraception. CONCLUSION: The four aspects of the Health Extension Program approach increased uptake of contraception in our sample. In contexts where community health workers are valued by the health systems and local communities they serve, this type of approach to widening modern contraception use could help increase uptake and address unmet need. Understanding these granular aspects of the program in one local context may help explain how use of contraception increased in the country as a whole.

Characterizing performance improvement in primary care systems in Mesoamerica: A realist evaluation protocol.

Background. Improving performance of primary care systems in low- and middle-income countries (LMICs) may be a necessary condition for achievement of universal health coverage in the age of Sustainable Development Goals. The Salud Mesoamerica Initiative (SMI), a large-scale, multi-country program that uses supply-side financial incentives directed at the central-level of governments, and continuous, external evaluation of public, health sector performance to induce improvements in primary care performance in eight LMICs. This study protocol seeks to explain whether and how these interventions generate program effects in El Salvador and Honduras. Methods. This study presents the protocol for a study that uses a realist evaluation approach to develop a preliminary program theory that hypothesizes the interactions between context, interventions and the mechanisms that trigger outcomes. The program theory was completed through a scoping review of relevant empirical, peer-reviewed and grey literature; a sense-making workshop with program stakeholders; and content analysis of key SMI documents. The study will use a multiple case-study design with embedded units with contrasting cases. We define as a case the two primary care systems of Honduras and El Salvador, each with different context characteristics. Data will be collected through in-depth interviews with program actors and stakeholders, documentary review, and non-participatory observation. Data analysis will use inductive and deductive approaches to identify causal patterns organized as 'context, mechanism, outcome' configurations. The findings will be triangulated with existing secondary, qualitative and quantitative data sources, and contrasted against relevant theoretical literature. The study will end with a refined program theory. Findings will be published following the guidelines generated by the Realist and Meta-narrative Evidence Syntheses study (RAMESES II). This study will be performed contemporaneously with SMI's mid-term stage of implementation. Of the methods described, the preliminary program theory has been completed. Data collection, analysis and synthesis remain to be completed.

The RANI Project: A socio-normative intervention to reduce anemia in Odisha, India: A formative research protocol.

Background: More than half of women of reproductive age in India are anemic. Anemia is associated with increased risk of preterm delivery, higher maternal mortality and contributes to fatigue, which affects women's work productivity. The World Health Organization (WHO) recommends daily oral iron and folic acid (IFA) supplements during pregnancy and weekly supplements for women of reproductive age. Government programs and global donors have distributed and promoted IFA supplements in India for over four decades. However, initial intake and compliance remain inadequate. Objectives: This protocol describes the formative research phase of a larger study, called the Reduction in Anemia through Normative Innovations (RANI) Project, which will test, through a randomized controlled trial, the hypothesis that a social norms-based behavioral intervention in Odisha, India will improve uptake of IFA supplements and reduce anemia among reproductive age women as compared to usual care. The focus of this paper is on the formative research required to develop a sound intervention. We will examine socio-normative barriers to and facilitators of IFA supplement uptake. Methods and analysis: Based on the Theory of Normative Social Behavior, we will adopt a mixed-method, multilevel approach. We will collect data using focus groups, in-depth interviews, observations, Rapid Participatory Ethnographic Evaluation and Research (PEER) techniques, and perceptual mapping methods. Our sample includes reproductive age women (pregnant and not pregnant), their husbands, their mothers/in law and key stakeholders. Before collecting the data, and after analyzing the results, we will hold convenings in India to engage key stakeholders in collaborative design. Following the intervention design, we will test components of the intervention, gather user feedback and fine-tune as necessary. Impact: This study will contribute to the social norms and behavioral intervention research and inform policymakers about the value of adopting a socio-normative approach.

Evidence gap map of performance measurement and management in primary care delivery systems in low- and middle-income countries - Study protocol.

Background . For the last two decades there has been growing interest in governmental and global health stakeholders about the role that performance measurement and management systems can play for the production of high-quality and safely delivered primary care services. Despite recognition and interest, the gaps in evidence in this field of research and practice in low- and middle-income countries remain poorly characterized. This study will develop an evidence gap map in the area of performance management in primary care delivery systems in low- and middle-income countries. Methods. The evidence gap map will follow the methodology developed by 3Ie, the International Initiative for Impact Evaluation, to systematically map evidence and research gaps. The process starts with the development of the scope by creating an evidence-informed framework that helps identify the interventions and outcomes of relevance as well as help define inclusion and exclusion criteria. A search strategy is then developed to guide the systematic search of the literature, covering the following databases: Medline (Ovid), Embase (Ovid), CAB Global Health (Ovid), CINAHL (Ebsco), Cochrane Library, Scopus (Elsevier), and Econlit (Ovid). Sources of grey literature are also searched. Studies that meet the inclusion criteria are systematically coded, extracting data on intervention, outcome, measures, context, geography, equity, and study design. Systematic reviews are also critically appraised using an existing standard checklist. Impact evaluations are not appraised but will be coded according to study design. The process of map-building ends with the creation of an evidence gap map graphic that displays the available evidence according to the intervention and outcome framework of interest. Discussion . Implications arising from the evidence map will be discussed in a separate paper that will summarize findings and make recommendations for the development of a prioritized research agenda.

Scaling-up impact in perinatology through systems science: Bridging the collaboration and translational divides in cross-disciplinary research and public policy.

Despite progress over the past decade in reducing the global burden of newborn deaths, gaps in the knowledge base persist, and means of translating empirical findings into effective policies and programs that deliver life-saving interventions remain poorly understood. Articles in this issue highlight the relevance of transdisciplinary research in perinatology and calls for increased efforts to translate research into public policy and to integrate interventions into existing primary care delivery systems. Given the complexity and multi-causality of many of the remaining challenges in newborn health, and the effects that social and economic factors have over many newborn conditions, it has further been proposed that integrated, multi-sector public policies are also required. In this article, we discuss the application of systems science methods to advance transdisciplinary research and public policy-making in perinatology. Such approaches to research and public policy have been used to address various global challenges but have rarely been implemented in developing country settings. We propose that they hold great promise to improve not only our understanding of complex perinatology problems but can also help translate research-based insights into effective, multi-pronged solutions that deliver positive, intended effects. Examples of successful transdisciplinary science exist, but successes and failures are context specific, and there are no universal blueprints or formulae to reproduce what works in a specific context into different social system settings. Group model building is a tool, based in the field of System Dynamics, that we have used to facilitate transdisciplinary research and, to a lesser extent, policy formulation in a systematic and replicable way. In this article, we describe how group model building can be used and argue for scaling its use to further the translation of empirical evidence and insights into policy and action that increase maternal and neonatal survival and well-being.

Newborn health: everybody's business.

Despite advances in issue-attention and in evidence of what works to save newborn lives (e.g., kangaroo mother care, antenatal corticosteroids, immediate and exclusive breastfeeding), we are still falling short on impact. To advance the unfinished newborn survival agenda, newborns must become an integral priority in developing countries where the burden of neonatal mortality is highest. Interventions must be adapted to local contexts and cultures and integrated into packages along the continuum of care delivered through the primary health-care systems that countries have at their disposal.