Pathways of change for achieving sustainability results: A tool to facilitate adaptive programming.

Traditional approaches to development programming with fixed targets and outcomes do not fit complex problems where the pathway to achieve results differs in each context and evolves constantly. Adaptive programming improves responses to complex problems by identifying which solutions bring change. This paper reviews the theory behind adaptive programming approaches and introduces the 'Pathways of Change' tool for achieving sustainability results, developed for the multi-country Women's Integrated Sexual Health programme. Qualitative data, using semi-structured interviews and group discussions from teams in over 17 countries in Africa and South Asia, are presented which examine the application of the Pathways of Change (PoC) tool focusing on successes and challenges across different intervention areas. The PoC responds to the need for a more practical adaptive programming tool that can be tailored to support flexibility in global health programme implementation while meeting donor requirements. Findings suggest that the PoC tool provides a flexible yet robust alternative to traditional monitoring frameworks and is able to facilitate adaptive, contextualised planning and monitoring for multi-country programmes. The PoC tool offers a solution to realise the ambitions of implementing adaptive programming within global health programmes and potentially beyond.

Effectiveness of post-campaign, door-to-door, hang-up, and communication interventions to increase long-lasting, insecticidal bed net utilization in Togo (2011-2012): a cluster randomized, control trial.

BACKGROUND: It is well established that insecticide-treated bed nets (ITNs), in particular long-lasting, insecticidal nets (LLINs), can be used as one of the primary interventions for effective malaria control. A consistent gap between net ownership and use has been observed, indicating that factors exist that prevent an owned mosquito net from being used. One approach used in the context of LLIN campaigns is a post-distribution, door-to-door visit of households with educational messages and to physically assist with hang-up of nets. METHODS: A cluster randomized trial was conducted in the Plateaux Region of Togo to evaluate the effectiveness of different approaches to post-LLIN campaign home visits (number of visits and timing) by volunteers to enhance LLIN hang-up and utilization. RESULTS: It was found that, in general, households that received intervention visits, particularly the most recent intervention visit, had levels of use that were typically 5 to 10% higher than the control households, while access did not differ among control and intervention households. Eight months post-campaign, ITN use by all individuals, children under five years and women of reproductive age was 11.3 to 14.4 percentage points greater in the study arm that received all three intervention visits than in the control communities. In households that received one or two additional door-to-door visits, the majority of respondents indicated that the volunteer provided new information during the visit regarding the use and importance of ITNs despite having received previous multiple visits. CONCLUSIONS: The impact of the interventions appears to have been primarily through the delivery and reinforcement of key behaviour-change communication (BCC) messages regarding the importance of using an ITN and its care. Regardless of whether the respondents in fact received new information or had forgotten earlier information, this suggests that regular visits from community agents are useful in reinforcing key BCC messages.

Ambulance service within a comprehensive intervention for reproductive health in remote settings: a cost-effective intervention.

OBJECTIVE: To assess the cost-effectiveness of an ambulance service within a comprehensive hospital/community-based program aimed at improving access and quality of reproductive health in poor-resources settings. METHODS: Obstetrical cases referred to the hospital with the ambulance during a 3-month period were prospectively recorded. Clinical indications were used to determine the effectiveness of the referral; the direct costs of the service were calculated. Overall effectiveness was then measured against WHO thresholds. RESULTS: Ninety-two obstetrical referrals were recorded. Eleven (12%) were considered effective, corresponding to 611.7 years saved. Cost per year saved was 15.82 US dollars which about half of WHO's 30 US dollar benchmark defining very attractive interventions. Sensitivity analyses on the costs of the ambulance and the rate of effective referrals emphasized the robustness of the result. CONCLUSIONS: The cost-effectiveness profile of an ambulance service within a series of interventions aimed at improving reproductive health in remote settings is very attractive.

A comprehensive and integrated project to improve reproductive health at Oyam district, northern Uganda: insights from maternal death review at the district hospital.

PURPOSE: To perform a district hospital-based maternal death review aimed at assessing the benefits and limits of an integrated and comprehensive project for reproductive health in Oyam district, northern Uganda. METHODS: From April 01, 2009 to March 31, 2010, all cases of maternal death occurring in the hospital were prospectively recorded using a specific questionnaire. A clinical review of these maternal deaths was systematically done. The hospital is located in a rural area and it offers the possibility to perform cesarean sections, obstetrics ultrasounds, and blood transfusions. No emergency room and pathological services are available. RESULTS: Seventeen cases were recorded. Thirteen (76%) were classified as direct obstetrics deaths (post-partum hemorrhagia in five cases, unsafe abortion in five cases, eclampsia in two cases and ante-partum hemorrhagia for placenta previa in one case). The remaining cases (n = 4, 24%) were indirect obstetrics deaths (meningitis HIV-related in two cases, cardiopathy in one case and cerebral malaria in one case). An important negligence of the health staff of the health centers was evident in three cases. The availability of an emergency room service was estimated to potentially prevent death in six cases. CONCLUSIONS: Three main targets for future interventions were identified: improving the quality of assistance in the health centers, implementing an emergency room service in the hospital and counteract unsafe abortion.