Health Systems Strengthening to Tackle the Global Burden of Pediatric and Congenital Heart Disease: A Diagonal Approach

1 Background Congenital heart disease(CHD)is the most common major congenital anomaly,affecting approximately one in every 100 live births[1].Among congenital anomalies,66%of preventable deaths are due to CHD,and 58%of the avertable morbidity and mortality due to congenital anomalies would result from scaling congenital heart surgery services[2].Every year,nearly 300,000 children and adults die from CHD,the majority of whom live in low-and middle-income countries(LMICs)[3].Approximately 49%of all individuals with CHD will require surgical or interventional care at some point in their lifetime[4];as a result of advances in access to and the delivery of such services,over 95%of children born with CHD in high-income countries now live into adulthood[3].Here,adults have surpassed children in the number of CHD cases at a ratio of 2:1[5].

Coronavirus disease 2019 (COVID-19) pandemic: how countries shouldbuild more resilient health systems for preparedness and response

Objective: A resilient health system plays a crucial role in pandemic preparedness and response. Althoughthe World Health Organization (WHO) has required all states parties to strengthen core capacities to respondto public health emergencies under the International Health Regulations (2005), the actions of most countriesto combating coronavirus disease 2019 (COVID-19) has showed that they are not well-prepared. This crosssectionalstudy aimed to examine the health system resilience of selected countries and analyze their strategiesand measures in response to the COVID-19 pandemic.Methods: This study selected five countries including the Iran, Japan, Republic of Korea (South Korea), the U.K.,and the U.S., based on the severity of the national epidemic, the geographical location, and the developmentlevel. Cumulative number of death cases derived from WHO COVID-19 dashboard was used to measure theseverity of the impact of the pandemic in each country;WHO State Parties Self-Assessment Annual Reporting (SPAR)Scores and Global Health Security (GHS) Index were applied to measure the national health system resilience;and research articles and press materials were summarized to identify the strategies and measures adopted bycountries during response to COVID-19. This study applied the resilient health systems framework to analyzehealth system resilience in the selected countries from five dimensions, including awareness, diversity, selfregulation,integration and adaptation.Results: The SPAR Scores and GHS Index of the four developed countries, Japan, South Korea, the U.K. and theU.S. were above the global and regional averages;the SPAR Scores of Iran were above the global average whilethe GHI Index lain below the global average. In terms of response strategies, Japan, the U.K. and the U.S. investedmore health resources in the treatment of severe patients, while South Korea and Iran had adopted a strategyof extensive testing and identification of suspected patients. In terms of specific measures, all the five countriesadopted measures such as restrictions on entry and international travel, closure of schools and industries,lockdown and quarantine. Nevertheless, the effectiveness of implementing these measures varied acrosscountries, based on the response strategies.Conclusion: Although SPAR Scores and GHS Index have evaluated the national core capacities for preparednessand response, the actions to cope with the COVID-19 pandemic has revealed the fact that most countries stilldo not build resilient health systems in response to public health emergencies. Health system strengtheningand health security efforts should be pursued in tandem, as part of the same mutually reinforcing approach todeveloping resilient health systems.

International Conference on Environment and Human Health Systems Engineering 2017 Held in Xi＇an

The first International Conference on Environment and Human Health Systems Engineering was held on July 8,2017 in Northwestern Polytechnical University（NPU）,Xi’an.This conference was jointly held by the School of Life Sciences of NPU,the Office of International Cooperation of NPU and the China Aerospace Academy of Systems Science and Engineering（CAASSE）.

Moving from medical to health systems classifications of deaths:extending verbal autopsy to collect information on the circumstances of mortality

Background:Verbal autopsy(VA)is a health surveillance technique used in low and middle-income countries to establish medical causes of death(CODs)for people who die outside hospitals and/or without registration.By virtue of the deaths it investigates,VA is also an opportunity to examine social exclusion from access to health systems.The aims were to develop a system to collect and interpret information on social and health systems determinants of deaths investigated in VA.Methods:A short set of questions on care pathways,circumstances and events at and around the time of death were developed and integrated into the WHO 2012 short form VA(SF-VA).Data were subsequently analysed from two census rounds in the Agincourt Health and Socio-Demographic Surveillance Site(HDSS),South Africa in 2012 and 2013 where the SF-VA had been applied.InterVA and descriptive analysis were used to calculate cause-specific mortality fractions(CSMFs),and to examine responses to the new indicators and whether and how they varied by medical CODs and age/sex sub-groups.Results:One thousand two hundred forty-nine deaths were recorded in the Agincourt HDSS censuses in 2012-13 of which 1,196(96%)had complete VA data.Infectious and non-communicable conditions accounted for the majority of deaths(47%and 39%respectively)with smaller proportions attributed to external,neonatal and maternal causes(5%,2%and 1%respectively).5%of deaths were of indeterminable cause.The new indicators revealed multiple problems with access to care at the time of death:39%of deaths did not call for help,36%found care unaffordable overall,and 33%did not go to a facility.These problems were reported consistently across age and sex sub-groups.Acute conditions and younger age groups had fewer problems with overall costs but more with not calling for help or going to a facility.An illustrative health systems interpretation suggests extending and promoting existing provisions for transport and financial access in this setting.Conclusions:Supplementing VA with questions on the circumstances of mortality provides complementary information to CSMFs relevant for health planning.Further contextualisation of the method and results are underway with health systems stakeholders to develop the interpretation sequence as part of a health policy and systems research approach.

Frameworks for health systems performance assessment:how comprehensive is Ghana’s holistic assessment tool?

Background:Measuring the performance of a health system is an essential requirement in creating systems that generate efficient,equitable,patient-focused,accessible and sustainable results.A fundamental requirement for a performance measurement system is the development of an assessment framework within which specific performance measures could be defined and applied regularly.This paper examines the comprehensiveness of Ghana’s health system assessment framework called the Holistic Assessment Tool in relation to some of the internationally recognized frameworks.The paper also analyzes trends in the performance of the health system to understand whether or not an improvement has been recorded following the adoption and implementation of the Holistic Assessment Tool.Methods:Mainly secondary data were used in this analysis.Searches were conducted on Google Scholar,PubMed,Scopus and Science Direct between May and July,2019 for published documents on health system performance assessment.We also obtained unpublished documents from Ghana’s Ministry of Health,Ghana Health Service website,and Ghana Statistical Service database.Descriptive statistics were used to examine trends in the performance of the Ghanaian health system.Results:While the tool provides a national framework for evaluating the performance of the Ghana Health system in several domains,the Holistic Assessment Tool does not cover key health system domains such as information systems for health,access to essential medicines,and patient-centeredness.Also,the scope of the assessment program seems limited to the evaluation of the Ministry of Health’s annual plans,programs and projects.However,the health system has recorded improvements in population health indicators,such as life expectancy at birth,infant mortality,under-5 mortality,HIV prevalence and disease burden(in terms of disability adjusted life years).Conclusions:The Holistic Assessment Tool is a useful framework,but needs further refinement,both in scope and in conceptual robustness.Future studies should consider exploring factors influencing performance of the Ghanaian health system.Such information will help in strategizing for better and more improvements.

Personalized Health Monitoring Systems: Integrating Wearable and AI

The integration of wearable technologies and artificial intelligence (AI) has revolutionized healthcare, enabling advanced personal health monitoring systems. This article explores the transformative impact of wearable technologies and AI on healthcare, highlighting the development and theoretical application of the Integrated Personal Health Monitoring System (IPHMS). By integrating data from various wearable devices, such as smartphones, Apple Watches, and Oura Rings, the IPHMS framework aims to revolutionize personal health monitoring through real-time alerts, comprehensive tracking, and personalized insights. Despite its potential, the practical implementation faces challenges, including data privacy, system interoperability, and scalability. The evolution of healthcare technology from traditional methods to AI-enhanced wearables underscores a significant advancement towards personalized care, necessitating further research and innovation to address existing limitations and fully realize the benefits of such integrated health monitoring systems.

Exploring China's Western and Central County Systems Performance Measured by Outcomes Framework Scores-A Cross-sectional Survey of Routine Healthcare Data

This study was designed to measure the performance of county health systems in central and western China utilizing routine healthcare data.Drawing on a literature review and expert consultation,the study established a theoretical framework and an indicator system for performance review.Questionnaires were designed and disseminated to collect empirical data on health system performance in four counties of two central and western provinces.Quantitative data were subjected to descriptive statistical analysis through SPSS12.0.Three dimensions were introduced in the performance review framework—health outcomes,financial risk protection and consumer and provider satisfaction.Health outcomes were assessed from four secondary indicators：infant mortality rate;maternal mortality rate;under-5 child mortality rate;and the incidence of Class A and Class B notifiable diseases.Financial risk was assessed using two secondary indicators：the proportion of the cost of inpatient care that was reimbursed under the New Cooperative Medical System（NCMS） insurance scheme,and the rate of NCMS funds utilization.The assessment of satisfaction was made using two secondary indicators：the overall satisfaction of local residents with healthcare services,and the satisfaction of health practitioners at the township and village level.The study indicated better health system performance in the two counties in Chongqing than those in Shanxi.It was concluded that outcome framework scores can fairly reveal performance differences among county health systems in central and western China,and can provide practical evidence for optimizing the operation and inputs of county health systems.Caution needs to be exercised in generalizing such performance outcomes as many factors such as spending and organization that contribute to county health system performance were not included in the study.

Strengthening Weak Healthcare Systems for Maternal and Neonatal Care in Low and Middle Income Countries: The Missing Link

Introduction: Preventable maternal and newborn mortalities still occur in local communities in Kenya since access to maternal and newborn healthcare services remains a big challenge. Barriers to access in resource-constrained settings have not been examined adequately in literature. The World Health Organization (WHO) has 6 building blocks for strengthening healthcare systems that informed this study. This paper examines how user-side and institutional factors influence access and use of Maternal and Newborn Healthcare (MNH) Services in Matayos sub-County-Busia County. Methods: A mixed method approach, with an ethnographic inquiry and a descriptive cross-sectional design, was adopted to assess access to MNH services in Matayos-Busia County, Western Kenya. Postpartum women who had delivered within the previous 12 months and health care providers in the study area were recruited as respondents. A total of 348 postpartum women were selected through stratified systematic random sampling for the survey. Purposive sampling was used to select postpartum women, conventional and traditional health care providers for 16 in-depth interviews and 7 focus group discussions. Data were analyzed using descriptive and inferential statistics. Qualitative data analysis was done thematically. Results: Institutional delivery was low at 68% and family planning at 75% although demand for services was high at 99%. User-side barriers to access included shared beliefs and practices in the community;high direct transport costs from home;and high costs for missing drugs and other supplies in hospitals. Middle (5th-7th) order deliveries occurred at home with traditional birth attendants. The choice of place of delivery in households was influenced by spouses to respondents and communities of residence where respondents lived or were married. All 6 WHO health system building blocks were weak in Matayos sub-County and needed system-wide strengthening involving all pillars. The user-community voice alone was insufficient and the 7th pillar for user-community engagement was absent. The underlying factors were weak governance and underfunding for healthcare. Conclusion: The six WHO building blocks were inadequate due to weak governance and inadequate funding. User-community engagement, the 7th Pillar, was absent in these resource-limited settings. We recommend user-community empowerment, engagement and participation, adoption of a system thinking approach and adequate funding.

Integration of community health workers into health systems in developing countries:Opportunities and challenges

Background:Developing countries have the potential to reach vulnerable and underserved populations marginalized by the country’s health care systems by way of community health work-ers(CHWs).It is imperative that health care systems focus on improving access to quality continu-ous primary care through the use of CHWs while paying attention to the factors that impact on CHWs and their effectiveness.Objective:To explore the possible opportunities and challenges of integrating CHWs into the health care systems of developing countries.Methods:Six databases were examined for quantitative,qualitative,and mixed-methods stud-ies that included the integration of CHWs,their motivation and supervision,and CHW policy making and implementation in developing countries.Thirty-three studies met the inclusion criteria and were double read to extract data relevant to the context of CHW programs.Thematic coding was conducted and evidence on the main categories of contextual factors influencing integration of CHWs into the health system was synthesized.Results:CHWs are an effective and appropriate element of a health care team and can assist in addressing health disparities and social determinants of health.Important facilitators of integration of CHWs into health care teams are support from other health workers and inclusion of CHWs in case management meetings.Sustainable integration of CHWs into the health care system requires the formulation and implementation of polices that support their work,as well as financial and nonfinancial incentives,motivation,collaborative and supportive supervision,and a manageable workload.Conclusions:For sustainable integration of CHWs into health care systems,high-performing health systems with sound governance,adequate financing,well-organized service delivery,and adequate supplies and equipment are essential.Similarly,competent communities could contrib-ute to better CHW performance through sound governance of community resources,promotion of inclusiveness and cohesion,engagement in participatory decision making,and mobilization of local resources for community welfare.

Virtual healthcare services and digital health technologies deployed during coronavirus disease 2019(COVID-19)pandemic in South Africa:a systematic review

Aims:To identify virtual healthcare services and digital health technologies deployed in South Africa during coronavirus disease 2019(COVID-19)and the challenges associated with their use.Metiiods:To determine the status of digital health utilization during COVID-19 in South Africa,the preferred reporting items for systematic reviews and meta-analyses model was used to perform a systematic and in-depth critical analysis of previously published studies in well-known and trusted online electronic databases using specific search keywords words that are relevant to this study.We selected published peer-reviewed articles available from the onset of COVID-19 to July 2021.Results:Total of 24 articles were included into this study.This study revealed that South Africa adopted digital technologies such as SMS-based solutions,mobile health applications,telemedicine and telehealth,WhatsApp-based systems,artificial intelligence and chatbots and robotics to provide healthcare services during COVID-19 pandemic.These innovative technologies have been used for various purposes including screening infectious and non-infectious diseases,disease surveillance and monitoring,medication and treatment compliance,creating awareness and communication.The study also revealed that teleconsultation and e-prescription,telelaboratory and telepharmacy,teleeducation and teletraining,teledermatology,teleradiology,telecardiology,teleophthalmology,teleneurology,telerehabilitation,teleoncology and telepsychiatry are among virtual healthcare services delivered through digital health technologies during COVID-19 in South Africa.However,these smart digital health technologies face several impediments such as infrastructural and technological barriers,organization and financial barriers,policy and regulatory barriers as well as cultural barriers.Conclusion:Although COVID-19 has invigorated the use of digital health technologies,there are still some shortcomings.The outbreak of pandemics like COVID-19 in the future is not inevitable.Therefore,we recommend increasing community networks in rural areas to bridge the digital divide and the modification of mHealth policy to advocate for the effective use of innovative technologies in healthcare and the development of sustainable strategies for resources mobilization through private-public partnerships as well as joining available international initiatives advocating for smart digital health.

Excess mortality in Northeast Iran caused by COVID-19:Neglect of offset community transformations of health

Objective:To make evidence-based decisions based on broad mortality trends for Razavi Khorasan province,Iran.Methods:In order to determine the baseline number of deaths,we used univariate time series analyses for monthly data from the monthly vital statistics reports(From April 2015 to March 2022).For excess mortalities,these baselines were subtracted from reported deaths with a 95%prediction interval.To compare time and causes,a P-score was calculated.Results:From March 2020 to March 2022,there were 61949 registered deaths,and the estimated deaths with a 95%confidence interval(CI)were 43246.16(35718.28,50774.05).So,in 2020-2021 and 2021-2022,the death counts were 35.15%and 51.33%higher than projected.A total of 18666 cardiovascular diseases were reported and a total of 15704.46(12006.95,19401.96)was estimated.The P-score for this duration was 14.49%and 23.23%higher than expected.Infectious and parasitic diseases plus COVID-19 were 16633 and estimated to be 1044.87(456.77,1632.96).A total of 4420 diseases of the respiratory system were reported,and 4564.94 deaths were predicted(2277.43,6852.43).In the first year of the pandemic,the P-score dropped to-35.28%and in the second year,it jumped sharply to 22.38%.Conclusions:Excess mortality,along with cause-specific mortality,can be helpful for monitoring trends and developing public health policies at the local,national,and international levels.

A longitudinal surgical systems strengthening research program for medical students:the exploration of a model for global health education

Background:In response to the staggering global burden of conditions requiring emergency and essential surgery,the development of international surgical system strengthening(SSS)is fundamental to achieving universal,timely,quality,and affordable surgical care.Opportunity exists in identifying optimal collaborative processes that both promote global surgery research and SSS,and include medical students.This study explores an education model to engage students in academic global surgery and SSS via institutional support for longitudinal research.Objectives:We set out to design a program to align global health education and longitudinal health systems research by creating an education model to engage medical students in academic global surgery and SSS.Program design and implementation:In 2015,medical schools in the United States and Colombia initiated a collaborative partnership for academic global surgery research and SSS.This included development of two longitudinal academic tracks in global health medical education and academic global surgery,which we differentiated by level of institutional resourcing.Herein is a retrospective evaluation of the first two years of this program by using commonly recognized academic output metrics.Main achievements:In the first two years of the program,there were 76 total applicants to the two longitudinal tracks.Six of the 16(37.5%)accepted students selected global surgery faculty as mentors(Acute Care Surgery faculty participating in SSS with Colombia).These global surgery students subsequently spent 24 total working weeks abroad over the two-year period participating in culminating research experiences in SSS.As a quantitative measure of the program’s success,the students collectively produced a total of twenty scholarly pieces in the form of accepted posters,abstracts,podium presentations,and manuscripts in partnership with Colombian research mentors.Policy implications:The establishment of scholarly global health education and research tracks has afforded our medical students an active role in international SSS through participation in academic global surgery research.We propose that these complementary programs can serve as a model for disseminated education and training of the future global systems-aware surgeon workforce with bidirectional growth in south and north regions with traditionally under-resourced SSS training programs.

Features of long-term health monitored strains of a bridge with wavelet analysis

This paper analyses the five years’ monitored strains collected from a long-term health monitoring system installed on a bridge with wavelet transform.In the analysis,the monitored strains are pre-processed,features of the monitored data are summarized briefly.The influences of the base functions on the results of wavelet analysis are studied simultaneously.The results show that the db wavelet is a good mother wavelet function in the analysis,and the order N should be larger than 20,but less than 46 in decomposing the monitored strains of the bridge.According to the strain variation features of concrete bridge,the proper decomposition level is 4 in the wavelet multi-resolution analysis.With the present method,the strains caused by random loads and daily sunlight can be accurately extracted from the monitored strains.The decomposed components of the monitored strains show that the amplitudes of the strains caused by random loads,daily sunlight,and annual temperature effect,are about 5 με,25 με,and 50 με respectively.The structural response under random load is smaller than the other parts.

Looking ahead to significant improvements in mining safety and health through innovative research and effective diffusion into the industry

Mining safety and health improvements over the past decades are remarkable by many metrics, and yet the expectation of society, and the goal of the mining industry, is zero harm. If we examine the underlying enablers for the significant gains that have been achieved, the key role that research to help understand the causes of problems and to develop lasting solutions is clear. Many of the remaining challenges have been resistant to solutions by various approaches. Some, such as fatalities and injuries from ground control or powered haulage are prominent year after year. Different approaches are indicated and new solutions will be required if we are to achieve a goal of zero harm. These will originate with research, but into which topics, and what are some of these different approaches? This paper examines the current state of mine safety in the United States and highlights areas of significant opportunity for research that will lead to solutions. The likely direction of research that will enable realization of the ‘‘zero harm'' goal is described in terms of evolutionary and revolutionary approaches. Both are important, but the author's view is that some of the largest gains will be made with trans-disciplinary approaches that break from the past. Topical areas of research are suggested and several research questions are given to illustrate the direction of future research in mining safety and health.

The Impact of Computerized Health Information System on Medical &Administrative Decisions, Sana’a Hospitals, Yemen (2017-2020)

Background: Health information systems (HIS) play a major role in decision-making. The aim is to identify the components of computerized HIS and their relationship to administrative decisions at the main referral hospitals for Sana’a city. Method: This applied research is a descriptive, cross-sectional study in which the HIS of 7 hospitals affiliated with Sana’a city hospitals during “2017-2020”, was evaluated based on Self-administered questionnaires. Data were collected by using Self-administered questionnaires and analyzed in SPSS 16 by using descriptive statistics. Results: A total of 626 users (95.7%) had responded. 73%, 75%, 69%, 70%, 71% of users mentioned that resources were available, for physical, software, human, organizational, and decision computerized HIS, respectively. The study showed a strong relationship between computerized information systems with their physical, software, human and organizational components, and medical and administrative decisions. While the study showed the absence of a relationship between demographic factors and computerized information systems with their hardware, software, human and organizational components, medical and administrative decisions, except for gender with organizational components, age, qualification with hardware and software components, and years of experience with all study variables. Conclusion: The application of HIS at hospitals in decision-making has several challenges, including the lack of updating of hardware and software components Furthermore, the absence of specific, focusing on developing their technical staffs, and mobilizing financial resources to achieve implementation properly. Therefore, establishing the technical management with clear roles and tasks with multi-disciplinary, and increasing the support of the administrative leadership in the process of implementing HIS are recommended.

Evaluation of the Usability of a Telehealth System for COVID-19 According to the Perception of the User Professional

With the advent of the pandemic, the Brazilian Ministry of Health structured in record time the Telehealth Service of the Unified Health System called TeleSUS, an ecosystem based on the intensive use of information technology involving automated mechanisms and a personalized health care center at distance. In addition to constant evaluations carried out in the service as a public health strategy, at clinical and epidemiological levels, the team involved in the project was also concerned with evaluating the system developed to enable the operation of remote care, from the conception of the organization of health actions to the technological development of the digital health tool. The objective of this study was to carry out an evaluation of a telehealth system, measuring the degree of satisfaction of users of health professionals regarding its usability and identifying factors that positively and/or negatively influence the evaluation.

STM32-based Health Monitoring System for Infants and Toddlers

In order to allow the guardians to monitor the physiological parameters of the infant more intuitively and to be able to respond to sudden irregularities in the pulse rate,abnormal blood oxygen,high or low body temperature and other conditions,and to facilitate communication with the medical staff or to request assistance in treatment,an STM32 microcontroller-based infant health monitoring system is designed.The digital signal acquisition module for pulse,blood oxygen and body temperature acquire the raw data,and the microcontroller performs algorithmic processing to display the physiological parameters such as pulse,blood oxygen and body temperature of the infant,and configures the threshold alarms for the physiological parameters by means of a keypad module.Finally,the test results are compared and tested against the standard physiological parameters of infants and children to verify that the system meets the requirements of medical precision and accuracy.

Subnational health management and the advancement of health equity:a case study of Ethiopia

Background:Health equity is a cross-cutting theme in the United Nations 2030 Agenda for Sustainable Development,and a priority in health sector planning in countries including Ethiopia.Subnational health managers in Ethiopia are uniquely positioned to advance health equity,given the coordination,planning,budgetary,and administration tasks that they are assigned.Yet,the nature of efforts to advance health equity by subnational levels of the health sector is poorly understood and rarely researched.This study assesses how subnational health managers in Ethiopia understand health equity issues and their role in promoting health equity and offers insight into how these roles can be harnessed to advance health equity.Methods:A descriptive case study assessed perspectives and experiences of health equity among subnational health managers at regional,zonal,district and Primary Health Care Unit administrative levels.Twelve in-depth interviews were conducted with directors,vice-directors,coordinators and technical experts.Data were analyzed using thematic analysis.Results:Subnational managers perceived geographical factors as a predominant concern in health service delivery inequities,especially when they intersected with poor infrastructure,patriarchal gender norms,unequal support from non-governmental organizations or challenging topography.Participants used ad hoc,context-specific strategies(such as resource-pooling with other sectors or groups and shaming-as-motivation)to improve health service delivery to remote populations and strengthen health system operations.Collaboration with other groups facilitated cost sharing and access to resources;however,the opportunities afforded by these collaborations,were not realized equally in all areas.Subnational health managers’efforts in promoting health equity are affected by inadequate resource availability,which restricts their ability to enact long-term and sustainable solutions.Conclusions:Advancing health equity in Ethiopia requires:extra support to communities in hard-to-reach areas;addressing patriarchal norms;and strategic aligning of the subnational health system with non-health government sectors,community groups,and non-governmental organizations.The findings call attention to the unrealized potential of effectively coordinating governance actors and processes to better align national priorities and resources with subnational governance actions to achieve health equity,and offer potentially useful knowledge for subnational health system administrators working in conditions similar to those in our Ethiopian case study.

Aid effectiveness and programmatic effectiveness:a proposed framework for comparative evaluation of different aid interventions in a particular health system

Background:Against a backdrop of changing concepts of aid effectiveness,development effectiveness,health systems strengthening,and increasing emphasis on impact evaluation,this article proposes a theory-driven impact evaluation framework to gauge the effect of aid effectiveness principles on programmatic outcomes of different aid funded programs in the health sector of a particular country.Methods:The foundation and step-by-step process of implementing the framework are described.Results:With empirical evidence from the field,the steps involve analysis of context,program designs,implementation mechanisms,outcomes,synthesis,and interpretation of findings through the programs’underlying program theories and interactions with the state context and health system.Conclusions:The framework can be useful for comparatively evaluating different aid interventions both in fragile and non-fragile state contexts.

The impacts of the global gag rule on global health:a scoping review

Background:The 1984 Mexico City Policy is a U.S.federal policy that has prohibited foreign nongovernmental organizations that receive U.S.international family planning assistance from using their own,non-U.S.funds to provide,counsel on,or refer for abortion services as a method of family planning,or advocate for the liberalization of abortion laws-except in cases of rape,incest,and life endangerment.The policy became known as the global gag rule(GGR)due to its silencing effect on abortion advocacy.Historically,it has only been attached to family planning funding,until 2017 when a presidential memorandum expanded the policy to nearly all US$8.8 billion in global health foreign assistance.In light of the aforementioned expansion,this scoping review aimed to describe and map the impacts of the GGR on global health,which in turn would identify research and policy gaps.This is the first time that all of the existing literature on the policy’s impact has been synthesized into one article and comprehensively reviewed.Methods:The review utilized Arksey and Malley’s five-stage methodological framework to conduct a scoping review.Fourteen peer-reviewed databases and 25 grey literature sources were searched for publications between January 1984 and October 2017.Organizations and individuals working on GGR research and impact were also contacted to access their works from the same time period.These publications reported on impacts of the global gag rule on 14 domains in global health.Results:The searches yielded 1355 articles,of which 43 were included.Overall,80%of the identified sources were qualitative.The misunderstanding,miscommunication,and chilling effect of the policy underpinned the GGR’s impacts.The frequently reported impacts on family planning delivery systems(34 articles)and the loss of U.S.funding(21 articles)were often related.Sources reported on the impact of the GGR on HIV and AIDS programs,advocacy and coalition spaces,and maternal and child health.Only three studies(6.9%)quantified associations between the GGR and abortion rates,concluding that the policy does not decrease rates of abortion.Discussion:The GGR’s development and implementation was consistently associated with poor impacts on health systems’function and outcomes.More peer-reviewed and quantitative research measuring and monitoring the policy’s impact on health outcomes are needed.More research and policy analysis exploring the GGR’s development and its implementation on the ground will improve knowledge on GGR consequences,and potentially shape its reform.