Objectives: To evaluate the effectiveness of road safety interventions in low and middleincome co... more Objectives: To evaluate the effectiveness of road safety interventions in low and middleincome countries (LMICs), considering the principles of systems theory presented in the Global Plan for the Decade of Action for Road Safety. Methods: We conducted a systematic review according to PRISMA guidelines. We searched for original research studies published during 2011-2019 in the following databases: Medline, Embase, PsycInfo, Scopus, Web of Science, Cochrane library, Global Health Library, ProQuest and TRID. We included studies conducted in LMICs, evaluating the effects of road traffic safety interventions and reporting health-related outcomes. Results: Of 12,353 non-duplicate records, we included a total of 33 studies. Most interventions were related to legislation and enforcement (n = 18), leadership (n = 5) and speed management (n = 4). Overall, legislation and enforcement interventions appear to have the largest impact. Few studies were found for road infrastructure, vehicle safety standard and post crash response interventions. Based on the currently available evidence, legislation and enforcement interventions appear most impactful in LMICs. However, many interventions remain understudied and more holistic approaches capturing the complexity of road transport systems seem desirable.
Objectives: We aimed to understand the information architecture and degree of integration of mort... more Objectives: We aimed to understand the information architecture and degree of integration of mortality surveillance systems in Ghana and Peru.Methods: We conducted a cross-sectional study using a combination of document review and unstructured interviews to describe and analyse the sub-systems collecting mortality data.Results: We identified 18 and 16 information subsystems with independent databases capturing death events in Peru and Ghana respectively. The mortality information architecture was highly fragmented with a multiplicity of unconnected data silos and with formal and informal data collection systems.Conclusion: Reliable and timely information about who dies where and from what underlying cause is essential to reporting progress on Sustainable Development Goals, ensuring policies are responding to population health dynamics, and understanding the impact of threats and events like the COVID-19 pandemic. Integrating systems hosted in different parts of government remains a ...
IntroductionAlmost all sub-Saharan African countries have adopted some form of integrated communi... more IntroductionAlmost all sub-Saharan African countries have adopted some form of integrated community case management (iCCM) to reduce child mortality, a strategy targeting common childhood diseases in hard-to-reach communities. These programs are complex, maintain diverse implementation typologies and involve many components that can influence the potential success of a program or its ability to effectively perform at scale. While tools and methods exist to support the design and implementation of iCCM and measure its progress, these may not holistically consider some of its key components, which can include program structure, setting context and the interplay between community, human resources, program inputs and health system processes.MethodsWe propose a Global South-driven, systems-based framework that aims to capture these different elements and expand on the fundamental domains of iCCM program implementation. We conducted a content analysis developing a code frame based on iCCM...
Additional file 2: Figure S1. Age distribution of deaths according to GBD broad causes and unusab... more Additional file 2: Figure S1. Age distribution of deaths according to GBD broad causes and unusable code severity level for the most recent year (2018). Red = Group 1 Communicable, maternal, neonatal and nutritional conditions. Blue = Group 2 Non-communicable diseases. Green = Group 3 External causes including injury. Grey = Unusable causes of varying levels of severity.
Low-income countries with their funding and implementing partners are increasingly recognizing he... more Low-income countries with their funding and implementing partners are increasingly recognizing health information systems (HIS) as an essential way to strengthen and support health systems. There is tremendous potential for innovations in information and communication technologies to assist health managers, health workers, and patients. Yet individual technologies and software applications are often developed without specifying how they will interact and communicate with existing and future information systems. Furthermore, they are developed without giving adequate attention to the needs the information system is supposed to address, resulting in software applications that do not effectively meet user needs. There is a lack of documented systematic methodology for gathering and documenting requirements for developing HIS. This article introduces a systematic, architected, and rational approach (SARA) for the design and development of health information systems. SARA, based on an En...
throw down a compelling challenge to the global health community to intensify its response to the... more throw down a compelling challenge to the global health community to intensify its response to the neglected tropical diseases. The authors discuss opportunities for integrating neglected disease control with interventions against the “big three, ” namely, HIV/AIDS, tuberculosis, and malaria [1]. They highlight 13 neglected tropical diseases: seven helminthic infections (e.g., schistosomiasis), three vectorborne protozoan infections (e.g., lymphatic filariasis), and three bacterial infections (e.g., trachoma). The main
Effect of an armed conflict on relative socioeconomic position of rural households: case study fr... more Effect of an armed conflict on relative socioeconomic position of rural households: case study from western Côte d’Ivoire
Low-income countries with their funding and implementing partners are increasingly recognizing he... more Low-income countries with their funding and implementing partners are increasingly recognizing health information systems (HIS) as an essential way to strengthen and support health systems. There is tremendous potential for innovations in information and communication technologies to assist health managers, health workers, and patients. Yet individual technologies and software applications are often developed without specifying how they will interact and communicate with existing and future information systems. Furthermore, they are developed without giving adequate attention to the needs the information system is supposed to address, resulting in software applications that do not effectively meet user needs. There is a lack of documented systematic methodology for gathering and documenting requirements for developing HIS. This article introduces a systematic, architected, and rational approach (SARA) for the design and development of health information systems. SARA, based on an Enterprise Architecture (EA) approach, represents a portfolio of practices, tools, and methods that can be easily and appropriately adapted and applied in the design phase of health information system development. This article will present early efforts to develop this portfolio including lessons learned from applying SARA in Tanzania.
Complexity is inherent to any system or program. This is especially true of integrated interventi... more Complexity is inherent to any system or program. This is especially true of integrated interventions, such as integrated community case management (iCCM). iCCM is a child health strategy designed to provide services through community health workers (CHWs) within hard-to-reach areas of low-and-middle-income countries (LMICs). It is comprised of many interlinked program components, processes and stakeholders. Elucidating the complexity of such programs is essential to designing interventions that respond to local contexts and successfully plan for sustainable integration. A pragmatic approach has yet to be developed that holistically assesses the many dimensions of iCCM or other integrated programs, their alignment with local systems, and how well they provide effective care. We propose an accessible systems approach to both measuring systems effectiveness and assessing its underlying complexity using a combination of systems thinking tools. We propose an effectiveness decay model for iCCM implementation to measure where patient loss occurs along the trajectory of care. The approach uses process mapping to examine critical bottlenecks of iCCM processes, their influence on effectiveness decay, and their integration into local systems; regression analysis and structural equation modeling to determine effects of key indicators on programmatic outcomes; and qualitative analysis with causal loop diagramming to assess stakeholder dynamics and their interactions within the iCCM program. An accurate assessment of the quality, effectiveness, and strength of community-based interventions relies on more than measuring core indicators and program outcomes; it requires an exploration of how its actors and core components interact as part of a system. Our approach produces an interactive iCCM effectiveness decay model to understand patient loss in context, examines key systems issues, and uses a range of systems thinking tools to assess the dynamic interactions that coalesce to produce observed program outcomes.
It has been questioned whether demographic surveillance system (DSS) sites, which normally operat... more It has been questioned whether demographic surveillance system (DSS) sites, which normally operate in relatively small, homogeneous areas, and in relatively small populations of the order of 100,000 people, are large enough to examine inequalities and inequities in health. The Rufiji DSS in Tanzania has attempted to apply principal components analysis (PCA) to asset and other household data collected in the routine course of a DSS, to rank individuals according to a household socioeconomic index and investigate whether this predicts health system access or outcomes. In this study, we determined wealth indices for individuals in 12,604 rural households in the Rufiji DSS area using principal components analysis for the year 2000. The index was based on the presence or absence of items from a list of 20 specific household assets and 9 household characteristics dealing with household ownership, construction features, water supply, sanitation, and type of fuel. PCA revealed 49 principal components of which the first accounted for 12.9% of the total variance. Asset ownership and housing features contributed equally to the variance in the first component. Scores for each asset or feature were internally consistent with expectations. In this study, we examined mosquito net ownership as an example of health intervention access, and infant, child and under-5 mortality rates as examples of health outcomes, all in relation to quintiles of populations and determined poorest-least poor ratios, concentration indices, and chi-square for linear trend. Results showed significant gradients in both access and outcome measures across wealth quintiles, even in this relatively homogeneous rural area. Poorest-least poor ratios for infant, child and under-5 mortality were 1.46, 1.41 and 1.53 respectively while lack of access to mosquito nets was 1.82. The findings call for more attention to strategies or approaches for reducing health inequalities. These could include reforms in the health sector to provide more equitable resource allocation, improvement in the quality of the health services offered to the poor, and redesigning interventions and
Objectives: With the application of a systems thinking lens, we aimed to assess the national COVI... more Objectives: With the application of a systems thinking lens, we aimed to assess the national COVID-19 response across health systems components in Switzerland, Spain, Iran, and Pakistan.Methods: We conducted four case studies on the policy response of national health systems to the early phase of the COVID-19 pandemic. Selected countries include different health system typologies. We collected data prospectively for the period of January–July 2020 on 17 measures of the COVID-19 response recommended by the WHO that encompassed all health systems domains (governance, financing, health workforce, information, medicine and technology and service delivery). We further monitored contextual factors influencing their adoption or deployment.Results: The policies enacted coincided with a decrease in the COVID-19 transmission. However, there was inadequate communication and a perception that the measures were adverse to the economy, weakening political support for their continuation and leadin...
ABSTRACT Over the past 70 years, significant advances have been made in determining the causes of... more ABSTRACT Over the past 70 years, significant advances have been made in determining the causes of death in populations not served by official medical certification of cause at the time of death using a technique known as Verbal Autopsy (VA). VA involves an interview of the family or caregivers of the deceased after a suitable bereavement interval about the circumstances, signs and symptoms of the deceased in the period leading to death. The VA interview data are then interpreted by physicians or, more recently, computer algorithms, to assign a probable cause of death. VA was originally developed and applied in field research settings. This paper traces the evolution of VA methods with special emphasis on the World Health Organization’s (WHO)’s efforts to standardize VA instruments and methods for expanded use in routine health information and vital statistics systems in low- and middle-income countries (LMICs). These advances in VA methods are culminating this year with the release of the 2022 WHO Standard Verbal Autopsy (VA) Toolkit. This paper highlights the many contributions the late Professor Peter Byass made to the current VA standards and methods, most notably, the development of InterVA, the most commonly used automated computer algorithm for interpreting data collected in the WHO standard instruments, and the capacity building in low- and middle-income countries (LMICs) that he promoted. This paper also provides an overview of the methods used to improve the current WHO VA standards, a catalogue of the changes and improvements in the instruments, and a mapping of current applications of the WHO VA standard approach in LMICs. It also provides access to tools and guidance needed for VA implementation in Civil Registration and Vital Statistics Systems at scale.
Additional file 1: Table S1. Number of expected deaths and proportions with MCCD ICD-10 each year... more Additional file 1: Table S1. Number of expected deaths and proportions with MCCD ICD-10 each year (mainland Tanzania).
Following successful establishment of Expanded Program on Immunization (EPI) in the 1970's as... more Following successful establishment of Expanded Program on Immunization (EPI) in the 1970's as vertical program, the burden of disease for many of the vaccine preventable diseases was pushed to low levels. The current round of health reforms in Tanzania calls for decentralization and integration of vertical programs. This has the potential to assist or erode generally good performance of EPI. Reforms on the programme have been undertaken in Tanzania since 1996, and have included 1) integration of the procurement, storage, and distribution of vaccine and related equipment into the operations of a quasi-autonomous drug procurement agency. 2) government financing of procurement of the oral polio vaccine, cold chain kerosene, and 3) the integration of kerosene and vaccine distribution, supervision and monitoring to district health system. Our analysis shows that the integration of the procurement and distribution of vaccines into the operations of the drug procurement agency, and pri...
Objectives: To evaluate the effectiveness of road safety interventions in low and middleincome co... more Objectives: To evaluate the effectiveness of road safety interventions in low and middleincome countries (LMICs), considering the principles of systems theory presented in the Global Plan for the Decade of Action for Road Safety. Methods: We conducted a systematic review according to PRISMA guidelines. We searched for original research studies published during 2011-2019 in the following databases: Medline, Embase, PsycInfo, Scopus, Web of Science, Cochrane library, Global Health Library, ProQuest and TRID. We included studies conducted in LMICs, evaluating the effects of road traffic safety interventions and reporting health-related outcomes. Results: Of 12,353 non-duplicate records, we included a total of 33 studies. Most interventions were related to legislation and enforcement (n = 18), leadership (n = 5) and speed management (n = 4). Overall, legislation and enforcement interventions appear to have the largest impact. Few studies were found for road infrastructure, vehicle safety standard and post crash response interventions. Based on the currently available evidence, legislation and enforcement interventions appear most impactful in LMICs. However, many interventions remain understudied and more holistic approaches capturing the complexity of road transport systems seem desirable.
Objectives: We aimed to understand the information architecture and degree of integration of mort... more Objectives: We aimed to understand the information architecture and degree of integration of mortality surveillance systems in Ghana and Peru.Methods: We conducted a cross-sectional study using a combination of document review and unstructured interviews to describe and analyse the sub-systems collecting mortality data.Results: We identified 18 and 16 information subsystems with independent databases capturing death events in Peru and Ghana respectively. The mortality information architecture was highly fragmented with a multiplicity of unconnected data silos and with formal and informal data collection systems.Conclusion: Reliable and timely information about who dies where and from what underlying cause is essential to reporting progress on Sustainable Development Goals, ensuring policies are responding to population health dynamics, and understanding the impact of threats and events like the COVID-19 pandemic. Integrating systems hosted in different parts of government remains a ...
IntroductionAlmost all sub-Saharan African countries have adopted some form of integrated communi... more IntroductionAlmost all sub-Saharan African countries have adopted some form of integrated community case management (iCCM) to reduce child mortality, a strategy targeting common childhood diseases in hard-to-reach communities. These programs are complex, maintain diverse implementation typologies and involve many components that can influence the potential success of a program or its ability to effectively perform at scale. While tools and methods exist to support the design and implementation of iCCM and measure its progress, these may not holistically consider some of its key components, which can include program structure, setting context and the interplay between community, human resources, program inputs and health system processes.MethodsWe propose a Global South-driven, systems-based framework that aims to capture these different elements and expand on the fundamental domains of iCCM program implementation. We conducted a content analysis developing a code frame based on iCCM...
Additional file 2: Figure S1. Age distribution of deaths according to GBD broad causes and unusab... more Additional file 2: Figure S1. Age distribution of deaths according to GBD broad causes and unusable code severity level for the most recent year (2018). Red = Group 1 Communicable, maternal, neonatal and nutritional conditions. Blue = Group 2 Non-communicable diseases. Green = Group 3 External causes including injury. Grey = Unusable causes of varying levels of severity.
Low-income countries with their funding and implementing partners are increasingly recognizing he... more Low-income countries with their funding and implementing partners are increasingly recognizing health information systems (HIS) as an essential way to strengthen and support health systems. There is tremendous potential for innovations in information and communication technologies to assist health managers, health workers, and patients. Yet individual technologies and software applications are often developed without specifying how they will interact and communicate with existing and future information systems. Furthermore, they are developed without giving adequate attention to the needs the information system is supposed to address, resulting in software applications that do not effectively meet user needs. There is a lack of documented systematic methodology for gathering and documenting requirements for developing HIS. This article introduces a systematic, architected, and rational approach (SARA) for the design and development of health information systems. SARA, based on an En...
throw down a compelling challenge to the global health community to intensify its response to the... more throw down a compelling challenge to the global health community to intensify its response to the neglected tropical diseases. The authors discuss opportunities for integrating neglected disease control with interventions against the “big three, ” namely, HIV/AIDS, tuberculosis, and malaria [1]. They highlight 13 neglected tropical diseases: seven helminthic infections (e.g., schistosomiasis), three vectorborne protozoan infections (e.g., lymphatic filariasis), and three bacterial infections (e.g., trachoma). The main
Effect of an armed conflict on relative socioeconomic position of rural households: case study fr... more Effect of an armed conflict on relative socioeconomic position of rural households: case study from western Côte d’Ivoire
Low-income countries with their funding and implementing partners are increasingly recognizing he... more Low-income countries with their funding and implementing partners are increasingly recognizing health information systems (HIS) as an essential way to strengthen and support health systems. There is tremendous potential for innovations in information and communication technologies to assist health managers, health workers, and patients. Yet individual technologies and software applications are often developed without specifying how they will interact and communicate with existing and future information systems. Furthermore, they are developed without giving adequate attention to the needs the information system is supposed to address, resulting in software applications that do not effectively meet user needs. There is a lack of documented systematic methodology for gathering and documenting requirements for developing HIS. This article introduces a systematic, architected, and rational approach (SARA) for the design and development of health information systems. SARA, based on an Enterprise Architecture (EA) approach, represents a portfolio of practices, tools, and methods that can be easily and appropriately adapted and applied in the design phase of health information system development. This article will present early efforts to develop this portfolio including lessons learned from applying SARA in Tanzania.
Complexity is inherent to any system or program. This is especially true of integrated interventi... more Complexity is inherent to any system or program. This is especially true of integrated interventions, such as integrated community case management (iCCM). iCCM is a child health strategy designed to provide services through community health workers (CHWs) within hard-to-reach areas of low-and-middle-income countries (LMICs). It is comprised of many interlinked program components, processes and stakeholders. Elucidating the complexity of such programs is essential to designing interventions that respond to local contexts and successfully plan for sustainable integration. A pragmatic approach has yet to be developed that holistically assesses the many dimensions of iCCM or other integrated programs, their alignment with local systems, and how well they provide effective care. We propose an accessible systems approach to both measuring systems effectiveness and assessing its underlying complexity using a combination of systems thinking tools. We propose an effectiveness decay model for iCCM implementation to measure where patient loss occurs along the trajectory of care. The approach uses process mapping to examine critical bottlenecks of iCCM processes, their influence on effectiveness decay, and their integration into local systems; regression analysis and structural equation modeling to determine effects of key indicators on programmatic outcomes; and qualitative analysis with causal loop diagramming to assess stakeholder dynamics and their interactions within the iCCM program. An accurate assessment of the quality, effectiveness, and strength of community-based interventions relies on more than measuring core indicators and program outcomes; it requires an exploration of how its actors and core components interact as part of a system. Our approach produces an interactive iCCM effectiveness decay model to understand patient loss in context, examines key systems issues, and uses a range of systems thinking tools to assess the dynamic interactions that coalesce to produce observed program outcomes.
It has been questioned whether demographic surveillance system (DSS) sites, which normally operat... more It has been questioned whether demographic surveillance system (DSS) sites, which normally operate in relatively small, homogeneous areas, and in relatively small populations of the order of 100,000 people, are large enough to examine inequalities and inequities in health. The Rufiji DSS in Tanzania has attempted to apply principal components analysis (PCA) to asset and other household data collected in the routine course of a DSS, to rank individuals according to a household socioeconomic index and investigate whether this predicts health system access or outcomes. In this study, we determined wealth indices for individuals in 12,604 rural households in the Rufiji DSS area using principal components analysis for the year 2000. The index was based on the presence or absence of items from a list of 20 specific household assets and 9 household characteristics dealing with household ownership, construction features, water supply, sanitation, and type of fuel. PCA revealed 49 principal components of which the first accounted for 12.9% of the total variance. Asset ownership and housing features contributed equally to the variance in the first component. Scores for each asset or feature were internally consistent with expectations. In this study, we examined mosquito net ownership as an example of health intervention access, and infant, child and under-5 mortality rates as examples of health outcomes, all in relation to quintiles of populations and determined poorest-least poor ratios, concentration indices, and chi-square for linear trend. Results showed significant gradients in both access and outcome measures across wealth quintiles, even in this relatively homogeneous rural area. Poorest-least poor ratios for infant, child and under-5 mortality were 1.46, 1.41 and 1.53 respectively while lack of access to mosquito nets was 1.82. The findings call for more attention to strategies or approaches for reducing health inequalities. These could include reforms in the health sector to provide more equitable resource allocation, improvement in the quality of the health services offered to the poor, and redesigning interventions and
Objectives: With the application of a systems thinking lens, we aimed to assess the national COVI... more Objectives: With the application of a systems thinking lens, we aimed to assess the national COVID-19 response across health systems components in Switzerland, Spain, Iran, and Pakistan.Methods: We conducted four case studies on the policy response of national health systems to the early phase of the COVID-19 pandemic. Selected countries include different health system typologies. We collected data prospectively for the period of January–July 2020 on 17 measures of the COVID-19 response recommended by the WHO that encompassed all health systems domains (governance, financing, health workforce, information, medicine and technology and service delivery). We further monitored contextual factors influencing their adoption or deployment.Results: The policies enacted coincided with a decrease in the COVID-19 transmission. However, there was inadequate communication and a perception that the measures were adverse to the economy, weakening political support for their continuation and leadin...
ABSTRACT Over the past 70 years, significant advances have been made in determining the causes of... more ABSTRACT Over the past 70 years, significant advances have been made in determining the causes of death in populations not served by official medical certification of cause at the time of death using a technique known as Verbal Autopsy (VA). VA involves an interview of the family or caregivers of the deceased after a suitable bereavement interval about the circumstances, signs and symptoms of the deceased in the period leading to death. The VA interview data are then interpreted by physicians or, more recently, computer algorithms, to assign a probable cause of death. VA was originally developed and applied in field research settings. This paper traces the evolution of VA methods with special emphasis on the World Health Organization’s (WHO)’s efforts to standardize VA instruments and methods for expanded use in routine health information and vital statistics systems in low- and middle-income countries (LMICs). These advances in VA methods are culminating this year with the release of the 2022 WHO Standard Verbal Autopsy (VA) Toolkit. This paper highlights the many contributions the late Professor Peter Byass made to the current VA standards and methods, most notably, the development of InterVA, the most commonly used automated computer algorithm for interpreting data collected in the WHO standard instruments, and the capacity building in low- and middle-income countries (LMICs) that he promoted. This paper also provides an overview of the methods used to improve the current WHO VA standards, a catalogue of the changes and improvements in the instruments, and a mapping of current applications of the WHO VA standard approach in LMICs. It also provides access to tools and guidance needed for VA implementation in Civil Registration and Vital Statistics Systems at scale.
Additional file 1: Table S1. Number of expected deaths and proportions with MCCD ICD-10 each year... more Additional file 1: Table S1. Number of expected deaths and proportions with MCCD ICD-10 each year (mainland Tanzania).
Following successful establishment of Expanded Program on Immunization (EPI) in the 1970's as... more Following successful establishment of Expanded Program on Immunization (EPI) in the 1970's as vertical program, the burden of disease for many of the vaccine preventable diseases was pushed to low levels. The current round of health reforms in Tanzania calls for decentralization and integration of vertical programs. This has the potential to assist or erode generally good performance of EPI. Reforms on the programme have been undertaken in Tanzania since 1996, and have included 1) integration of the procurement, storage, and distribution of vaccine and related equipment into the operations of a quasi-autonomous drug procurement agency. 2) government financing of procurement of the oral polio vaccine, cold chain kerosene, and 3) the integration of kerosene and vaccine distribution, supervision and monitoring to district health system. Our analysis shows that the integration of the procurement and distribution of vaccines into the operations of the drug procurement agency, and pri...
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Papers by Don de Savigny