Commenced in January 2007
Frequency: Monthly
Edition: International
Paper Count: 20

Search results for: USAID

20 US Foreign Aids and Its Institutional and Non-Institutional Impacts in the Middle East, Africa, Southeast Asia, and Latin America (2000 - 2020)

Authors: Mahdi Fakheri, Mohammad Mohsen Mahdizadeh Naeini


This paper addresses an understudied aspect of U.S. foreign aids between the years 2000 and 2020. Despite a growing body of literature on the impacts of U.S. aids, the question about how the United States uses its foreign aids to change developing countries has remained unanswered. As foreign aid is a tool of the United States' foreign policy, answering this very question can reveal the future that the U.S. prefers for developing countries and that secures its national interest. This paper will explore USAID's official dataset, which includes the data of foreign aids to the Middle East, Africa, Latin America, and Southeast Asia from 2000 to 2020. Through an empirical analysis, this paper argues that the focus of U.S. foreign aid is evenly divided between institutional and non-institutional (i.e., slight enhancement of status quo) changes. The former is induced by training and education, funding the initiatives and projects, making capacity and increasing the efficiency of human, operational, and management sectors, and enhancing the living condition of the people. Moreover, it will be demonstrated that the political, military, cultural, economic, and judicial are some of the institutions that the U.S. has planned to change in the aforementioned period and regions.

Keywords: USAID, foreign aid, development, developing countries, Middle East, Africa, Southeast Asia, Latin America

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19 Rapid Situation Assessment of Family Planning in Pakistan: Exploring Barriers and Realizing Opportunities

Authors: Waqas Abrar


Background: Pakistan is confronted with a formidable challenge to increase uptake of modern contraceptive methods. USAID, through its flagship Maternal and Child Survival Program (MCSP), in Pakistan is determined to support provincial Departments of Health and Population Welfare to increase the country's contraceptive prevalence rates (CPR) in Sindh, Punjab and Balochistan to achieve FP2020 goals. To inform program design and planning, a Rapid Situation Assessment (RSA) of family planning was carried out in Rawalpindi and Lahore districts in Punjab and Karachi district in Sindh. Methodology: The methodology consisted of comprehensive desk review of available literature and used a qualitative approach comprising of in-depth interviews (IDIs) and focus group discussions (FGDs). FGDs were conducted with community women, men, and mothers-in-law whereas IDIs were conducted with health facility in-charges/chiefs, healthcare providers, and community health workers. Results: Some of the oft-quoted reasons captured during desk review included poor quality of care at public sector facilities, affordability and accessibility in rural communities and providers' technical incompetence. Moreover, providers had inadequate knowledge of contraceptive methods and lacked counseling techniques; thereby, leading to dissatisfied clients and hence, discontinuation of contraceptive methods. These dissatisfied clients spread the myths and misconceptions about contraceptives in their respective communities which seriously damages community-level family planning efforts. Private providers were found reluctant to insert Intrauterine Contraceptive Devices (IUCDs) due to inadequate knowledge vis-à-vis post insertion issues/side effects. FGDs and IDIs unveiled multi-faceted reasons for poor contraceptives uptake. It was found that low education and socio-economic levels lead to low contraceptives uptake and mostly uneducated women rely on condoms provided by Lady Health Workers (LHWs). Providers had little or no knowledge about postpartum family planning or lactational amenorrhea. At community level family planning counseling sessions organized by LHWs and Male Mobilizers do not sensitize community men on permissibility of contraception in Islam. Many women attributed their physical ailments to the use of contraceptives. Lack of in-service training, job-aids and Information, Education and Communications (IEC) materials at facilities seriously comprise the quality of care in effective family planning service delivery. This is further compounded by frequent stock-outs of contraceptives at public healthcare facilities, poor data quality, false reporting, lack of data verification systems and follow-up. Conclusions: Some key conclusions from this assessment included capacity building of healthcare providers on long acting reversible contraceptives (LARCs) which give women contraception for a longer period. Secondly, capacity building of healthcare providers on postpartum family planning is an enormous challenge that can be best addressed through institutionalization. Thirdly, Providers should be equipped with counseling skills and techniques including inculcation of pros and cons of all contraceptive methods. Fourthly, printed materials such as job-aids and Information, Education and Communications (IEC) materials should be disseminated among healthcare providers and clients. These concluding statements helped MCSP to make informed decisions with regard to setting broad objectives of project and were duly approved by USAID.

Keywords: capacity building, contraceptive prevalence rate, family planning, Institutionalization, Pakistan, postpartum care, postpartum family planning services

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18 Promoting Couple HIV Testing among Migrants for HIV Prevention: Learnings from Integrated Counselling and Testing Centre (ICTC) in Odisha, India

Authors: Sunil Mekale, Debasish Chowdhury, Sanchita Patnaik, Amitav Das, Ashok Agarwal


Background: Odisha is a low HIV prevalence state in India (ANC-HIV positivity of 0.42% as per HIV sentinel surveillance 2010-2011); however, it is an important source migration state with 3.2% of male migrants reporting to be PLHIV. USAID Public Health Foundation of India -PIPPSE project is piloting a source-destination corridor programme between Odisha and Gujarat. In Odisha, the focus has been on developing a comprehensive strategy to reach out to the out migrants and their spouses in the place of their origin based on their availability. The project has made concerted attempts to identify vulnerable districts with high out migration and high positivity rate. Description: 48 out of 97 ICTCs were selected from nine top high out migration districts through multistage sampling. A retrospective descriptive analysis of HIV positive male migrants and their spouses for two years (April 2013-March 2015) was conducted. A total of 3,645 HIV positive records were analysed. Findings: Among 34.2% detected HIV positive in the ICTCs, 23.3% were male migrants and 11% were spouses of male migrants; almost 50% of total ICTC attendees. More than 70% of the PLHIV male migrants and their spouses were less than 45 years old. Conclusions: Couple HIV testing approach may be considered for male migrants and their spouses. ICTC data analysis could guide in identifying the locations with high HIV positivity among male migrants and their spouses.

Keywords: HIV testing, migrants, spouse of migrants, Integrated Counselling and Testing Centre (ICTC)

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17 Lactational Amenorrhea Method for Family Planning: An Evaluation of Compliance in the Philippines

Authors: Ellen Bautista, Rebecca M. Flueckiger, Easter Dasmarinas, Rajeev Colaco, Fulbert Alec R. Gillego, Alma M. Lozada, Cristina Bisson


Lactational Amenorrhea Method (LAM) for family planning is at least 98% effective at preventing pregnancy when all criteria are met; (1) the mother is exclusively or nearly exclusively breastfeeding, (2) the mother is amenorrheic (not menstruating), and (3) the baby is six months old or younger. LAM is particularly suited for women interested in family planning accepted by religious authorities. As a majority catholic nation, LAM is a common and accepted form of family planning in the Philippines. The USAID funded, LuzonHealth project conducted a prospective evaluation in Legazpi City to inform the enhancement of guidelines aimed at increasing LAM compliance and encouraging a second form of contraceptive once LAM protection expires. LAM compliance, reasons for non-compliance, family planning referral and uptake of secondary modern family planning methods were tracked over a nine-month period among 521 postpartum women. The evaluation found that at three months postpartum, 97% of women either met LAM criteria or had shifted to a non-LAM modern family planning method. In month six 87% of women no longer met LAM criteria and of these only 35% had shifted to an alternative modern family planning method. This means that at six-months postpartum 65% of the women in this evaluation were not protected against pregnancy through modern family planning methods. By postpartum month nine, 70% of the women had been referred to family planning counseling, yet of those referred only 34% reported using modern family planning methods. This evaluation clearly indicates scale-up of non-LAM modern family planning does not sufficiently complement the scale-down of LAM compliance. There is a need to increase client knowledge and understanding of LAM as a temporary family planning method with a strong focus on preparing to shift to another form of modern family planning once LAM protection expires. Additionally, there is great need to restructure the referral mechanism to ensure efficacy and quality of care.

Keywords: Philippines, family planning, lactational amenorrhea method, contraceptives

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16 A Qualitative Analysis of People Views of Microfinance in Lebanon

Authors: Ali Abu Ali, Mohammad Salhab


Introduction: In the Middle East and North Africa (MENA) microfinance struggles to find momentum. The Lebanese economy has been struggling through the years due to domestic and external, political and social instability. Although as of 2014 there are around 23 MFIs that are mainly subsidized by the USAID, operating in the country, the Lebanese microfinance market is mostly dominated by three microfinance institutions: Al Majmoua, Vitas, and Al Quard Al Hassan Association. Methodology: A quantitative approach using a standardized questionnaire would analyse the perception of the average Lebanese towards microfinance. A questionnaire was designed and validated. Results: Almost half of the respondents earn a monthly income ranged between $100 and $600. Almost 52% of the respondents were university graduates, around 25% finished secondary and high school, and 12% hold a masters or MBA degree. Topic understanding towards microfinance differs across Lebanese areas. The highest percentage of respondents who claim that microfinance offers financial services to low income people are the residents of Beirut (35.1%), Bekaa (30.8%), and South of Lebanon (24.7%). Higher levels of topic understanding were associated with lower levels of age range. Al Quard el Hassan foundation was regarded as the most known micro financial institution operating in Lebanon. In general, Lebanese people tend to believe that microfinance can play an important role in reducing unemployment rates and poverty levels in Lebanon. When people were asked what would motivate you to get a loan from MFIs, most of the respondent (57.4%) across all the Lebanese region claimed that it was the need for money to satisfy a need such as paying back a loan, to fix something at home, or for self-consideration like buying a car. Conclusion: Our findings showed that in general Lebanese tend to have a positive perception towards microfinance. However, most Lebanese perceive microfinance as the process of just providing loans without specifying for whom it is intended. We advise that government introduces laws to regulate the microfinance market.

Keywords: microfinance, economics, finance, business, analysis, theory

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15 Community Involvement in Reducing Maternal and Perinatal Mortality in Cross River State, Nigeria: 'The Saving Mother Giving Life' Strategic Approach in Cross River State

Authors: Oluwayemisi Femi-Pius, Kazeem Arogundade, Eberechukwu Eke, Jimmy Eko


Introduction: Globally, community involvement in improving their own health has been widely adopted as a strategy in Sub-Saharan Africa principally to ensure equitable access to essential health care as well as improve the uptake of maternal and newborn health services especially in poor-resource settings. Method: The Saving Mother Giving Life (SMGL) Initiative implemented by Pathfinder International with funding support from USAID conducted a Health Facility Assessment (HFA) and found out that maternal mortality ratio in Cross River State was 812 per 100,000 live birth and perinatal mortality was 160 per 1000 live birth. To reduce maternal and perinatal mortality, Pathfinder International mobilized, selected and trained community members as community volunteers, traditional birth attendants, and emergency transport service volunteer drivers mainly to address the delay in decision making and reaching the health facility among pregnant women. Results: The results showed that maternal mortality ratio in Cross River State decrease by 25% from 812 per 100,000 live birth at baseline to 206 per 100,000 live birth at June 2018 and perinatal mortality reduced by 35% from 160 per 100,000 at baseline to 58 per 1000 live birth at June 2018. Data also show that ANC visit increased from 7,451 to 11,344; institutional delivery increased from 8,931 at baseline to 10,784 in June 2018. There was also a remarkable uptake of post-partum family planning from 0 at baseline to 233 in June 2018. Conclusion: There is clear evidence that community involvement yields positive maternal outcomes and is pivotal for sustaining most health interventions.

Keywords: maternal mortality, Nigeria, pathfinder international, perinatal mortality, saving mother giving life

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14 Co-Creating an International Flipped Faculty Development Model: A US-Afghan Case Study

Authors: G. Alex Ambrose, Melissa Paulsen, Abrar Fitwi, Masud Akbari


In 2016, a U.S. business college was awarded a sub grant to work with FHI360, a nonprofit human development organization, to support a university in Afghanistan funded by the State Department’s U.S. Agency for International Development (USAID). A newly designed Master’s Degree in Finance and Accounting is being implemented to support Afghanistan’s goal of 20% females in higher education and industry by 2020 and to use finance and accounting international standards to attract capital investment for economic development. This paper will present a case study to describe the co-construction of an approach to an International Flipped Faculty Development Model grounded in blended learning theory. Like education in general, faculty development is also evolving from the traditional face to face environment and interactions to the fully online and now to a best of both blends. Flipped faculty development is both a means and a model for careful integration of the strengths of the synchronous and asynchronous dynamics and technologies with the combination of intentional sequencing to pre-online interactions that prepares and enhances the face to face faculty development and mentorship residencies with follow-up post-online support. Initial benefits from this model include giving the Afghan faculty an opportunity to experience and apply modern teaching and learning strategies with technology in their own classroom. Furthermore, beyond the technological and pedagogical affordances, the reciprocal benefits gained from the mentor-mentee, face-to-face relationship will be explored. Evidence to support this model includes: empirical findings from pre- and post-Faculty Mentor/ Mentee survey results, Faculty Mentorship group debriefs, Faculty Mentorship contact logs, and student early/end of semester feedback. In addition to presenting and evaluating this model, practical challenges and recommendations for replicating international flipped faculty development partnerships will be provided.

Keywords: educational development, faculty development, international development, flipped learning

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13 Factors Associated with Condom Breakage among Female Sex Workers: Evidence from Behavioral Tracking Survey in Thane District of Maharashtra, India

Authors: Sukhvinder Kaur, Jayanta Bora, Ashok Agarwal, Sangeeta Kaul


Background: HIV and STI transmission can be prevented if condoms are used properly, but condom tear may lead to infections even if are used consistently. Studies reveal high rates of condom breakage among Female Sex Workers (FSWs). USAID PHFI-PIPPSE is piloting a prevention model among high risk groups at Thane district of Maharashtra, India by implementing prevention and advocacy efforts for such risk behaviors. The current analysis highlights the correlates of condom breakage among FSWs from Thane. Method: A Behavioral Tracking Survey was conducted in 2014-15 among 503 FSWs through probability-based two stage random sampling from 3,660 FSWs at 100 hotspots, to understand levels of high risk behaviors, awareness and exposure to prevention programs. Bi-variate and multivariate-logistic regression methods used to assess the association of condom breakage while having sex with age, STI occurrence, anal sex with clients and alcohol consumption. Only self-reported STIs (Genital sore/ulcer, yellowish/ greenish discharge from vagina with/without foul smell, lower abdominal pain without diarrhea/dysentery or menses) were considered. Major Findings: Results depicted FSWs who reported condom breakage while having sex with any type of partner (paying clients, non-paying partners and other than main partner husband/boyfriend) had significantly high number of STIs (42.3% vs 16.9 %, P, 0.000) and had started sexual relationship in <16 years of age (31.0% vs 16.4 %, P, 0.000). Multivariate analysis after controlling the age at sex, knowledge about HIV and literacy, highlighted significantly higher odds of condom breakage among FSWs who have reported currently suffering with STI [AOR 2.91, 95% CI 1.75 - 4.83; P, 0.000]; who had anal sex with their paying client [AOR 2.59, 95% CI 1.59 - 4.19; P, 0.000]; and who consumed alcohol in the last 12 months [AOR 1.89, 95% CI 1.01 - 3.53; P, 0.047]. Conclusion: Risky behavior like anal sex with paying clients and impact of alcohol while having sex are main factors for condom breakage among young sex workers; and condom breakage leads to STIs. Hence, program interventions should address measures for prevention of condom breakage for HIV/STI prevention.

Keywords: female sex workers, condom breakage, anal sex, young sex workers

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12 Diplomacy in Times of Disaster: Management through Reputational Capital

Authors: Liza Ireni-Saban


The 6.6 magnitude quake event that occurred in 2003 (Bam, Iran) made it impossible for the Iranian government to handle disaster relief efforts domestically. In this extreme event, the Iranian government reached out to the international community, and this created a momentum that had to be carried out by trust-building efforts on all sides, often termed ‘Disaster Diplomacy’. Indeed, the circumstances were even more critical when one considers the increasing political and economic isolation of Iran within the international community. The potential for transformative political space to be opened by disaster has been recognized by dominant international political actors. Despite the fact that Bam 2003 post-disaster relief efforts did not catalyze any diplomatic activities on all sides, it is suggested that few international aid agencies have successfully used disaster recovery to enhance their popular legitimacy and reputation among the international community. In terms of disaster diplomacy, an actor’s reputational capital may affect his ability to build coalitions and alliances to achieve international political ends, to negotiate and build understanding and trust with foreign publics. This study suggests that the post-disaster setting may benefit from using the ecology of games framework to evaluate the role of bridging actors and mediators in facilitating collaborative governance networks. Recent developments in network theory and analysis provide means of structural embeddedness to explore how reputational capital can be built through brokerage roles of actors engaged in a disaster management network. This paper then aims to structure the relations among actors that participated in the post-disaster relief efforts in the 2003 Bam earthquake (Iran) in order to assess under which conditions actors may be strategically utilized to serve as mediating organizations for future disaster events experienced by isolated nations or nations in conflict. The results indicate the strategic use of reputational capital by the Iranian Ministry of Foreign Affairs as key broker to build a successful coordinative system for reducing disaster vulnerabilities. International aid agencies rarely played brokerage roles to coordinate peripheral actors. U.S. foreign assistance (USAID), despite coordination capacities, was prevented from serving brokerage roles in the system.

Keywords: coordination, disaster diplomacy, international aid organizations, Iran

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11 Association of Vulnerability and Behavioural Outcomes of FSWs Linked with TI Prevention HIV Program: An Evidence from Cross-Sectional Behavioural Study in Thane District of Maharashtra

Authors: Jayanta Bora, Sukhvinder Kaur, Ashok Agarwal, Sangeeta Kaul


Background: It is important for targeted interventions to consider vulnerabilities of female sex workers (FSWs) such as poverty, work-related mobility and literacy for effective human immunodeficiency virus (HIV) prevention. This paper examines the association between vulnerability and behavioural outcomes among FSWs in Thane district, Maharashtra under USAID PHFI-PIPPSE project. Methods: Data were used from the Behavioural Tracking Survey, a cross-sectional behavioural study conducted in 2015 with 503 FSWs randomly selected from 12 TI-NGOs which were functioning and providing services to FSWs in Thane district prior to April 2014 in Thane district of Maharashtra. We have created the “vulnerability index”, a composite index of literacy, factors of dependence (alternative livelihood options, current debt), and aspects of sex work (mobility and duration in sex work) as a dependent variable. The key independent measures used were program exposure to intervention, service uptake, self-confidence, and self-identity. Bi-variate and multivariate logistic regressions were used to examine the study objectives. Results: A higher proportion of FSWs who were in the age-group 18–25 years from brothel/street /home/ lodge-based were categorized as highly vulnerable to HIV risk as compared to bar-based sex worker (74.1% versus 59.8%, P,0.002); regression analysis highlighted lower odds of vulnerability among FSWs who were aware of services and visited NGO clinic for medical check-up and counselling for STI [AOR= 0.092, 95% CI 0.018-0.460; P,0.004], However, lower odds of vulnerability on confident in supporting fellow sex worker in crisis [AOR= 0.601, 95% CI 0.476-0.758; P, 0.000] and were able to turn away clients when they refused to use a condom during sex [AOR= 0.524, 95% CI 0.342-0.802; P, 0.003]. Conclusion: The results highlight that FSWs associated with TIs and getting services are less vulnerable and highly empowered. As a result of behavioural change communication and other services provided by TIs, FSWs were able to successfully negotiate about condom use with their clients and manage solidarity in the crisis situation for fellow FSWs. Therefore, it is evident from study paper that TI prevention programs may transform the lives of masses considerably and may open a window of opportunity to infuse the information and awareness about HIV risk.

Keywords: female sex worker, HIV prevention, HIV service uptake, vulnerability

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10 Need for a Tailor Made HIV Prevention Services to the Migrants Community: Evidence from Implementing Migrant Service Delivery System (MSDS) among Migrant Workers, National AIDS Control Program, and India

Authors: Debasish Chowdhury, Sunil Mekale, Sarvanamurthy Sakthivel, Sukhvinder Kaur, Rambabu Khambampati, Ashok Agarwal


Introduction: The migrant intervention in India was initiated during the National AIDS Control Program (NACP) Phase-2 (2002-2007). HIV Sentinel surveillance Studies (HSS) conducted in 2012-13 indicated higher HIV prevalence among migrants (0.99%) compared to general populations (0.35%). Migrants continue to bear a heightened risk of HIV infection which results from the condition and structure of the migration process. USAID PHFI-PIPPSE project in collaboration with the National AIDS Control Organization (NACO) developed a unique system called Migrant Service Delivery System (MSDS) to capture migrants profile with respect to their risk profile and to provide tailor made services to them. Description: MSDS is a web-based system, designed and implemented to increase service uptake among migrants through evidence based planning. 110 destination migrants Targeted Intervention (TI) from 11 states were selected for study with varied target populations in terms of occupations; to understand occupation related risk behaviors among the migrants. Occupation wise registration data of high risk vulnerable migrants were analyzed through MSDS for the period April 2014–June 2016. Analysis was made on specific indicators among these occupational groups to understand the risk behavior and their vulnerability to HIV and STIs. Findings: Out of total HIV positive migrant’s workers (N= 847) enrolled in MSDS HIV rate is found to be highest among Auto-Rickshaw (18.66%) followed by Daily wage laborers (14.46%), Loom workers (10.73%), Industrial workers (10.04%) and Construction worker 7.93%. With 45.14% positivity, industrial workers are found to be most vulnerable to Sexually Transmitted Infections (STIs) (N=10057) among all occupational categories followed by loom workers (16.28%), Skilled worker (Furniture, Jeweler)-7.14%, daily wage laborers (5.45%). Conclusion: MSDS is an effective tool to assess migrants’ risk and their vulnerability to HIV for designing evidence informed program. This system calls for a replication across all destination TIs by NACO for differential strategies for different occupation groups to ensure better yield through scientific planning of intervention among high risk and high vulnerable migrants.

Keywords: migrants, migrant service delivery system, risk, vulnerability

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9 The Positive Impact of Wheelchair Service Provision on the Health and Overall Satisfaction of Wheelchair Users with the Devices

Authors: Archil Undilashvili, Ketevan Stvilia, Dustin Gilbreath, Giorgi Dzneladze, Gordon Charchward


Introduction: In recent years, diverse types of wheelchairs, both local production and imported, have been made available on the Georgian market for wheelchair users. Some types of wheelchairs are sold together with a service package, while the others, including the State Program, Supported locally-produced ones, don’t provide adjustment and maintenance service packages to users. Within the USAID Physical Rehabilitation Project in Georgia, a study was conducted to assess the impact of the wheelchair service provision in line with the WHO guidelines on the health and overall satisfaction of wheelchair users in Georgia. Methodology: A cross-sectional survey was conducted in May 2021. A structured questionnaire was used for telephone interviews that, along with socio-demographic characteristics, included questions for assessment of accessibility, availability, timeliness, cost and quality of wheelchair services received. Out of 1060 individuals listed in the census of wheelchair users, 752 were available for interview, with an actual response rate of 73.4%. 552 wheelchair users (31%) or their caregivers (69%) agreed to participate in the survey. In addition to using descriptive statistics, the study used multivariate matching of wheelchair users who received wheelchair services and who did not (control group). In addition, to evaluate satisfaction with service provision, respondents were asked to assess services. Findings: The majority (67%) of wheelchair users included in the survey were male. The average age of participants was 43. The three most frequently named reasons for using a wheelchair were cerebral palsy (29%), followed by stroke (18%), and amputation (12%). Users have had their current chair for four years on average. Overall, 60% of respondents reported that they were assessed before providing a wheelchair, but only half of them reported that their preferences and needs were considered. Only 13% of respondents had services in line with WHO guidelines and only 22% of wheelchair users had training when they received their current chair. 16% of participants said they had follow-up services, and 41% received adjustment services after receiving the chair. A slight majority (56%) of participants were satisfied with the quality of service provision and the service provision overall. Similarly, 55% were satisfied with the accessibility of service provision. A slightly larger majority (61%) were satisfied with the timeliness of service provision. The matching analysis suggests that users that received services in line with WHO guidelines were more satisfied with their chairs (the difference 17 point/0-100 scale) and they were four percentage points less likely to have health problems attributed to the chair. The regression analysis provides a similar finding of a 21 point increase in satisfaction attributable to services. Conclusion: The provision of wheelchair services in line with WHO guidelines and with follow-up services is likely to have a positive impact on the daily lives of wheelchair users in Georgia. Wheelchair services should be institutionalized as a standard component of wheelchair provision in Georgia.

Keywords: physical rehabilitation, wheelchair users, persons with disabilities, wheelchair production

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8 Scale up of Isoniazid Preventive Therapy: A Quality Management Approach in Nairobi County, Kenya

Authors: E. Omanya, E. Mueni, G. Makau, M. Kariuki


HIV infection is the strongest risk factor for a person to develop TB. Isoniazid preventive therapy (IPT) for People Living with HIV (PLWHIV) not only reduces the individual patients’ risk of developing active TB but mitigates cross infection. In Kenya, IPT for six months was recommended through the National TB, Leprosy and Lung Disease Program to treat latent TB. In spite of this recommendation by the national government, uptake of IPT among PLHIV remained low in Kenya by the end of 2015. The USAID/Kenya and East Africa Afya Jijini project, which supports 42 TBHIV health facilities in Nairobi County, began addressing low uptake of IPT through Quality Improvement (QI) teams set up at the facility level. Quality is characterized by WHO as one of the four main connectors between health systems building blocks and health systems outputs. Afya Jijini implements the Kenya Quality Model for Health, which involves QI teams being formed at the county, sub-county and facility levels. The teams review facility performance to identify gaps in service delivery and use QI tools to monitor and improve performance. Afya Jijini supported the formation of these teams in 42 facilities and built the teams’ capacity to review data and use QI principles to identify and address performance gaps. When the QI teams began working on improving IPT uptake among PLHIV, uptake was at 31.8%. The teams first conducted a root cause analysis using cause and effect diagrams, which help the teams to brainstorm on and to identify barriers to IPT uptake among PLHIV at the facility level. This is a participatory process where program staff provides technical support to the QI teams in problem identification and problem-solving. The gaps identified were inadequate knowledge and skills on the use of IPT among health care workers, lack of awareness of IPT by patients, inadequate monitoring and evaluation tools, and poor quantification and forecasting of IPT commodities. In response, Afya Jijini trained over 300 health care workers on the administration of IPT, supported patient education, supported quantification and forecasting of IPT commodities, and provided IPT data collection tools to help facilities monitor their performance. The facility QI teams conducted monthly meetings to monitor progress on implementation of IPT and took corrective action when necessary. IPT uptake improved from 31.8% to 61.2% during the second year of the Afya Jijini project and improved to 80.1% during the third year of the project’s support. Use of QI teams and root cause analysis to identify and address service delivery gaps, in addition to targeted program interventions and continual performance reviews, can be successful in increasing TB related service delivery uptake at health facilities.

Keywords: isoniazid, quality, health care workers, people leaving with HIV

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7 Nutrition Budgets in Uganda: Research to Inform Implementation

Authors: Alexis D'Agostino, Amanda Pomeroy


Background: Resource availability is essential to effective implementation of national nutrition policies. To this end, the SPRING Project has collected and analyzed budget data from government ministries in Uganda, international donors, and other nutrition implementers to provide data for the first time on what funding is actually allocated to implement nutrition activities named in the national nutrition plan. Methodology: USAID’s SPRING Project used the Uganda Nutrition Action Plan (UNAP) as the starting point for budget analysis. Thorough desk reviews of public budgets from government, donors, and NGOs were mapped to activities named in the UNAP and validated by key informants (KIs) across the stakeholder groups. By relying on nationally-recognized and locally-created documents, SPRING provided a familiar basis for discussions to increase credibility and local ownership of findings. Among other things, the KIs validated the amount, source, and type (specific or sensitive) of funding. When only high-level budget data were available, KIs provided rough estimates of the percentage of allocations that were actually nutrition-relevant, allowing creation of confidence intervals around some funding estimates. Results: After validating data and narrowing in on estimates of funding to nutrition-relevant programming, researchers applied a formula to estimate overall nutrition allocations. In line with guidance by the SUN Movement and its three-step process, nutrition-specific funding was counted at 100% of its allocation amount, while nutrition sensitive funding was counted at 25%. The vast majority of nutrition funding in Uganda is off-budget, with over 90 percent of all nutrition funding is provided outside of the government system. Overall allocations are split nearly evenly between nutrition-specific and –sensitive activities. In FY 2013/14, the two-year study’s baseline year, on- and off-budget funding for nutrition was estimated to be around 60 million USD. While the 60 million USD allocations compare favorably to the 66 million USD estimate of the cost of the UNAP, not all activities are sufficiently funded. Those activities with a focus on behavior change were the most underfunded. In addition, accompanying qualitative research suggested that donor funding for nutrition activities may shift government funding into other areas of work, making it difficult to estimate the sustainability of current nutrition investments.Conclusions: Beyond providing figures, these estimates can be used together with the qualitative results of the study to explain how and why these amounts were allocated for particular activities and not others, examine the negotiation process that occurred, and suggest options for improving the flow of finances to UNAP activities for the remainder of the policy tenure. By the end of the PBN study, several years of nutrition budget estimates will be available to compare changes in funding over time. Halfway through SPRING’s work, there is evidence that country stakeholders have begun to feel ownership over the ultimate findings and some ministries are requesting increased technical assistance in nutrition budgeting. Ultimately, these data can be used within organization to advocate for more and improved nutrition funding and to improve targeting of nutrition allocations.

Keywords: budget, nutrition, financing, scale-up

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6 Lessons Learned from Implementation of Remote Pregnant and Newborn Care Service for Vulnerable Women and Children During COVID-19 and Political Crisis in Myanmar

Authors: Wint Wint Thu, Htet Ko Ko Win, Myat Mon San, Zaw Lin Tun, Nandar Than Aye, Khin Nyein Myat, Hayman Nyo Oo, Nay Aung Lin, Kusum Thapa, Kyaw Htet Aung


Background: In Myanmar, the intense political instability happened to start in Feb-2021, while the COVID-19 pandemic waves are also threatening the public health system, which subsequently led to severe health sector crisis, including difficulties in accessing maternal and newborn health care for vulnerable women and children. The Remote Pregnant and Newborn Care (RPNC) uses a telehealth approach United States Agency for International Development (USAID)-funded Essential Health Project. Implementation: The Remote Pregnant and Newborn Care (RPNC) service has adapted to the MNCH needs of vulnerable pregnant women and was implemented to mitigate the risk of limited access to essential quality MNH care in Yangon, Myanmar, under women, and the project trained 13 service providers on a telehealth care package for pregnancy and newborn developed Jhpiego to ensure understanding of evidence-based MNCH care practices. The phone numbers of the pregnant women were gathered through the preexisting and functioning community volunteers, who reach the most vulnerable pregnant women in the project's targeted area. A total of 212 pregnant women have been reached by service providers for RPNC during the implementation period. The trained service providers offer quality antenatal and postnatal care, including newborn care, via telephone calls. It includes 24/7 incoming calls and time-allotted outgoing calls to the pregnant women during antenatal and postnatal periods, including the newborn care. The required data were collected daily in time with the calls, and the quality of the medical services is made assured with the track of the calls, ensuring data privacy and patient confidentiality. Lessons learned: The key lessons are 1) cost-effectiveness: RPNC service could reduce out of pocket expenditure of pregnant women as it only costs 1.6 United States dollars (USD) per one telehealth call while it costs 8 to 10 USD per one time in-person care service at private service providers, including transportation cost, 2) network of care: telehealth call could not replace the in-person antenatal and postnatal care services, and integration of telehealth calls with in-person care by local healthcare providers with the support of the community is crucial for accessibility to essential MNH services by poor and vulnerable women, and 3) sharing information on health access points: most of the women seem to have financial barriers in accessing private health facilities while public health system collapse and telehealthcare could provide information on low-cost facilities and connect women to relevant health facilities. These key lessons are important for future efforts regarding the implementation of remote pregnancy and newborn care in Myanmar, especially during the political crisis and COVID-19 pandemic situation.

Keywords: telehealth, accessibility, maternal care, newborn care

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5 Where do Pregnant Women Miss Out on Nutrition? Analysis of Survey Data from 22 Countries

Authors: Alexis D'Agostino, Celeste Sununtunasuk, Jack Fiedler


Background: Iron-folic acid (IFA) supplementation during antenatal care (ANC) has existed in many countries for decades. Despite this, low national coverage persists and women do not often consume appropriate amounts during pregnancy. USAID’s SPRING Project investigated pregnant women’s access to, and consumption of, IFA tablets through ANC. Cross-country analysis provided a global picture of the state of IFA-supplementation, while country-specific results noted key contextual issues, including geography, wealth, and ANC attendance. The analysis can help countries prioritize strategies for systematic performance improvements within one of the most common micronutrient supplementation programs aimed at reducing maternal anemia. Methodology: Using falter point analysis on Demographic and Health Survey (DHS) data collected from 162,958 women across 22 countries, SPRING identified four sequential falter points (ANC attendance, IFA receipt or purchase, IFA consumption, and number of tablets taken) where pregnant women fell out of the IFA distribution structure. SPRING analyzed data on IFA intake from DHS surveys with women of reproductive age. SPRING disaggregated these data by ANC participation during the most recent pregnancy, residency, and women’s socio-economic status. Results: Average sufficient IFA tablet use across all countries was only eight percent. Even in the best performing countries, only about one-third of pregnant women consumed 180 or more IFA tablets during their most recent pregnancy. ANC attendance was an important falter point for a quarter of women across all countries (with highest falter rates in Democratic Republic of the Congo, Nigeria, and Niger). Further analysis reveals patterns, with some countries having high ANC coverage but low IFA provision during ANC (DRC and Haiti), others having high ANC coverage and IFA provision but few women taking any tablets (Nigeria and Liberia), and countries that perform well in ANC, supplies, and initial consumption but where very few women consume the recommended 180 tablets (Malawi and Cambodia). Country-level analysis identifies further patterns of supplementation. In Indonesia, for example, only 62% of women in the poorest quintile took even one IFA tablet, while 86% of the wealthiest women did. This association between socioeconomic status and IFA intake held across nearly all countries where these data are available and was also visible in rural/urban comparisons. Analysis of ANC attendance data also suggests that higher numbers of ANC visits are associated with higher tablet intake. Conclusions: While it is difficult to disentangle which specific aspects of supply or demand cause the low rates of consumption, this tool allows policy-makers to identify major bottlenecks to scaling-up IFA supplementation during ANC. In turn, each falter point provides possible explanations of program performance and helps strategically identify areas for improved IFA supplementation. For example, improving the delivery of IFA supplementation in Ethiopia relies on increasing access to ANC, but also on identifying and addressing program gaps in IFA supply management and health workers’ practices in order to provide quality ANC services. While every country requires a customized approach to improving IFA supplementation, the multi-country analysis conducted by SPRING is a helpful first step in identifying country bottlenecks and prioritizing interventions.

Keywords: iron and folic acid, supplementation, antenatal care, micronutrient

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4 Urban Slum Communities Engage in the Fight Against TB in Karnataka, South India

Authors: N. Rambabu, H. Gururaj, Reynold Washington, Oommen George


Motivation: Under the USAID Strengthening Health Outcomes through Private Sector (SHOPS-TB) initiative, Karnataka Health Promotion Trust (KHPT) with technical support of Abt associates is implementing a TB prevention and care model in Karnataka State, South India. KHPT is the interface agency between the public and private sectors, and providers and the target community facilitating early TB case detection and enhancing treatment compliance through private health care providers (pHCP) engagement in RNTCP. The project coverage is 0.84 million urban poor from 663 slums in 12 districts of Karnataka. Problem Statement: India with the highest burden of global TB (26%) and two million cases annually, accounts for approximately one fifth of the global incidence. WHO estimates 300,000 people die from TB annually in India. India expanded the coverage of Directly Observed Treatment, Short-course chemotherapy (DOTS) to the entire country as early as 2006. However, the performance of RNTCP has not been uniform across states. While the national annual new smear-positive (NSP) case notification rate is 53, it is much lower at 47 in Karnataka. A third of TB patients in India reside in urban slums. Approach: Under SHOPS, KHPT actively engages with communities through key opinion leaders and community structures. Interpersonal communication, by Outreach workers through house-to-house visits and at aggregation points, is the primary method used for communication about TB and its management and to increase demand for sputum examination and DOTS. pHCP are mapped, trained and mentored by KHPT. ORWs also provide patient and family counseling on TB treatment, side effects and adherence, screen close contacts of index patients especially children under 6 years of age and screen co-morbidities including HIV, diabetes and malnutrition and risk factors including alcoholism, tobacco use, occupational hazards making appropriate accompanied or documented referrals. A treatment ‘buddy’ system for the patients involving close friends or family members, ICT-based support, DOTS Prerana (inspiration) groups of TB patients, family members and community, DOTS Mitra (friend) helpline services are also used for care and support services. Results: The intervention educated 39988 slum dwellers, referred 1731 chest symptomatics, tested 1061 patients and initiated 248 patients on anti-TB treatment within three months of intervention through continuous community engagement. Conclusions: The intervention’s potential to increase access to preferred health care providers, reduce patient and health system delays in diagnosis and initiation of treatment, improve health seeking behaviour and enhance compliance of pHCPs to standard treatment protocols is being monitored. Initial results are promising.

Keywords: DOTS, KHPT, health outcomes, public and private sector

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3 A Descriptive Study on Water Scarcity as a One Health Challenge among the Osiram Community, Kajiado County, Kenya

Authors: Damiano Omari, Topirian Kerempe, Dibo Sama, Walter Wafula, Sharon Chepkoech, Chrispine Juma, Gilbert Kirui, Simon Mburu, Susan Keino


The One Health concept was officially adopted by the international organizations and scholarly bodies in 1984. It aims at combining human, animal and environmental components to address global health challenges. Using collaborative efforts optimal health to people, animals, and the environment can be achieved. One health approach plays a significant approach role in prevention and control of zoonosis diseases. It has also been noted that 75% of new emerging human infectious diseases are zoonotic. In Kenya, one health has been embraced and strongly advocated for by One Health East and Central Africa (OHCEA). It was inaugurated on 17th of October 2010 at a historic meeting facilitated by USAID with participants from 7 public health schools, seven faculties of veterinary medicine in Eastern Africa and 2 American universities (Tufts and University of Minnesota) in addition to respond project staff. The study was conducted in Loitoktok Sub County, specifically in the Amboseli Ecosystem. The Amboseli ecosystem covers an area of 5,700 square kilometers and stretches between Mt. Kilimanjaro, Chyulu Hills, Tsavo West National park and the Kenya/Tanzania border. The area is arid to semi-arid and is more suitable for pastoralism with a high potential for conservation of wildlife and tourism enterprises. The ecosystem consists of the Amboseli National Park, which is surrounded by six group ranches which include Kimana, Olgulului, Selengei, Mbirikani, Kuku and Rombo in Loitoktok District. The Manyatta of study was Osiram Cultural Manyatta in Mbirikani group ranch. Apart from visiting the Manyatta, we also visited the sub-county hospital, slaughter slab, forest service, Kimana market, and the Amboseli National Park. The aim of the study was to identify the one health issues facing the community. This was done by a conducting a community needs assessment and prioritization. Different methods were used in data collection for the qualitative and numerical data. They include among others; key informant interviews and focus group discussions. We also guided the community members in drawing their Resource Map this helped identify the major resources in their land and also help them identify some of the issues they were facing. Matrix piling, root cause analysis, and force field analysis tools were used to establish the one health related priority issues facing community members. Skits were also used to present to the community interventions to the major one health issues. Some of the prioritized needs among the community were water scarcity and inadequate markets for their beadwork. The group intervened on the various needs of the Manyatta. For water scarcity, we educated the community on water harvesting methods using gutters as well as proper storage by the use of tanks and earth dams. The community was also encouraged to recycle and conserve water. To improve markets; we educated the community to upload their products online, a page was opened for them and uploading the photos was demonstrated to them. They were also encouraged to be innovative to attract more clients.

Keywords: Amboseli ecosystem, community interventions, community needs assessment and prioritization, one health issues

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2 Stakeholder Engagement to Address Urban Health Systems Gaps for Migrants

Authors: A. Chandra, M. Arthur, L. Mize, A. Pomeroy-Stevens


Background: Lower and middle-income countries (LMICs) in Asia face rapid urbanization resulting in both economic opportunities (the urban advantage) and emerging health challenges. Urban health risks are magnified in informal settlements and include infectious disease outbreaks, inadequate access to health services, and poor air quality. Over the coming years, urban spaces in Asia will face accelerating public health risks related to migration, climate change, and environmental health. These challenges are complex and require multi-sectoral and multi-stakeholder solutions. The Building Health Cities (BHC) program is funded by the United States Agency for International Development (USAID) to work with smart city initiatives in the Asia region. BHC approaches urban health challenges by addressing policies, planning, and services through a health equity lens, with a particular focus on informal settlements and migrant communities. The program works to develop data-driven decision-making, build inclusivity through stakeholder engagement, and facilitate the uptake of appropriate technology. Methodology: The BHC program has partnered with the smart city initiatives of Indore in India, Makassar in Indonesia, and Da Nang in Vietnam. Implementing partners support municipalities to improve health delivery and equity using two key approaches: political economy analysis and participatory systems mapping. Political economy analyses evaluate barriers to collective action, including corruption, security, accountability, and incentives. Systems mapping evaluates community health challenges using a cross-sectoral approach, analyzing the impact of economic, environmental, transport, security, health system, and built environment factors. The mapping exercise draws on the experience and expertise of a diverse cohort of stakeholders, including government officials, municipal service providers, and civil society organizations. Results: Systems mapping and political economy analyses identified significant barriers for health care in migrant populations. In Makassar, migrants are unable to obtain the necessary card that entitles them to subsidized health services. This finding is being used to engage with municipal governments to mitigate the barriers that limit migrant enrollment in the public social health insurance scheme. In Indore, the project identified poor drainage of storm and wastewater in migrant settlements as a cause of poor health. Unsafe and inadequate infrastructure placed residents of these settlements at risk for both waterborne diseases and injuries. The program also evaluated the capacity of urban primary health centers serving migrant communities, identifying challenges related to their hours of service and shortages of health workers. In Da Nang, the systems mapping process has only recently begun, with the formal partnership launched in December 2019. Conclusion: This paper explores lessons learned from BHC’s systems mapping, political economy analyses, and stakeholder engagement approaches. The paper shares progress related to the health of migrants in informal settlements. Case studies feature barriers identified and mitigating steps, including governance actions, taken by local stakeholders in partner cities. The paper includes an update on ongoing progress from Indore and Makassar and experience from the first six months of program implementation from Da Nang.

Keywords: informal settlements, migration, stakeholder engagement mapping, urban health

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1 Assessing Diagnostic and Evaluation Tools for Use in Urban Immunisation Programming: A Critical Narrative Review and Proposed Framework

Authors: Tim Crocker-Buque, Sandra Mounier-Jack, Natasha Howard


Background: Due to both the increasing scale and speed of urbanisation, urban areas in low and middle-income countries (LMICs) host increasingly large populations of under-immunized children, with the additional associated risks of rapid disease transmission in high-density living environments. Multiple interdependent factors are associated with these coverage disparities in urban areas and most evidence comes from relatively few countries, e.g., predominantly India, Kenya, Nigeria, and some from Pakistan, Iran, and Brazil. This study aimed to identify, describe, and assess the main tools used to measure or improve coverage of immunisation services in poor urban areas. Methods: Authors used a qualitative review design, including academic and non-academic literature, to identify tools used to improve coverage of public health interventions in urban areas. Authors selected and extracted sources that provided good examples of specific tools, or categories of tools, used in a context relevant to urban immunization. Diagnostic (e.g., for data collection, analysis, and insight generation) and programme tools (e.g., for investigating or improving ongoing programmes) and interventions (e.g., multi-component or stand-alone with evidence) were selected for inclusion to provide a range of type and availability of relevant tools. These were then prioritised using a decision-analysis framework and a tool selection guide for programme managers developed. Results: Authors reviewed tools used in urban immunisation contexts and tools designed for (i) non-immunization and/or non-health interventions in urban areas, and (ii) immunisation in rural contexts that had relevance for urban areas (e.g., Reaching every District/Child/ Zone). Many approaches combined several tools and methods, which authors categorised as diagnostic, programme, and intervention. The most common diagnostic tools were cross-sectional surveys, key informant interviews, focus group discussions, secondary analysis of routine data, and geographical mapping of outcomes, resources, and services. Programme tools involved multiple stages of data collection, analysis, insight generation, and intervention planning and included guidance documents from WHO (World Health Organisation), UNICEF (United Nations Children's Fund), USAID (United States Agency for International Development), and governments, and articles reporting on diagnostics, interventions, and/or evaluations to improve urban immunisation. Interventions involved service improvement, education, reminder/recall, incentives, outreach, mass-media, or were multi-component. The main gaps in existing tools were an assessment of macro/policy-level factors, exploration of effective immunization communication channels, and measuring in/out-migration. The proposed framework uses a problem tree approach to suggest tools to address five common challenges (i.e. identifying populations, understanding communities, issues with service access and use, improving services, improving coverage) based on context and available data. Conclusion: This study identified many tools relevant to evaluating urban LMIC immunisation programmes, including significant crossover between tools. This was encouraging in terms of supporting the identification of common areas, but problematic as data volumes, instructions, and activities could overwhelm managers and tools are not always suitably applied to suitable contexts. Further research is needed on how best to combine tools and methods to suit local contexts. Authors’ initial framework can be tested and developed further.

Keywords: health equity, immunisation, low and middle-income countries, poverty, urban health

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