JSI staff regularly publish their research and results from work in peer-reviewed journals. This section provides a brief abstract with a link to the journal where you can read more and either download or order the article, depending on the journal.
Beyond the Crisis: Did the Ebola Epidemic Improve Resilience of Liberia's Health System? in Health Policy and Planning, Volume 32, Issue suppl_3, 1 November 2017, Pages iii40–iii47
Resilience was widely identified as a critical attribute for strong health systems following the 2014–15 West Africa Ebola epidemic. In Liberia, Sierra Leone, and Guinea, struggles to control the disease and suspension of the operation of many health services demonstrated that health systems must plan for resilience long before a crisis. However, the operational elements of resilience and ways that a crisis experience can shape resilience are not well described in the literature.
To understand how a health system adapts to crisis and how the priorities of different health system actors influence this response we conducted interviews with global, national, and local respondents in Liberia between July and September 2015, several months after the country was first declared Ebola-free.
We found that health system resilience functions prioritized by global and national actors improved to a greater extent than those valued by community leaders and local health actors over the course of the epidemic. Although the Ebola epidemic stimulated some positive adaptations in Liberia’s health system, building a truly resilient health system will require longer-term investments and sustained attention long beyond the crisis.
Research methods and results are presented in the full article, available at Health Policy and Planning
Authors: Emilia Ling, Elysia Larson, Rose Jallah Macauley, Yvonne Kodl, Brian VanDeBogert, Saye Baawo, Margaret E Kruk
Reducing missed opportunities for vaccination in selected provinces of Mozambique: A study protocol in Gates Open Res 2017, 1:5
Background: A missed opportunity for vaccination (MOV) refers to any contact with health services by an individual who is eligible for vaccination, which does not result in the person receiving the vaccine doses for which s/he is eligible. A consortium of partners, including VillageReach, the Ministry of Health in Mozambique, and the World Health Organization, will implement a strategy to reduce MOV in Mozambique. The strategy involves demonstrating the magnitude of missed opportunities and their causes, and exploring tailored health system interventions to reduce them, with the aim of increasing vaccination coverage and timeliness of vaccinations.
Methods: A mixed-methods approach will incorporate both quantitative and qualitative tools. The assessment will target caregivers of children between the ages of 0–23 months who attend a health facility in the selected districts on the day of the assessment. Caregivers who are at least 18 years old will be eligible for inclusion. Another component of the assessment will target all health workers in the selected health facilities on the day of the assessment. A sample of 30 health facilities in different regions of the country will be assessed, with a target sample size of 600 caregiver exit interviews, 300 health worker interviews and focus group discussions with both caregivers and health workers. Data collection will commence late 2017, and the data will be electronically captured, managed and analyzed. Thematic analysis of data from the qualitative aspects of the assessment will be conducted, presenting the scope of interviews, representative verbatim quotes and key conclusions.
Conclusions: A concerted effort to reduce or eliminate MOV could increase vaccine coverage by up to 30% and may contribute to wider improvements in efficiencies of service delivery beyond the immunization program. In addition, the findings could contribute to a better understanding of MOV in similar settings.
Authors: Bvudzai Priscilla Magadzire; Gabriel Joao;Stephanie Shendale; Ikechukwu Udo Og.buanu
Upgrading Supply Chain Management Systems to Improve Availability of Medicines in Tanzania: Evaluation of Performance and Cost Effects in Global Health: Science and Practice, September 2017
To address challenges in public health supply chain performance, Tanzania invested in a national logistics management unit (LMU) and a national electronic logistics management information system (eLMIS). This evaluation examined the impact of these two key management upgrades approximately one year after they were introduced. It was found that investing in a LMU and eLMIS resulted in better data use and improvements in some, but not all, management practices. After one year, key improvements included: reduced stock-out rates, stock-out duration, and expiry rates. The upgraded systems contributed to a greater system efficiency and generated modest savings that defrayed much of the investment and maintenance costs.
Authors: Marasi Mwencha, James Rosen, Cary Spisak, Noel Watson, Noela Kisoka, Happiness Mberesero
Use of Cellular Phone Contacts to Increase Return Rates for Immunization Services in Kenya in The Pan African Medical Journal. 2017;28:24. doi:10.11604/pamj.2017.28.24.12631
In Kenya, failure to complete immunization schedules by children who previously accessed immunization services is an obstacle to ensuring that children are fully immunized. Home visit approaches used to track defaulting children have not been successful in reducing the drop-out rate. This study tested the use of phone contacts as an approach for tracking immunization defaulters in 12 facilities in three districts of western Kenya. For nine months, children accessing immunization services in the facilities were tracked and caregivers were asked their reasons for defaulting.
In all of the facilities, caregiver phone ownership was above 80%. Caregivers provided reliable contact information and health workers positively perceived phone-based defaulter communications. Competing tasks and concerns about vaccinating sick children and side-effects were the most cited reasons for caregivers defaulting.
It was concluded that use of phone contacts for follow-up is a feasible and cost-effective method for tracking defaulters. This approach should complement traditional home visits, especially for caregivers without phones. Given communication-related reasons for defaulting, it is important that immunization programs scale-up community education activities. But a system for health facilities to share details of defaulting children should be established to reduce "false defaulters."
Research methods and results are presented in the full article available at Pan African Medical Journal
Authors: Evans Mokaya, Isaac Mugoya, Jane Raburu, Lora Shimp
Barriers and Facilitators to HIV Testing Among Zambian Female Sex Workers in Three Transit Hubs in AIDS Patient Care and STDs, Volume: 31 Issue 7
Zambia has a generalized HIV epidemic, and HIV is concentrated along transit routes. Female sex workers (FSWs) are disproportionately affected by the epidemic. HIV testing is the crucial first step for engagement in HIV care and HIV prevention activities. However, to date little work has been done with FSWs in Zambia, and little is known about barriers and facilitators to HIV testing in this population.
FSW peer educators were recruited through existing sex worker organizations for participation in a trial related to HIV testing among FSWs. We conducted five focus groups with FSW peer educators (N= 40) in three transit towns in Zambia (Livingstone, Chirundu, and Kapiri Mposhi) to elicit community norms related to HIV testing.
Emerging themes demonstrated barriers and facilitators to HIV testing occurring at multiple levels, including individual, social network, and structural. Stigma and discrimination, including healthcare provider stigma, were a particularly salient barrier. Improving knowledge, social support, and acknowledgment of FSWs and women’s role in society emerged as facilitators to testing. Interventions to improve HIV testing among FSWs in Zambia will need to address barriers and facilitators at multiple levels to be maximally effective.
Authors: Michael M. Chanda, Amaya G. Perez-Brumer, Katrina F. Ortblad, Magdalene Mwale, Steven Chongo, Nyambe Kamungoma, Catherine Kanchele, Andrew Fullem, Leah Barresi, Till Barnighausen, Catherine E. Oldenburg.
This study investigates potential bias that may arise when surveys include question items for which multiple units are elicited. Examples of such items include questions about experiences with multiple health centers, comparison of different products, of the solicitation of egocentric network data. The larger the number of items asked about each named individual or location, the greater potential interviewer and respondent burden accrues to the naming of more names. Interviewers may be inclined to limit the number of names elicited to reduce the amount of time required to complete the interviews. We tested whether such bias occurred from data collected in northwest Ghana by contrasting group learning with individual learning. The results provided mixed evidence for both group and individual learning and stress the need to take actions such as increased training, change in incentives, and/or monitoring responses to guard against such results.
Authors: Thomas Valente, Leanne Dougherty and Emily Stammer.
Seeing RED to Immunize in an Evolving African Landscape in The Pan African Medical Hournal, 2017.27.3.11627
Learning lessons from implementing context-specific Reach Every District (RED) approaches in Africa has potential to generate more evidence for policy makers who need to know what works and what does not for strengthening immunization systems. Renewed political and financial commitment for countries to roll out and integrate context-specific RED approaches into health programs could play a central role in strengthening underlying immunization systems to deliver interventions more effectively, equitably, efficiently and sustainably. With its operational approach and explicit links to community needs, applying the RED approach has much potential not only to contribute to countries immunization plans, but also overall UHC and development plans. There is currently support to revise the 2008 RED guidelines to take into consideration the challenges of urbanization, integration, community engagement, life cycle and financial sustainability.
Author: Craig Burgess
Effect on neonatal mortality of newborn infection management at health posts when referral is not possible: A cluster-randomized trial in rural Ethiopia in Glob Health Sci Pract. 2017 Jun 27; 5(2): 202–216.
Published online 2017 Jun 27. Prepublished online 2017 Jun 12. doi: 10.9745/GHSP-D-16-00312
The World Health Organization recently provided guidelines for outpatient treatment of possible severe bacterial infections (PSBI) in young infants, when referral to hospital is not feasible. This study evaluated newborn infection treatment at the most peripheral level of the health system in rural Ethiopia. When referral to higher levels of care is not possible, health extension workers can deliver outpatient antibiotic treatment of newborns with PSBI, but estimated treatment coverage in a rural Ethiopian setting was only around 50%. While our data suggest a mortality reduction consistent with that which might be expected at this level of coverage, they do not provide conclusive results.
Authors: Tedbabe Degefie Hailegebriel; Brian Mulligan; Simon Cousens;Bereket Mathewos; Steve Wall; Abeba Bekele; Jeanne Russell; Deborah Sitrin; Biruk Tensou; Jay Lawn; Joseph de Graft Johnson; Hailemariam Legesse; Sirak Hailu; Assaye Nigussie; Bogale Worku; Abdullah Baqui.
Efforts to monitor global progress on individual and community demand for immunization: Development of definitions and indicators for the Global Vaccine Action Plan Strategic Objective 2 in Vaccine, Vol 35, Issue 28, pps 3515-3519
The Second Strategic Objective of the Global Vaccine Action Plan says ‘‘individuals and communities understand the value of vaccines and demand immunization as both their right and responsibility.” This plan differs from the other five in that it does not focus on supply-side aspects of immunization programs but rather on public demand for vaccines and immunization services.
This commentary summarizes the work (literature review, consultations with experts, and with potential users) and findings of the UNICEF/World Health Organization Strategic Objective 2 informal Working Group on Vaccine Demand, which developed a definition for demand and indicators related to Strategic Objective 2. Demand for vaccines and vaccination is a complex concept that is not external to supply systems but rather encompasses the interaction between human behaviors and system structure and dynamics.
Authors: Benjamin Hickler; Noni MacDonald; Kamel Senouci; Holly Schuh.
Value-Based Payment Models for Community Health Centers. Time to (Cautiously) Take the Plunge? in Journal of the American Medical Association online May 4, 2017. doi:10.1001/jama.2017.5174
In the current system, community Health centers (CHCs) provide care to all individuals, regardless of insurance status or ability to pay, they are entitled to a set level of reimbursement that is linked to the cost of care for Medicaid patients (standard Medicaid rates are insufficient in many settings). CHCs also receive federal grants to cover care for uninsured patients (but to be eligible, HCs must be federally approved and meet lengthy requirements). Under the current payment model (prospective payment system) because rates are set prospectively, states work with CHCs to determine a flat rate for qualified Medicaid visits, and can also receive supplementary payment from state to cover the difference between managed care payment and prospective payment system rate.
This system is limited by traditional volume-based reimbursement, meaning CHCs have incentives to schedule reimbursable in-person visits for simple issues (some of which could be managed more efficiently by telephone or electronic communication). So the visit volume remains the driving force behind financial stability impeding the evolution of advanced primary care delivery models.
A shift to value-based payment among CHCs could promote higher-quality, more efficient and more patient-centric care. This is an evidence-based strategy for improving health outcomes and slowing cost increases.
Authors: Jay Bhatia, Rachel Tobey, Michael Hochman
Integrating Mental Health and HIV Services in Zimbabwean Communities: A Nurse and Community-led Approach to Reach the Most Vulnerable in Journal of the Association of Nurses in AIDS Care Volume 28, Issue 2, Pages 186–198
Alcohol use and depression negatively impact adherence, retention in care, and HIV progression, and people living with HIV (PLWH) have disproportionally higher depression rates. In developing countries, more than 76% of people with mental health issues, receive no treatment. This team hypothesized that stepped-care mental health/HIV integration provided by multiple service professionals in Zimbabwe would be acceptable and feasible. Screenings were done by nurses, community health workers and traditional medicine practitioners in nine communities.
Results indicate that integrating mental health and HIV services is feasible that integration can effectively expand availability of mental health services for PLWH. A standard operating procedure on the stepped-care approach for mental health and HIV integration that resulted from this pilot study has been share with the MOHCC, which is seeking funding to scale-up the program nationwide.
Non-communicable Diseases and HIV Care and Treatment: Models of Integrated Service Delivery in Tropical Medicine and International Health, Vol 22(8); pp926-937
Non-communicable diseases (NCD) are a growing cause of morbidity in low-income countries including people living with human immunodeficient virus (HIV). Integration of NCD and HIV services can build upon experience with chronic care models from HIV programs. A literature review was conducted and three models of models of NCD and HIV service delivery integration were identified: NCD services integrated into centers originally providing HIV care, HIV care integrated into primary health care (PHC) already offering NCD services, and simultaneous introduction of integrated HIV and NCD services. It was concluded that regardless of model integration, leveraging experience from HIV care models and adapting existing systems and toos is a feasible method to provide efficient care and treatment for the growing numbers of patients with NCDs. Operational research should be conducted to further study how successful models of HIV and NCD integration can be expanded in scope and scaled-up by managers and policymakers seeking to address all the chronic care needs of their patients.
Authors: Malia Duffy, Bisola Ojikutu, Soa Andrian, Elaine Sohng, Thomas Minior, Lisa Hirschhorn
Doses per Vaccine Vial Container: An Understated and Underestimated Driver of Performance that Needs More Evidence in Vaccine, 2017 April 19. pii: S0264-410X(16)31137-9.
The widespread use of multidose vaccine containers in low and middle income countries' immunization programs is assumed to have multiple benefits and efficiencies for health systems, yet the broader impacts on immunization coverage, costs, and safety are not well understood. To document what is known on this topic, how it has been studied, and confirm the gaps in evidence that allow us to assess the complex system interactions, the authors undertook a review of published literature that explored the relationship between doses per container and immunization systems. The relationships examined in this study are organized within a systems framework consisting of operational costs, timely coverage, safety, product costs/wastage, and policy/correct use, with the idea that a change in dose per container affects all of them, and the optimal solution will depend on what is prioritized and used to measure performance. Studies on this topic are limited and largely rely on modeling to assess the relationship between doses per container and other aspects of immunization systems. Very few studies attempt to look at how a change in doses per container affects vaccination coverage rates and other systems components simultaneously. This article summarizes the published knowledge on this topic to date and suggests areas of current and future research to ultimately improve decision making around vaccine doses per container and increase understanding of how this decision relates to other program goals.
Authors: Alexis Heaton, Kirstin Krudwig, Tina Lorenson, Craig Burgess, Andrew Cunningham and Robert Steinglass
Maternal characteristics and obstetrical complications impact neonatal outcomes in Indonesia: a prospective study in BMC Pregnancy and Childbirth (2017) 17:100
The authors investigated associations between maternal characteristics, access to care, and obstetrical complications including near-miss status on admission or during hospitalization on perinatal outcomes among Indonesian singletons. Data was collected prospectively on inborn singletons at two hospitals in East Java. Outcomes of interest included low- and very-low birthweight (LBW/VLBW), asphyxia and death.
Referral from a care facility was associated with reduced risk of LBW and VLBW, stillbirth, and neonatal death. Mothers aged less than 20 years increased the risk of VLBW and neonatal death. Mal-presentation on admission increased the risk of asphyxia, still birth, and perinatal death, as did poor prenatal care. Near-miss admission increased the risk of neonatal and perinatal death.
The authors concluded that mothers in labor should be encouraged to seek care early and be taught to identify early danger signs. Adequate prenatal care (PNC) significantly reduced perinatal deaths. Improved hospital management of mal-presentation may significantly reduce perinatal morbidity and mortality. The importance of hospital-based prospective studies helps evaluate specific areas of need in training of obstetrical care providers.
Authors: Trisari Anggondowati, Ayman El-Mohandes, S. Nurul Qomariyah, Michele Kiely, Judith Ryon, Reginald Gipson, Benjamin Zinner, Anhari Achadi and Linda Wright, 2017.
Beyond new vaccine introduction: The uptake of pneumococcal conjugate vaccine in the African Region in The Pan African Medical Journal, 2017.27.3.11531
The number of vaccines available to low-income countries has increased dramatically over the last decade. Overall infant immunization coverage in the WHO African region has stagnated in the past few years while countries' ability to maintain high immunization coverage rates following introduction of new vaccines has been uneven.
This case study examines post-introduction coverage among African countries that introduced PCV (Pneumococcal Conjugate Vaccine) between 2008 and 2013 and the factors affecting PCV introduction. It was found that nearly one-third of countries did not achieve 80% infant PCV3 coverage by two years post-introduction and more than half of countries experienced a decline in coverage between the second and fourth year. Major factors affecting coverage rates include: introduction without adequate preparation, insufficient supply chain capacity/management, poor communication between organizations and the public, insufficient data systems.
Deliberately addressing these issues as well as longstanding weaknesses during new vaccine introduction can strengthen the immunization and broader health systems. Immunization with PCV is one of the most important interventions protecting against pneumonia, the second leading cause of death for children under five globally.
Authors: Folake Olayinka, Leah Ewald, Robert Steinglass
Immunization review meetings: "Low Hanging Fruit" for capacity building and data quality improvement? in The Pan African Medical Journal, 2007.27.3.11516
Although systematic program review meetings are common practice in many health and immunization programs, there is little documentation on their implementation and role. Adult education principles espouse opportunities for peer exchange to build capacity and cross-learning, for which review meetings have been a forum utilized in immunization programs for many years.
This study describes the process and use of review meetings to build immunization technical capacity in Ethiopia, Kenya, Tanzania and Uganda from 2011-2016. Based on findings from 200+ review meetings in these four countries, these meetings have been shown to be effective tools for improving immunization program performance and the capacity of health staff. In combination with other performance improvement approaches (such as supportive supervision, training, and on-the-job learning and assessment), review meetings can also contribute to achievement of immunization and health outcomes.
Authors: Lora Shimp, Nassor Mohammed, Lisa Oot, Evans Mokaya, Timothy Kiyemba, Gerald Ssekitto, Adriana Alminana
Implementing At-scale, Community-based Distribution of Misoprostol Tablets to Mothers in the Third Stage of Labor for the Prevention of Postpartum Haemorrhage in Sokoto State, Nigeria: Early Results and Lessons Learned in PLoS ONE 12(2): e0170739.
Postpartum haemorrhage (PPH) is a leading cause of maternal death in Sokoto State, Nigeria, where 95% of women give birth outside of a health facility. Although pilot schemes have demonstrated the value of community-based distribution of misoprostol for the prevention of PPH, none have provided practical insight on taking such programs to scale. A community-based system for the distribution of misoprostol tablets and chlorhexidine digluconate gel to mother-newborn dyads was introduced by state government officials and community leaders throughout Sokoto State in April 2013. A simple outcome form that collected distribution and consumption data was used to assess the percentage of mothers that received misoprostol at labor through December 2014. Mothers' conditions were tracked through 6 weeks postpartum. Verbal autopsies were conducted on associated maternal deaths.
Misoprostol distribution was successfully introduced and reached mothers in labor in all 244 wards in Sokoto State. Community data collection systems were successfully operational in all 244 wards with reliable capacity to record maternal deaths. 70,982 women or 22% of expected births received misoprostol from April 2013 to December 2014.
It was concluded that it is feasible and safe to utilize government guidelines on results-based primary health care to successfully introduce community distribution of life saving misoprostol at scale to reduce PPH and improve maternal outcomes. Lessons from Sokoto State's at-scale program implementation, to assure every mother's right to uterotonics, can inform scale-up elsewhere in Nigeria.
Authors: Nosakhare Orobaton, Jumare Abdulazeez, Dele Abegunde, Kamil Shoretire, Abubakar Maishanu, Nnenna Ikoro, Bolaji Fapohunda, Wapada Balami, Katherine Beal, Akeem Ganiyu, Ringpon Gwamzhi, Anne Austin
The Health of the Transgender Community: Out, Proud, and Coming Into Their Own in American Journal of Public Health, 2017 February; 107(2): 205-206
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With the public more aware than ever of the transgender population, now is a time for public health and health care professionals to understand and address their issues. While training programs on transgender health are necessary to improve medical care and health outcomes, other issues affecting the transgender population must be addressed as well. Violence against transgender persons is disproportionally higher, and the greater likelihood of negative health outcomes is directly related to stress from fear of violence or trauma associated with being a victim of violence. Respect for the transgender population includes rational policies that allow for changes of identity documents including birth certificates and driving licenses. And while asking for and using the preferred pronoun of an individual, regardless of what pronoun the speaker thinks should apply, may seem unimportant to some of us, doing so is a common courtesy and shows the respect due to out and proud transgender people.
Authors: Stewart Landers and Farzana Kapadia
Recommendations for Multi-sector Nutrition Planning: Cross-context Lessons from Nepal and Uganda in Field Exchange, 54: Feb 2017; p 90
SPRING Pathways to Better Nutrition (PBN) case studies documented successes and challenges in implementing national multi-sector nutrition action plans (NNAPs) in Nepal and Uganda.
Common drivers of change across both countries included strong multi-sector coordination of nutrition activities that involved national nutrition secretariats and strong advocacy partnerships and communication. Barriers to change included vertical coordination, poor coordination with academia and business, high staff turnover and constrained staff availability.
Integrating NNAPs into existing local and national policy and work planning structures, budgeting processes and monitoring and evaluation (M&E) systems remains a key challenge. Linked to NNAPs, increased prioritization of nutrition across sectors and increased funding allocation for nutrition was observed; however, nutrition spend did not necessarily increase. Lack of clear accounting mechanisms for nutrition-related allocations and spending limited analysis. Cross-country recommendations include: setting long-terms goals for scale-up; all partners, including donors and the UN agencies aligning with NNAPs; consideration of formal funding mechanisms for nutrition; and embedding nutrition into national strategies, financial reporting systems and M&E mechanisms.
Authors: Amanda Pomeroy-Stevens, Heather Viland, and Sascha Lamstein
HIV testing and knowledge of status are starting points for HIV treatment and prevention interventions. Among female sex workers (FSWs), HIV testing and status knowledge remain far from universal. HIV self-testing (HIVST) is an alternative to existing testing services for FSWs, but little evidence exists how it can be effectively and safely implemented. Here, we describe the rationale and design of a cluster randomised trial designed to inform implementation and scale-up of HIVST programmes for FSWs in Zambia.
The Zambian Peer Educators for HIV Self-Testing (ZEST) study is a 3-arm cluster randomised trial taking place in 3 towns in Zambia. Participants (N=900) are eligible if they are women who have exchanged sex for money or goods in the previous 1?month, are HIV negative or status unknown, have not tested for HIV in the previous 3?months, and are at least 18?years old. Participants are recruited by peer educators working in their communities. Participants are randomised to 1 of 3 arms: (1) direct distribution (in which they receive an HIVST from the peer educator directly); (2) fixed distribution (in which they receive a coupon with which to collect the HIVST from a drug store or health post) or (3) standard of care (referral to existing HIV testing services only, without any offer of HIVST). Participants are followed at 1 and 4?months following distribution of the first HIVST. The primary end point is HIV testing in the past month measured at the 1-month and 4-month visits.
This study is one of the first reporting the effectiveness and safety of an HIVST intervention among female sex workers. The results allows for assessment of the feasibility and acceptability of HIV self-test kits in general. They also provide evidence on whether HIVST is used by FSWs if it is accessible via existing distribution points within the health system.
Authors: Catherine Oldenburg, Katrina Ortblad, Michael Chanda, Kalasa Mwanda, Wendy Nicodemus, Rebecca Sikaundi, Andrew Fullem, Leah Barresi, Guy Harling, Till Barnighausen.
Geographic Information System for Improving Maternal and Newborn Health: Recommendations for Policy and Programs in BMC Pregnancy and Childbirth, (2017) 17:26.
In a letter to the editor of BMC Pregnancy and Childbirth, JSI staff and other authors argue and offer recommendations for how geographic information systems (GIS) applied to maternal and newborn health data could potentially be used as part of the broader efforts for ending preventable maternal and newborn mortality.
The recommendations were generated from a technical consultation on reporting and mapping maternal deaths that was held in Washington, DC from January 12 to 13, 2015 and hosted by the USAID-funded Maternal and Child Survival Program (MCSP). Approximately 72 participants participated in the meeting, which focused on how improved use of mapping could contribute to the post-2015 United Nation’s Sustainable Development Goals (SDGs) agenda in general and to better maternal and neonatal health outcomes in particular.
Researchers and policy makers have been calling for more equitable improvement in maternal and newborn health (MNH), specifically addressing hard-to-reach populations at sub-national levels. Data visualization using mapping and geospatial analyses play a significant role in addressing the emerging need for improved spatial investigation at subnational scale. This correspondence identifies key challenges and recommendations so GIS may be better applied to maternal health programs in resource poor settings. The challenges and recommendations are broadly grouped into three categories: ancillary geospatial and MNH data sources, technical and human resources needs and community participation.
Authors: Yordanos Molla, Barbara Rawlins, Prestige Tatenda Makanga, Marc Cunningham, Juan Eugenio Hernandez Avila, Corrine Warren Ruktanonchai, Kavita Singh, Sylvia Alford, Mira Thompson, Vikas Dwivedi, Allisyn C. Moran, and Zoe Matthews.