Corrina Moucheraud
Corrina Moucheraud
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Associate Professor of Public Health Policy and Management
Co-Director of the Global Center for Implementation Science
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Professional overview
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Corrina Moucheraud, ScD, MPH is an Associate Professor in the Department of Public Health Policy & Management, and Co-Director of the Global Center for Implementation Science. As a global health researcher and implementation scientist, she seeks to improve outcomes by strengthening health systems and enabling the delivery of effective, equitable health services. Much of Dr. Moucheraud’s focus is on meeting the needs of women and young people, particularly in low- and middle-income countries. Dr. Moucheraud is currently leading efforts for cervical cancer prevention, including HPV vaccination, in Kenya and Malawi. She also researches HIV & non-communicable disease prevention and treatment internationally and in the U.S.
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Education
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MPH, Health Behavior, University of North Carolina Gillings School of Public Health, Chapel Hill, NCScD, Global Health & Population, Harvard T.H. Chan School of Public Health, Cambridge, MA
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Honors and awards
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Visiting Scholar, Clinical and Translational Science Awards Program (NCATS, NIH) (2021)Delta Omega Honorary Society (2020)Faculty Career Development Award (UCLA) (2017)Hellman Fellowship (UCLA) (2017)Maternal Health Task Force award (Harvard University) (2013)
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Publications
Publications
ART Adherence Among Malawian Youth Enrolled in Teen Clubs: A Retrospective Chart Review
AbstractMcBride, K., Parent, J., Mmanga, K., Chivwala, M., Nyirenda, M. H., Schooley, A., Mwambene, J. B., Dovel, K., Lungu, E., Balakasi, K., Hoffman, R. M., & Moucheraud, C. (n.d.).Publication year
2019Journal title
AIDS and BehaviorVolume
23Issue
9Page(s)
2629-2633AbstractTo improve outcomes among HIV-positive adolescents, the Malawi Ministry of Health is supporting scale-up of “Teen Clubs,” a facility-based antiretroviral treatment (ART) delivery model. Teen Clubs are monthly ART clinics for adolescents (10–19 years old) that provide clinical services and peer psychosocial support. This paper assesses ART adherence among Teen Club attendees in Malawi. We performed a retrospective analysis of medical records and Teen Club attendance data on 589 HIV-positive adolescents at 16 Partners in Hope (PIH)—Extending Quality Improvement for HIV/AIDS in Malawi (EQUIP) supported facilities across Malawi, from January to June of 2017, who attended at least two Teen Club sessions. Multi-level logistic regression models were used to examine the role of gender and age on optimal ART adherence (≥ 95% based on pill count) among HIV-positive adolescents enrolled in Teen Clubs. The median age of adolescents in this sample was 14 years, and 47% were male. Older adolescent males (15–19 years) were 64% more likely to achieve ≥ 95% ART adherence (aOR 1.64, 95% CI 1.16–2.31, p ' 0.01) compared to younger (10–14 years) males. The effect of age on adherence was smaller and not significant among females (aOR 1.36, 95% CI 0.96–1.94, p = 0.08). In the full model including males and females, older adolescence was associated with higher odds of optimal adherence (aOR 1.48, 95% CI 1.16–1.90, p ' 0.01). These results reinforce the need for age-specialized programming for adolescents, and future research should evaluate this in achieving optimal ART adherence.Barriers to HIV treatment adherence: A qualitative study of discrepancies between perceptions of patients and health providers in Tanzania and Uganda
AbstractMoucheraud, C., Stern, A. F., Ahearn, C., Ismail, A., Nsubuga-Nyombi, T., Ngonyani, M. M., Mvungi, J., & Ssensamba, J. (n.d.).Publication year
2019Journal title
AIDS patient care and STDsVolume
33Issue
9Page(s)
406-413AbstractPrevious qualitative studies about antiretroviral therapy (ART) adherence have largely focused on patient experiences. Less is known about the perspective of health care providers - particularly in low-income countries - who serve as gatekeepers and influencers of patients' HIV care experiences. This study explored patients' and providers' perceptions of important ART adherence determinants. Interviews were conducted at HIV treatment sites in Tanzania and Uganda, with adult patients on ART (n = 148), and with health care providers (n = 49). Patients were asked about their experiences with ART adherence, and providers were asked about their perceptions of what adherence challenges are faced by their patients. All interviews were conducted in local languages; transcripts were translated into English and analyzed using a codebook informed by the social ecological model. Themes were examined across and within countries. Adherence-related challenges were frequently reported, but patients and providers did not often agree about the reasons. Many patients cited challenges related to being away from home and therefore away from their pill supply; and, in Uganda, challenges picking up refills (access to care) and related to food sufficiency/diet. Providers also identified these access to care barriers, but otherwise focused on different key determinants (e.g., they rarely mentioned food/diet); instead, providers were more likely to mention alcohol/alcoholism, stigma, and lack of understanding about the importance of adhering. These findings suggest areas of opportunity for future research and for improving clinical care by aligning perceptions of adherence challenges, to deliver better-informed and useful ART counseling and support.Does health worker performance affect clients' health behaviors? A multilevel analysis from Bangladesh
AbstractEpstein, A., Moucheraud, C., Sarma, H., Rahman, M., Tariqujjaman, M., Ahmed, T., Glenn, J., Bossert, T., & Kruk, M. E. (n.d.).Publication year
2019Journal title
BMC health services researchVolume
19Issue
1AbstractBackground: Suboptimal healthcare quality may be a barrier to achieving child health improvements, yet little is known about the relationship between provider compliance with evidence-based practices and client behavior change. We assess provider compliance in the context of infant and young child feeding (IYCF) counseling, its relationship with client IYCF behaviors in Bangladesh, and explore its potential determinants. Methods: We use data from a 2017 evaluation of an IYCF program that includes a health worker survey (n = 74), caregiver survey (n = 232), and direct service observation checklists of counseling sessions (n = 232 observations of 74 health workers). We assess the relationship between provider compliance with recommended IYCF counseling topics and behaviors (standardized to a 100-point scale) and three reported IYCF behaviors among clients using multi-level models with random effects at the health worker and sub-district (sampling) levels. We also evaluate whether health worker self-efficacy, satisfaction, and technical knowledge are associated with provider compliance. Results: Health worker compliance was significantly associated with reported exclusive breastfeeding for children under 6 months of age (adjusted odds ratio per 1 percentage point increase in counseling compliance score = 1.06, 95% CI 1.01, 1.12) and marginally associated with minimum dietary diversity (adjusted odds ratio per 1 percentage point increase in counseling compliance score = 1.05, 95% CI 1.00, 1.11). Counseling compliance was significantly and positively associated with both health worker self-efficacy and technical knowledge. Conclusions: We find evidence for an association between health worker compliance and client health behaviors; however, small effect sizes suggest that behavior change is multifactorial and affected by factors beyond care quality. Improvements to technical quality of care may contribute to desired health outcomes; but policies and programs seeking to change health behaviors through counseling may also wish to target upstream factors such as self-efficacy, alongside technical skill-building and knowledge, for maximum impact.Engagement in Agriculture Protects Against Food Insecurity and Malnutrition in Peri-Urban Nepal
AbstractMoucheraud, C., Chandyo, R. K., Henjum, S., Strand, T. A., Ulak, M., Fawzi, W. W., Locks, L. M., Webb, P., & Thorne-Lyman, A. L. (n.d.).Publication year
2019Journal title
Current Developments in NutritionVolume
3Issue
1AbstractBackground: Urbanization is occurring rapidly in many low- and middle-income countries, which may affect households' livelihoods, diet, and food security and nutritional outcomes. Objective: The main objective of our study was to explore whether agricultural activity among a peri-urban population in Nepal was associated with better or worse food household security, household and maternal dietary diversity, and nutritional outcomes for children and women. Methods: A cross-sectional survey was administered to 344 mother-child pairs in Bhaktapur district, Nepal, including data on household agricultural practices, livestock ownership, food security, dietary diversity and expenditures, anthropometric measurements of children (aged 5-6 y), maternal body mass index (BMI), and maternal anemia. Multivariable adjusted odds ratios (AORs) and unadjusted odds ratios were calculated using logistic regression. Results: Our findings suggest that in this sample, cultivation of land was associated with lower odds of child stunting (AOR: 0.55; 95% CI: 0.33, 0.93) and household food insecurity (AOR: 0.33; 95% CI: 0.18, 0.63), but not low (or high) maternal BMI or anemia. Livestock ownership (mostly chickens) was associated with lower food insecurity (AOR: 0.34; 95% CI: 0.16, 0.73) but not with nutrition outcomes. Women in farming households were significantly more likely to eat green leafy vegetables than were women in nonfarming households, and children living in households that grew vegetables had a lower odds of stunting than children in households that cultivated land but did not grow vegetables (AOR: 0.49; 95% CI: 0.25, 0.98). Conclusions: Our study suggests that households involved in cultivation of land in peri-urban Bhaktapur had lower odds of children's stunting and of food insecurity than noncultivating households, and that vegetable consumption is higher among those households. Given Nepal's rapid urbanization rate, more attention is needed on the potential role of peri-urban agriculture in shaping diets and nutrition.Scaling up diagnostic-driven management of sexually transmitted infections in pregnancy
Wynn, A., Moucheraud, C., Morroni, C., Ramogola-Masire, D., Klausner, J. D., & Leibowitz, A. (n.d.). In The Lancet Infectious Diseases (1–).Publication year
2019Volume
19Issue
8Page(s)
809-810The costs of diabetes treatment in low- A nd middle-income countries: A systematic review
AbstractMoucheraud, C., Lenz, C., Latkovic, M., & Wirtz, V. J. (n.d.).Publication year
2019Journal title
BMJ Global HealthVolume
4Issue
1AbstractIntroduction The rising burden of diabetes in low- A nd middle-income countries may cause financial strain on individuals and health systems. This paper presents a systematic review of direct medical costs for diabetes (types 1 and 2) in low- A nd middle-income countries. Methods Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, databases (PubMed, International Bibliography of Social Science, EconLit) were searched for publications reporting direct medical costs of type 1 and 2 diabetes. Data were extracted from all peer-reviewed papers meeting inclusion criteria, and were standardised into per-patient-visit, per-patient-year and/or per-complication-case costs (2016 US$). Results The search yielded 584 abstracts, and 52 publications were included in the analysis. Most articles were from Asia and Latin America, and most focused on type 2 diabetes. Per-visit outpatient costs ranged from under $5 to over $40 (median: $7); annual inpatient costs ranged from approximately $10 to over $1000 (median: $290); annual laboratory costs ranged from under $5 to over $100 (median: $25); and annual medication costs ranged from $15 to over $500 (median: $177), with particularly wide variation found for insulin. Care for complications was generally high-cost, but varied widely across countries and complication types. Conclusion This review identified substantial variation in diabetes treatment costs; some heterogeneity could be mitigated through improved methods for collecting, analysing and reporting data. Diabetes is a costly disease to manage in low- A nd middle-income countriesand should be a priority for the global health community seeking to achieve Universal Health Coverage.Using partner notification to address curable sexually transmitted infections in a high HIV prevalence context: A qualitative study about partner notification in Botswana
AbstractWynn, A., Moucheraud, C., Moshashane, N., Offorjebe, O. A., Ramogola-Masire, D., Klausner, J. D., & Morroni, C. (n.d.).Publication year
2019Journal title
BMC public healthVolume
19AbstractBackground: Partner notification is an essential component of sexually transmitted infection (STI) management. The process involves identifying exposed sex partner(s), notifying these partner(s) about their exposure to a curable STI, and offering counselling and treatment for the STI as a part of syndromic management or after results from an STI test. When implemented effectively, partner notification services can prevent the index patient from being reinfected with a curable STI from an untreated partner, reduce the community burden of curable STIs, and prevent adverse health outcomes in both the index patient and his or her sex partner(s). However, partner notification and treatment rates are often low. This study seeks to explore experiences and preferences related to partner notification and treatment for curable STIs among pregnant women receiving care in an antenatal clinic with integrated HIV and curable STI testing. Results are intended to inform efforts to improve partner notification and treatment rates in Southern Africa. Methods: We conducted qualitative interviews among women diagnosed with Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and/or Trichomonas vaginalis (TV) infection while seeking antenatal care in Gaborone, Botswana. Semi-structured interviews were used to obtain women's knowledge about STIs and their experiences and preferences regarding partner notification. Results: Fifteen women agreed to participate in the study. The majority of women had never heard of CT, NG, or TV infections prior to testing. Thirteen out of 15 participants had notified partners about the STI diagnosis. The majority of notified partners received some treatment; however, partner treatment was often delayed. Most women expressed a preference for accompanying partners to the clinic for treatment. Experiences and preferences did not differ by HIV infection status. Conclusions: The integration of STI, HIV, and antenatal care services may have contributed to most women's willingness to notify partners. However, logistical barriers to partner treatment remained. More research is needed to identify effective and appropriate strategies for scaling-up partner notification services in order to improve rates of partners successfully contacted and treated, reduce rates of STI reinfection during pregnancy, and ultimately reduce adverse maternal and infant outcomes attributable to antenatal STIs.Основные (жизненно важные) лекарства для всеобщего охвата медицинской помощью
Wirtz, V. J., Hogerzeil, H. V., Gray, A. L., Bigdeli, M., De Joncheere, C. P., Ewen, M. A., Gyansa-Lutterodt, M., Jing, S., Luiza, V. L., Mbindyo, R. M., Möller, H., Moucheraud, C., Pécoul, B., Rägo, L., Rashidian, A., Ross-Degnan, D., Stephens, P. N., Teerawattananon, Y., T’Hoen, E. F., … Reich, M. R. (n.d.).Publication year
2019Journal title
Kazan Medical JournalVolume
100Issue
1Page(s)
4-111Association of antiretroviral therapy with high-risk human papillomavirus, cervical intraepithelial neoplasia, and invasive cervical cancer in women living with HIV: a systematic review and meta-analysis
Failed generating bibliography.AbstractPublication year
2018Journal title
The Lancet HIVVolume
5Issue
1Page(s)
e45-e58AbstractBackground The interactions between antiretroviral therapy (ART) and high-risk human papillomavirus (HPV) and cervical lesions in women living with HIV are poorly understood. We reviewed the association of ART with these outcomes. Methods We did a systematic review and meta-analysis by searching MEDLINE and Embase databases for cross-sectional or cohort studies published in English between Jan 1, 1996, and May 6, 2017, which reported the association of ART with prevalence of high-risk HPV or prevalence, incidence, progression, or regression of histological or cytological cervical abnormalities, or incidence of invasive cervcal cancer. Studies were eligible if they reported the association of combination ART or highly active ART use with the following outcomes: high-risk HPV prevalence; squamous intraepithelial lesion (SIL) or cervical intraepithelial neoplasia (CIN) prevalence, incidence, progression, or regression; and invasive cervical cancer incidence among women living with HIV. We did random-effects meta-analyses to estimate summary statistics. We examined heterogeneity with the I2 statistic. This review is registered on the PROSPERO database at the Centre of Reviews and Dissemination, University of York, York, UK (registration number CRD42016039546). Findings We identified 31 studies of the association of ART with prevalence of high-risk HPV (6537 women living with HIV) and high grade cervical lesions (HSIL-CIN2+; 9288 women living with HIV). Women living with HIV on ART had lower prevalence of high-risk HPV than did those not on ART (adjusted odds ratio [aOR] 0·83, 95% CI 0·70–0·99; I2=51%, adjusted for CD4 cell count and ART duration), and there was some evidence of association with HSIL-CIN2+ (0·65, 0·40–1·06; I2=30%). 17 studies reported the association of ART with longitudinal cervical lesion outcomes. ART was associated with a decreased risk of HSIL-CIN2+ incidence among 1830 women living with HIV (0·59, 0·40–0·87; I2=0%), SIL progression among 6212 women living with HIV (adjusted hazard ratio [aHR] 0·64, 95% CI 0·54–0·75; I2=18%), and increased likelihood of SIL or CIN regression among 5261 women living with HIV (1·54, 1·30–1·82; I2=0%). In three studies among 15 846 women living with HIV, ART was associated with a reduction in invasive cervical cancer incidence (crude HR 0·40, 95% CI 0·18–0·87, I2=33%). Interpretation Early ART initiation and sustained adherence is likely to reduce incidence and progression of SIL and CIN and ultimately incidence of invasive cervical cancer. Future cohort studies should aim to confirm this possible effect. Funding UK Medical Research Council.Maternal Health Behaviors and Outcomes in a Nomadic Tibetan Population
AbstractMoucheraud, C., Gyal, L., Gyaltsen, K., Tsering, L., Narasimhan, S., & Gipson, J. (n.d.).Publication year
2018Journal title
Maternal and Child Health JournalVolume
22Issue
2Page(s)
264-273AbstractIntroduction Despite significant global improvements in maternal health, large disparities persist. In China, rural women and women who live in western regions experience lower rates of maternal healthcare utilization and higher rates of maternal mortality than women elsewhere in the country. This paper examines maternal health care-seeking among nomadic Tibetan women in rural western China, a particularly understudied group. Methods Secondary data analysis was conducted with survey data collected in 2014 in Qinghai Province, China. Participants (rural, nomadic, adult women) provided birth histories and information on care received during antenatal, intrapartum and/or postpartum period(s). Using bivariate and multivariable logistic regression models, these outcomes were explored in relation to maternal characteristics (e.g., educational attainment and parity), use of health insurance, and time. Results Approximately half of all women had ever used antenatal care, institutional delivery, and/or skilled birth attendance. The utilization of these services has increased over time, from 10% of births prior to the year 2000, to approximately 50% since 2000. Utilization increased by year (odds ratios ranging from 1.1 to 1.3) even after controlling for covariates. Women with health insurance coverage were significantly more likely to use these services than women without insurance, although less than 20% of women reported that insurance paid for any antenatal and/or childbirth care. Discussion Utilization of maternal care is improving among this population but rates remain low in comparison to other women in rural, western China. Further targeted interventions may be needed to reach and adequately address the maternal health needs of this unique population.Service readiness for noncommunicable diseases was low in five countries in 2013-15
AbstractMoucheraud, C. (n.d.).Publication year
2018Journal title
Health AffairsVolume
37Issue
8Page(s)
1321-1330AbstractThe growing burden of noncommunicable diseases (NCDs) may pose challenges for resource-limited health systems. This study used standardized, nationally representative data from Service Provision Assessments conducted in 2013-15 and the Service Availability and Readiness Assessment methodology to examine NCD service availability and readiness in Bangladesh, Haiti, Malawi, Nepal, and Tanzania. Both service availability and readiness were found to be very low: Very few facilities were fully "ready" to provide any one NCD service. Shortages of trained health workers and essential medicines were critical limitations to readiness. Rural and free facilities had lower availability and readiness, which may present access barriers. Policy makers should draw on decades of experience with global health initiatives to close these service gaps through the training of health workers on NCD screening and treatment, engaging the private sector on NCDs, and ensuring access to NCD medicines. Such efforts must be attentive to distributional equity and the multiple dimensions of care quality.Simple screening tool to help identify high-risk children for targeted HIV testing in malawian inpatient wards
AbstractMoucheraud, C., Chasweka, D., Nyirenda, M., Schooley, A., Dovel, K., & Hoffman, R. M. (n.d.).Publication year
2018Journal title
Journal of Acquired Immune Deficiency SyndromesVolume
79Issue
3Page(s)
352-357AbstractBackground: To meet global AIDS goals, pediatric HIV diagnosis must be strengthened. Provider-initiated testing and counseling, which is recommended by the WHO, faces persistent implementation challenges in low-resource settings. Alternative approaches are needed. Setting: Malawi has achieved high coverage of HIV diagnosis and treatment, but there are gaps among pediatric populations. This study assessed the sensitivity and specificity of a brief screening tool to identify at-risk pediatric patients for targeted HIV testing in Malawi. Methods: A tool containing 6 yes/no items was used for children (aged 1-15 years) in the inpatient pediatric wards at 12 hospitals in Malawi (July 2016-July 2017). Questions were based on an established tool, translated to Chichewa, and implemented by HIV diagnostic assistants. All participating children were provided HIV testing and counseling per Ministry of Health guidelines. Analysis estimated the tool's characteristics including sensitivity, specificity, negative, and positive predictive values. Results: HIV prevalence among the 8602 participants was 1.1% (n = 90). Children with a screening tool score of 1 had double the odds of being HIV positive than those with a score of 0. Frequent sickness was the most sensitive predictor of HIV status (55.1%), and having a deceased parent was the most specific (96.7%). False classification of HIV-negative status was rare (n = 14) but occurred more often among boys and younger children. Conclusions: A brief screening tool for pediatric inpatients helped target HIV testing in those most at risk in a low-pediatric-prevalence, resource-constrained setting. Future research should include a direct, rigorous comparison with PITC including comparative effectiveness, efficiency, and cost effectiveness.Essential medicines for universal health coverage
Wirtz, V. J., Hogerzeil, H. V., Gray, A. L., Bigdeli, M., De Joncheere, C. P., Ewen, M. A., Gyansa-Lutterodt, M., Jing, S., Luiza, V. L., Mbindyo, R. M., Möller, H., Moucheraud, C., Pécoul, B., Rägo, L., Rashidian, A., Ross-Degnan, D., Stephens, P. N., Teerawattananon, Y., Hoen, E. F., … Reich, M. R. (n.d.).Publication year
2017Journal title
The LancetVolume
389Issue
10067Page(s)
403-476Improving quality of care for maternal and newborn health: A pre-post evaluation of the Safe Childbirth Checklist at a hospital in Bangladesh
AbstractNababan, H. Y., Islam, R., Mostari, S., Tariqujjaman, M., Sarker, M., Islam, M. T., & Moucheraud, C. (n.d.).Publication year
2017Journal title
BMC Pregnancy and ChildbirthVolume
17Issue
1AbstractBackground: Bangladesh has achieved major gains in maternal and newborn survival, facility childbirth and skilled birth attendance between 1991 and 2010, but excess maternal mortality persists. High-quality maternal health care is necessary to address this burden. Implementation of WHO Safe Childbirth Checklist (SCC), whose items address the major causes of maternal deaths, is hypothesized to improve adherence of providers to essential childbirth practices. Method: The SCC was adapted for the local context through expert consultation meetings, creating a total of 27 checklist items. This study was a pre-post evaluation of SCC implementation. Data were collected over 8 months at Magura District Hospital. We analysed 468 direct observations of birth (main analysis using 310 complete observations and sensitivity analysis with the additional 158 incomplete observations) from admission to discharge. The primary outcome of interest was the number of essential childbirth practices performed before compared to after SCC implementation. The change was assessed using adjusted Poisson regression models accounting for clustering by nurse-midwives. Result: After checklist introduction, significant improvements were observed: on average, around 70% more of these safe childbirth practices were performed in the follow-up period compared to baseline (from 11 to 19 out of 27 practices). Substantial increases were seen in communication between nurse-midwives and mothers (counselling), and in management of complications (including rational use of medicines). In multivariable models that included characteristics of the mothers and of the nurse-midwives, the rate of delivering the essential childbirth practices was 1.71 times greater in the follow-up compared to baseline (95% CI 1.61-1.81). Conclusion: Implementation of SCC has the potential to improve essential childbirth practice in resource-poor settings like Bangladesh. This study emphasizes the need for health system strengthening in order to achieve the full advantages of SCC implementation.Sustainability of health information systems: A three-country qualitative study in southern Africa
AbstractMoucheraud, C., Schwitters, A., Boudreaux, C., Giles, D., Kilmarx, P. H., Ntolo, N., Bangani, Z., St Louis, M. E., & Bossert, T. J. (n.d.).Publication year
2017Journal title
BMC health services researchVolume
17Issue
1AbstractBackground: Health information systems are central to strong health systems. They assist with patient and program management, quality improvement, disease surveillance, and strategic use of information. Many donors have worked to improve health information systems, particularly by supporting the introduction of electronic health information systems (EHIS), which are considered more responsive and more efficient than older, paper-based systems. As many donor-driven programs are increasing their focus on country ownership, sustainability of these investments is a key concern. This analysis explores the potential sustainability of EHIS investments in Malawi, Zambia and Zimbabwe, originally supported by the United States President's Emergency Plan for AIDS Relief (PEPFAR). Methods: Using a framework based on sustainability theories from the health systems literature, this analysis employs a qualitative case study methodology to highlight factors that may increase the likelihood that donor-supported initiatives will continue after the original support is modified or ends. Results: Findings highlight commonalities around possible determinants of sustainability. The study found that there is great optimism about the potential for EHIS, but the perceived risks may result in hesitancy to transition completely and parallel use of paper-based systems. Full stakeholder engagement is likely to be crucial for sustainability, as well as integration with other activities within the health system and those funded by development partners. The literature suggests that a sustainable system has clearly-defined goals around which stakeholders can rally, but this has not been achieved in the systems studied. The study also found that technical resource constraints - affecting system usage, maintenance, upgrades and repairs - may limit EHIS sustainability even if these other pillars were addressed. Conclusions: The sustainability of EHIS faces many challenges, which could be addressed through systems' technical design, stakeholder coordination, and the building of organizational capacity to maintain and enhance such systems. All of this requires time and attention, but is likely to enhance long-term outcomes.Countdown to 2015 country case studies: What have we learned about processes and progress towards MDGs 4 and 5?
AbstractMoucheraud, C., Owen, H., Singh, N. S., Ng, C. K., Requejo, J., Lawn, J. E., Berman, P., Salehi, A., Hong, Z., Ronsmans, C., Yanqiu, G., Kebede, H., Mann, C., Ruducha, J., Tadesse, M., Ngugi, A., Keats, E., Macharia, W., Ravishankar, N., … Msemo, G. (n.d.).Publication year
2016Journal title
BMC public healthVolume
16AbstractBackground: Countdown to 2015 was a multi-institution consortium tracking progress towards Millennium Development Goals (MDGs) 4 and 5. Case studies to explore factors contributing to progress (or lack of progress) in reproductive, maternal, newborn and child health (RMNCH) were undertaken in: Afghanistan, Bangladesh, China, Ethiopia, Kenya, Malawi, Niger, Pakistan, Peru, and Tanzania. This paper aims to identify cross-cutting themes on how and why these countries achieved or did not achieve MDG progress. Methods: Applying a standard evaluation framework, analyses of impact, coverage and equity were undertaken, including a mixed methods analysis of how these were influenced by national context and coverage determinants (including health systems, policies and financing). Results: The majority (7/10) of case study countries met MDG-4 with over two-thirds reduction in child mortality, but none met MDG-5a for 75 % reduction in maternal mortality, although six countries achieved >75 % of this target. None achieved MDG-5b regarding reproductive health. Rates of reduction in neonatal mortality were half or less that for post-neonatal child mortality. Coverage increased most for interventions administered at lower levels of the health system (e.g., immunisation, insecticide treated nets), and these experienced substantial political and financial support. These interventions were associated with ~30-40 % of child lives saved in 2012 compared to 2000, in Ethiopia, Malawi, Peru and Tanzania. Intrapartum care for mothers and newborns - which require higher-level health workers, more infrastructure, and increased community engagement - showed variable increases in coverage, and persistent equity gaps. Countries have explored different approaches to address these problems, including shifting interventions to the community setting and tasks to lower-level health workers. Conclusions: These Countdown case studies underline the importance of consistent national investment and global attention for achieving improvements in RMNCH. Interventions with major global investments achieved higher levels of coverage, reduced equity gaps and improvements in associated health outcomes. Given many competing priorities for the Sustainable Development Goals era, it is essential to maintain attention to the unfinished RMNCH agenda, particularly health systems improvements for maternal and neonatal outcomes where progress has been slower, and to invest in data collection for monitoring progress and for rigorous analyses of how progress is achieved in different contexts.PEPFAR investments in governance and health systems were one-fifth of countries' budgeted funds, 2004-14
AbstractMoucheraud, C., Sparkes, S., Nakamura, Y., Gage, A., Atun, R., & Bossert, T. J. (n.d.).Publication year
2016Journal title
Health AffairsVolume
35Issue
5Page(s)
847-855AbstractLaunched in 2003, the US President's Emergency Plan for AIDS Relief (PEPFAR) is the largest disease-focused assistance program in the world. We analyzed PEPFAR budgets for governance and systems for the period 2004-14 to ascertain whether PEPFAR's stated emphasis on strengthening health systems has been manifested financially. The main outcome variable in our analysis, the first of its kind using these data, was the share of PEPFAR's total annual budget for a country that was designated for governance and systems. The share of planned PEPFAR funding for governance and systems increased from 14.9 percent, on average, in 2004 to 27.5 percent in 2013, but it declined in 2014 to 20.8 percent. This study shows that the size of a country's PEPFAR budget was negatively associated with the share allocated for governance and systems (compared with other budget program areas); it also shows that there was no significant relationship between budgets for governance and systems and HIV prevalence. It is crucial for the global health policy community to better understand how such investments are allocated and used for health systems strengthening.Bedside availability of prepared oxytocin and rapid administration after delivery to prevent postpartum Hemorrhage: An observational study in Karnataka, India
AbstractMoucheraud, C., Gass, J., Lipsitz, S., Spector, J., Agrawal, P., Hirschhorn, L. R., Gawande, A., & Kodkany, B. (n.d.).Publication year
2015Journal title
Global health, science and practiceVolume
3Issue
2Page(s)
300-304AbstractPostpartum hemorrhage is a leading cause of maternal death worldwide. Rapid provision of uterotonics after childbirth is recommended to reduce the incidence and severity of postpartum hemorrhage. Data obtained through direct observation of childbirth practices, collected in a study of the World Health Organization's Safe Childbirth Checklist in Karnataka, India, were used to measure if oxytocin prepared for administration and available at the bedside before birth was associated with decreased time to administration after birth. This was an observational study of provider behavior: Data were obtained during a baseline assessment of health worker practices prior to introduction of the Safe Childbirth Checklist, representing behavior in the absence of any intervention. Analysis was based on 330 vaginal deliveries receiving oxytocin at any point postpartum. Oxytocin was prepared and available at bedside for approximately 39% of deliveries. We found that advance preparation and bedside availability of oxytocin was associated with increased likelihood of oxytocin administration within 1 minute after delivery (adjusted risk ratio = 4.89, 95% CI = 2.61, 9.16), as well as with decreased overall time to oxytocin administration after delivery (2.9 minutes sooner in adjusted models, 95% CI = -5.0, -0.9). Efforts to reduce postpartum hemorrhage should include recommendations and interventions to ensure advance preparation and bedside availability of oxytocin to facilitate prompt administration of the medicine after birth.Consequences of maternal mortality on infant and child survival: A 25-year longitudinal analysis in Butajira Ethiopia (1987-2011)
AbstractMoucheraud, C., Worku, A., Molla, M., Finlay, J. E., Leaning, J., & Yamin, A. E. (n.d.).Publication year
2015Journal title
Reproductive HealthVolume
12Issue
1AbstractBackground: Maternal mortality remains the leading cause of death and disability for reproductive-age women in resource-poor countries. The impact of a mother's death on child outcomes is likely severe but has not been well quantified. This analysis examines survival outcomes for children whose mothers die during or shortly after childbirth in Butajira, Ethiopia. Methods: This study uses data from the Butajira Health and Demographic Surveillance System (HDSS) site. Child outcomes were assessed using statistical tests to compare survival trajectories and age-specific mortality rates for children who did and did not experience a maternal death. The analyses leveraged the advantages of a large, long-term longitudinal dataset with a high frequency of data collection; but used a strict date-based method to code maternal deaths (as occurring within 42 or 365 days of childbirth), which may be subject to misclassification or recall bias. Results: Between 1987 and 2011, there were 18189 live births to 5119 mothers; and 73 mothers of 78 children died within the first year of their child's life, with 45% of these (n=30) classified as maternal deaths due to women dying within 42 days of childbirth. Among the maternal deaths, 81% of these infants also died. Children who experienced a maternal death within 42 days of their birth faced 46 times greater risk of dying within one month when compared to babies whose mothers survived (95% confidence interval 25.84-81.92; or adjusted ratio, 57.24 with confidence interval 25.31-129.49). Conclusions: When a woman in this study population experienced a maternal death, her infant was much more likely to die than to survive - and the survival trajectory of these children is far worse than those of mothers who do not die postpartum. This highlights the importance of investigating how clinical care and socio-economic support programs can better address the needs of orphans, both throughout the intra- and post-partum periods as well as over the life course.Evaluating the quality and use of economic data in decisions about essential medicines
AbstractMoucheraud, C., Wirtz, V. J., & Reich, M. R. (n.d.).Publication year
2015Journal title
Bulletin of the World Health OrganizationVolume
93Issue
10Page(s)
693-699AbstractObjective To evaluate the quality of economic data provided in applications to the World Health Organization (WHO) Model List of Essential Medicines and to evaluate the role of these data in decision-making by the expert committee that considers the applications. Methods We analysed applications submitted to the WHO Expert Committee on the Selection and Use of Essential Medicines between 2002 and 2013. The completeness of data on the price and cost–effectiveness of medicines was extracted from application documents and coded using a four-point scale. We recorded whether or not the expert committee discussed economic information and the outcomes of each application. Associations between the completeness of economic data and application outcomes were assessed using χ2 tests. Findings The expert committee received 134 applications. Only eight applications (6%) included complete price data and economic evaluation data. Many applicants omitted or misinterpreted the economic evaluation section of the application form. Despite the lack of economic data, all applications were reviewed by the committee. There was no significant association between the completeness of economic information and application outcomes. The expert committee tried to address information gaps in applications by further review and analysis of data related to the application. Conclusion The World Health Organization should revise the instructions to applicants on economic data requirements; develop new mechanisms to assist applicants in completing the application process; and define methods for the use of economic data in decision-making.The Effects of Maternal Mortality on Infant and Child Survival in Rural Tanzania: A Cohort Study
AbstractFinlay, J. E., Moucheraud, C., Goshev, S., Levira, F., Mrema, S., Canning, D., Masanja, H., & Yamin, A. E. (n.d.).Publication year
2015Journal title
Maternal and Child Health JournalVolume
19Issue
11Page(s)
2393-2402AbstractObjectives: The full impact of a maternal death includes consequences faced by orphaned children. This analysis adds evidence to a literature on the magnitude of the association between a woman’s death during or shortly after childbirth, and survival outcomes for her children. Methods: The Ifakara and Rufiji Health and Demographic Surveillance Sites in rural Tanzania conduct longitudinal, frequent data collection of key demographic events at the household level. Using a subset of the data from these sites (1996–2012), this survival analysis compared outcomes for children who experienced a maternal death (42 and 365 days definitions) during or near birth to those children whose mothers survived. Results: There were 111 maternal deaths (or 229 late maternal deaths) during the study period, and 46.28 % of the index children also subsequently died (40.73 % of children in the late maternal death group) before their tenth birthday—a much higher prevalence of child mortality than in the population of children whose mothers survived (7.88 %, p value <0.001). Children orphaned by early maternal deaths had a 51.54 % chance of surviving to their first birthday, compared to a 94.42 % probability for children of surviving mothers. A significant, but lesser, child survival effect was also found for paternal deaths in this study period. Conclusions: The death of a mother compromises the survival of index children. Reducing maternal mortality through improved health care—especially provision of high-quality skilled birth attendance, emergency obstetric services and neonatal care—will also help save children’s lives.Do Price Subsidies on Artemisinin Combination Therapy for Malaria Increase Household Use?: Evidence from a Repeated Cross-Sectional Study in Remote Regions of Tanzania
AbstractCohen, J. L., Yadav, P., Moucheraud, C., Alphs, S., Larson, P. S., Arkedis, J., Massaga, J., & Sabot, O. (n.d.).Publication year
2013Journal title
PloS oneVolume
8Issue
7AbstractBackground:The Affordable Medicines Facility-malaria (AMFm) is a pilot program that uses price subsidies to increase access to Artemisinin Combination Therapies (ACTs), currently the most effective malaria treatment. Recent evidence suggests that availability and affordability of ACTs in retail sector drug shops (where many people treat malaria) has increased under the AMFm, but it is unclear whether household level ACT use has increased.Methods and Findings:Household surveys were conducted in two remote regions of Tanzania (Mtwara and Rukwa) in three waves: March 2011, December 2011 and March 2012, corresponding to 3, 13 and 16 months into the AMFm implementation respectively. Information about suspected malaria episodes including treatment location and medications taken was collected. Respondents were also asked about antimalarial preferences and perceptions about the availability of these medications. Significant increases in ACT use, preference and perceived availability were found between Rounds 1 and 3 though not for all measures between Rounds 1 and 2. ACT use among suspected malaria episodes was 51.1% in March 2011 and increased by 10.9 percentage points by Round 3 (p =. 017). The greatest increase was among retail sector patients, where ACT use increased from 31% in Round 1 to 49% in Round 2 (p =. 037) and to 61% (p<.0001) by Round 3. The fraction of suspected malaria episodes treated in the retail sector increased from 30.2% in Round 1 to 46.7% in Round 3 (p =. 0009), mostly due to a decrease in patients who sought no treatment at all. No significant changes in public sector treatment seeking were found.Conclusions:The AMFm has led to significant increases in ACT use for suspected malaria, especially in the retail sector. No evidence is found supporting the concerns that the AMFm would crowd out public sector treatment or neglect patients in remote areas and from low SES groups.