Scaling up Access to Misoprostol at the Community Level to Improve Maternal Health Outcomes in Ethiopia, Ghana, and Nigeria

Over the past decade (2004–2014), the Population and Reproductive Health area of the MacArthur Foundation has focused on supporting projects aimed at reducing maternal mortality. In particular, it has supported efforts to use misoprostol to prevent postpartum hemorrhage, the anti-shock garment to aid in the treatment of hemorrhage, and magnesium sulfate to decrease deaths from eclampsia. In recent years, the Foundation has invested in a range of research and evaluation efforts to better understand these interventions, their effectiveness, and the extent to which successful pilot projects have been scaled up.In 2014, the Foundation commissioned the Public Health Institute to evaluate the grants it had made to increase community-based access to misoprostol for postpartum hemorrhage prevention in Ethiopia, Ghana, and Nigeria. Specifically, the Foundation was interested in documenting the models and approaches used and the progress toward scaling up the respective models in the three countries. Between June and November 2014, the evaluation team reviewed grantee reports, proposals, and the literature; interviewed key informants and global, national, and local stakeholders; conducted focus group discussions with local stakeholders; and made observations during site-visits in each country. From this the team produced case study reports relating to misoprostol use in each country. This report is a synthesis of those three case studies, highlighting the common findings across the projects, identifying differences, and interpreting the lessons learned for broader use and scale up of misoprostol at the community level in Africa and globally

PROMOTING HEALTH SYSTEMS RESILIENCE IN THE FRAGILE CONTEXT OF NORTHERN GHANA: A STUDY OF COMMUNITY-BASED HEALTH PLANNING AND SERVICES (CHPS) EFFECTIVENESS

In 1999, the government of Ghana adopted the Community-based Health Planning and Services (CHPS) programme as a national policy. It then launched a scaling-up initiative in 2000 to support its Universal Health Care (UHC) agenda. Since its adoption, CHPS has significantly contributed to health service delivery in Ghana, such as improved family planning and immunization coverage. Despite these gains, however, critical implementation gaps persist. Doorstep services and volunteer support, necessary for supporting population health and family planning in marginalised communities, continue to diminish and CHPS scale-up in fragile settings such as the Northern region of Ghana, where poverty is high and health indicators relatively low, is slow. This research investigated the factors constraining the implementation and effectiveness of CHPS in the fragile context of the Northern region of Ghana using a mixed-methods research methodology. Data collection was completed in three distinct stages, comprising 1) a review of the district health information management system (DHIMS) data; 2) key informant interviews and focus group discussions (FGDs) with CHPS stakeholders at the national, regional, district, sub-district, CHPS and community levels; and 3) participatory research using group model building (GMB) in the Kumbungu and Gushiegu districts of the former Northern region. Findings identify that the Ghanaian Government is the main contributor to CHPS infrastructure. However, nearly all participating district facilities were ill-equipped and did not have adequate equipment and medicines owing to lapses in central government funding and National Health Insurance Scheme (NHIS) reimbursement challenges. As a result, there was a general perception of neglect among community members. The participatory research findings conclude that CHPS implementation was confronted by inadequate funding to support the programme’s implementation, poor community engagement and support, and diminished health worker capacity owing to gaps in training, logistics, equipment, and infrastructure. These are further compounded by the drivers of fragility resulting from high poverty levels and a vicious cycle of debt servicing. To mitigate the identified barriers, stakeholders during the study developed a set of interventions aimed at improving CHPS effectiveness. Feedback interviews twelve months after the GMBs showed good progress for interventions targeting health worker capacity, logistics management and community engagement. Comparatively, there was more progress for community engagement interventions than interventions relating to increasing political commitment and funding. Beyond identifying the enablers for CHPS effectiveness, this study supports the argument that the concept of fragility reaches beyond situations of conflict and disasters to include systemic challenges, such as the failure of governments to provide adequate resources to foster the smooth delivery of basic health services. This is particularly so in the context of this research where funding for health services is mainly centralised in a decentralised country. Comparatively, the community engagement interventions had more progress than the interventions for increasing political commitment and funding. In poor and marginalised settings, effective and sustained community engagement can bridge resource gaps, empower users to demand accountability from officials and contribute to resilient health systems. Using the GMB systems thinking methodology presented a holistic approach to understanding the systemic barriers to CHPS implementation and identified enablers that can minimise their impact on the programme. This approach of bringing together community members, health workers and policymakers on a shared platform was particularly appreciated by community members who seldom share a common platform with government officials in matters of social discourse

Addressing the needs of women and girls on the move:Toward an inclusive, intersectional and culturally sensitive approach

This briefing outlines the intersecting and complex needs of women and girls (hereafter referred to as women) on the move, aiming to support humanitarian efforts in developing inclusive, intersectional and culturally sensitive approaches to help improve their health and well-being. The document is based on a synthesis of evidence from various displacement settings and is intended for humanitarian and development practitioners, advocates and policymakers from a range of international and local organisations.The objectives of this briefing are:• To inform diverse humanitarian actors about displaced women’s intersecting and complex needs at different stages of forced migration• To inform the development of more inclusive humanitarian policy and programmes, encouraging more support for women on the mov

Plasmodium falciparum binding interactions with human brain endothelial cells

Cerebral malaria is the most severe form of malaria and mostly affects children under 5 years causing impaired consciousness, coma and neurological disorders, with life-threatening consequences in affected individuals. A pathological feature of the disease is the sequestration of mature Plasmodium falciparum infected erythrocytes (IEs) in the microvasculature of the brain. P. falciparum Erythrocyte Membrane Protein 1 (PfEMP1) expressed on the surface of IEs is thought to enable the parasites bind to human brain endothelial cells (HBEC) to avoid splenic clearance. An in vitro model of cytoadherence in cerebral malaria has been developed using a human brain endothelial cell line called HBEC-5i, which enables the study of IEs binding to HBEC. Previous work based on three laboratory parasite lines showed that HBEC-binding IEs express a specific subset of the diverse PfEMP1 family which contain sets of cysteine-rich domains called domain cassettes (DC) 8 and 13. Parasites from children diagnosed with cerebral malaria have also been independently shown to express the DC8 and DC13 PfEMP1 types. The adhesion of IEs to HBEC is suggested to occur by binding of a domain of the DC8 and DC13 PfEMP1 variants called CIDRα1, to Endothelial Protein C Receptor (EPCR) on HBEC. However, investigations of the effect of parasite and host environmental factors on adhesion to HBEC are lacking, and further studies are needed to confirm the association of these DC8 and DC13 PfEMP1 to HBEC-binding and the role of EPCR in mediating the cytoadhesion. Therefore, the aim of this thesis was to examine the hypothesis that HBEC-binding would be affected by changes in environmental conditions, and that all IEs that bind to HBEC would express group A-like PfEMP1 containing DC8 and DC13, for binding to EPCR on HBEC. In this study, the effect of pH, parasitaemia, gas, temperature, and serum on cytoadhesion, were investigated using four HBEC-binding parasite lines. Adhesion of IEs to HBEC was found to be pH and parasitaemia -dependent with optimal binding at pH 7.3 and IE adhesion positively correlated with parasitaemia. There was no significant effect of increase in temperature to 39°C and no significant difference between hypoxic and normoxic conditions on adhesion in all parasite lines. Human serum, however, abolished binding of the DC8-expressing parasite line but had minimal effects on adhesion of the DC13-expressing parasite lines. Two Kenyan isolates recently adapted to culture were selected for binding to HBEC and were found to also predominantly express group A-like PfEMP1 including a DC8 PfEMP1 variant and PfEMP1 (s) that contained DBLα1.2 domains. Attempts were made to localise the binding domain within the DC8 and DC13 PfEMP1 variants using recombinant proteins and antibodies. However, the CIDRα1 domain appeared to mediate adhesion of the DC8-expressing parasite line but had no effect on adhesion of the DC13-expressing parasite lines. Only antibodies to the N-terminal domain, known as NTS.DBLα, significantly inhibited binding of all the parasites lines. The role of EPCR and other receptor molecules on endothelial cells including ICAM-1, CD36, CSA, PECAM-1, HABP-1 and heparin, in mediating adhesion to HBEC was also investigated. Using EPCR recombinant protein, monoclonal and polyclonal antibodies, and EPCR-siRNA knockdown in binding assays, EPCR was shown to be involved in adhesion of only the DC8-expressing parasite line and did not affect adhesion of the DC13-expressing parasite lines to HBEC. Binding of DC8-expressing parasite line to HBEC was also inhibited by soluble recombinant PECAM-1. There was no significant adhesion of both types of parasite lines to the other receptor molecules, although minimal binding to HABP-1 was observed. This study expands current knowledge on the parasite binding interactions with HBEC by elucidating some of the environmental factors that affect the binding properties, and gives the optimal conditions for the in vitro model of HBEC-adhesion in cerebral malaria. Findings presented here confirm the association of expression of group A-like PfEMP1 to HBEC-binding and shows that the EPCR-CIDRα1 interaction does not mediate adhesion of all DC8 and DC13- expressing parasite lines to HBEC. Additional receptors, other than EPCR, are therefore required for HBEC-binding in cerebral malaria. The ability of normal human serum to abolish binding of the DC8-expressing parasite line also raises the question of whether IE binding to EPCR is physiologically relevant and suggest that the DC8- expressing parasites associated with cerebral malaria may contribute to the disease in a mechanism other than binding to brain endothelial cell

Addressing the needs of women and girls on the move:Toward an inclusive, intersectional and culturally sensitive approach

This briefing outlines the intersecting and complex needs of women and girls (hereafter referred to as women) on the move, aiming to support humanitarian efforts in developing inclusive, intersectional and culturally sensitive approaches to help improve their health and well-being. The document is based on a synthesis of evidence from various displacement settings and is intended for humanitarian and development practitioners, advocates and policymakers from a range of international and local organisations.The objectives of this briefing are:• To inform diverse humanitarian actors about displaced women’s intersecting and complex needs at different stages of forced migration• To inform the development of more inclusive humanitarian policy and programmes, encouraging more support for women on the mov

DAMPAK SOSIO-EKONOMI KEBERADAAN PSK ( Kajian Sosiologis Terhadap Keberadaan PSK di Gang Sadar Baturaden )

Fenomena wanita tunasusila atau yang sering disebut PSK sudah tidak asing lagi dalam kehidupan masyarakat indonesia bahkan di dunia, akan tetapi keberadaanya masih menimbulkan pro dan kontra di masyarakat. Pekerja seks komersil ( PSK ) adalah orang yang menjual dirinya dengan melakukan hubungan seks dengan orang lain untuk tujuan ekonomi. PSK juga dapat diartikan dengan wanita yang menjual dirinya kepada banyak laki-laki yang membutuhkan pemuasan nafsu seksual, dan wanita tersebut mendapat sejumlah uang sebagai imbalan, serta dilakukan diluar pernikahan. Ini artinya bahwa para perempuan itu adalah orang yang tidak bermral karena melakukan suatu pekerjaan yang bertentangan dengan nilai-nilai kesusilaan yang berlaku dalam masyarakat. Dalam Islam sendiri jelas-jelas melarang seseorang melakukan hubungan seks di luar nikah ( zina ) dan pelakunya akan mendapat balasan dari Allah SWT. Praktek perzinaan sendiri dapat mendatangkan dampak yang tidak baik bagi para pelakunya, yang dapat mengakibatkan munculnya berbagi penyakit seperti HIV/AIDS dimana jumlah kasusnya terus meningkat dari tahun ke tahun. Tak lepas dari itu semua bisnis PSK merupakan salah satu bagian yang tak terpisahkan dari dunia pariwisata Baturaden ribuan warga ikut menikmati bisnis ini, banyak komunitas yang menggantungkan kehidupan dari di wilayah ini. Oleh karena itu penalitian ini bertujuan untuk mengetahui bagaimanakah Dampak Sosio - Ekonomi Keberadaan PSK di Baturaden . Jenis penelitian yang digunakan adalah penelitian deskriptif kualitatif yaitu penelitian yang mengungkapkan gejala menyeluruh dan sesuai dengan konteks ( holistik-kontektual) melalui pengumpulan data dari latar alami dengan memanaatkan diri peneliti sebagi instrumen kunci. Pengumpulan data melalui teknik wawancara mendalam denagn bantuan pedoman wawancara, obserfasi dan dokumtasi. Validitas data menggunakan trianggulasi sumber. Teknik analisis data yang digunaan adalah teknik analisis interaktif yang bergerak dari reduksi data, pengumpulan data, penyajian data dan penarikan k esimpulan. Berdasarkan hasil penelitian diketahui bahwa keberadan Gang Sadar di Baturaden memang banyak memberikan dampak positif pada tingkat perekonomian waraga, namun juga memberikan dampak yang negatif bagi kelangsungan moral generasi muda

Addressing the needs of women and girls on the move: Toward an inclusive, intersectional and culturally sensitive approach

This briefing outlines the intersecting and complex needs of women and girls (hereafter referred to as women) on the move, aiming to support humanitarian efforts in developing inclusive, intersectional and culturally sensitive approaches to help improve their health and well-being. The document is based on a synthesis of evidence from various displacement settings and is intended for humanitarian and development practitioners, advocates and policymakers from a range of international and local organisations. The objectives of this briefing are: • To inform diverse humanitarian actors about displaced women’s intersecting and complex needs at different stages of forced migration • To inform the development of more inclusive humanitarian policy and programmes, encouraging more support for women on the move Displaced women’s needs vary based on their socio-economic and cultural backgrounds, but some specific gendered dimensions of needs relate to displaced populations in general across forced migrant routes. Vulnerability to harm and exclusion is based on factors such as gender, age, disability and other diversity factors. An intersectional lens recognises the diversity of experiences and identities which shape women’s needs and their vulnerability to discrimination in displacement that is determined by various social identity markers and power structures.1,2 To make aid work for women, it is essential to adequately adapt interventions across different stages of forced migration, based on the needs of diverse groups of women, in a culturally sensitive and inclusive manner. It is also important to provide specialist support to survivors of torture and sexual and gender-based violence, unaccompanied minors and other groups requiring assistance (for example, older women, women with disabilities and women from minority backgrounds).https://makingaidwork.org/maw-news/addressing-the-needs-of-women-and-girls-on-the-move-toward-an-inclusive-intersectional-and-culturally-sensitive-approach/pubpu

Bliss' and Loewe's additive and synergistic effects in Plasmodium falciparum growth inhibition by AMA1-RON2L, RH5, RIPR and CyRPA antibody combinations

Plasmodium invasion of red blood cells involves malaria proteins, such as reticulocyte-binding protein homolog 5 (RH5), RH5 interacting protein (RIPR), cysteine-rich protective antigen (CyRPA), apical membrane antigen 1 (AMA1) and rhoptry neck protein 2 (RON2), all of which are blood-stage malaria vaccine candidates. So far, vaccines containing AMA1 alone have been unsuccessful in clinical trials. However, immunization with AMA1 bound with RON2L (AMA1-RON2L) induces better protection against P. falciparum malaria in Aotus monkeys. We therefore sought to determine whether combinations of RH5, RIPR, CyRPA and AMA1-RON2L antibodies improve their biological activities and sought to develop a robust method for determination of synergy or additivity in antibody combinations. Rabbit antibodies against AMA1-RON2L, RH5, RIPR or CyRPA were tested either alone or in combinations in P. falciparum growth inhibition assay to determine Bliss' and Loewe's additivities. The AMA1-RON2L/RH5 combination consistently demonstrated an additive effect while the CyRPA/RIPR combination showed a modest synergistic effect with Hewlett’s =1.07[95%CI:1.03,1.19]. Additionally, we provide a publicly-available, online tool to aid researchers in analyzing and planning their own synergy experiments. This study supports future blood-stage vaccine development by providing a solid methodology to evaluate additive and/or synergistic (or antagonistic) effect of vaccine-induced antibodies