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This paper uses nationally representative data from the Child Health Supplement of the 1981 National Health Interview Survey to test the hypothesis that the larger the groups in which children receive care, the more days per year they spend in bed due to illness. We estimate a model of annual bed days for children ages six months to two and one-half years old, and separately for children two and one-half to five years old. Our results show significantly higher numbers of bed days for children in day care centers than for IntroductionCurrently more than half of all women with children under the age of six years are in the labor force.' The majority of these children are cared for outside their homes, predominantly in family day care homes, or day care centers, and nursery schools.2 There is concern about possible negative health consequences of such care, because the daily interaction with other young children promotes the spread of infectious disease.Evidence suggests that children in group care are ill more

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Aims: The aim of this paper is to introduce an operational checklist to serve as a tool for policymakers in the WHO European Region to strengthen primary health care (PHC) services and address the COVID-19 pandemic more effectively and to present the results from piloting the tool in Armenia. Backgrounds: PHC has the potential to play a fundamental role in countries’ responses to COVID-19. However, this potential remains unrealized in many countries. To assist countries, the WHO Regional Office for Europe developed a guidance document – Strengthening the Health Systems Response to COVID-19: Adapting Primary Health Care Services to more Effectively Address COVID-19 – that identifies strategic actions countries can take to strengthen their PHC response to the pandemic. Based on this guidance document, an operational checklist was developed to serve as a tool for policymakers to operationalize the recommended actions. Methods: The operational checklist was developed by transforming key points in the guidance document into questions in order to identify potentially modifiable factors to strengthen PHC in response to COVID-19. The operational checklist was then piloted in Armenia in June 2020 as part of a WHO mission to provide technical advice on strengthening Armenia’s PHC response to COVID-19. Two WHO experts performed semi-structured, face-to-face interviews with nine key informants (both facility managers and clinical staff) in three PHC facilities (two in a rural and one in an urban area). The data collected were analyzed to identify underlying challenges limiting PHC providers’ ability to effectively and efficiently respond to COVID-19 and maintain essential health services. Findings: The paper finds that making adjustments only to health services delivery will be insufficient to address most of the challenges identified by PHC providers in the context of COVID-19 in Armenia. In particular, strategic responses to the pandemic were missed, due, in part, to the absence of COVID-19 management teams at the facility level. Furthermore, the absence of PHC experts in Armenia’s national pandemic response team meant that health system issues identified at the facility level could not easily be communicated to or addressed by policymakers. The checklist therefore helps policymakers identify critical challenges – at both the facility and health system level – that need to be addressed to strengthen the PHC response to the COVID-19 pandemic.

In 2016, the Flagship Program for improving health systems performance and equity, a partnership for leadership development between the World Bank and the Harvard T.H. Chan School of Public Health and other institutions, celebrates 20 years of achievement. Set up at a time when development assistance for health was growing exponentially, the Flagship Program sought to bring systems thinking to efforts at health sector strengthening and reform. Capacity-building and knowledge transfer mechanisms are relatively easy to begin but hard to sustain, yet the Flagship Program has continued for two decades and remains highly demanded by national governments and development partners. In this article, we describe the process used and the principles employed to create the Flagship Program and highlight some lessons from its two decades of sustained success and effectiveness in leadership development for health systems improvement. EMERGENCE OF HEALTH SYSTEMS REFORM AS A DRIVER OF DEVELOPMENT ASSISTANCE In the early 1990s, the donor community was in the process of rethinking the approach to supporting the health sectors of low-and middle-income countries. Up to that point, development assistance for health usually took one of three forms: (1) humanitarian support focused on emerging needs like disease outbreaks or natural disasters and wars; (2) attention to competing disease or population groups, such as childhood versus reproductive health, communicable diseases, etc.;