ObjectivesEfforts to scale-up maternal and child health services in lower and middle income countries will fail if services delivered are not of good quality. Although there is evidence of strategies to increase the quality of health services, less is known about the way these strategies affect health system goals and outcomes. We conducted a systematic review of the literature to examine this relationship.MethodsWe undertook a search of MEDLINE, SCOPUS and CINAHL databases, limiting the results to studies including strategies specifically aimed at improving quality that also reported a measure of quality and at least one indicator related to health system outcomes. Variation in study methodologies prevented further quantitative analysis; instead we present a narrative review of the evidence.FindingsMethodologically, the quality of evidence was poor, and dominated by studies of individual facilities. Studies relied heavily on service utilisation as a measure of strategy success, which did not always correspond to improved quality. The majority of studies targeted the competency of staff and adequacy of facilities. No strategies addressed distribution systems, public-private partnership or equity. Key themes identified were the conflict between perceptions of patients and clinical measures of quality and the need for holistic approaches to health system interventions.ConclusionExisting evidence linking quality improvement strategies to improved MNCH outcomes is extremely limited. Future research would benefit from the inclusion of more appropriate indicators and additional focus on non-facility determinants of health service quality such as health policy, supply distribution, community acceptability and equity of care.

Period and cohort trends in smoking and lung cancer were similar to many other Western countries. The effectiveness of smoking reduction campaigns in Australia clearly reduced male lung cancer mortality and provides guidance for other countries, such as China, where smoking prevalence remains high.

BackgroundOne of the greatest obstacles facing efforts to address quality of care in low and middle income countries is the absence of relevant and reliable data. This article proposes a methodology for creating a single “Quality Index” (QI) representing quality of maternal and neonatal health care based upon data collected as part of the Demographic and Health Survey (DHS) program.MethodsUsing the 2012 Indonesian Demographic and Health Survey dataset, indicators of quality of care were identified based on the recommended guidelines outlined in the WHO Integrated Management of Pregnancy and Childbirth. Two sets of indicators were created; one set only including indicators available in the standard DHS questionnaire and the other including all indicators identified in the Indonesian dataset. For each indicator set composite indices were created using Principal Components Analysis and a modified form of Equal Weighting. These indices were tested for internal coherence and robustness, as well as their comparability with each other. Finally a single QI was chosen to explore the variation in index scores across a number of known equity markers in Indonesia including wealth, urban rural status and geographical region.ResultsThe process of creating quality indexes from standard DHS data was proven to be feasible, and initial results from Indonesia indicate particular disparities in the quality of care received by the poor as well as those living in outlying regions.ConclusionsThe QI represents an important step forward in efforts to understand, measure and improve quality of MNCH care in developing countries.

Background: Recent studies in the Kingdom of Saudi Arabia (KSA) have shown that the increasing nursing turnover in the health care industry has become a great source of concern. The overdependence on the supply of expatriate nurses (74%) and coronavirus disease 2019 (COVID-19) travel restrictions have exacerbated this staffing issue. Aims: To examine the relationship between perception of nursing practice environment (NPE), job satisfaction and intention to leave (ITL) among critical care nurses working in the state of Ha'il in KSA. Design: Cross-sectional correlational (observational) design. Methods: Data were collected via electronic online survey distributed to registered critical care nurses working in King Khalid Hospital (KKH), Ha'il, KSA, between July and August 2020. Participant demographics and key variables data related to NPE, job satisfaction and ITL respectively were collected from the participants using existing and validated questionnaires. Descriptive statistics and correlational analysis and multivariable analyses were conducted.Results: A response rate of 98% was achieved (152/160) for the study. Findings showed that the NPE was largely favourable (M = 2.89, SD = 0.44); however, nurse participation in hospital affairs (M = 2.83, SD = 0.47) and staffing and resource adequacy (M = 2.88, SD = 0.47) scored lowest. NPE was found to be significantly correlated with job satisfaction (rs = .287, P < .01). A significant negative relationship was found between NPE and ITL (rs = À0.277**, P < .01). However, job satisfaction was associated with ITL (rs = À.007, P = .930).Conclusions: Maintaining a healthy work environment and job satisfaction levels in critical care units is key to improving, recruitment and retention of nursing staff.

BackgroundUnmet need for family planning is responsible for 7.4 million disability-adjusted life years and 30% of the maternity-related disease burden. An estimated 35% of births are unintended and some 200 million couples state a desire to delay pregnancy or cease fertility but are not using contraception. Unmet need is higher among the poorest, lesser educated, rural residents and women under 19 years. The barriers to, and successful strategies for, satisfying all demand for modern contraceptives are heavily influenced by context. Successfully overcoming this to increase the uptake of family planning is estimated to reduce the risk of maternal death by up to 58% as well as contribute to poverty reduction, women’s empowerment and educational, social and economic participation, national development and environmental protection.MethodsTo strengthen health systems for delivery of context-specific, equity-focused reproductive, maternal, newborn and child health services (RMNCH), the Investment Case study was applied in the Asia-Pacific region. Staff of local and central government and non-government organisations analysed data indicative of health service delivery through a supply–demand oriented framework to identify constraints to RMNCH scale-up. Planners developed contextualised strategies and the projected coverage increases were modelled for estimates of marginal impact on maternal mortality and costs over a five year period.ResultsIn Indonesia, Philippines and Nepal the constraints behind incomplete coverage of family planning services included: weaknesses in commodities logistic management; geographical inaccessibility; limitations in health worker skills and numbers; legislation; and religious and cultural ideologies. Planned activities included: streamlining supply systems; establishment of Community Health Teams for integrated RMNCH services; local recruitment of staff and refresher training; task-shifting; and follow-up cards. Modelling showed varying marginal impact and costs for each setting with potential for significant reductions in the maternal mortality rate; up to 28% (25.1-30.7) over five years, costing up to a marginal USD 1.34 (1.32-1.35) per capita in the first year.ConclusionLocal health planners are in a prime position to devise feasible context-specific activities to overcome constraints and increase met need for family planning to accelerate progress towards MDG 5.

Objective: The relationship of longterm population-level trends in oral, pharyngeal and oesophageal cancer mortality with major risk factors such as tobacco consumption have not been statistically analysed in Australia. We have demonstrated the long-term implications using historical data. Methods: Estimated age and sexspecific tobacco consumption backextrapolated to 1887 were used together with alcohol and fruit and vegetable consumption data to examine their association with trends in oral, pharyngeal and oesophageal cancer mortality. Log-linear Poisson regression models were applied to specify the relationship with oesophageal and pharyngeal mortality data. Results: Oral cancer mortality for males decreased sharply in the first half of the 20th Century in contrast to steadily rising tobacco consumption. Female oral and pharyngeal cancer remained steady at low levels. Post-World War II male and female oesophageal and male pharyngeal cancer mortality rose, then either fell or stabilised, without a clear relationship with risk factors. Conclusions: Tobacco and alcohol consumption have influenced post-World War II trends in oral, pharyngeal and oesophageal cancer mortality. However, the challenges in using historical population level data prevent precise interpretation of findings. Implications: There is increased exposure to risk factors for these cancers in many low-and middleincome countries. In particular, smoking cessation programs are needed to prevent increases in mortality from these cancers in such countries.

Eliana Jimenez Soto and colleagues describe the Investment Case framework, a health systems research approach for planning and budgeting, and detail the implementation of the framework in four Asian countries to improve maternal, newborn and child health.

As a part of the Millennium Development Goals, India seeks to substantially reduce its burden of childhood mortality. The success or failure of this goal may depend on outcomes within India's most populous state, Uttar Pradesh. This study examines the level of disparities in under-five and neonatal mortality across a range of equity markers within the state. Estimates of under-five and neonatal mortality rates were computed using five datasets, from three available sources: sample registration system, summary birth histories in surveys, and complete birth histories. Disparities were evaluated via comparisons of mortality rates by rural-urban location, ethnicity, wealth, and districts. While Uttar Pradesh has experienced declines in both rates of under-five (162-108 per 1,000 live births) and neonatal (76-49 per 1,000 live births) mortality, the rate of decline has been slow (averaging 2 % per annum). Mortality trends in rural and urban areas are showing signs of convergence, largely due to the much slower rate of change in urban areas. While the gap between rich and poor households has decreased in both urban and rural areas, trends suggest that differences in mortality will remain. Caste-related disparities remain high and show no signs of diminishing. Of concern are also the signs of stagnation in mortality amongst groups with greater ability to access services, such as the urban middle class. Notwithstanding the slow but steady reduction of absolute levels of childhood mortality within Uttar Pradesh, the distribution of the mortality by sub-state populations remains unequal. Future progress may require significant investment in quality of care provided to all sections of the community.