The landscape of primary care services in low-income and middle-income country cities is diverse and dynamic, yet the quality of care received is too often low and the financial cost to the patient high. In the second Paper in this Series, we argue that shaping the primary care market is likely to provide larger returns to scale than individual quality improvement initiatives. Among other things, the market can be shaped by regulation and targeted public investment to crowd out poor providers and motivate those that remain to improve. Additional supply-side initiatives for which there is evidence include measures to educate and motivate the workforce, skill substitution and formation of clinical primary care teams, information technology, and improving the supply of medicines and diagnostics. Demand-side measures include reducing out-of-pocket expenses and promoting health literacy and user advocacy. Research is urgently needed into access for people who are unregistered (eg, those who sleep on the streets), those in peri-urban areas and towns, and on cost-effectiveness, and sustainability of beneficial interventions.

Most people in low-income and middle-income countries (LMICs) now live in cities, as opposed to rural areas where access to care and provider choice is limited. Urban health-care provision is organised on very different patterns to those of rural care. We synthesise global evidence to show that health-care clinics are plentiful and easily accessible in LMIC cities and that they are seldom overcrowded. The costs that patients incur when they seek care are highly variable and driven mostly by drugs and diagnostics. We show that citizens have agency, often bypassing cheaper facilities to access preferred providers. Primary care service delivery in cities is thus best characterised as a market with a diverse range of private and public providers, where patients make active choices based on price, quality, and access. However, this market does not deliver high-quality consultations on average and does not provide continuity or integration of services for preventive care or long-term conditions. Since prices play a key role in accessing care, the most vulnerable groups of the urban population often remain unprotected.

Diarrhea is a leading cause of death in children globally, mostly due to inadequate sanitary conditions and overcrowding. Poor housing quality and lack of tenure security that characterize informal settlements are key underlying contributors to these risk factors for childhood diarrhea deaths. The objective of this study is to better understand the physical attributes of informal settlement households in Latin American cities that are associated with childhood diarrhea. We used data from a household survey (Encuesta CAF) conducted by the Corporación Andina de Fomento (CAF), using responses from sampled individuals in eleven cities. We created a household deprivation score based on household water and sewage infrastructure, overcrowding, flooring and wall material, and security of tenure. We fitted a multivariable logistic regression model to estimate odds ratios (OR) and 95

At the 2023 UN General Assembly, the global community reviewed progress towards the 2030 Agenda for Sustainable Development, adopted in 2015.1 Among the 13 targets related to health in the Sustainable Development Goals, target 3·7, "Ensure universal access to sexual and reproductive health-care services", is perhaps the most controversial—despite its profound implications for the health and wellbeing of individuals and families. An abundance of evidence shows that improvements in sexual and reproductive health and rights (SRHR) contribute to economic growth, poverty eradication, gains in education, reduced inequalities, and environmental sustainability.

Improvements in health and mortality, known as the health transition, played important roles in the rise of modern contraceptive prevalence across countries. We describe key mechanisms and selected research evidence that show how health transitions helped shape contraceptive transitions around the world. Mechanisms include how decreases in child mortality rates affect the motivation to use contraception and how the organization and expansion of health care affect key barriers to contraceptive use. Substantial increases in child survival resulting from health transitions increase demand for deliberate fertility regulation and contraceptive use. Improved access to primary health care, particularly maternal and child health services and expansion into rural communities, was associated with increases in modern method use. Country-specific policies that affected the organization and delivery of health care led to the dominance of particular modern methods in some countries. Empirical evidence is limited on how the quality of health care has affected aggregate level increases in modern method use. Using modern contraceptive prevalence to define the contraceptive transition reflects current data limitations but future research on the relationship of health transitions with macrolevel contraceptive prevalence trends may be able to incorporate more comprehensive aspects of how health transitions impact contraceptive choice and agency.

Introduction:Child marriage and teen pregnancy have negative health, social and development consequences. Highest rates of child marriage occur in sub-Saharan Africa (SSA) and 40% of women in Western and Central Africa got married before the age of 18. This systematic review was aimed to fill a gap in evidence of effectiveness to reduce teen pregnancy and child marriage in SSA.Methods:We considered studies conducted in sub-Saharan Africa that reported on the effect of interventions on child marriage and teen pregnancy among adolescent girls for inclusion. We searched major databses and grey literature sources.Results:We included 30 articles in this review. We categorized the interventions reported in the review into five general categories: (a) Interventions aimed to build educational assets, (b) Interventions aimed to build life skills and health assets, (c) Wealth building interventions, and (d) Community dialogue. Only few interventions were consistently effective across the studies included in the review. The provision of scholarship and systematically implemented community dialogues are consistently effective across settings.Conclusion:Program designers aiming to empower adolescent girls should address environmental factors, including financial barriers and community norms. Future researchers should consider designing rigorous effectiveness and cost effectiveness studies to ensure sustainability.Systematic Review Registration:https://www.crd.york.ac.uk/prospero/, identifier: CRD42022327397.

The focus is on the demographic drivers and demographic implications of urban health and wellbeing in towns and cities across the globe. The aim is to identify key linkages between demographic change and urban health – subjects of two largely disparate fields of research and practice – with a view to informing arguments and advocacy for urban health while identifying research gaps and priorities. The core arguments are threefold. First, urban health advocates should express a globalized perspective on demographic processes, encompassing age-structural shifts in addition to population growth and decrease, and acknowledging their uneven spatial distributions within and between urban settings in different contexts. Second, advocates should recognize the dynamic and transformational effects that demographic forces will exert on economic and political systems in all urban settings. While demographic forces underpin the production of (intra)urban inequities in health, they also present opportunities to address those inequities. Third, a demographic perspective may help to extend urban health thinking and intervention beyond a biomedical model of disease, highlighting the need for a multi-generational view of the changing societal bases for urban health, and enjoining significant advances in how interested parties collect, manage, analyse, and use demographic data. Accordingly, opportunities are identified to increase the availability of granular and accurate data to enable evidence-informed action on the demographic/health nexus.

Background Adolescent girls' right to achieve menstrual health and hygiene management (MHHM) healthfully is yet to be realized. One reason is the lack of practical guidance on the procurement, use, and disposal of menstrual products. This study defined interpersonal practical guidance (IPG) as face-to-face communication and mediated practical guidance (MPG) as social and behavior change communication (SBCC) intervention-driven communications through print and media materials. We examine the impact of these two delivery mechanisms of practical guidance on adolescent MHHM knowledge, attitudes, and practices (KAP) following an SBCC intervention in India. Objectives To understand how IPG and SBCC-driven MPG independently influence adolescent girls’ KAP on the procurement, use, and disposal of menstrual products and whether those who receive both IPG and MPG have better KAP related to the procurement, use, and disposal of menstrual cloth or sanitary pads than those who receive only one form of practical guidance or none at all. Methods Adolescent girls' questionnaire responses from GARIMA's case-comparison evaluation were analyzed using Stata/SE 17 ( n = 2,384). Girls were matched on sociodemographic and socioeconomic variables. χ 2 analysis examined relationships between sociodemographic, practical guidance, and KAP variables. Multivariate logistic regression assessed associations between practical guidance and KAP variables. Results There are significant associations between adolescent girls' KAP depending on whether they received IPG, SBCC-driven MPG, or both. IPG and MPG delivered together has greater odds of predicting correct menstrual management KAP than when delivered separately. These effects were most notable for adolescent girls' knowledge and practices related to using and disposing of menstrual hygiene products. Conclusion There is urgent need to create positive, sustainable changes to address menstrual health and hygiene management. This study introduces an innovative approach that utilizes interpersonal and mediated communication as mechanisms to deliver practical guidance on menstrual management. Future interventions should implement and evaluate to better understand the role of practical guidance in ensuring all women and girls are prepared to confidently manage their menstrual health.

Purpose: Adolescent girls (10-19 years) in Eastern and Southern Africa face a high risk of pregnancy and HIV infection. However, few studies have examined whether the profound developmental, social, and economic changes that accompany adolescent motherhood contribute to HIV risk. This study examines the intersection between adolescent motherhood and HIV infection across 10 Eastern and Southern African countries, where over half of all HIV infections occur among adolescent girls. Methods: To evaluate whether adolescent motherhood is associated with HIV infection, we used Demographic and Health Survey data on girls (15-19 years) with HIV test results (N 1/4 19,932) from Eswatini, Kenya, Lesotho, Malawi, Mozambique, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. We examined unweighted bivariate and multivariable associations between adolescent motherhood and HIV using mixed effects logistic regression models that included a country-level random intercept. We examined heterogeneity in the association by testing country-level random slopes using a likelihood ratio test and used intraclass correlation to measure the proportion of total variance explained at the country level. Results: Nearly one fifth of adolescent girls were mothers (range: 9.80%-38.90%), and the HIV prevalence among all adolescent girls was 3.3% (range: 1.03%-10.07%). Relative to nonmothers, adolescent mothers were, on average, older, poorer, and more likely to be married, rural dwellers, and household heads. Adolescent motherhood was positively associated with HIV infection in bivariate and multivariable analyses (odds ratio: 1.87; 95% confidence interval: 1.57-2.23; adjusted odds ratio: 1.53; 95% CI: 1.24-1.89). Discussion: Among adolescents with HIV test results, we observed a robust association between adolescent motherhood and HIV infection across 10 high-burden countries. (C) 2021 Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine.

Previous studies have documented significant differences in health and reproductive health outcomes between the poor and nonpoor across various countries in sub-Saharan Africa. However, a number of these studies is dated, and the past decade has witnessed significant shifts in health and reproductive health outcomes in many African countries. Using recent data from the Demographic and Health Surveys, this paper updates and extends the literature by examining patterns in contraceptive practice among poor and nonpoor married women in urban settings in 19 African countries. First, we analyze changes in the rich-poor gaps in modern contraceptive prevalence (mCP) in urban Africa over time. We then determine the public source of the supply of modern contraceptives to the urban poor and how that supply may have changed over a 10-year period. The findings show that, in most Eastern and Southern African countries, previous gaps in mCP between the rich and poor married women have disappeared. Countries in Central and Western Africa, however, continue to have significant gaps in mCP between rich and poor women, with urban poor women experiencing only a modest improvement in mCP over the past decade. This paper contributes to our understanding about sub-regional dynamics in reproductive health outcomes in urban settings in sub-Saharan Africa.

High quality research supervision is crucial for PhD training, yet it continues to pose challenges globally with important contextual factors impacting the quality of supervision. This article reports on responses to these challenges by a multi-institutional sub-Saharan Africa initiative (CARTA) at institutional, faculty and PhD fellow levels. The article describes the pedagogical approaches and structural mechanisms used to enhance supervision among supervisors of CARTA fellows. These include residential training for supervisors, and supervision contracts between primary supervisors and PhD fellows. The authors reflect on the processes and experiences of improving PhD supervision, and suggest research questions that CARTA and other training programmes could pursue in relation to PhD supervision in Africa and other lower- and middle-income countries.

Background Population-level health and mortality data are crucial for evidence-informed policy but scarce in Nigeria. To fill this gap, we undertook a comprehensive assessment of the burden of disease in Nigeria and compared outcomes to other west African countries. Methods In this systematic analysis, using data and results of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019, we analysed patterns of mortality, years of life lost (YLLs), years lived with disability (YLDs), life expectancy, healthy life expectancy (HALE), and health system coverage for Nigeria and 15 other west African countries by gender in 1998 and 2019. Estimates of all-age and age-standardised disability-adjusted life-years for 369 diseases and injuries and 87 risk factors are presented for Nigeria. Health expenditure per person and gross domestic product were extracted from the World Bank repository. Findings Between 1998 and 2019, life expectancy and HALE increased in Nigeria by 18% to 64.3 years (95% uncertainty interval [UI] 62.2-66.6), mortality reduced for all age groups for both male and female individuals, and health expenditure per person increased from the 11th to third highest in west Africa by 2018 (US$18.6 in 2001 to $83.75 in 2018). Nonetheless, relative outcomes remained poor; Nigeria ranked sixth in west Africa for age-standardised mortality, seventh for HALE, tenth for YLLs, 12th for health system coverage, and 14th for YLDs in 2019. Malaria (5176.3 YLLs per 100 000 people, 95% UI 2464.0-9591.1) and neonatal disorders (4818.8 YLLs per 100 000, 3865.9-6064.2) were the leading causes of YLLs in Nigeria in 2019. Nigeria had the fourth-highest under-five mortality rate for male individuals (2491.8 deaths per 100 000, 95% UI 1986.1-3140.1) and female individuals (2117.7 deaths per 100 000, 1756.7-2569.1), but among the lowest mortality for men older than 55 years. There was evidence of a growing non-communicable disease burden facing older Nigerians. Interpretation Health outcomes remain poor in Nigeria despite higher expenditure since 2001. Better outcomes in countries with equivalent or lower health expenditure suggest health system strengthening and targeted intervention to address unsafe water sources, poor sanitation, malnutrition, and exposure to air pollution could substantially improve population health. Copyright (C) 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

Health is central to the development of any country. Nigeria's gross domestic product is the largest in Africa, but its per capita income of about ₦770 000 (US$2000) is low with a highly inequitable distribution of income, wealth, and therefore, health. It is a picture of poverty amidst plenty. Nigeria is both a wealthy country and a very poor one. About 40% of Nigerians live in poverty, in social conditions that create ill health, and with the ever-present risk of catastrophic expenditures from high out-of-pocket spending for health. Even compared with countries of similar income levels in Africa, Nigeria's population health outcomes are poor, with national statistics masking drastic differences between rich and poor, urban and rural populations, and different regions. Nigeria also holds great promise. It is Africa's most populous country with 206 million people and immense human talent; it has a diaspora spanning the globe, 374 ethnic groups and languages, and a decentralised federal system of governance as enshrined in its 1999 Constitution. In this Commission, we present a positive outlook that is both possible and necessary for Nigeria to deliver equitable and optimal health outcomes. If the country confronts its toughest challenges—a complex political structure, weak governance, poor accountability, inefficiency, and corruption—it has the potential to vastly improve population health using a multisector, whole-of-government approach. Major obstacles include ineffective use of available resources, a dearth of robust population-level health and mortality data, insufficient financing for health and health care, sub-optimal deployment of available health funding to purchase health services, and large population inequities. Nigeria's demographic dividend has unguaranteed potential, with a high dependency ratio, a fast-growing population, and slow reduction in child mortality. Effective, quality reproductive, maternal, and child health services including family planning, and female education and empowerment are likely to accelerate demographic transition and yield a demographic dividend. This Commission was written in the context of the COVID-19 pandemic, which has laid bare the inability of the public health system to confront new pathogens with threats to human health. However, despite a history of weak surveillance and diagnostic infrastructure, the scale up of COVID-19 diagnostics suggests that it is possible to rapidly improve other areas with sufficient local effort and resources. The Lancet Nigeria Commission aims to reposition future health policy in Nigeria to achieve universal health coverage and better health for all. This Commission presents analysis and evidence to support a positive and realistic future for Nigeria. The Commission addresses historically intractable challenges with a new narrative. Nigeria's path to greater prosperity lies through investment in the social determinants of health and the health system. Nigeria is not making use of its most precious resource—its people—by not adequately enacting policies to address preventable health problems. Health is influenced by access to quality health services, but other influencing factors lie outside this sphere. Huge gains in health can and must be made by ensuring adequate sanitation and hygiene, access to clean water, and food security, especially for children, and by addressing environmental threats to health, including air pollution. Nigeria has a young population, yet, despite spending more on health than many countries in west Africa (mostly from out-of-pocket payment), Nigerians have a lower life expectancy (54 years) than many of their neighbours. Nigeria's lower life expectancy is partially due to having more deaths in children of 5 years and younger than any other country in the world, including more populous India and China and countries experiencing widespread long-term conflict, such as Somalia. Chronic diseases and a high infectious disease burden, and an ever-present risk of epidemics of Lassa fever, meningitis, and cholera, present additional challenges. A rising population and inadequate infrastructure development over the past 30 years have contributed to increasing deaths from trauma through road injuries and conflicts driven by inequitable distribution of resources. Addressing Nigeria's health challenges requires a whole-of-government and whole-of-society approach to prevent ill health. This means investing in highly cost-effective health-promoting policies and interventions, which have extremely high cost–benefit ratios, and offering clear political benefits for implementation. Interventions are needed to improve child nutrition, reduce indoor and outdoor air pollution, address unmet family planning needs, and improve access to safe drinking water and sanitation. Key messages•We call for a new social contract centred on health to address Nigeria's need to define the relationship between the citizen and the state. Health is a unique political lever, which to date has been under-utilised as a mechanism to rally populations. Good health can be at the core of the rebirth of a patriotic national identity and sense of belonging. A commitment to a “One Nation, One Health” policy would prioritise the attainment of Universal Health Coverage for the most vulnerable subpopulations, who also bear the highest disease burden.•We recommend that prevention should be at the heart of health policy given Nigeria's young population. This will require a whole-of-government approach and community engagement. An explicit consideration of equity in the implementation of programmes and provision of social welfare, education and employment opportunities should be paramount.•We propose an ambitious programme of healthcare reform to deliver a centrally determined, locally delivered health system. The goal of government should be to provide health insurance coverage for 83 million poor Nigerians who cannot afford to pay premiums. Implementation of a reinvigorated National Strategic Health Development Plan (NSHDP III) should be supported by structured and explicit approaches to ensure that Federal, State and Local Governments deliver and are held accountable for non-delivery. NSHDP III should be supported by a ring-fenced budget and have a longer horizon of at least a decade during which common rules should apply to all parts of the system.•At the same time, the system should encourage innovation. Future health system reform should engage communities to ensure that existing nationally driven schemes have local buy-in and are sustainable. Further, since more than 50% of health services are provided in the private sector, often with poor quality and high costs, reforming the policy and regulatory landscape to unleash the market potential of the private sector is important.•We outline options for improving health financing and ensuring better accountability and distribution of resources. The rationalised governance schemes we have proposed should improve the efficient use of existing resources devoted to health. Ultimately, the proportion of spending allocated to health needs to be increased. We envision a future of Nigeria's health without foreign aid. This will require substantial increase in domestic investments. Foreign aid (multilateral, bilateral, and philanthropic) has led to fragmentation of the already complex health development landscape, with huge asymmetries in legitimacy between foreign actors and the Nigerian state as well as weak accountability. Defragmenting and decolonizing the Nigerian health landscape requires domesticating health financing.•We recommend a whole system assessment of the invest-ment needs in Nigeria's health security. The COVID-19 pandemic has exposed the weaknesses of Nigeria's health security system. Nigeria needs better manufacturing capacity for essential health products, medicines and vaccines, the provision of diagnostics, surveillance and preventive public health measures in health facilities and community settings, as well as other preventive and curative measures.•We call on the Federal Government, working with state governments, to fund and lead the development of standards for the digitisation of health records and better data collection, registration and quality assurance systems. A National Medical Research Council with 2% of the health budget and central government funding to award competitive peer reviewed grants will support high quality evidence and innovation. •We call for a new social contract centred on health to address Nigeria's need to define the relationship between the citizen and the state. Health is a unique political lever, which to date has been under-utilised as a mechanism to rally populations. Good health can be at the core of the rebirth of a patriotic national identity and sense of belonging. A commitment to a “One Nation, One Health” policy would prioritise the attainment of Universal Health Coverage for the most vulnerable subpopulations, who also bear the highest disease burden.•We recommend that prevention should be at the heart of health policy given Nigeria's young population. This will require a whole-of-government approach and community engagement. An explicit consideration of equity in the implementation of programmes and provision of social welfare, education and employment opportunities should be paramount.•We propose an ambitious programme of healthcare reform to deliver a centrally determined, locally delivered health system. The goal of government should be to provide health insurance coverage for 83 million poor Nigerians who cannot afford to pay premiums. Implementation of a reinvigorated National Strategic Health Development Plan (NSHDP III) should be supported by structured and explicit approaches to ensure that Federal, State and Local Governments deliver and are held accountable for non-delivery. NSHDP III should be supported by a ring-fenced budget and have a longer horizon of at least a decade during which common rules should apply to all parts of the system.•At the same time, the system should encourage innovation. Future health system reform should engage communities to ensure that existing nationally driven schemes have local buy-in and are sustainable. Further, since more than 50% of health services are provided in the private sector, often with poor quality and high costs, reforming the policy and regulatory landscape to unleash the market potential of the private sector is important.•We outline options for improving health financing and ensuring better accountability and distribution of resources. The rationalised governance schemes we have proposed should improve the efficient use of existing resources devoted to health. Ultimately, the proportion of spending allocated to health needs to be increased. We envision a future of Nigeria's health without foreign aid. This will require substantial increase in domestic investments. Foreign aid (multilateral, bilateral, and philanthropic) has led to fragmentation of the already complex health development landscape, with huge asymmetries in legitimacy between foreign actors and the Nigerian state as well as weak accountability. Defragmenting and decolonizing the Nigerian health landscape requires domesticating health financing.•We recommend a whole system assessment of the invest-ment needs in Nigeria's health security. The COVID-19 pandemic has exposed the weaknesses of Nigeria's health security system. Nigeria needs better manufacturing capacity for essential health products, medicines and vaccines, the provision of diagnostics, surveillance and preventive public health measures in health facilities and community settings, as well as other preventive and curative measures.•We call on the Federal Government, working with state governments, to fund and lead the development of standards for the digitisation of health records and better data collection, registration and quality assurance systems. A National Medical Research Council with 2% of the health budget and central government funding to award competitive peer reviewed grants will support high quality evidence and innovation. We call for the thoughtful use of existing institutions as an approach to achieve better governance and prioritisation of health. Although corruption has undermined the Nigerian health system, we can harness existing institutions for the benefit of population health. All levels of Government in Nigeria (federal, state, and local), and traditional leadership structures, civil society, the private sector, religious organisations, and communities, influence health. Efforts towards a balance between centralisation and localisation should focus on common policies, standards, and accountability. Concurrently, there is an equal need for localisation of implementation, meaning actual community and local government ownership of health service delivery. All three levels of Government are crucial, and we provide recommendations for each level. Differences in regional needs and context must also dictate programmes and interventions. What is needed in the northeast, in a context of ongoing insecurity and a crisis of internally displaced persons, is quite different from needs in wealthier, more secure urban centres, or in the face of the different level of insecurity found in oil-producing areas in the Niger Delta. Prioritisation of health requires additional funds. We have provided a clear investment case on health to convince politicians and governments that improved population health will reap political, demographic, and economic dividends. Our call for a whole-of-government approach to health will allow the delivery of multisectoral policies to address the social determinants of health, prioritise health-care expenditure to major causes of burden of diseases, and substantially increase healthy and productive lifespans. Nigeria's health system was built in an ad hoc way, layering traditional community health systems with colonial medicine aimed at maximising resource extraction. This origin has resulted in inbuilt inequalities, a dysfunctional focus on curative care, and a detrimental social distance from users and communities. Post-independence policies to redress problems have only been partially implemented. However, the current health system is sprawling, multifarious, disintegrated, and frequently inaccessible, with very minimal financial risk protection and low financial accessibility of services. Nigerians variously seek care from medical personnel and auxiliaries, community health workers, medicine vendors, marabouts and spiritual healers, traditional birth attendants, and other informal providers. The system relies on a mixture of quasi-tax-funding, fee-for-service, and minimal health insurance coverage. What kind of health system do Nigerians deserve, and should the country's leaders work towards? The core need of most Nigerians today is for accessible basic health services, and for this to be achieved, improvements in public sector delivery supported by an enhanced complementary private sector, including faith-based organisations, is the way forward. We lay out a path for Nigeria to move towards a system that, although remaining diverse, better serves the needs of the population. Within this diversity, we believe there is an opportunity for a “one nation and one health” approach, whereby Nigeria guarantees a minimum standard and delivery of health care for all with an emphasis on strengthening public and private (including faith-based and non-profit) systems. Nigeria should also leverage the private sector for certain functions, such as expanding innovation, discovery, and manufacturing capacities to claim a leadership role on the African continent and globally. Government investment in private industry should be mission-driven, supporting innovation and claiming dividends for society from its investments. Core functions of the health system require immediate attention, in particular, good quality health data. This Commission strongly recommends better recording, storage, and use of data. Paper systems are unworkable. A drive towards digitisation can result in major improvements, for both patient care and devolved health decision-making. Mobile digital technologies should allow a relatively rapid expansion of population health data and linked existing datasets. Human resources in rural and poor regions of the country are worsened by brain drain. We propose prioritising the optimal development and redistribution of health workers at all levels. A viable health system requires dedicated, efficient, and equitable health financing mechanisms, complemented by optional health insurance. Countries with systems comparable with Nigeria's, such as Ethiopia and Indonesia, have planned or implemented ambitious programmes to deliver health insurance coverage.

The demographic age structure of sub-Saharan Africa contributes significantly to the low morbidity and mortality of COVID-19 compared to other regions in the world. Key Messages Evidence suggests the demographic age structure of sub-Saharan Africa is the leading factor of the low morbidity and mortality of COVID-19 compared to other regions of the world. Widespread social mitigation strategies, such as lockdowns, have resulted in severe economic and societal consequences in terms of food security, adolescent pregnancy, gender-based violence, and disruptions in treating other diseases. It is imperative to weigh the risks and benefits of social mitigation strategies for future waves.

OPINION article Front. Med., 17 February 2021Sec. Infectious Diseases: Pathogenesis and Therapy Volume 8 - 2021 | https://doi.org/10.3389/fmed.2021.595787

INTRODUCTION:The evidence for vertical transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is not well established. Therefore, the objective of this review is to summarize emerging evidence on the vertical transmission of Severe Acute Respiratory Syndrome Coronavirus 2. METHODS:We conducted a systematic search in PubMed, CINAHL, Web of Science, SCOPUS, and CENTRAL. Likewise, a search for preprint publications was conducted using MedRxiv and Research Square. Studies that addressed vertical transmission of SARS-CoV-2 (concept) among pregnant women infected by Covid-19 (population) in any setting (community, hospital, or home) in any country or context were considered for inclusion. Any types of studies or reports published between December 2019 and September 2020 addressing the effects of SARS-CoV-2 on pregnant women and their newborn babies were included. Studies were screened for eligibility against the inclusion criteria for the review by two reviewers. RESULTS:We identified 51 studies reporting 336 newborns screened for COVID-19. From the 336 newborns screened for COVID-19, only 15 (4.4%) were positive for throat swab RT-PCR. All neonates with positive throat swab RT-PCR were delivered by cesarean section. Among neonates with throat swab SARS-CoV-2 positive only five (33.3%) had concomitant placenta, amniotic fluid, and cord blood samples tested, of which only one amniotic fluid sample is positive for RT PCR. Five neonates had elevated IgG and IgM but without intrauterine tissue tested. Four neonates had chest imaging suggestive of COVID-19 pneumonia. CONCLUSION:Currently there is not enough evidence on vertical virologic transmission of COVID-19 infection during the third trimester of pregnancy. Additionally, there is no evidence to support cesarean delivery, abstaining from breast feeding nor mother and infant separation. Further research involving an adequate sample size of breast milk, placenta, amniotic fluid, and cord blood to ascertain the possibility of vertical transmission and breast milk transfer is needed.

District health managers (DHMs) lead and manage Ministry of Health programmes and system performance. We report on the acceptability and feasibility of inter-related activities to increase the agency of DHMs in Kenya, Nigeria, South Africa and Uganda using a cross-sectional rapid appraisal with 372 DHMs employing structured questionnaires. We found differences and similarities between the countries, in particular, who becomes a DHM. The opportunity to provide leadership and effect change and being part of a team were reported as rewarding aspects of DHMs’ work. Demotivating factors included limited resources, bureaucracy, staff shortages, lack of support from leadership and inadequate delegation of authority. District managers ranked the acceptability of the inter-related activities similarly despite differences between contexts. Activities highly ranked by DHMs were to employ someone to support primary care staff to compile and analyse district-level data; to undertake study tours to well-functioning districts; and joining an African Regional DHM Association. DHMs rated these activities as feasible to implement. This study confirms that DHMs are in support of a process to promote bottom-up, data-driven, context-specific actions that can promote self-actualisation, recognises the roles DHMs play, provides opportunities for peer learning and can potentially improve quality of care.

Sarki et al. Respond Ahmed M. SarkiPhD, MPH, Alex EzehPhD, and Saverio StrangesMD, PhD, MPH, FAHA Affiliation Ahmed M. Sarki is with the School of Nursing and Midwifery, Aga Khan University, Kampala, Uganda, and the Family and Youth Health Initiative, Jigawa State, Nigeria. Alex Ezeh is with the Dornsife School of Public Health, Drexel University, Philadelphia, PA, and the School of Public Health, University of the Witwatersrand, Johannesburg, South Africa. Saverio Stranges is with the Department of Epidemiology and Biostatistics, the Department of Family Medicine, and The Africa Institute, Western University, London, Ontario, Canada, and the Department of Population Health, Luxembourg Institute of Health, Strassen, Luxembourg. CopyRightCorrespondence should be sent to Ahmed M. Sarki, PhD, MPH, Assistant Professor, School of Nursing and Midwifery, Faculty of Health Sciences, Aga Khan University, 9-11 Colonel Muammar Gaddafi Rd, PO Box 8842, Kampala, Uganda (e-mail: ahmed.sarki@aku.edu). Reprints can be ordered at http://www.ajph.org by clicking the "Reprints" link. CONTRIBUTORS The authors contributed equally to this letter. https://doi.org/10.2105/AJPH.2021.306384 Accepted: May 05, 2021 Published Online: August 31, 2021

The coronavirus disease 2019 (COVID-19) is an ongoing pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The objective of this research communication is to describe the general epidemic preparedness of Ethiopia using "Ready score" criterion that was developed by PreventEpidemics.org. The ReadyScore criteria is used to determine whether a country is prepared to find, stop, and prevent epidemics. This set of criteria advises countries to take tailored measures based on their actual circumstances. Ethiopia's preparedness as assessed using the ReadyScore criteria is 52%, which indicates that much work is expected from the country. Based on the current situation of Ethiopia's epidemic preparedness, the currently increasing trend in the number of COVID-19 cases and the current situation of Ethiopia in relation to its preparedness to mitigate the pandemic of Covid-19, we recommend (a) mass communication and community mobilization, (b) social distancing measures, (c) sanitary measures, (d) maximizing case tracing and detection, (e) developing detailed operational guidelines on preventive measures across different businesses, organizational and community settings, (f) measures for sustaining essential health services and (g) proactive measures to sustain life during the lockdown.