OBJECTIVE:The immunisation programme in Zambia remains one of the most effective public health programmes. Its financial sustainability is, however, uncertain. Using administrative data on immunisation coverage rate, vaccine utilisation, the number of health facilities and human resources, expenditure on health promotion, and the provision of outreach services from 24 districts, we used Data Envelopment Analysis to determine the level of technical efficiency in the provision of immunisation services. Based on our calculated levels of technical efficiency, we determined the available fiscal space for immunisation.RESULTS:Out of the 24 districts in our sample, 9 (38%) were technically inefficient in the provision of immunisation services. The average efficiency score, however, was quite high, at 0.92 (CRS technology) and 0.95 (VRS technology). Based on the calculated level of technical efficiency, we estimated that an improvement in technical efficiency can save enough vaccine doses to supply between 5 and 14 additional districts. The challenge, however, lies in identifying and correcting for the sources of technical inefficiency.

Background: The COVID-19 pandemic has disrupted health systems globally, affecting various services, including immunization programs. This study evaluates the impact of COVID-19 on immunization program financing and service delivery in Zambia, a lower-middle-income country, to understand how such disruptions could reshape future healthcare priorities and funding. Methods: The study employed a mixed-methods approach, integrating both qualitative and quantitative data collection. Data were gathered at national and sub-national levels, including in-depth interviews with 36 healthcare workers and an online survey completed by 44 staff members. The evaluation focused on the changes in government funding, the effect on static and outreach immunization activities, vaccine supply distribution, and the impact on human resources within the Expanded Programme on Immunisation (EPI). Results: Findings indicated that while regular disbursements to districts improved in 2020, there was heightened competition for limited resources due to COVID-19, leading to a redirection of funds from routine immunization to pandemic-related activities. The study revealed a significant decline in immunization coverage, attributed to reduced health facility visits and outreach sessions. Additionally, financial constraints heightened by the pandemic made it challenging for districts to accommodate the extra costs associated with implementing COVID-19-compliant immunization services. Human resources for immunization were also impacted, with staff being reallocated to COVID-19 response activities, thus increasing workload and stress levels among remaining personnel. Conclusion: COVID-19 has substantially affected the funding, delivery, and human resource components of Zambia's immunization program. Despite an increase in regular funding disbursements, the redirection of funds to COVID-19 activities has strained routine immunization services. The pandemic has highlighted the need for robust health systems that can withstand global health crises without compromising essential services like immunization. Recommendations include closer monitoring of immunization service delivery impacts, assessment of COVID-19's financial implications on immunization, development of clear protocols for service delivery under pandemic conditions, and a re-investment in community engagement and education post-pandemic.

This scoping review synthesized the parameters integral to the cost-effectiveness studies on HPV vaccination programs in Africa, specifically aimed at informing a Markov model for Zambia. Out of an initial pool of 100 articles reviewed from 2010, eight met the stringent inclusion criteria. These studies established HPV vaccination as a cost-effective intervention against cervical cancer across different African contexts. However, the optimal vaccination strategy was found to depend upon varying assumptions, methodologies, and contextual factors such as location, vaccine efficacy, coverage rates, and costs. Some models recognized herd immunity effects, and duration of protection was generally assumed to be lifelong, with an analysis time horizon between 10 to 100 years. In developing a Markov model for the African context, identifying relevant inputs is essential. Despite some limitations, such as inconsistencies in costing perspectives, the reviewed studies provided valuable insights for model parameters. Evidence strongly supports the use of Markov models in assessing HPV vaccination cost-effectiveness, with most studies adhering to the CHEERS checklist guidelines. However, limitations in the current literature include assumptions unreflective of the local context, a focus on vaccinating young girls to the exclusion of boys or older demographics, lack of consideration for all HPV strains in newer vaccines, unattainable assumptions of vaccine coverage, and disregard for the impact of vaccine hesitancy. This review underscores the necessity for further research, particularly in understanding the influence of different modelling assumptions, expanding our comprehension of cost-effectiveness across diverse demographics, HPV strains, and realistic vaccine coverage. A nuanced understanding of these factors can empower the public health community to better tailor and optimize HPV vaccination strategies in Africa, ultimately curbing the burden of HPV-related diseases.

Background:Human papillomavirus (HPV) is a common sexually transmitted infection and the leading cause of cervical cancer. The HPV vaccine is a safe and effective way to prevent HPV infection. In Zambia, the vaccine is given during Child Health to girls aged 14 years who are in and out of school in two doses over two years. The focus of this evaluation was to establish the cost to administer a single dose of the vaccine well as for full immunisation of two doses.Methods:For HPV costing, both top-down and micro-costing approaches were used, depending on the cost data source, and economic costs were gathered from Expanded Programme for Immunisation Costing and Financing Project (EPIC). Data was collected from eight districts in four provinces, mainly using a structured questionnaire, document reviews and key informant interviews with staff at national, district and provincial levels.Results:Findings show that schools made up 53.3% of vaccination sites, community outreach sites 30.9% and finally health facilities 15.8%. In terms of coverage for 2020, for the eight districts sampled, schools had the highest coverage at 96.0%. Community outreach sites were at 6.0% of the coverage and health facilities accounted for only 1.0% of the coverage. School based delivery had the lowest cost economic cost at USD13.2 per dose and USD 26.4 per fully immunised child (FIC). Overall financial costs were US$6.0 per dose and US$11.9 per fully immunised child. Overall economic costs taking all delivery models into account were US$23.0 per dose and US$46.0 per FIC. The main cost drivers were human resources, building overhead and vehicles, microplanning, supplies and service delivery/outreach. were the top cost drivers. Nurses, environmental health technicians and community-based volunteers were the most involved in HPV vaccination.Conclusions:Future planning in Zambia and other African countries conducting HPV vaccination needs to prioritise these cost drivers as well as possibly find strategies to minimise some costs. Although not a challenge now due to Gavi support, vaccine costs are a major threat to sustainability in the long run. Countries like Zambia must find strategies to mitigate against this.

Background . Despite an increase in immunisation coverage rates and number vaccines offered in Zambia over the past decade, the financial sustainability to maintain these gains is uncertain. This paper analyses availability of fiscal space to sustain the immunisation programme in Zambia in the short to medium term. Methods . We assessed fiscal space using a standard framework consisting of five pillars: economic growth, expenditure reprioritisation, grants and loans, earmarking of funds, and efficiency gains on existing outlays. To determine fiscal space from the five sources, we applied various analytical techniques including regression analysis on time series data from 1995-2018, Data Envelopment Analysis on cross section administrative data from a sample of 25 health districts, and benchmarking. Results . The evidence shows that fiscal space for immunisation in Zambia is negligible. Health spending is too weakly related to national income to generate fiscal space from economic growth. Reprioritisation of expenditure is difficult because of the huge burden from sovereign debt. Further, introducing new taxes barely three years after the introduction of a social health insurance tax is politically not feasible. Additionally, grants from donors are erratic and likely to diminish in the medium to long-run. However, fiscal space from efficiency gains is quite substantial. Conclusions . Prospects for increasing funding for immunisation from the five sources of fiscal space are minimal. However, efficiency gains in the immunisation programme can go a long way in freeing up resources. The challenge lies in identifying and resolving the sources of technical inefficiency.

Introduction: There is a significant shortage of medical subspecialists in Zambia. The government of Zambia, through programmes at the Ministry ofHealth, spends considerable resources to send patients outside the country for subspecialist medical treatment. The objective of this analysis was to evaluate the current situation pertaining to medical subspecialty training at the University of Zambia School of Medicine (UNZASOM) and to illustrate the new programmes that are to be introduced. Methods: We collected data from formal desk reviews on the state of medical specialisation in Zambia, the UNZASOM graduation archives and patient referral records at the Ministry of Health (MoH). In addition, information on planned subspecialist programmes is presented. Results: From the first graduates in 1986up to 2019, UNZASOM produced 3 51 medical specialists, 63 (18%) in Internal Medicine, 77 (22%) in Obstetrics & Gynaecology, 82 (23%) in Paediatrics&Child Health, 68 (19%) in General Surgery, 17 (5%) in Anaesthesia & Critical Care, 20 (6%) in Orthopaedics &Trauma and 8 (2%) in Urology. The remaining graduates were in Ophthalmology, Psychiatry, Infectious Diseases, Paediatric Surgery and Pathology contributing 1% each. To enhance medical subspecialist training at UNZASOM, new curricula for Breast Surgery, Urology, Glaucoma, Vitreo-retinalSurgery, Adult Gastroentero logy, Forensic Pathology, Dermatology & Venereology, Ophthalmology, Gynaecological Oncology and Paediatric anaesthesia, Infectious Diseases, and Gastroenterology were developed. Since 2013, only 44 % of patients requiring subspecialist treatment out of Zambia got assisted with the remainder still on the waiting list or having had bad outcomes.

Background: Making changes in the existing curriculum aims, objectives, course contents learning outcomes and assessment strategies have become a fact of life for nurse educators.Purpose: To enhance the existing Bachelor of Science (BSc) in nursing curriculum through integration of evidence-based practice (EBP) and teaching of critical thinking skills.Materials and Methods: A needs analysis was conducted using a five-phased approach to review the BSc in nursing Curriculum.Kern's six-step model was adapted and introduced through a series of workshop exercises that highlighted the application of each step: 1) Desk review of the BSc curriculum offered globally; 2) Administration of the needs assessment questionnaire to key informants; 3) Strengths, weakness, opportunities and threat analysis; 4) Consultative meeting with major stakeholders; 5) Curriculum review.Results: The five-phased approach established some gaps in existing curricula, and identified critical core competences and best practices in integrating EPB and critical thinking in the BSc undergraduate curriculum and some "A" level content that was not in tandem with the practice of nurses.New courses were developed to support students in academic writing and enhance professionalism and duration of training was reduced from 5 to 4 years.Conclusion: The process demonstrated that BSc curriculum review, in fact, should be thoroughly scrutinized to encourage positive changes to the curriculum, provide opportunities for

Background: There is evidence that multidisciplinary healthcare teams can provide better quality of care and treatment outcomes compared to that delivered by individuals from a single health discipline. The project on which this article is based applied the interprofessional education model to university pre-licensure health students in the management of chronic care conditions in Zambia. Methods: Four distinct but interrelated approaches, namely desk review; module development workshops; review and validation of modules by experts; piloting and review of the training modules were employed. Results: Several models of interprofessional education currently in existence and used successfully by higher education institutions in other settings were identified. While several models of Interprofessional Education were identified, our project adapted the “didactic program, community-based experience, and interprofessional-simulation experience” models. To apply the models, modules of seven chronic care conditions were developed and piloted. The extent to which the module activities promoted interprofessional education were rated between 74 - 87% (agree or strongly agree) by the students. Conclusion: Three models of Interprofessional Education were identified and adapted in the project, and seven modules were developed and administered to the students. The process was effective for putting forth an interprofessional training program at the undergraduate level, with the potential to improve quality of care for patients.

The Zambia Immunisation Technical Advisory Group (ZITAG) was established in 2016 as an advisory body to provide evidence-based recommendations on vaccine policy. As part of the Gave Full Country Evaluation, we evaluated the functionality and effectiveness of ZITAG and related EPI committees through an online stakeholder survey of Interagnecy Coordinating Committee (ICC), ZITAG and Extended programme on Immunisation Technical Working Group (EPI-TWG) members, document review and key informant interviews. The survey was sent out via SurveyMonkey between May and July 2020 to 69 members of ZITAG, ICC or the EPI TWG. A total of 52 individuals responded (75%). Eight key informant interviews were also carried out at the national and global level in September 2020 to elaborate further on some of the quantitative findings and for triangulation. Findingsrevealed that the EPI committees were reasonably functional and effective entities, each with its unique role, though some overlaps occurred. Functionality was shown by having a broad membership with wide expertise and long-serving members; sub-committees existed and meetings were occurring regularly. Leadership and coordination structures also existed and were largely felt to be working well. Funding challenges however persisted, in particular for ZITAG operations and functionality of its subcommittees.Effectiveness and value addition fo the committees to the EPI was illustrated through decision-making processes and evidence use as well as relatively good country ownership in terms of commitment, legitimacy, capacity and accountability. Full independence and ownership may however be compromised by funding challenges. Recent changes to ICC terms of reference and focus beyond immunisation side-lined the EPI and weakened the linkage between ICC and ZITAG with many ZITAG recommendations not having been followed through by ICC as the ultimate endorsing entity.

Background:An Advanced Practice Nurse is a generalist or specialized nurse who has acquired thorough graduate education a minimum of a master's degree. The need for Advanced Practice Nurses is increasingly recognized globally. This paper describes the process, which was undertaken by School of Nursing Sciences, University of Zambia in reviewing and developing advanced practice nursing and midwifery curricula which will be implemented using the Early and Enhanced Clinical Exposure model (EECE).Materials and Methods:The curricula development/review process utilized a modified Taba's Model which followed a step-by-step approach including: 1) desk review, 2) diagnosis of needs (needs assessment), 3) stakeholder consultations, 4) content development, 5) validations and approval from which several lessons were learnt and recommendations made. Findings and recommendations from different stages were used as a basis for reviewing and developing advanced practice nursing and midwifery curricula.Results:Desk review needs assessment and stakeholder consultations identified both strengths and weaknesses in the existing curricula. Major strengths were duration and core courses which met the minimum requirement for postgraduate nursing and midwifery training. Major weaknesses/gaps included some content that was too basic for the master's level and the delayed exposure to practicum sites which limited the development of advanced practice skills. Others were inadequate competence for advanced practice, inadequate research methodology course, lack of content to foster development of personal soft skills and predominant use of traditional teaching methods. Stakeholders recommended implementing advanced, clinical and hands-on Masters of Nursing and Midwifery programmes which resulted in the review of four existing and development of five demand-driven curricula.Conclusion:The reviewed and developed curricula were strengthened to close the identified gaps. Both the reviewed and developed curricula have been implemented using the Early and Enhanced Clinical Exposure Model with a view to producing Advanced Practice Nurses and Midwives who are competent to meet diverse health care needs and contribute to improving patient outcomes.

Introduction: The COVID-19 pandemic imposed dramatic changes on teaching and learning worldwide. Many universities transitioned from contact classes to utilizing fully electronic online modes. This study aims to evaluate Cavendish University School of Medicine students' online learning experience during the COVID-19 pandemic. Method: This was an exploratory cross-sectional study that used simple random sampling to select participants at Cavendish University Zambia. An online questionnaire was distributed to the selected students at the time of the conclusion of the semester. The survey was voluntary, and all data were collected and recorded via google forms with maintaining anonymity. Results: A total of 385 participants took part in the survey. Most of the participants were female124 (50.4%) and studying MBChB 171 (44.7%). The study found that there was a significant difference in the level ofunderstanding(p value=0.01), the ability to explain online classes (p value=0.04), and internet reliability (p value=0.04) across and within programs. Most students were affected by load­ shedding but the observed difference in median scores was not significant (p value=0.07). Conclusion: Teaching online presented an opportunity to complete the semesters' curriculum during the coronavirus pandemic. With obstacles like electricity load shedding and unstable internet reliability, students reported high rates of motivation, confidence in the materials taught, and exam preparedness.

BackgroundStress is the way in which the body reacts to uncomfortable situations. The University Of Zambia School of Medicine (UNZA-SoM) is the first medical school in Zambia established in 1965 and is located at the Ridgeway Campus. Students at the campus face a number of challenges, including inadequate accommodation, struggling to pay university fees, demanding learning load and alcohol and substance abuse. Methods:The study was a quantitative cross-sectional design. Third to seventh year medical students were recruited using simple random sampling. The data collection instrument was a self-administered questionnaire. Results:The overall findings showed that 71.2% of all the respondents experienced some levels of stress, and the highest prevalence was among the third year students. Prevalence of stress among students who took alcohol was lower (43.3%) than among those who did not (61.1%). Academic pressure (93.94%), financial problems (68.94%) and lecturers’ attitudes (72.72%) were the three most important sources of stress while attending church services (61.36%), watching movies (77.27%) and taking a walk (58.33%) were the three most common coping strategies. Conclusion:The prevalence of moderate to severe stress was 53.03% which was very high. Students in this category qualify for further clinical assessment and appropriate treatment. However, most of these students were not offered help in form of therapy.Students should be encouraged to employ more of the physically active coping mechanisms and encouraged to seek help from the university counseling services. The government should endeavor to include more students on government sponsorship programs and build more accommodation facilities on cam

Background Musculoskeletal conditions and/or disorders (MSDs), which affect muscles, tendons and ligaments, are the main causes of disability in many patients even though such disorders can be addressed through orthopaedic care. Little was known on the determinants of Orthopaedic services utilisation among young people between the ages of 5-24 in Zambia.Methods An embedded mixed methods design was used to conduct a hospital based cross sectional study that focused on high and low level of orthopaedic services utilisation. Stratified random sampling was used to draw a sample of 162 children and young people (5-24) from the hospital registers. Purposive sampling was used for eight service providers and convenient sampling for 10 parents and six young people. A data extraction checklist and self-administered questionnaires were for service providers. In-depth interviews with parents and a focus group discussion with six clients aged 15 to 24. Quantitative data was analysed using STATA version 14. Statistical tests included chi square, univariate and investigator led stepwise multiple logistic regression. Content and thematic analysis were done for qualitative data.Results 41 percent of clients had high level of service utilisation. Physiotherapy clients were 84 percent significantly less likely to use services compared to clients from prosthetic and orthotics workshops [AOR 0.16; 95% CI 0.05, 0.59; P=0.01]. Clients living in low density residential areas were 86 percent times less likely to use Orthopaedic services compared to those in high density residential areas [AOR 0.14; 95% CI 0.05, 0.43; P<0.0001]. Participants without Insurance were 83 percent less likely to use Orthopaedic services compared to those with Insurance [AOR 0.17; 95% CI 0.05, 0.55; P=0.003]. At service level, barriers were inadequate financial and human resources. For care givers,key barriers included inadequate information about practices and other essential health actions to manage MSDs at home; costs of transport and fear of marital discord to discuss matters at length.Conclusion The type of service used, area of residence and Health Insurance are significant determinants of Orthopaedic services utilisation. It is highly recommended that such services be decentralised to address key family barriers. Inadequate resources for orthopaedic service provision also need to be adequately addressed.

BACKGROUND:Iron and Folic Acid are two of the micronutrients recommended for pregnant women to support optimal maternal outcomes with regard to preventing anaemia and foetal birth defects. It is difficult to establish if women provided with iron and folic acid supplementation in Zambia benefit from it and how well it is implemented. The overall objective of this study was to determine the levels of uptake and compliance to iron and folic acid in pregnancy among women of child-bearing age in Zambia, with a focus on both supply and demand factors.METHODS:A cross sectional, mixed method study was done. Data was collected in August and September 2015 from six of the 14 districts in which Scaling Up Nutrition interventions were being undertaken as well as Lusaka district. A household survey covering 402 males and females of child-bearing age, 27 key informant interviews amongst key stakeholders and 12 focus group discussions at community level were conducted.RESULTS:Antenatal clinic attendance was almost universal (98.7%); the majority of both men (92.1%) and women (97.4%) had heard messages about iron and folic acid supplementation; the majority (96.5%) of women reported having taken iron and folic acid tablets during their last pregnancy, with 61.3% starting in the second trimester, 27.2% during the first trimester, and 7.7% in their third trimester. Eighty-five per cent (80.5%) of the women reported that they had taken all the tablets they were given with about 13.4% not taking all the tablets received.CONCLUSIONS:Root cause analysis, using both qualitative and quantitative findings, showed that the main challenges faced were long distances to health facilities and high transport costs; some women not being reached with supplementation messaging; lack of formalised and uniform training around delivery of antenatal messages across health care workers; women not attending antenatal monthly to replenish supplements; and forgetfulness to take the drugs daily. While male involvement may be a supportive factor, it sometimes hinders women from accessing antenatal services. Results showed that both uptake and compliance to iron and folic acid supplementation in pregnancy in Zambia were sub-optimal.

Vaccination, like most other public health services, relies on a complex package of intervention components, functioning systems and committed actors to achieve universal coverage. Despite significant investment in immunization programmes, national coverage trends have slowed and equity gaps have grown. This paper describes the design and implementation of the Gavi Full Country Evaluations, a multi-country, prospective, mixed-methods approach whose goal was to monitor and evaluate processes, inputs, outputs and outcomes of immunization programmes in Bangladesh, Mozambique, Uganda and Zambia. We implemented the Full Country Evaluations from 2013 to 2018 with the goal of identifying the drivers of immunization programme improvement to support programme implementation and increase equitable immunization coverage. The framework supported methodological and paradigmatic flexibility to respond to a broad range of evaluation and implementation research questions at global, national and cross-country levels, but was primarily underpinned by a focus on evaluating processes and identifying the root causes of implementation breakdowns. Process evaluation was driven by theories of change for each Gavi funding stream (e.g. Health Systems Strengthening) or activity, ranging from global policy development to district-level programme implementation. Mixing of methods increased in relevance and rigour over time as we learned to build multiple methods into increasingly tailored evaluation questions. Evaluation teams in country-based research institutes increasingly strengthened their level of embeddedness with immunization programmes as the emphasis shifted over time to focus more heavily on the use of findings for programme learning and adaptation. Based on our experiences implementing this approach, we recommend it for the evaluation of other complex interventions, health programmes or development assistance.

The Full Country Evaluations were Gavi-funded real-time evaluations of immunisation programmes in Bangladesh, Mozambique, Uganda and Zambia, from 2013 to 2016. The evaluations focused on providing evidence for improvement of immunisation delivery in these countries and spanned all phases of Gavi support. The process evaluation approach of the evaluations utilised mixed methods to track progress against defined theories-of-change and related milestones during the various stages of implementation of the Gavi support streams. This article highlights complexities of this type of real-time evaluation and shares lessons learnt on conducting such evaluation from the Zambian experience. Real-time process evaluation is a complex evaluation methodology that requires sensitivity to the context of the evaluation, catering for various information needs of stakeholders, and establishment of mutually beneficial relationships between programme implementers and evaluators. When used appropriately, it can be an effective means of informing programme decisions and aiding programme improvement for both donors and local implementers.

Background: Stress among health care workers is a subject that has received much attention worldwide. However, there have been few studies that address the issue of work-related stress among health care workers in Africa and in Zambia in particular. There was an urgent need to study burnout at the University Teaching Hospital in order to have concrete evidence for planning and policy purposes in order to help address some of the human resource for health problems in Zambia. This study sought to measure the levels of work-related burnout among doctors at the University Teaching Hospital and to investigate associated factors. Methods: This was a cross-sectional study. Data was collected by means of a self-administered survey using Maslach Burnout Inventory provided by mindgarden.com. Data analysis was done using guidelines as set out in the Maslach Burnout Inventory manual using Epi-info software. Cross tabulations and chi-square and statistical analysis tests were done in order to establish whether there were any statistically significant associations between levels of burnout and other variables such as sex, age, seniority, department and marital status, among others. Results: More than half, 54.4.%, of doctors studied at the University Teaching Hospital experienced average or high levels of emotional exhaustion with 44.8% experiencing average or high levels of depersonalisation and 66.4% experiencing average or low levels of personal accomplishment. Personal accomplishment was the subscale with the highest indication of burnout, followed by emotional exhaustion and depersonalisation. There were no significant associations between demographic and individual work factors studied and burnout levels. Conclusions: Burnout levels are significant at the University Teaching Hospital. There were no significant associations between demographic and individual work factors studied and burnout levels. This study has highlighted that burnout is a problem that needs to be addressed at the hospital and further investigation is required to assess what factors maybe contributing to it, particularly those related to the work environment, since personal and demographiccharacteristics did not show any associations to burnout.

BACKGROUND:The under-5 mortality rate (U5MR) is an important metric of child health and survival. Country-level estimates of U5MR are readily available, but efforts to estimate U5MR subnationally have been limited, in part, due to spatial misalignment of available data sources (e.g., use of different administrative levels, or as a result of historical boundary changes).METHODS:We analyzed all available complete and summary birth history data in surveys and censuses in six countries (Bangladesh, Cameroon, Chad, Mozambique, Uganda, and Zambia) at the finest geographic level available in each data source. We then developed small area estimation models capable of incorporating spatially misaligned data. These small area estimation models were applied to the birth history data in order to estimate trends in U5MR from 1980 to 2015 at the second administrative level in Cameroon, Chad, Mozambique, Uganda, and Zambia and at the third administrative level in Bangladesh.RESULTS:We found substantial variation in U5MR in all six countries: there was more than a two-fold difference in U5MR between the area with the highest rate and the area with the lowest rate in every country. All areas in all countries experienced declines in U5MR between 1980 and 2015, but the degree varied both within and between countries. In Cameroon, Chad, Mozambique, and Zambia we found areas with U5MRs in 2015 that were higher than in other parts of the same country in 1980. Comparing subnational U5MR to country-level targets for the Millennium Development Goals (MDG), we find that 12.8% of areas in Bangladesh did not meet the country-level target, although the country as whole did. A minority of areas in Chad, Mozambique, Uganda, and Zambia met the country-level MDG targets while these countries as a whole did not.CONCLUSIONS:Subnational estimates of U5MR reveal significant within-country variation. These estimates could be used for identifying high-need areas and positive deviants, tracking trends in geographic inequalities, and evaluating progress towards international development targets such as the Sustainable Development Goals.

Introduction Zambia is facing a chronic shortage of health care workers. The paper aimed at understanding how the Medical Education Partnership Initiative (MEPI) program facilitated strengthening and expanding of the national capacity and quality of medical education as well as processes for retaining faculty in Zambia. Methods Data generated through documentary review, key informant interviews and observations were analyzed using a thematic approach. Results The MEPI program triggered the development of new postgraduate programs thereby increasing student enrollment. This was achieved by leveraging of existing and new partnerships with other universities and differentiating the old Master in Public Health into specialized curriculum. Furthermore, the MEPI program improved the capacity and quality of training by facilitating installation and integration of new technology such as the eGranary digital library, E-learning methods and clinical skills laboratory into the Schools. This technology enabled easy access to relevant data or information, quicker turn around of experiments and enhanced data recording, display and analysis features for experiments. The program also facilitated transforming of the academic environment into a more conducive work place through strengthening the Staff Development program and support towards research activities. These activities stimulated work motivation and interest in research by faculty. Meanwhile, these processes were inhibited by the inability to upload all courses on to Moodle as well as inadequate operating procedures and feedback mechanisms for the Moodle. Conclusion Expansion and improvement in training processes for health care workers requires targeted investment within medical institutions and strengthening local and international partnerships.

Purpose African medical schools are expanding, straining resources at tertiary health facilities. Decentralizing clinical training can alleviate this tension. This study assessed the impact of decentralized training and contribution of undergraduate medical students at health facilities. Method Participants were from 11 Medical Education Partnership Initiative-funded medical schools in 10 African countries. Each school identified two clinical training sites-one rural and the other either peri-urban or urban. Qualitative and quantitative data collection tools were used to gather information about the sites, student activities, and staff perspectives between March 2015 and February 2016. Interviews with site staff were analyzed using a collaborative directed approach to content analysis, and frequencies were generated to describe site characteristics and student experiences. Results The clinical sites varied in level of care but were similar in scope of clinical services and types of clinical and nonclinical student activities. Staff indicated that students have a positive effect on job satisfaction and workload. Respondents reported that students improved the work environment, institutional reputation, and introduced evidence-based approaches. Students also contributed to perceived improvements in quality of care, patient experience, and community outreach. Staff highlighted the need for resources to support students. Conclusions Students were seen as valuable resources for health facilities. They strengthened health care quality by supporting overburdened staff and by bringing rigor and accountability into the work environment. As medical schools expand, especially in low-resource settings, mobilizing new and existing resources for decentralized clinical training could transform health facilities into vibrant service and learning environments.