PLOS Global Public Health

Sexually transmitted infections (STIs) remain a major global public health concern, with a disproportionate burden in low- and middle-income countries affected by conflict and displacement. In Nigeria, STI prevention and treatment sit within a crowded sexual and reproductive health (SRH) policy landscape shaped by vertically financed HIV programmes, expanding self-care agendas and one of the largest internally displaced populations in Africa. This qualitative study examines how structural, institutional and sociocultural forces shape STI service delivery for IDPs and how they reproduce or challenge sexual and reproductive health and rights. We conducted in-depth interviews with federal and state policymakers, United Nations representatives and national and international non-governmental actors involved in SRH and humanitarian programming in Nigeria. Using an interpretive, structurally informed approach, we explored participants accounts of funding architectures, governance priorities, humanitarian protocols, provider practices and gendered norms. Nigeria was considered "policy-rich but implementation-poor", with HIV-centred vertical financing creating a hierarchy of infections that renders non-HIV STIs comparatively invisible, unsubsidised and often effectively privatised in displacement settings. Chronic commodity shortages, workforce depletion in conflict-affected areas, weak surveillance systems and reliance on informal providers were seen as routine features of STI care in IDP camps. Sociocultural dynamics, including toilet infection narratives, gendered gatekeeping of womens healthcare and STI-related stigma, shaped how IDPs interpreted symptoms, when they sought care and which providers they used. At programme and government levels, self-care and task-shifting policies, although framed as expanding choice and autonomy, were implemented through fragile supply chains, limited regulation of informal providers and uneven access to digital platforms. The findings indicate that improving STI care for IDPs in Nigeria will require rebalancing HIV-dominated financing, securing affordable STI commodities, strengthening supervision and data systems and referral pathways so that self-care and humanitarian responses translate into accessible, reliable services.

Background: Antenatal care (ANC) utilization is critical for improving maternal and neonatal health outcomes. Despite the World Health Organization recommendation of at least eight ANC contacts during pregnancy and the implementation of free maternal healthcare policies in Ghana, significant geographic and socioeconomic disparities in ANC utilization persist. This study therefore assessed the spatial distribution and geographically varying determinants of ANC utilization among women in Ghana. Methods: A cross sectional analytical study was conducted using women data from the 2022 Ghana Demographic and Health Survey. The analysis included women aged 15 to 49 years with an index child younger than five years preceding the survey. Descriptive statistics were computed using Stata version 18, while spatial analyses were conducted in QGIS version 3.44. Global Morans I was used to assess spatial autocorrelation, whereas Local Morans I and Getis Ord Gi analyses identified spatial clusters, hotspots, and coldspots of ANC utilization. Ordinary Least Squares (OLS) regression and Geographically Weighted Regression (GWR) models were fitted to assess global and local determinants of ANC utilization. Results: Overall, only 26.0% of women achieved adequate ANC utilization, while 74.0% reported inadequate ANC attendance. Adequate ANC utilization was higher among women with higher education (42.0%) and those from the richest households (41.3%) compared with women without formal education (19.1%) and those from the poorest households (17.6%). Regional disparities were observed, with Western (48.8%), Eastern (48.0%), and Greater Accra (47.3%) regions recording the highest ANC utilization, whereas Savannah (24.7%), Northern (25.8%), and North East (26.8%) regions recorded the lowest utilization levels. Global Morans I demonstrated significant positive spatial autocorrelation (Morans I = 0.457, p = 0.044), indicating geographic clustering of ANC utilization across Ghana. Getis Ord Gi analysis identified significant coldspots within Northern, Savannah, and North East regions, while Central Region demonstrated significant hotspot clustering. OLS regression showed that maternal education (B = 0.284, p = 0.003) and household wealth (B = 0.191, p = 0.011) positively influenced ANC utilization, whereas distance to health facility negatively influenced utilization (B = -0.156, p = 0.019). The GWR model demonstrated improved explanatory performance (Adjusted R-squared = 0.71), confirming substantial spatial heterogeneity in ANC determinants across Ghana. Conclusion: Adequate ANC utilization in Ghana remains low and geographically unequal. Maternal education, household wealth, and geographic accessibility significantly influence ANC utilization, with pronounced disparities concentrated within Northern Ghana. Spatially targeted maternal health interventions aimed at improving education, reducing socioeconomic inequalities, and enhancing healthcare accessibility are required to improve equitable ANC utilization across Ghana.

South Sudan faces among the highest maternal and newborn mortality rates globally, with approximately 87% of deliveries occurring at home without skilled birth attendance. In 2024, the International Rescue Committee launched a Community-Based Maternal and Newborn Care (CBMNC) program in Aweil East County, Northern Bahr El Ghazal, deploying trained Boma Health Workers (BHWs) to deliver essential maternal and newborn health services at the household level. This study explored the acceptability of the CBMNC model among diverse stakeholders. This qualitative descriptive study was grounded in the Theoretical Framework of Acceptability (TFA). Data were collected between May and July 2025 through 17 focus group discussions (FGDs), 14 in-depth interviews (IDIs), and 10 key informant interviews (KIIs) with 185 participants, including program recipients, male partners, mothers and mothers-in-law, Boma and Hospital Health Committee (BHC/HHC) members, BHWs, supervisors, and health system stakeholders at state and national levels. Framework analysis, combining deductive coding based on the seven TFA constructs with inductive thematic analysis, was used. CBMNC was well accepted by recipients and their families, despite provider and health system concerns about sustainability. Trust in community-selected BHWs made home-based care valuable, especially given limited facility access. Intervention coherence relied on pictorial aids, repeated visits, and peer learning to address low literacy. Participants perceived commodity interventions like misoprostol and chlorhexidine as impactful, while behavioral counseling was less recognized. Clients faced minimal burden, but providers experienced significant challenges and inadequate compensation. Health stakeholders were cautiously optimistic but questioned lay provider capacity and long-term viability in a fragile environment. CBMNC can achieve high community acceptability when delivered through trusted, community-selected health workers using contextually appropriate strategies. However, community acceptability alone is insufficient for sustainable scale-up. Addressing provider compensation, workload, and structural integration into national health systems is essential to ensure that gains in acceptability translate into sustained service delivery.

Background Tanzanias Direct Health Facility Financing (DHFF) reform was introduced to strengthen primary health care through decentralized financing, autonomy, and accountability, but persistent weaknesses in monitoring and evaluation (M&E) data management and use continue to constrain implementation effectiveness, particularly in rural settings. Methods A convergent mixed-methods design was used to examine how M&E data management and use influence DHFF implementation effectiveness in an urban council (Kinondoni Municipal Council, KMC) and a rural council (Morogoro District Council, MDC), while also assessing the role of stakeholder perceptions of the DHFF M&E framework and contextual variation. Quantitative data were analyzed using descriptive statistics, relative importance indices, regression and ANOVA, while qualitative data from key informant interviews and focus group discussions were thematically analyzed and triangulated with quantitative results. Results Of 233 respondents analysed, 51.1% were from Morogoro District Council, 48.9% from Kinondoni Municipal Council, 51.2% worked in rural settings, 42.9% were from health centres, and 38.2% from dispensaries, providing an analytically useful spread across managerial and frontline contexts relevant to DHFF implementation. Descriptive statistics showed generally favourable perceptions across the five major constructs, with mean scores ranging from 3.09 for M&E capacity to 3.73 for urban-rural M&E practice context, while DHFF implementation effectiveness scored 3.71 overall. Data quality checks showed acceptable factor loadings above 0.4, reliability coefficients above 0.7, bivariate correlations of 0.34-0.76, and VIF values of 1.31-2.95, indicating that the dataset was screened, cleaned and analytically fit for regression and ANOVA modelling. In the aggregated model, the explanatory variables jointly accounted for about 52% of the variation in DHFF implementation effectiveness, with M&E data management and use, stakeholder perceptions of the DHFF M&E framework, and urban-rural context emerging as the most influential predictors. Qualitative testimonies clarified these patterns: one council respondent explained, "We have DHIS2... GoTHOMIS... FFARS... also PlanRep," while another facility respondent observed, "We only add up numbers for the monthly report--we dont really analyze what they mean," illustrating the contrast between data availability and meaningful local use. Conclusions DHFF implementation effectiveness in Tanzania depends substantially on robust M&E data management and use, supportive stakeholder perceptions of the M&E framework, and context-sensitive strategies that address persistent urban-rural inequities. Strengthening technical capacity, digital infrastructure, participatory governance and feedback systems is essential for sustaining DHFF gains and improving equitable service delivery.

Poor menstrual health (MH) has been associated with reduced participation in school activities and diminished psychosocial wellbeing among adolescent girls. Despite increasing recognition of the importance of MH interventions, there is limited economic evidence to inform large-scale adoption and financial planning. We conducted an incremental costing analysis of an MH intervention (MENISCUS) alongside a cluster-randomized trial in 60 secondary schools in Uganda. MENISCUS delivered puberty education, a drama skit, an MH kit, pain management strategies and improvements to water, sanitation and hygiene (WASH) facilities. We categorized the provider costs into start-up and implementation, and calculated unit costs per school, per student (male and female) and per female student respectively. We modelled two potential national scale-up scenarios (basic and enhanced) to 2,995 secondary schools using government delivery structures. The total cost of the basic scenario is US$10,224,685 and the enhanced scenario is US$16,549,123. The unit cost of scaling the intervention nationwide was estimated at US$28 per student and US$58 per female student (basic scenario) and US$46 per student and US$95 per female student (enhanced scenario). The primary cost drivers were the MH kit and associated training, followed by pain management activities and improvements to WASH facilities. The enhanced scenario generated a higher unit cost per student and unit cost per female student due to additional components. Compared with trial costs, unit costs were lower in national scale-up, demonstrating economies of scale. This study provides the first economic analysis of a potential national implementation of a school-based MH intervention in a low-resource setting. The findings provide critical benchmarks for governments seeking to integrate MH into national education curriculum and inform future investment decisions in adolescent health.

Rational use of medicines (RUM) is a global health priority, yet significant challenges persist in low- and middle-income countries (LMICs), particularly around medicine access, affordability, and quality. While RUM studies often focus on prescribing practices, systemic barriers such as supply chain inefficiencies and pricing receive less attention. This study assessed three key health system components of RUM (availability, affordability, and quality of essential medicines) at two public primary health facilities in Ghana and examined patient care practices against WHO RUM standards. A quantitative, cross-sectional study was conducted at Kekele Polyclinic and Rawlings Circle Polyclinic in Accra. Retrospective data were extracted from prescription sheets, medicine tally cards, and ledgers to evaluate WHO Level II core drug use indicators. Fifteen essential medicines were selected based on the Ghana Essential Medicines List, Standard Treatment Guidelines, and municipal disease burden data. Exit interviews with 107 patients assessed dispensing and counselling practices, and structured observation covered storage conditions and pharmaceutical handling. Availability of key medicines fell significantly short of WHO targets, with Rawlings Circle meeting only 40% and Kekele 73.3% of the 100% benchmark. Treatment of malaria and pneumonia cost patients up to three times the national daily minimum wage, indicating poor affordability. The average number of medicines prescribed per encounter (3.2) exceeded the WHO recommended standard ([≤]2). Storage and handling infrastructure was inadequate, with both facilities falling short of recommended conservation standards. Gaps in medicine availability, affordability, and infrastructure undermine rational medicine use in primary healthcare. Strengthening procurement systems, enforcing storage protocols, and implementing financial protection mechanisms are essential for equitable and safe medicine use within Ghanas health system.

Indigenous and nomadic communities worldwide face disproportionate and persistent barriers to reproductive health services, including family planning and safe abortion. The Raute of Nepal -- one of the country's last nomadic hunter-gatherer groups represent a uniquely marginalized population for whom no prior population-level quantitative reproductive health data exist. This gap prevents health authorities and program implementers from designing evidence-based, culturally appropriate interventions for this community. This census-based cross-sectional study enrolled all 192 eligible married women of reproductive age in the Raute community of Parshuram Municipality, Dadeldhura district, Sudurpaschim Province, Nepal. Data were collected through structured, pre-tested, face-to-face interviews, and analyzed using descriptive statistics, chi-square tests, and binary logistic regression in IBM SPSS version 16. More than half of participants (53.6%) currently used family planning, with injectable contraceptives being the most common method (42.7%), followed by female sterilization (33.0%) and implants (24.3%). Condom use was negligible at 1.0%. Among non-users (46.4%), 97.7% cited lack of interest as the primary reason for non-use. Knowledge of safe abortion services was reported by 61.5% of women, yet only 8.3% had ever accessed such services, and awareness of Nepal's national safe abortion policy, which has been in effect since 2002 was critically low at 10.4%. In bivariate analysis, no socio-demographic or socioeconomic variable was significantly associated with family planning use. The sole significant independent predictor of current family planning utilization in the adjusted logistic regression model was non-utilization of safe abortion services (adjusted odds ratio = 4.275; 95% confidence interval: 1.145-15.954; p = 0.030), suggesting that contraceptive use and abortion service use represent alternative reproductive management strategies in this community. Younger age ([≤]30 years) and urban residence were significantly associated with safe abortion use in bivariate analysis but were attenuated after adjustment, reflecting limited statistical power arising from the small number of outcome events (n = 16). These findings reveal critical gaps in reproductive method diversity, safe abortion policy literacy, and male partner engagement. Community-based mobile outreach tailored to nomadic movement patterns, targeted legal literacy programs in the local language, and structured male involvement strategies are urgently required to improve reproductive health equity in this vulnerable indigenous population.

BackgroundLimited access to and use of contraceptive services among adolescents remain a major public health concern in Nepal, influenced by their experiences and satisfaction with health services. Understanding the factors that influence adolescents satisfaction with health services is essential for improving access to and utilization of contraceptive services. This study explores determinants of adolescents satisfaction with health services and how these factors influence contraceptive service use in Nepal. MethodAn explanatory sequential mixed-methods design was employed in 154 health facilities across randomly selected 28 local levels in six districts (Surkhet, Banke, Pyuthan, Nuwakot, Parsa, and Siraha) of Nepal. Quantitative data were collected through client-exit interviews with154 adolescents on their health facility visit day, followed by qualitative interviews. Total 12 focus group discussions were conducted with adolescent girls and boys. Quantitative data were analyzed using SPSS version 26, while qualitative data were transcribed, systematically coded, and analyzed using deductive thematic approach. FindingIn quantitative results, it is found that overall, 82.5% of adolescents reported satisfaction with health services on the day of visit. The key health system factors were significantly associated with satisfaction, including confidentiality (AOR: 3.50; 95% CI: 1.19-10.37) and ease of obtaining appointments (AOR: 6.28; 95% CI: 2.18-18.08). No significant association were observed between satisfaction and adolescents socio-demographic characteristics. Despite the high-level satisfaction reported in quantitative interviews, qualitative findings revealed contrasting experiences. Adolescents reported issues such as providers judgmental attitude, inadequate confidentiality and privacy, discriminatory behavior, and limited participation in decision-making processes, influencing their service seeking behavior from public health facilities. ConclusionThis study highlights the central role of health system factors in shaping adolescents satisfaction with and use of contraceptive services. Strengthening these dimensions is essential to improve contraceptive uptake among adolescents in Nepal.

Family planning (FP) self-care is a strategic pillar for advancing Universal Health Coverage (UHC) and mitigating health workforce shortages. However, a significant disconnect persists between global normative frameworks and local implementation realities. This study examines the local meanings, perceptions, and experiences of FP self-care in Niger to inform contextualized scale-up of self-care interventions. We employed a sequential mixed-methods design in the Niamey (urban) and Zinder (rural) regions of Niger. A quantitative household survey was conducted with 510 women and 357 men to assess fertility awareness, method preferences, and information-seeking behaviors. This was complemented by qualitative in-depth interviews with 36 women, 18 men, 12 healthcare providers, and 15 community leaders. Quantitative data were analyzed using descriptive statistics, while qualitative transcripts underwent iterative thematic analysis mapped to global self-care frameworks. "Self-care" was locally reconstructed not as autonomy. While defined by all participants as hygiene, it was uniquely reconstructed by men and community leaders as economic provision. A distinct "medicalization paradox" emerged: women defined self-care as the agency to seek clinical dependence, prioritizing facility-based providers over community sources (e.g., 58.1% vs. 12.1% for oral contraceptives) to mitigate fears regarding product quality and side effects. Conversely, men favored Community Health Workers (34.3%) driven by logistical efficiency and economic motivations. Physiological knowledge was low; only 11.8% of women correctly identified the fertile window, with misconceptions reinforced by fatalistic narratives propagated by community gatekeepers. Furthermore, providers expressed strong skepticism regarding user competence, fearing "chaos" without medical supervision. Implementing FP self-care in Niger requires shifting from a "product-first" to a "values-first" approach. Strategies must be gender-stratified: leveraging "medicalized validation" to address womens safety concerns while utilizing community-based channels to meet mens efficiency needs. Ultimately, self-care should be framed not as independence from the health system, but as an empowered partnership with it.

Ensuring the coverage of essential maternal health services during pregnancy is critical for reducing maternal morbidity and mortality. However, in low-resource settings such as Somaliland, the completeness of antenatal care remains a major challenge. This study aimed to assess the prevalence and determinants of suboptimal essential maternal health services among women in Somaliland. A cross-sectional study was conducted using data from the 2020 Somaliland Demographic and Health Survey (SLDHS). A total of 2,835 women were included in the analysis. A composite index was constructed based on key antenatal care components, including blood pressure measurement, urine testing, blood testing, iron supplementation, malaria prophylaxis, and deworming treatment. The outcome variable was categorized as suboptimal (1) and adequate (0). Multilevel logistic regression analysis was performed to identify factors associated with suboptimal maternal health services, accounting for the hierarchical structure of the data. The prevalence of suboptimal essential maternal health services was 59.9%, while only 40.1% of women received adequate services. Preventive interventions such as iron supplementation (28.5%), malaria prophylaxis (0.5%), and deworming (0.9%) were particularly low compared to routine screening services. Higher educational attainment and wealth status were significantly associated with lower odds of suboptimal care, while multiparity and regional disparities were associated with higher odds. Adequate antenatal care utilization was the strongest protective factor (AOR = 0.006; 95% CI: 0.002-0.018). Suboptimal maternal health service delivery remains a significant challenge in Somaliland. Improving maternal health outcomes requires not only increasing antenatal care coverage but also ensuring the completeness and quality of essential service components. Targeted interventions addressing socioeconomic and regional inequalities are crucial.

Male involvement in family planning remains a critical yet underexplored factor influencing contraceptive uptake and decision-making support for long-acting reversible contraceptives (LARCs) in Kampala, Uganda. This mixed-methods study assessed male participation in decision-making and support for long-acting reversible contraceptives among couples in Kampala. The study involved 362 male participants who completed structured questionnaires, six focus group discussions (FGDs) conducted with both men and women, and five key informant interviews (KIIs) with healthcare providers. Ethical approval was obtained from the Kampala International University Research Ethics Committee and the Uganda National Council for Science and Technology. Quantitative findings revealed that 96.4% of men reported that their partners discussed contraception with healthcare providers ({chi}{superscript 2} = 31.366, p < 0.001), yet only 9.7% of men accompanied their partners to clinics. Male support for family planning was primarily financial (60.2%), while joint decision-making on LARCs was reported by only 38.7% ({chi}{superscript 2} = 2.776, p = 0.596). Key determinants of male involvement included marital status, education level, and number of children. However, cultural norms ({chi}{superscript 2} = 42.813, p < 0.000) and religious beliefs ({chi}{superscript 2} = 29.402, p < 0.021) were identified as significant barriers to male participation. Qualitative findings from FGDs and KIIs echoed the limited involvement of men in family planning services, attributing this to entrenched gender norms, misconceptions about contraceptives, and the perception that reproductive health services are primarily for women. Although 44.2% of participants indicated that mens concerns were addressed during consultations, 77.3% reported limited availability of couple-focused counseling ({chi}{superscript 2} = 6.294, p = 0.178). The study concludes that male involvement in family planning decision-making and support for LARCs remains low, largely due to socio-cultural barriers and limited male-friendly services. The study recommends strengthening male engagement strategies by training health workers on inclusive counseling, involving community and religious leaders in awareness campaigns, and promoting male-friendly and couple-centered reproductive health services through community-based platforms.

Exclusive breastfeeding (EBF) for the first six months is a critical protective practice, yet determinants beyond knowledge among young mothers in peri-urban sub-Saharan Africa remain insufficiently understood. This facility-based cross-sectional study assessed factors associated with EBF among 413 mothers aged 15-29 attending postnatal services at two public facilities in Lusaka, Zambia (Aug-Oct, 2025). Data from structured interviewer-administered questionnaires covered demographic, socioeconomic, cultural, mental health, peer support, and neonatal care knowledge factors. Logistic regression produced adjusted odds ratios (AOR) with 95% confidence intervals (CI). Although 99.5% reported receiving neonatal care education, 71.6% practiced EBF. Mothers aged 25-29 had lower odds of EBF than those aged 15-19 (AOR = 0.17, 95% CI: 0.03-0.99). Married mothers were more likely to exclusively breastfeed (AOR = 4.83, 95% CI: 1.59-14.65). Separated mothers also showed higher odds (AOR = 13.66, 95% CI: 1.89-98.71), although the wide confidence interval indicates substantial uncertainty and its based on a small subgroup (n=13). Formal employment was positively associated with EBF (AOR = 3.94, 95% CI: 1.12-13.85). Avoidance of specific traditional neonatal practices (AOR = 0.14, 95% CI: 0.04-0.53) and not consulting traditional healers (AOR = 0.06, 95% CI: 0.02-0.18) were also independently associated with EBF. Postnatal anxiety showed a strong inverse association (AOR = 0.14, 95% CI: 0.03-0.76). Parity, income, education, neonatal care awareness, and receipt of health education were not independently associated. These findings suggest that EBF in peri-urban Lusaka is shaped more by social, cultural, and psychological influences than knowledge alone, underscoring the need to integrate mental health screening, culturally sensitive counselling, and family-centred support within postnatal services to improve EBF uptake among young mothers in similar settings.

Background: Vasectomy remains one of the most underutilized contraceptive methods in Uganda, with a prevalence of only 0.2% despite its safety, effectiveness, and potential contribution to fertility reduction. Understanding the factors influencing awareness, knowledge, and attitudes toward vasectomy acceptance is crucial for developing effective promotion strategies in the Ugandan context. Methods: A cross-sectional study was conducted among 617 men aged 20-60 years, selected through simple random sampling of participants attending Kapchorwa General Hospital. Data were collected using a structured questionnaire. Results: Knowledge scores showed a negative association with age ({beta} = -0.044, p < 0.001) and varied significantly by marital status, with married participants demonstrating higher knowledge than single ({beta} = -0.624, p < 0.001) and widowed ({beta} = -0.950, p < 0.001) individuals. Counterintuitively, higher knowledge was associated with more negative attitudes ({beta} = -1.729, p < 0.001). Age demonstrated the strongest negative effect on attitudes ({beta} = -0.249, p < 0.001), and 99.9% of participants believed contraception is primarily women's responsibility. Behavioral data revealed that 75.0% desired more children, with 51.2% preferring a family size of 3-4 as the ideal. Conclusion: The study shows a disconnect between knowledge, attitudes, and behaviors regarding vasectomy. While general awareness is high, deep-seated misconceptions, cultural norms around masculinity and contraceptive responsibility, and fertility preferences present significant barriers to acceptance.

Background: Primary health centres in tribal areas of India collect large volumes of maternal and child health (MCH) data through routine health information systems, yet this data rarely informs local clinical or programmatic decision-making. The gap between data collection and data use in tribal settings, where health disparities are most acute, remains poorly documented from the perspective of frontline decision-makers. Methods: We conducted a qualitative study embedded in the diagnostic phase of an Action Research project in three tribal primary health centres under the Integrated Tribal Development Agency (ITDA), Rampachodavaram, Alluri Sitharama Raju District, Andhra Pradesh. Eight key informant interviews were conducted with medical officers (n=5), a district programme officer (n=1), and data entry operators (n=2). Participant observation at weekly convergence meetings and document review of registers and reports supplemented interview data. Transcripts were independently coded by two analysts using Braun and Clarke's reflexive thematic analysis. Findings: Three interconnected domains emerged. First, local MCH decision-makers needed individual-level, geographically disaggregated, prospective information to plan outreach and follow-up, but formal systems provided only retrospective aggregate statistics. Second, three structural constraints prevented formal systems from meeting these needs: digital infrastructure designed for connected settings, upward data flows with no local feedback, and a single-point- of-access governance vulnerability where one data entry operator's mobile phone controlled portal authentication for all facilities in the jurisdiction. Third, decision-makers constructed four complementary information practices (WhatsApp networks, self-built tracking tools, cross-sectoral convergence meetings, and reliance on intermediary-consolidated reports) to bridge the gap. Interpretation: Complementary information practices are expressions of local ingenuity under structural constraint, not system failures. MCH digital health reform should map and strengthen these practices rather than bypass them. Authentication governance in low- connectivity tribal settings requires urgent policy attention

BackgroundIntimate partner violence (IPV) during pregnancy is a critical public health and human rights issue that affect almost 30% of women and threatens maternal and fetal health among pregnant women. Despite the recognized burden of IPV in Tanzania, the prevalence and determinants among pregnant women need to be well identified using the national representative data. ObjectiveThis study aimed to determine the forms, prevalence, and factors associated with intimate partner violence among pregnant women in Tanzania using the 2022 Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) data. MethodsA cross-sectional study analyzed secondary data from the 2022 Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) on intimate partner violence (IPV) among pregnant women aged 15 - 49 years. A total of 435 pregnant women who responded to the IPV module were included. Weighted descriptive statistics estimated prevalence and forms of IPV, while modified Poisson regression determined factors associated with IPV. Adjusted prevalence ratios (APRs) with 95% confidence intervals (CIs) were reported. ResultsThe overall prevalence of IPV among pregnant women was 27.46% (95% CI: 22.94-32.50). Emotional violence was most common (25.26%), followed by sexual (11.04%) and physical (11.01%) violence. IPV prevalence was highest in Mara (60.3%), Songwe (50.1%), and Singida (39.0%) regions. Factors independently associated with IPV included partner alcohol use (APR = 2.55; 95% CI: 1.50-4.31), partner having other wives (APR = 1.75; 95% CI: 1.11-2.87), and union duration of 5-9 years (APR = 2.65; 95% CI: 1.14-6.18). Having a marriage certificate (APR = 0.51; 95% CI: 0.28-0.92) and one child (APR = 0.40; 95% CI: 0.17-0.95) were protective. ConclusionsIPV affects more than one in four pregnant women in Tanzania, with emotional abuse being predominant. Partner alcohol use, polygamy, and longer union duration heighten IPV risk. Integrating IPV screening and counseling into antenatal care and implementing behavior change interventions for partners could reduce the burden of violence during pregnancy.

Rectal artesunate (RAS) is a pre-referral intervention recommended for children with suspected severe malaria in remote settings where injectable treatment is not readily available. Although clinical trials have demonstrated efficacy, less is known about the behavioural and health system factors influencing effectiveness under routine conditions. A convergent parallel mixed-methods design was used to assess implementation of Zambia's RAS intervention package across three districts: Serenje, Chama, and Mwinilunga. A retrospective case-tracking investigation of all 300 children with suspected severe malaria recorded by community health workers (CHWs) assigned to study facilities examined progression and attrition across the severe malaria care cascade. In-depth interviews and focus group discussions with caregivers, CHWs, and other stakeholders explored barriers and facilitators influencing progression. Among 300 enrolled children, early attrition occurred due to negative rapid diagnostic test results. Of 239 RDT-positive children, 218 (91.2%) received RAS. Referral completion was lower; among 261 children referred and followed up at health facilities, 209 (80.1%) were confirmed to have completed referral. Of 186 children diagnosed with severe malaria at the facility, 167 (89.8%) received both injectable artesunate and follow-on artemether-lumefantrine. Patterns of disengagement varied by district, with Serenje demonstrating the most consistent progression, Chama experiencing the largest drop-off at RAS administration, and Mwinilunga showing the lowest completion of follow-on treatment. Qualitative findings revealed strong community appreciation for RAS despite stockouts, alongside social and behavioural barriers, including gendered responsibilities, transport challenges, and confusion following symptom improvement, that discouraged referral completion. RAS can be a life-saving intervention when embedded within strong health systems and community structures. Zambia's experience underscores the need for comprehensive implementation strategies that extend beyond drug distribution to include sustained CHW training, reliable commodity supply, functional referral systems, and meaningful caregiver engagement.

Malaria imposes societal costs beyond health, including substantial effects on education, yet economic evaluations often overlook these broader impacts. We conducted a cross-sectoral benefit-cost analysis of malaria chemoprevention in school-aged children (SAC) across ten high-burden sub-Saharan African countries. Using recent trial data, we estimated impacts on malaria morbidity, mortality, school absenteeism, and literacy. The intervention was projected to cost $422 million and generate $5.7 billion in societal net benefits, yielding a benefit-cost ratio (BCR) of 14.3. Country-level BCRs ranged from 3.71 to 39.5, with the highest returns in Nigeria. Results were sensitive to drug choice, discount rate, and valuation of education benefits. When using school quality metrics (estimated via Learning-Adjusted Years of Schooling (LAYS)), BCRs increased up to 100-fold compared to estimates based on school quantity alone. Probabilistic sensitivity analysis yielded a mean simulated BCR of 11.00 (95% CI: 10.89-11.11), with a >95% probability of being cost-beneficial at a BCR threshold of 3. This study advances the evidence base for malaria chemoprevention in SAC, highlighting its dual health and educational benefits. These findings offer policymakers and funders strong evidence to prioritize malaria chemoprevention in SAC as a high-value investment in both health and human capital in malaria-endemic regions.

BackgroundKenyas facility autonomy reforms are intended to improve health system equity, efficiency, and responsiveness to community needs by shifting decision-making to the frontline. This study evaluates the implementation process and experience of facility autonomy reforms in Kenya post devolution of health services. MethodsWe conducted a concurrent mixed methods study of counties (n=6) in Kenya, selected based on their implementation of facility financial autonomy reforms as of June 2023. For the quantitative aspect, we assessed 141 randomly selected public health facilities across all levels of service provision. We then did a descriptive analysis to measure the level and perceptions of autonomy. For the qualitative aspect, we reviewed documents and interviewed purposively selected stakeholders (n=71) involved with autonomy reforms at national, county, and facility levels, cutting across health, finance, legal, political and community actors. We analyzed the transcripts thematically using NVivo 12. ResultsThe emergence of the FIF reforms in Kenya was driven by the convergence of political, technical, and public needs. While counties have developed their own facility autonomy laws to fit local contexts, some provisions are not fully aligned with the national legislation. Some aspects of both the county specific and national laws are not implemented. These include allocation of matching funds from the exchequer and reimbursing facilities for expenses incurred from providing care to indigents and for unpaid bills. The implementation of autonomy also varies, with some aspects partially or not implemented. Autonomy reforms have contributed to improved decision-making, staff satisfaction, availability of essential medicines, and facility maintenance. However, challenges have emerged, including the failure of counties to provide matching funds, which disproportionately affects lower-level facilities that do not generate revenue. Additionally, the absence of waiver repayment mechanisms has led to inequities, and the risk of increased service costs threatens financial accessibility for marginalized populations. ConclusionFacility autonomy reforms support people-centered decision-making and aligns with PHC principles. While these reforms hold promise for improving service delivery and access, their success depends on complementary measures such as sustainable funding mechanisms and stronger protections for vulnerable populations.

The global occurrence of sexually transmitted infections (STIs) continues to rise, necessitating accurate diagnosis and treatment to curb their spread and associated complications. With the alarming increase in antimicrobial resistance (AMR) in Neisseria gonorrhoeae, effective STI management relies heavily on etiological diagnosis. The Tanzania National Standard for Medical Laboratories 2017 outlines recommended STI testing protocols based on facility levels, yet adherence to these guidelines and associated challenges remain poorly documented. This study describes the diagnostic capacity for different STIs in northern Tanzania. A cross-sectional study was conducted between May and July 2023, encompassing 14 laboratories across Moshi Municipal Council, Kilimanjaro region. The laboratories assessed were in five hospitals and nine health centres (HCs). Data regarding facility type and STI diagnostic capabilities were gathered through questionnaires administered during site visits and supplemented by observations. All five hospitals were equipped to conduct rapid diagnostic tests for HIV, syphilis, and wet preparation microscopy for Trichomonas vaginalis (TV). Only three hospitals had the capacity to perform culture and sensitivity testing using chocolate and blood agar medium, however none reported isolating Neisseria gonorrhoeae in the past year. Critical STI diagnostic tests including the Treponema pallidum particle agglutination assay (TPPA) and Treponema pallidum hemagglutination assay (TPHA) for the laboratory confirmation of syphilis, assays for Chlamydia trachomatis, Herpes Simplex virus -2, and Human papillomavirus (HPV) were absent across all five hospitals. Conversely, all health centers demonstrated proficiency in rapid treponemal tests for syphilis, together with rapid HIV test and TV testing, although one health center lacked the capacity for wet laboratory preparation for TV detection. Findings underscore a concerning lack of STI testing capacity within surveyed healthcare facilities, posing significant barriers to effective STI management and exacerbating the threat of AMR in Tanzania. In particular, the capacity for conventional microbiology culture was limited in most settings, severely compromising the ability to track and monitor AMR. Urgent investment in laboratory infrastructure and training is imperative to enhance STI diagnosis and treatment, ultimately curtailing transmission and mitigating the impact of AMR.

IntroductionAccess to safe water, sanitation, and hygiene (WASH) in schools is critical for child health, learning, and gender equity. In Kenya, the Kenya School Health Policy and the Basic Education Act outline standards for school WASH; however, implementation remains uneven due to inadequate infrastructure, weak inter-sectoral coordination, and limited financing. This study aimed to identify priority components for strengthening school WASH implementation and generate policy-relevant recommendations based on expert consensus in Uasin Gishu County, Kenya. Methods and ResultsA Delphi technique consisting of two iterative rounds was used to reach expert consensus. In Round 1, 20 purposively selected experts including head teachers, county education officials, public health officers, water and public works officers, and NGO representatives participated in key informant interviews. Emergent themes informed development of a structured Round 2 questionnaire administered through CommCare online app. Quantitative data were analyzed using descriptive statistics (means, standard deviations, percentage agreement), while qualitative responses underwent thematic coding using NVivo 12. Experts reached strong consensus on essential components required for strengthening school WASH implementation. Key priorities included clear governance structures, designated budget lines, inclusive infrastructure, menstrual hygiene management (MHM), curriculum integration, sustained capacity building, and systematic monitoring. Multi-sectoral collaboration and recognition of best-performing schools were also emphasized as important motivators for compliance and sustainability. Equity considerations particularly the need for disability-friendly facilities and school-community outreach were highlighted as critical. Agreement levels ranged from 74% to 100%, with most items scoring mean values between 4.5 and 4.8 on a 5-point Likert scale, indicating strong consensus among experts. Conclusionstrengthening implementation of school WASH in Kenya requires coordinated governance, predictable funding, reliable water systems, inclusive sanitation, strengthened MHM, and consistent monitoring beyond infrastructure investment alone. Integrating these expert-validated priorities within existing national policies offers a practical pathway to improving learner health, reducing absenteeism especially among girls and promoting equitable educational outcomes.