InterAction [to 31 October 2015]
http://www.interaction.org/media-center/press-releases

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InterAction’s Laky Pissalidis Recognized as Security Industry Leader
Oct 27, 2015
Every year, Security magazine recognizes leaders in the security sector who have influenced the national and global security landscape through projects, programs, or departments. The recently released list of 2015’s most influential professionals included one individual from the NGO sector – InterAction Director of Security Basile (Laky) Pissalidis.

Start Network [to 31 October 2015]
http://www.start-network.org/news-blog/#.U9U_O7FR98E
[Consortium of British Humanitarian Agencies]

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Sean Lowrie on how the Start Fund enables local and international NGOs to work together
October 30, 2015
Posted by Helen James in Blog.
Start Network director Sean Lowrie describes the Start Fund and says it demonstrates how local and international NGOs can work together.
The international aid system rests on a population of thousands of organisations around the world, but governments who provide most of the funding don’t have the resources to process lots of contracts to fund those organisations, so we can either consolidate or we can aggregate.

Aggregation is better for the system because it allows for a more diverse population of organisation, and diversity is more resilient, it’s more agile, it’s more responsive, and it enables the local and international NGOs to work together.

The Start Fund does just that, it provides aggregation, a single point of entry for governments to access a large population of organisations, and the ownership and power is diverse across the Start Network…

Global Humanitarian Assistance (GHA) [to 31 October 2015]
http://www.globalhumanitarianassistance.org/

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Crisis Briefing
Earthquake in northern Pakistan
2015/10/30
On the 29 October 2015 we responded to a funding alert in response to an earthquake in northern regions of Pakistan: Khyber Pakhtunkhwa, Gilgit Baltistan, Azad Jammu Kashmir and Federally Administered Tribal Areas.

ODI [to 31 October 2015]
http://www.odi.org/media

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In quest of inclusive progress: exploring intersecting inequalities in human development
Research reports and studies | October 2015 | Amanda Lenhardt and Emma Samman
For 16 countries with appropriate data, this paper seeks to ascertain to what extent wealth status, urban/rural place of residence and ethnicity – and overlaps between them – explain inequalities in education and health; and how these inequalities have changed over…

Markets in crises: South Sudan case study
Working and discussion papers | October 2015 | Irina Mosel and Emily Henderson
This paper looks at how conflict and aid impact markets and businesses in Juba, South Sudan.

The European Union’s new Gender Action Plan 2016-2020: gender equality and women’s empowerment in external relations
Research reports and studies | October 2015 | Helen O’Connell, Mikaela Gavas
An analysis of the European Union’s framework, ‘Gender equality and women’s empowerment: transforming the lives of girls and women through EU external relations 2016-2020’.

Private sector and water supply, sanitation and hygiene
Research reports and studies | October 2015 | Nathaniel Mason, Mariana Matoso and William Smith
This report provides a framework and recommendations for private sector engagement in support of universal access to water supply, sanitation and hygiene.

The Ebola response in West Africa: Exposing the politics and culture of international aid
Working and discussion papers | October 2015 | Marc DuBois and Caitlin Wake, with Scarlett Sturridge and Christina Bennett
An examination of the strengths and weakness of the international aid system through the lens of the Ebola response.

Professionals in Humanitarian Assistance and Protection (PHAP) [to 31 October 2015]
https://phap.org/

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PHAP members provide input to Global Protection Cluster strategy review
26 October 2015
In 2015, the Global Protection Cluster (GPC) will update its Strategic Framework and revitalize its structures to react better to the needs of the field. As part of the consultations for this revision, PHAP fielded a survey to its members and wider contact network in September in order to gather…

HHMI – Howard Hughes Medical Institute [to 7 November 2015]
https://www.hhmi.org/news

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Research [ October 28, 2015 ]
Researchers Identify New Factors that Guide Organization of Plant Roots
HHMI scientists have identified a set of proteins that plays a surprisingly broad role in guiding tissue formation in plant roots.

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Research [ October 26, 2015 ]
Seeing the Big Picture
Within less than a second, the new IsoView microscope produces images of entire organisms, such as a zebrafish or fruit fly embryo, with enough resolution in all three dimensions that each cell appears as a distinct structure.

Rockefeller Foundation [to 7 November 2015]
http://www.rockefellerfoundation.org/newsroom

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Richard D. Parsons Elected Next Chair of The Rockefeller Foundation Board
October 28, 2015
David Rockefeller Jr. to Step Down at End of Five Year Term
NEW YORK—The Trustees of The Rockefeller Foundation announced today the unanimous election of business executive Richard D. Parsons as the next Chair of the Board of Trustees. Parsons will serve as Chair-Elect until June of 2016 when he will take over as Chair at the end of the term of the current Board Chair, David Rockefeller Jr. Parsons joined The Rockefeller Foundation Board of Trustees in 2008.
David Rockefeller Jr., joined The Rockefeller Foundation board of trustees in 2006 and he began serving as Board Chair in December 2010. His term of Chair included the Foundation’s Centennial in 2013, an historic opportunity to reflect on one hundred years of impact and to launch new work for a second century.
David Rockefeller Jr. said: “It has been an enormous honor to serve as Board Chair of the philanthropy established by my great-grandfather in 1913. It gives me great pleasure that my successor will be Dick Parsons, a good friend of mine. Dick has led an inspiring career in both business and public service and has been an invaluable member of the board since 2007. I am certain that under Dick and Judith’s leadership the Foundation will continue to go from strength to strength.”…

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HAMILTON: The Musical and The Rockefeller Foundation Announce Partnership to Provide 20,000 NYC Public School Students with Tickets to Hamilton on Broadway With $1.46 Million Grant
October 27, 2015
Innovative Educational Collaboration with the Gilder Lehrman Institute of American History and the NYC Department of Education Will Support Classroom Studies

Robert Wood Johnson Foundation [to 7 November 2015]
http://www.rwjf.org/en/about-rwjf/newsroom/news-releases.html

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RWJF Awards Eight Communities with RWJF Culture of Health Prize
October 28, 2015
The Robert Wood Johnson Foundation announced the eight winners of the 2015 RWJF Culture of Health Prize, which honors communities that are working to ensure that everyone has the opportunity to live a longer, healthier, and more productive life.

American Journal of Infection Control
November 2015 Volume 43, Issue 11, p1147-1268, e67-e81
http://www.ajicjournal.org/current

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Social and political determinants of vaccine hesitancy: Lessons learned from the H1N1 pandemic of 2009-2010
Gustavo S. Mesch, Kent P. Schwirian
p1161–1165
Preview
Public acceptance of vaccination programs is essential for vaccine preventable diseases. However, increasing sectors of the population have expressed hesitancy about participating in such programs, leading to the re-emergence of vaccine preventable diseases. In this study we rely on a recreancy hypothesis to test the association between confidence in the government and local hospitals and the willingness to take the vaccine.

American Journal of Public Health
Volume 105, Issue S5 (November 2015)
http://ajph.aphapublications.org/toc/ajph/current

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Universal Health Coverage: A Political Struggle and Governance Challenge
Scott L. Greer, Claudio A. Méndez
American Journal of Public Health: November 2015, Vol. 105, No. S5: S637–S639
Abstract
Universal health coverage has become a rallying cry in health policy, but it is often presented as a consensual, technical project. It is not.
A review of the broader international literature on the origins of universal coverage shows that it is intrinsically political and cannot be achieved without recognition of its dependence on, and consequences for, both governance and politics.

On one hand, a variety of comparative research has shown that health coverage is associated with democratic political accountability. Democratization, and in particular left-wing parties, gives governments particular cause to expand health coverage. On the other hand, governance, the ways states make and implement decisions, shapes any decision to strive for universal health coverage and the shape of its implementation.

BMC Pregnancy and Childbirth
http://www.biomedcentral.com/bmcpregnancychildbirth/content
(Accessed 7 November 2015)

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Research article
Determinants of postnatal care use at health facilities in rural Tanzania: multilevel analysis of a household survey
Diwakar Mohan, Shivam Gupta, Amnesty LeFevre, Eva Bazant, Japhet Killewo, Abdullah H Baqui BMC Pregnancy and Childbirth 2015, 15:282 (30 October 2015)

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Research article
Adverse pregnancy outcomes in rural Uganda (1996–2013): trends and associated factors from serial cross sectional surveys
Gershim Asiki, Kathy Baisley, Rob Newton, Lena Marions, Janet Seeley, Anatoli Kamali, Lars Smedman
BMC Pregnancy and Childbirth 2015, 15:279 (29 October 2015)

BMC Public Health
http://www.biomedcentral.com/bmcpublichealth/content
(Accessed 7 November 2015)

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Research article
Prevalence and care-seeking for chronic diseases among Syrian refugees in Jordan
Shannon Doocy, Emily Lyles, Timothy Roberton, Laila Akhu-Zaheya, Arwa Oweis, Gilbert Burnham
BMC Public Health 2015, 15:1097 (7 November 2015)
Abstract
Background
There are currently more people displaced by conflict than at any time since World War II. The profile of displaced populations has evolved with displacement increasingly occurring in urban and middle-income settings. Consequently, an epidemiological shift away from communicable diseases that have historically characterized refugee populations has occurred. The high prevalence of non-communicable diseases (NCDs) poses a challenge to in terms of provision of appropriate secondary and tertiary services, continuity of care, access to medications, and costs. In light of the increasing burden of NCDs faced by refugees, we undertook this study to characterize the prevalence of NCDs and better understand issues related to care-seeking for NCDs among Syrian refugees in non-camp settings in Jordan.
Methods
A cross-sectional survey of 1550 refugees was conducted using a multi-stage cluster design with probability proportional to size sampling to obtain a nationally representative sample of Syrian refugees outside of camps. To obtain information on chronic conditions, respondents were asked a series of questions about hypertension, cardiovascular disease, diabetes, chronic respiratory disease, and arthritis. Differences by care-seeking for these conditions were examined using chi-square and t-test methods and characteristics of interest were included in the adjusted logistic regression model.
Results
Among adults, hypertension prevalence was the highest (9.7 %, CI: 8.8–10.6), followed by arthritis (6.8 %, CI: 5.9–7.6), diabetes (5.3 %, CI: 4.6–6.0), chronic respiratory diseases (3.1 %, CI: 2.4–3.8), and cardiovascular disease (3.7 %, CI: 3.2, 4.3). Of the 1363 NCD cases, 84.7 % (CI: 81.6–87.3) received care in Jordan; of the five NCDs assessed, arthritis cases had the lowest rates of care seeking at 65 %, (CI:0–88, p=0.005). Individuals from households in which the head completed post-secondary and primary education, respectively, had 89 % (CI: 22–98) and 88 % (CI: 13–98) lower odds of seeking care than those with no education (p=0.028 and p=0.037, respectively). Refugees in North Jordan were most likely to seek care for their condition; refugees in Central Jordan had 68 % (CI: 1–90) lower odds of care-seeking than those in the North (p=0.047).
Conclusion
More than half of Syrian refugee households in Jordan reported a member with a NCD. A significant minority did not receive care, citing cost as the primary barrier. As funding limitations persist, identifying the means to maintain and improve access to NCD care for Syrian refugees in Jordan is essential.

Bulletin of the World Health Organization
Volume 93, Number 11, November 2015, 741-816
http://www.who.int/bulletin/volumes/93/11/en/

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EDITORIALS
Gender, health and the Sustainable Development Goals
Veronica Magar

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RESEARCH
An insecticide-treated bed-net campaign and childhood malaria in Burkina Faso
Valérie R Louis, Anja Schoeps, Justin Tiendrebéogo, Claudia Beiersmann, Maurice Yé, Marie R Damiba, Guang Y Lu, André H Mbayiha, Manuela De Allegri, Albrecht Jahn, Ali Sié, Heiko Becher & Olaf Müller
doi: 10.2471/BLT.14.147702

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POLICY & PRACTICE
Evidence on global medical travel
Kai Ruggeri, Ladislav Záliš, Christopher R Meurice, Ian Hilton, Terry-Lisa Ly, Zorana Zupan & Saba Hinrichs
doi: 10.2471/BLT.14.146027
Abstract
The potential benefits of travelling across national borders to obtain medical treatment include improved care, decreased costs and reduced waiting times. However, medical travel involves additional risks, compared to obtaining treatment domestically. We review the publicly-available evidence on medical travel. We suggest that medical travel needs to be understood in terms of its potential risks and benefits so that it can be evaluated against alternatives by patients who are seeking care. We propose three domains –quality standards, informed decision-making, economic and legal protection – in which better evidence could support the development of medical travel policies.

Conflict and Health
http://www.conflictandhealth.com/
[Accessed 7 November 2015]

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Debate
Coincident polio and Ebola crises expose similar fault lines in the current global health regime
Philippe Calain, Caroline Abu Sa’Da
Conflict and Health 2015, 9:29 (16 Sept 2015)
Abstract
Background
In 2014, the World Health Organization (WHO) declared two “public health emergencies of international concern”, in response to the worldwide polio situation and the Ebola epidemic in West Africa respectively. Both emergencies can be seen as testing moments, challenging the current model of epidemic governance, where two worldviews co-exist: global health security and humanitarian biomedicine.
Discussion
The resurgence of polio and the spread of Ebola in 2014 have not only exposed the weaknesses of national health systems, but also the shortcomings of the current global health regime in dealing with transnational epidemic threats. These shortcomings are of three sorts. Firstly, the global health regime is fragmented and dominated by the domestic security priorities of industrialised nations. Secondly, the WHO has been constrained by constitutional country allegiances, crippling reforms and the limited impact of the (2005) International Health Regulations (IHR) framework. Thirdly, the securitization of infectious diseases and the militarization of humanitarian aid undermine the establishment of credible public health surveillance networks and the capacity to control epidemic threats.
Summary
The securitization of communicable diseases has so far led foreign aid policies to sideline health systems. It has also been the source of ongoing misperceptions over the aims of global health initiatives. With its strict allegiance to Member States, the WHO mandate is problematic, particularly when it comes to controlling epidemic diseases. In this context, humanitarian medical organizations are expected to palliate the absence of public health services in the most destitute areas, particularly in conflict zones. The militarization of humanitarian aid itself threatens this fragile and imperfect equilibrium. None of the reforms announced by the WHO in the wake of the 68 th World Health Assembly address these fundamental issues.

Global Public Health
Volume 10, Issue 10, 2015
http://www.tandfonline.com/toc/rgph20/current

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Global governmentality: Biosecurity in the era of infectious diseases
Jlateh Vincent Jappah & Danielle Taana Smith
pages 1139-1156
DOI:10.1080/17441692.2015.1038843
Abstract
This paper uses Foucault’s concept of governmentality to examine relationships between globalisation, the threat of infectious diseases and biosecurity. It draws attention to forms of calculated practices which Foucault notes as technologies of power that aim to foster positive demographic and economic trends in societies through the apparatus of security. These practices are employed at the global level with similar ambitions; hence, we adopt the term global governmentality. We discuss the applications of global governmentality by actors in the global core through the apparatus of security and (neo)liberal economic practices. We then provide examples of resistance/contestation from actors mainly in the global periphery through discussions of viral sovereignty; access to essential medicines, including HIV drugs; and health for all as a human right. We conclude that despite the core-periphery power asymmetry and competing paradigms, these developments tend to complement and/or regulate the phenomenon termed global governmentality, which is made evident by the tremendous successes in global health.

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Making surgical missions a joint operation: NGO experiences of visiting surgical teams and the formal health care system in Guatemala
Stephanie Roche & Rachel Hall-Clifford
pages 1201-1214
DOI:10.1080/17441692.2015.1011189
Abstract
Each year, thousands of Guatemalans receive non-emergent surgical care from short-term medical missions (STMMs) hosted by local non-governmental organizations (NGOs) and staffed by foreign visiting medical teams (VMTs). The purpose of this study was to explore the perspectives of individuals based in NGOs involved in the coordination of surgical missions to better understand how these missions articulate with the larger Guatemalan health care system. During the summers of 2011 and 2013, in-depth interviews were conducted with 25 representatives from 11 different Guatemalan NGOs with experience with surgical missions. Transcripts were analysed for major themes using an inductive qualitative data analysis process. NGOs made use of the formal health care system but were limited by several factors, including cost, issues of trust and current ministry of health policy. Participants viewed the government health care system as a potential resource and expressed a desire for more collaboration. The current practices of STMMs are not conducive to health system strengthening. The role of STMMs must be defined and widely understood by all stakeholders in order to improve patient safety and effectively utilise health resources. Priority should be placed on aligning the work of VMTs with that of the larger health care system.

Infectious Diseases of Poverty
http://www.idpjournal.com/content
[Accessed 31 October2015]

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Research Article
Indirect costs associated with deaths from the Ebola virus disease in West Africa
Joses Kirigia, Felix Masiye, Doris Kirigia, Patricia Akweongo Infectious Diseases of Poverty 2015, 4:45 (29 October 2015)
Editor’s summary
Deaths associated with Ebola Virus Disease have been shown to impose a significant economic burden on the affected West African countries. The team did this study to complement the projection by the World Bank in 2014; and made a plea for increased domestic and external investments to enable Guinea, Liberia and Sierra Leone (and other vulnerable African countries) to develop resilient health systems. Image: Ebola v?rus disease treatment centre in Monrovia, Sierra Leone.

Abstract
Background
By 28 June 2015, there were a total of 11,234 deaths from the Ebola virus disease (EVD) in five West African countries (Guinea, Liberia, Mali, Nigeria and Sierra Leone). The objective of this study was to estimate the future productivity losses associated with EVD deaths in these West African countries, in order to encourage increased investments in national health systems.
Methods
A cost-of-illness method was employed to calculate future non-health (NH) gross domestic product (GDP) (NHGDP) losses associated with EVD deaths. The future non-health GDP loss (NHGDPLoss) was discounted at 3 %. Separate analyses were done for three different age groups (< =14 years, 15–44 years and = >45 years) for the five countries (Guinea, Liberia, Mali, Nigeria, and Sierra Leone) affected by EVD. We also conducted a one-way sensitivity analysis at 5 and 10 % discount rates to gauge their impacts on expected NHGDPLoss.
Results
The discounted value of future NHGDPLoss due to the 11,234 deaths associated with EVD was estimated to be Int$ (international dollars) 155,663,244. About 27.86 % of the loss would be borne by Guinea, 34.84 % by Liberia, 0.10 % by Mali, 0.24 % by Nigeria and 36.96 % by Sierra Leone. About 27.27 % of the loss is attributed to those aged under 14 years, 66.27 % to those aged 15–44 years and 6.46 % to those aged over 45 years. The average NHGDPLoss per EVD death was estimated to be Int$ 17,473 for Guinea, Int$ 11,283 for Liberia, Int$ 25,126 for Mali, Int$ 47,364 for Nigeria and Int$ 14,633 for Sierra Leone.
Conclusion
In spite of alluded limitations, the estimates of human and economic losses reported in this paper, in addition to those projected by the World Bank, show that EVD imposes a significant economic burden on the affected West African countries. That heavy burden, coupled with human rights and global security concerns, underscores the urgent need for increased domestic and external investments to enable Guinea, Liberia and Sierra Leone (and other vulnerable African countries) to develop resilient health systems, including core capacities to detect, assess, notify, verify and report events, and to respond to public health risks and emergencies.

Intervention – Journal of Mental Health and Psychological Support in Conflict Affected Areas
November 2015 – Volume 13 – Issue 3 pp: 200-296
http://journals.lww.com/interventionjnl/pages/currenttoc.aspx

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Mental health and psychosocial support in humanitarian settings: reflections on a review of UNHCR’s approach and activities
Meyer, Sarah; Morand, Mary-Beth
Abstract
Mental health and psychosocial support activities are increasingly becoming a core component of humanitarian response and support for displaced persons in emergencies. However, recognition of the mental health and psychosocial impacts of conflict, disaster and displacement is relatively new within the sphere of humanitarian assistance. This paper, therefore, describes and expands on findings from a review of the UN Refugee Agency’s engagement with mental health and psychosocial support for refugees. While this review specifically focused on one agency within the humanitarian field, it should be useful to many humanitarian agencies working in the field as the number of displacement scenarios grow and mental health and psychosocial aspects of displacement are increasingly evident. This review identified three key themes; 1) engaging with mental health and psychosocial support in humanitarian settings as an approach and as a set of interventions was found to be a useful framework; 2) challenges in measuring and evaluating mental health and psychosocial support activities, and the ways in which these challenges influence mental health and psychosocial support in humanitarian settings is discussed; and 3) limitations in provision of clinical mental health services were evident.

Journal of International Development
October 2015 Volume 27, Issue 7 Pages 881–1350
http://onlinelibrary.wiley.com/doi/10.1002/jid.v27.6/issuetoc

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Rescuing Girls, Investing in Girls: A Critique of Development Fantasies (pages 881–897)
Cynthia M. Caron and Shelby A. Margolin
Article first published online: 24 SEP 2015 | DOI: 10.1002/jid.3146
Abstract
The girl child increasingly is at the centre of development programming. We draw on Slavoj Zizek’s notion of fantasy to show how and, more importantly, why girl-centred initiatives reproduce the shortcomings of women and gender-focused programmes before them. Through an analysis of three girl-centred campaigns, we illustrate how experts identify and diagnose girls’ problems and prescribe solutions that not only circumscribe girls’ futures, but are also counterproductive. We argue that even as campaigns try to integrate lessons learned from earlier gender and development initiatives, the critical reflection that a Zizekian approach promotes would better enable development actors to reformulate campaigns and fundamental campaign assumptions.

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Knowing and Doing Between the Academic and Policy Worlds in Development Assistance (pages 1294–1311)
Morgan Brigg, Jodie Curth-Bibb, Elizabeth Strakosch and Martin Weber
Article first published online: 22 JAN 2015 | DOI: 10.1002/jid.3068
Abstract
Policy professionals overseeing the provision of development assistance and their critical academic counterparts are often at odds with each other. Although many agree that it is useful to deal with this tension, current efforts to do so tend to exhort each to be more like the other under the rhetoric of ‘evidence-based policy’. Meanwhile, the differences between these players are kept alive by mutual misunderstandings that can border upon stereotyping. This paper reflects on this situation from the perspective of the critical academic and offers an enhanced understanding of key positions and misapprehensions to contribute to a foundation for improved relationships.

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From Unconventional to Ordinary? The Bill and Melinda Gates Foundation and the Homogenizing Effects of International Development Cooperation (pages 1098–1112)
Adam Moe Fejerskov
Article first published online: 9 SEP 2015 | DOI: 10.1002/jid.3149
Abstract
The majority of the literature on new actors in development cooperation explores how these alter the field. This article presents a reverse case of how the strong homogenizing norms and principles of international development may turn an unconventional development actor into something quite conventional and more alike to well-established actors. Drawing on insights from institutional theory, it examines organizational changes in the Bill and Melinda Gates Foundation from formation until today and argues that the foundation has progressed from a state of intentional isolation to one of actively engaging in and adhering to the field’s norm and principle-setting. Copyright © 2015 John Wiley & Sons, Ltd.

The Lancet
Oct 31, 2015 Volume 386 Number 10005 p1707-1794 e22-e26
http://www.thelancet.com/journals/lancet/issue/current

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Editorial
What next for the malaria RTS,S vaccine candidate?
The Lancet
DOI: http://dx.doi.org/10.1016/S0140-6736(15)00733-3
Summary
On Oct 23, the Strategic Advisory Group of Experts on Immunization (SAGE) and the Malaria Policy Advisory Committee (MPAC) announced their much-anticipated recommendations for the world’s first malaria vaccine candidate known as RTS,S/AS01. Their decision is not to recommend widespread deployment of the vaccine based on existing evidence, but instead to assess the feasibility of delivering the vaccine and its impact in real-world settings. This decision was perhaps unexpected given the fact that earlier this year the European Medicines Agency reviewed the same safety and efficacy data, and approved the vaccine’s use in young children.

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Series
Faith-based health care
Understanding the roles of faith-based health-care providers in Africa: review of the evidence with a focus on magnitude, reach, cost, and satisfaction
Jill Olivier, Clarence Tsimpo, Regina Gemignani, Mari Shojo, Harold Coulombe, Frank Dimmock, Minh Cong Nguyen, Harrison Hines, Edward J Mills, Joseph L Dieleman, Annie Haakenstad, Quentin Wodon

Faith-based health care
Controversies in faith and health care
Andrew Tomkins, Jean Duff, Atallah Fitzgibbon, Azza Karam, Edward J Mills, Keith Munnings, Sally Smith, Shreelata Rao Seshadri, Avraham Steinberg, Robert Vitillo, Philemon Yugi

Faith-based health care
Strengthening of partnerships between the public sector and faith-based groups
Jean F Duff, Warren W Buckingham
1786

The Lancet Global Health
Nov 2015 Volume 3 Number 11 e654-e724
http://www.thelancet.com/journals/langlo/issue/current

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Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali: a cluster-randomised controlled trial
Amy J Pickering, Habiba Djebbari, Carolina Lopez, Massa Coulibaly, Maria Laura Alzua
Summary
Background
Community-led total sanitation (CLTS) uses participatory approaches to mobilise communities to build their own toilets and stop open defecation. Our aim was to undertake the first randomised trial of CLTS to assess its effect on child health in Koulikoro, Mali.
Methods
We did a cluster-randomised trial to assess a CLTS programme implemented by the Government of Mali. The study population included households in rural villages (clusters) from the Koulikoro district of Mali; every household had to have at least one child aged younger than 10 years. Villages were randomly assigned (1:1) with a computer-generated sequence by a study investigator to receive CLTS or no programme. Health outcomes included diarrhoea (primary outcome), height for age, weight for age, stunting, and underweight. Outcomes were measured 1·5 years after intervention delivery (2 years after enrolment) among children younger than 5 years. Participants were not masked to intervention assignment. The trial is registered with ClinicalTrials.gov, number NCT01900912.
Findings
We recruited participants between April 12, and June 23, 2011. We assigned 60 villages (2365 households) to receive the CLTS intervention and 61 villages (2167 households) to the control group. No differences were observed in terms of diarrhoeal prevalence among children in CLTS and control villages (706 [22%] of 3140 CLTS children vs 693 [24%] of 2872 control children; prevalence ratio [PR] 0·93, 95% CI 0·76–1·14). Access to private latrines was almost twice as high in intervention villages (1373 [65%] of 2120 vs 661 [35%] of 1911 households) and reported open defecation was reduced in female (198 [9%] of 2086 vs 608 [33%] of 1869 households) and in male (195 [10%] of 2004 vs 602 [33%] of 1813 households) adults. Children in CLTS villages were taller (0·18 increase in height-for-age Z score, 95% CI 0·03–0·32; 2415 children) and less likely to be stunted (35% vs 41%, PR 0·86, 95% CI 0·74–1·0) than children in control villages. 22% of children were underweight in CLTS compared with 26% in control villages (PR 0·88, 95% CI 0·71–1·08), and the difference in mean weight-for-age Z score was 0·09 (95% CI –0·04 to 0·22) between groups. In CLTS villages, younger children at enrolment (<2 years) showed greater improvements in height and weight than older children.
Interpretation
In villages that received a behavioural sanitation intervention with no monetary subsidies, diarrhoeal prevalence remained similar to control villages. However, access to toilets substantially increased and child growth improved, particularly in children <2 years. CLTS might have prevented growth faltering through pathways other than reducing diarrhoea.
Funding
Bill & Melinda Gates Foundation.