The multivariable analyses by Keats and colleagues identifie

The multivariable analyses by Keats and colleagues identified factors associated with higher coverage of key interventions in Kenya. Current and prospective efforts tracking key indicators and their determinants over time could enable time-series regression and more sophisticated causal inference analyses in future. Such analyses should provide further enlightenment about what interventions work and how, where, and when they work, to enable the demand, provision, and receipt of timely and good quality care for all who need it. There needs to be a focus on improvement of mechanisms to translate evidence into policy and practice in Kenya, so that the analysis of Keats and colleagues, and those that follow, speak to those in charge of formulating and delivering the necessary policies. It is important to recognise that country-based researchers, who often have the attention of such policymakers and managers, need to lead and disseminate such analytical efforts. The results of the Kenya Countdown to 2015 country case study show that concerted and coordinated action by a responsive government and partner organisations can lead to results. With increased efforts in quality of care, equitable financing, heat shock protein inhibitors interventions, and improved monitoring, targeting, and implementation, accelerated gains can be made.
In this issue of , Sajid Soofi and colleagues assessed the effectiveness of adding neonatal bag and mask resuscitation and oral antibiotic therapy for suspected newborn infections to a basic preventive and promotive interventions package delivered by community-based lady health workers (LHWs) in rural Pakistan. When LHWs attended births they could successfully resuscitate neonates when necessary. But—and here is the crux—LHWs attended only 14% of all births and resuscitated just 4% of neonates who were reported to be not breathing after birth. This lack of availability of health-care providers severely restricted the effectiveness of the intervention. The authors concluded that health systems need to be strengthened if community-based newborn care is to achieve its full potential. Although the authors do not situate their research in terms of task shifting, insights from published work in that area can help to explain their findings. Task shifting refers to the delegation of skills and responsibilities traditionally held by professional workers to workers with lower qualifications. Codified in 1978 as a key component of the Alma Ata declaration on primary health care, task shifting has been praised on several fronts for its potential to address health worker shortages, reduce costs for training and remuneration, and shift care to cadres that are more easily retained in rural areas, which might be considered undesirable postings by highly trained staff. WHO has set out extensive guidelines for the operationalisation of task shifting. The intervention that Soofi and colleagues assessed was essentially an effort to test whether neonatal resuscitation could be task shifted from expected (but non-existent) facility-based clinicians to minimally trained but existing community-based health workers. Their findings have, perhaps inadvertently, shed light on a more fundamental question: can task shifting address the structural weaknesses in health systems that are responsible in the first place for failure to provide facility-based newborn care? The task-shifting literature suggests that delegation of tasks from one part of a weak health system to another is no more likely to be successful than the status quo unless more fundamental structural changes to strengthen the health system are brought about. Soofi and colleagues\' Article has also highlighted the dangers of developing interventions built on hypothetical assumptions that do not take evidence and on-the-ground realities into account. A common oversight in programme design is failure to account for local contextual sociocultural values and norms. Health systems are culturally embedded social systems, the functioning of which is contingent on norms and ideologies of wider society. The LHWs\' poor attendance at births in Soofi and colleagues\' study fits with previous findings that LHWs are as constrained by wider gender values and norms of limited mobility as the community women they are supposed to serve. The Pakistani LHW programme was designed to provide doorstep services to women, in acknowledgment of the reality that gendered values of seclusion prevent women from travelling to health facilities. Furthermore, only women could work as community health workers, again because gendered values restrict women\'s contact to female health-care providers. Research has shown that LHWs\' ability to deliver domiciliary care of all types is severely restricted because they are required to violate a key gender proscription around women\'s mobility, with resultant loss of status. According to Haq and colleagues, mobility requirements of the job are a source of mental distress for these workers.