ObjectiveFew studies have examined the link between health system strength and important public health outcomes across nations. We examined the association between health system indicators and mortality rates.MethodsWe used mixed effects linear regression models to investigate the strength of association between outcome and explanatory variables, while accounting for geographic clustering of countries. We modelled infant mortality rate (IMR), child mortality rate (CMR), and maternal mortality rate (MMR) using 13 explanatory variables as outlined by the World Health Organization.ResultsSignificant protective health system determinants related to IMR included higher physician density (adjusted rate ratio [aRR] 0.81; 95% Confidence Interval [CI] 0.71-0.91), higher sustainable access to water and sanitation (aRR 0.85; 95% CI 0.78-0.93), and having a less corrupt government (aRR 0.57; 95% CI 0.40-0.80). Out-of-pocket expenditures on health (aRR 1.29; 95% CI 1.03-1.62) were a risk factor. The same four variables were significantly related to CMR after controlling for other variables. Protective determinants of MMR included access to water and sanitation (aRR 0.88; 95% CI 0.82-0.94), having a less corrupt government (aRR 0.49; 95%; CI 0.36-0.66), and higher total expenditures on health per capita (aRR 0.84; 95% CI 0.77-0.92). Higher fertility rates (aRR 2.85; 95% CI: 2.02-4.00) were found to be a significant risk factor for MMR.ConclusionSeveral key measures of a health system predict mortality in infants, children, and maternal mortality rates at the national level. Improving access to water and sanitation and reducing corruption within the health sector should become priorities.

The prevalence of mental illness is alarmingly high in this population-based sample of food insecure Canadians. These findings suggest that government and community-based programming aimed at strengthening food security should integrate supports for mental illness in this population.

Structured Summary Background Adherence to antiretroviral therapy (ART) is a necessary condition to the improvement of HIV patient health and public health through ART. This study sought to determine the comparative effectiveness of different interventions for improving ART adherence among HIV-infected persons living in Africa. Methods We searched for randomized trials that evaluated an intervention to promote antiretroviral adherence within Africa. We created a network of the differing interventions by pooling the published and individual patient data for comparable treatments and comparing them across the individual interventions using Bayesian network meta-analyses. Outcomes included self-reported adherence and viral suppression. Findings We obtained data on 14 randomized controlled trials, involving 7,110 patients. Interventions included daily and weekly short message service (SMS) messaging, calendars, peer supporters, alarms, counseling, and basic and enhanced standard of care (SOC). For self-reported adherence, we found distinguishable improvement in adherence compared to SOC with enhanced SOC (odds ratio [OR]: 1.46, 95% credibility interval [CrI]: 1.06–1.98), weekly SMS messages (OR:1.65; 95% CrI: 1.25–2.18), counseling and SMS combined (OR:2.07; 95% CrI: 1.22–3.53), and treatment supporters (OR:1.83; 95% CrI:1.36–2.45). We found no compelling evidence for the remaining interventions. Results were similar when using viral suppression as an outcome, although the network of evidence was sparser. Treatment supporters with enhanced SOC (OR:1.46; 95% CrI: 1.09–1.97) and weekly SMS messages (OR:1.55; 95% CrI: 1.00–2.39) were significantly superior to basic SOC. Interpretation Several recommendations for improving adherence are unsupported by the available evidence. These findings should influence guidance documents on improving ART adherence in poor settings.