Showing papers in "Bulletin of The World Health Organization in 2006"

Assessing country-level efforts to link research to action

Abstract: We developed a framework for assessing country-level efforts to link research to action. The framework has four elements. The first element assesses the general climate (how those who fund research, universities, researchers and users of research support or place value on efforts to link research to action). The second element addresses the production of research (how priority setting ensures that users' needs are identified and how scoping reviews, systematic reviews and single studies are undertaken to address these needs). The third element addresses the mix of four clusters of activities used to link research to action. These include push efforts (how strategies are used to support action based on the messages arising from research), efforts to facilitate "user pull" (how "one-stop shopping" is provided for optimally packaged high-quality reviews either alone or as part of a national electronic library for health, how these reviews are profiled during "teachable moments" such as intense media coverage, and how rapid-response units meet users' needs for the best research), "user pull" efforts undertaken by those who use research (how users assess their capacity to use research and how structures and processes are changed to support the use of research) and exchange efforts (how meaningful partnerships between researchers and users help them to jointly ask and answer relevant questions). The fourth element addresses approaches to evaluation (how support is provided for rigorous evaluations of efforts to link research to action).

Mental illness and suicidality after Hurricane Katrina

Abstract: Objective To estimate the impact of Hurricane Katrina on mental illness and suicidality by comparing results of a post-Katrina survey with those of an earlier survey. Methods The National Comorbidity Survey-Replication, conducted between February 2001 and February 2003, interviewed 826 adults in the Census Divisions later affected by Hurricane Katrina. The post-Katrina survey interviewed a new sample of 1043 adults who lived in the same area before the hurricane. Identical questions were asked about mental illness and suicidality. The post-Katrina survey also assessed several dimensions of personal growth that resulted from the trauma (for example, increased closeness to a loved one, increased religiosity). Outcome measures used were the K6 screening scale of serious mental illness and mild–moderate mental illness and questions about suicidal ideation, plans and attempts. Findings Respondents to the post-Katrina survey had a significantly higher estimated prevalence of serious mental illness than respondents to the earlier survey (11.3% after Katrina versus 6.1% before; c²1= 10.9; P < 0.001) and mild–moderate mental illness (19.9% after Katrina versus 9.7% before; c²1 = 22.5; P < 0.001). Among respondents estimated to have mental illness, though, the prevalence of suicidal ideation and plans was significantly lower in the post-Katrina survey (suicidal ideation 0.7% after Katrina versus 8.4% before; c²1 = 13.1; P < 0.001; plans for suicide 0.4% after Katrina versus 3.6% before; c²1 = 6.0; P = 0.014). This lower conditional prevalence of suicidality was strongly related to two dimensions of personal growth after the trauma (faith in one’s own ability to rebuild one’s life, and realization of inner strength), without which between-survey differences in suicidality were insignificant. Conclusion Despite the estimated prevalence of mental illness doubling after Hurricane Katrina, the prevalence of suicidality was unexpectedly low. The role of post-traumatic personal growth in ameliorating the effects of trauma-related mental illness on suicidality warrants further investigation.

Verbal autopsy: current practices and challenges

Abstract: Cause-of-death data derived from verbal autopsy (VA) are increasingly used for health planning, priority setting, monitoring and evaluation in countries with incomplete or no vital registration systems. In some regions of the world it is the only method available to obtain estimates on the distribution of causes of death. Currently, the VA method is routinely used at over 35 sites, mainly in Africa and Asia. In this paper, we present an overview of the VA process and the results of a review of VA tools and operating procedures used at demographic surveillance sites and sample vital registration systems. We asked for information from 36 field sites about field-operating procedures and reviewed 18 verbal autopsy questionnaires and 10 cause-of-death lists used in 13 countries. The format and content of VA questionnaires, field-operating procedures, cause-of-death lists and the procedures to derive causes of death from VA process varied substantially among sites. We discuss the consequences of using varied methods and conclude that the VA tools and procedures must be standardized and reliable in order to make accurate national and international comparisons of VA data. We also highlight further steps needed in the development of a standard VA process.

Causes of stillbirths and early neonatal deaths: data from 7993 pregnancies in six developing countries

Abstract: OBJECTIVE: To report stillbirth and early neonatal mortality and to quantify the relative importance of different primary obstetric causes of perinatal mortality in 171 perinatal deaths from 7993 pregnancies that ended after 28 weeks in nulliparous women. METHODS: A review of all stillbirths and early newborn deaths reported in the WHO calcium supplementation trial for the prevention of pre-eclampsia conducted at seven WHO collaborating centres in Argentina, Egypt, India, Peru, South Africa and Viet Nam. We used the Baird-Pattinson system to assign primary obstetric causes of death and classified causes of early neonatal death using the International classification of diseases and related health problems, Tenth revision (ICD-10). FINDINGS: Stillbirth rate was 12.5 per 1000 births and early neonatal mortality rate was 9.0 per 1000 live births. Spontaneous preterm delivery and hypertensive disorders were the most common obstetric events leading to perinatal deaths (28.7% and 23.6%, respectively). Prematurity was the main cause of early neonatal deaths (62%). CONCLUSIONS: Advancements in the care of premature infants and prevention of spontaneous preterm labour and hypertensive disorders of pregnancy could lead to a substantial decrease in perinatal mortality in hospital settings in developing countries.

Methods for establishing a surveillance system for cardiovascular diseases in Indian industrial populations

Abstract: OBJECTIVE: To establish a surveillance network for cardiovascular diseases (CVD) risk factors in industrial settings and estimate the risk factor burden using standardized tools. METHODS: We conducted a baseline cross-sectional survey (as part of a CVD surveillance programme) of industrial populations from 10 companies across India, situated in close proximity to medical colleges that served as study centres. The study subjects were employees (selected by age and sex stratified random sampling) and their family members. Information on behavioural, clinical and biochemical determinants was obtained through standardized methods (questionnaires, clinical measurements and biochemical analysis). Data collation and analyses were done at the national coordinating centre. FINDINGS: We report the prevalence of CVD risk factors among individuals aged 20-69 years (n = 19 973 for the questionnaire survey, n = 10 442 for biochemical investigations); mean age was 40 years. The overall prevalence of most risk factors was high, with 50.9% of men and 51.9% of women being overweight, central obesity was observed among 30.9% of men and 32.8% of women, and 40.2% of men and 14.9% of women reported current tobacco use. Self-reported prevalence of diabetes (5.3%) and hypertension (10.9%) was lower than when measured clinically and biochemically (10.1% and 27.7%, respectively). There was marked heterogeneity in the prevalence of risk factors among the study centres. CONCLUSION: There is a high burden of CVD risk factors among industrial populations across India. The surveillance system can be used as a model for replication in India as well as other developing countries.

Responsive parenting: interventions and outcomes

Abstract: In addition to food, sanitation and access to health facilities children require adequate care at home for survival and optimal development. Responsiveness, a mother's/caregiver's prompt, contingent and appropriate interaction with the child, is a vital parenting tool with wide-ranging benefits for the child, from better cognitive and psychosocial development to protection from disease and mortality. We examined two facets of responsive parenting -- its role in child health and development and the effectiveness of interventions to enhance it -- by conducting a systematic review of literature from both developed and developing countries. Our results revealed that interventions are effective in enhancing maternal responsiveness, resulting in better child health and development, especially for the neediest populations. Since these interventions were feasible even in poor settings, they have great potential in helping us achieve the Millennium Development Goals. We suggest that responsiveness interventions be integrated into child survival strategies.

Effect of the HIV epidemic on infant feeding in South Africa: "When they see me coming with the tins they laugh at me".

Abstract: Objective To explore how the human immunodeficiency virus (HIV) epidemic has affected the infant-feeding experiences of HIVpositive mothers in South Africa. Methods This was a qualitative interview study within a prospective cohort study. We purposively selected a subsample of 40 women from a larger cohort of 650 HIV-positive mothers for in-depth interviews. Findings The HIV epidemic has changed the context in which infant-feeding choices are made and implemented. HIV-positive mothers in this study — who were predominantly young, single and unemployed — were struggling to protect their decision-making autonomy. Uncertainty about the safety of breastfeeding has increased the power and influence of health workers, who now act as gatekeepers to not only this new knowledge but also to essential resources such as formula milk. Fear of disclosure of HIV status and stigma has also weakened the ability of mothers to resist entrenched family and community norms that encourage early introduction of fluids and foods and that question non-breastfeeding. Women who chose to exclusively formula feed had difficulties accessing formula milk because of inflexible policies and a lack of supplies at clinics. Limited postpartum support led to social isolation and mothers doubting their ability to care for their children. Conclusion The infant-feeding experiences of HIV-positive mothers have serious implications for the operational effectiveness of programmes that aim to prevent HIV transmission from mother to child. A better understanding of how HIV is changing infant-feeding practices can inform the development of interventions to improve infant-feeding counselling and postpartum support.

Improved triage and emergency care for children reduces inpatient mortality in a resource-constrained setting.

Abstract: PROBLEM: Early assessment, prioritization for treatment and management of sick children attending a health service are critical to achieving good outcomes. Many hospitals in developing countries see large numbers of patients and have few staff, so patients often have to wait before being assessed and treated. APPROACH: We present the example of a busy Under-Fives Clinic that provided outpatient services, immunizations and treatment for medical emergencies. The clinic was providing an inadequate service resulting in some inappropriate admissions and a high case-fatality rate. We assessed the deficiencies and sought resources to improve services. LOCAL SETTING: A busy paediatric outpatient clinic in a public tertiary care hospital in Blantyre, Malawi. RELEVANT CHANGES: The main changes we made were to train staff in emergency care and triage, improve patient flow through the department and to develop close cooperation between inpatient and outpatient services. Training coincided with a restructuring of the physical layout of the department. The changes were put in place when the department reopened in January 2001. LESSONS LEARNED: Improvements in the process and delivery of care and the ability to prioritize clinical management are essential to good practice. Making the changes described above has streamlined the delivery of care and led to a reduction in inpatient mortality from 10-18% before the changes were made (before 2001) to 6-8% after.

Rates, timing and causes of neonatal deaths in rural India: implications for neonatal health programmes

Abstract: OBJECTIVE: To assess the rates, timing and causes of neonatal deaths and the burden of stillbirths in rural Uttar Pradesh, India. We discuss the implications of our findings for neonatal interventions. METHODS: We used verbal autopsy interviews to investigate 1048 neonatal deaths and stillbirths. FINDINGS: There were 430 stillbirths reported, comprising 41% of all deaths in the sample. Of the 618 live births, 32% deaths were on the day of birth, 50% occurred during the first 3 days of life and 71% were during the first week. The primary causes of death on the first day of life (i.e. day 0) were birth asphyxia or injury (31%) and preterm birth (26%). During days 1-6, the most frequent causes of death were preterm birth (30%) and sepsis or pneumonia (25%). Half of all deaths caused by sepsis or pneumonia occurred during the first week of life. The proportion of deaths attributed to sepsis or pneumonia increased to 45% and 36% during days 7-13 and 14-27, respectively. CONCLUSION: Stillbirths and deaths on the day of birth represent a large proportion of perinatal and neonatal deaths, highlighting an urgent need to improve coverage with skilled birth attendants and to ensure access to emergency obstetric care. Health interventions to improve essential neonatal care and care-seeking behavior are also needed, particularly for preterm neonates in the early postnatal period.

Using knowledge brokering to promote evidence-based policy-making: the need for support structures

Abstract: Knowledge brokering is a promising strategy to close the "know-do gap" and foster greater use of research findings and evidence in policy-making. It focuses on organizing the interactive process between the producers and users of knowledge so that they can co-produce feasible and research-informed policy options. We describe a recent successful experience with this novel approach in the Netherlands and discuss the requirements for effective institutionalization of knowledge brokering. We also discuss the potential of this approach to assist health policy development in low-income countries based on the experience of developing the Regional East-African Health (REACH)-Policy Initiative. We believe that intermediary organizations, such as regional networks, dedicated institutional mechanisms and funding agencies, can play key roles in supporting knowledge brokering. We recommend the need to support and learn from the brokerage approach to strengthen the relationship between the research and policy communities and hence move towards a stronger culture of evidence-based policy and policy-relevant research.

The knowledge-value chain: a conceptual framework for knowledge translation in health

Abstract: This article briefly discusses knowledge translation and lists the problems associated with it. Then it uses knowledge-management literature to develop and propose a knowledge-value chain framework in order to provide an integrated conceptual model of knowledge management and application in public health organizations. The knowledge-value chain is a non-linear concept and is based on the management of five dyadic capabilities: mapping and acquisition, creation and destruction, integration and sharing/transfer, replication and protection, and performance and innovation.

HIV testing in national population-based surveys: experience from the Demographic and Health Surveys

Abstract: OBJECTIVES: To describe the methods used in the Demographic and Health Surveys (DHS) to collect nationally representative data on the prevalence of human immunodeficiency virus (HIV) and assess the value of such data to country HIV surveillance systems. METHODS: During 2001-04, national samples of adult women and men in Burkina Faso, Cameroon, Dominican Republic, Ghana, Mali, Kenya, United Republic of Tanzania and Zambia were tested for HIV. Dried blood spot samples were collected for HIV testing, following internationally accepted ethical standards. The results for each country are presented by age, sex, and urban versus rural residence. To estimate the effects of non-response, HIV prevalence among non-responding males and females was predicted using multivariate statistical models for those who were tested, with a common set of predictor variables. RESULTS: Rates of HIV testing varied from 70% among Kenyan men to 92% among women in Burkina Faso and Cameroon. Despite large differences in HIV prevalence between the surveys (1-16%), fairly consistent patterns of HIV infection were observed by age, sex and urban versus rural residence, with considerably higher rates in urban areas and in women, especially at younger ages. Analysis of non-response bias indicates that although predicted HIV prevalence tended to be higher in non-tested males and females than in those tested, the overall effects of non-response on the observed national estimates of HIV prevalence are insignificant. CONCLUSIONS: Population-based surveys can provide reliable, direct estimates of national and regional HIV seroprevalence among men and women irrespective of pregnancy status. Survey data greatly enhance surveillance systems and the accuracy of national estimates in generalized epidemics.

Measuring the Impact of Intimate Partner Violence on the Health of Women in Victoria, Australia/Mesure Des Effets De la Violence Du Partenaire Sexuel Sur la Sante De la Femme Dans l'Etat De Victoria (Australie)/Medicion del Impacto De la Violencia De la Pareja En la Salud De la Mujer En Victoria (Australia)

Abstract: Introduction Reliable and comparable analysis of risks to health is essential for informing efforts to prevent disease and injury. (1) The burden of disease methodology provides a tool for estimating the impact of health problems and risky behaviours across a population, taking into account both illness and premature death. (2) Previous burden of disease studies have been criticized for failing to provide an accurate and comprehensive picture of the burden of disease and injury among women by excluding some reproductive health conditions associated with significant rates of morbidity, and by omitting to measure the contribution of important risk factors, such as intimate partner violence (IPV), to burden of disease. (3,4) Increasing evidence indicates that IPV is highly prevalent globally and has serious and long-lasting health consequences. (3,5) These include many disorders for which significant gender disparities in prevalence exist, such as depression, anxiety, eating disorders and reproductive and physical health problems. (6-9) To decrease gender disparities in health outcomes it is essential that the associated risk factors be clearly identified, measured and recognized as a priority for intervention. Globally, evidence on the prevalence and the health consequences of IPV is growing steadily but, to date, the contribution of IPV to the burden of disease has not been estimated. The overall aim of our study was to estimate the contribution of IPV to the total burden of disease for women living in Victoria, Australia, in 2001. We were able to carry out this study due to the availability of good prevalence data on exposure to IPV and survey data on the health consequences of IPV in Australia, combined with a keen interest among government and nongovernmental organizations in Victoria. The first estimates of burden of disease for Victoria were developed for 1996 and updated to 2001 including IPV as a risk factor for the first time. (10,11) Methods Using the comparative risk assessment methods, we estimated the disease burden attributable to a particular risk factor by comparing current health status with a theoretical minimum counterfactual status. (1,12) For IPV, the theoretical minimum was defined by the counterfactual status of no past or current exposure to IPV in a population. The attributable fraction of disease burden in the population was determined by the prevalence of exposure to the risk factor and the relative risk of disease occurrence attributed to exposure. We then applied the attributable factions to overall population estimates of mortality or disability burden for each of the health outcomes causally linked with the risk factor. Prevalence The national Women's Safety Survey (WSS) constitutes the most recent, comprehensive measurement of the prevalence of IPV in Australia. (13) We used two categories of exposure to IPV--physical or sexual violence by a partner in the past 12 months and physical or sexual violence by a partner more than 12 months ago (Table 1). We opted to use the Australian prevalence as the Victorian age-specific estimates had wide confidence intervals. Health outcomes We based most of our estimates of the risk of adverse health outcomes on the Australian Longitudinal Study on Women's Health (ALSWH). (14) Three representative cohorts of Australian women aged 18-23, 45-50 and 70-75 years when first surveyed in 1996, have been re-surveyed at three-year intervals. (15) We obtained data from the first two surveys from the study custodians (1996 and 2000 for the youngest cohort; 1996 and 1998 for the middle-aged cohort). The sample sizes for each cohort at first interview were 14 739 and 14 011 for the youngest and middle-aged cohorts, respectively. For the youngest cohort we defined exposure to IPV by combining separate questions on "being pushed, grabbed, shoved, kicked, or hit", "being forced to take part in unwanted sexual activity" and "ever having been in a violent relationship with a partner/spouse". …

Cause-specific mortality rates in sub-Saharan Africa and Bangladesh.

Abstract: OBJECTIVE: To provide internationally comparable data on the frequencies of different causes of death. METHODS: We analysed verbal autopsies obtained during 1999 -2002 from 12 demographic surveillance sites in sub-Saharan Africa and Bangladesh to find cause-specific and age-specific mortality rates. The cause-of-death codes used by the sites were harmonized to conform to the ICD-10 system, and summarized with the classification system of the Global Burden of Disease 2000 (Version 2). FINDINGS: Causes of death in the African sites differ strongly from those in Bangladesh, where there is some evidence of a health transition from communicable to noncommunicable diseases, and little malaria. HIV dominates in causes of mortality in the South African sites, which contrast with those in highly malaria endemic sites elsewhere in sub-Saharan Africa (even in neighbouring Mozambique). The contributions of measles and diarrhoeal diseases to mortality in sub-Saharan Africa are lower than has been previously suggested, while malaria is of relatively greater importance. CONCLUSION: The different patterns of mortality we identified may be a result of recent changes in the availability and effectiveness of health interventions against childhood cluster diseases.

Measuring the impact of intimate partner violence on the health of women in Victoria, Australia

Abstract: OBJECTIVE Using burden of disease methodology, estimate the health risks of intimate partner violence (IPV) among women in Victoria, Australia. METHODS We calculated population attributable fractions (from survey data on the prevalence of IPV and the relative risks of associated health problems in Australia) and determined health outcomes by applying them to disability-adjusted life year estimates for the relevant disease and injury categories for Victoria, Australia for 2001. FINDINGS For women of all ages IPV accounted for 2.9% (95% uncertainty interval 2.4-3.4%) of the total disease and injury burden. Among women 18-44 years of age, IPV was associated with 7.9% (95% uncertainty interval 6.4-9.5%) of the overall disease burden and was a larger risk to health than risk factors traditionally included in burden of disease studies, such as raised blood pressure, tobacco use and increased body weight. Poor mental health contributed 73% and substance abuse 22% to the disease burden attributed to IPV. CONCLUSION Our findings suggest that IPV constitutes a significant risk to women's health. Mental health policy-makers and health workers treating common mental health problems need to be aware that IPV is an important risk factor. Future research should concentrate on evaluating effective interventions to prevent women being exposed to violence, and identifying the most appropriate mental health care for victims to reduce short- and long-term disability.

Performance-based financing and changing the district health system: experience from Rwanda

Abstract: Evidence from low-income Asian countries shows that performance-based financing (as a specific form of contracting) can improve health service delivery more successfully than traditional input financing mechanisms. We report a field experience from Rwanda demonstrating that performance-based financing is a feasible strategy in sub-Saharan Africa too. Performance-based financing requires at least one new actor, an independent well equipped fundholder organization in the district health system separating the purchasing, service delivery as well as regulatory roles of local health authorities from the technical role of contract negotiation and fund disbursement. In Rwanda, local community groups, through patient surveys, verified the performance of health facilities and monitored consumer satisfaction. A precondition for the success of performance-based financing is that authorities must respect the autonomous management of health facilities competing for public subsidies. These changes are an opportunity to redistribute roles within the health district in a more transparent and efficient fashion.

Re-emerging schistosomiasis in hilly and mountainous areas of Sichuan, China

Abstract: Despite great strides in schistosomiasis control over the past several decades in Sichuan Province, China the disease has re-emerged in areas where it was previously controlled. We reviewed historical records and found that schistosomiasis had re-emerged in eight counties by the end of 2004 - seven of 21 counties with transmission control and one of 25 with transmission interruption as reported in 2001 were confirmed to have local disease transmission. The average "return time" (from control to re-emergence) was about eight years. The onset of re-emergence was commonly signalled by the occurrence of acute infections. Our survey results suggest that environmental and sociopolitical factors play an important role in re-emergence. The main challenge would be to consolidate and maintain effective control in the longer term until "real" eradication is achieved. This would be possible only by the formulation of a sustainable surveillance and control system.

Public-private partnerships for hospitals

Abstract: While some forms of public-private partnerships are a feature of hospital construction and operation in all countries with mixed economies, there is increasing interest in a model in which a public authority contracts with a private company to design, build and operate an entire hospital. Drawing on the experience of countries such as Australia, Spain, and the United Kingdom, this paper reviews the experience with variants of this model. Although experience is still very limited and rigorous evaluations lacking, four issues have emerged: cost, quality, flexibility and complexity. New facilities have, in general, been more expensive than they would have been if procured using traditional methods. Compared with the traditional system, new facilities are more likely to be built on time and within budget, but this seems often to be at the expense of compromises on quality. The need to minimize the risk to the parties means that it is very difficult to "future-proof" facilities in a rapidly changing world. Finally, such projects are extremely, and in some cases prohibitively, complex. While it is premature to say whether the problems experienced relate to the underlying model or to their implementation, it does seem that a public-private partnership further complicates the already difficult task of building and operating a hospital.

The links between agriculture and health: an intersectoral opportunity to improve the health and livelihoods of the poor

Abstract: Agriculture and health are linked in many ways. First, agriculture is essential for good health: it produces the world's food, fibre and materials for shelter; in many countries it is also an important source of livelihood among the poor. At the same time, agriculture can be linked with poor health, including malnutrition, malaria, foodborne illnesses, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), livestock-related diseases, chronic diseases and occupational ill-health. Health also affects agriculture: people's health status influences the demand for agricultural outputs, and in agricultural communities, poor health reduces work performance, reducing income and productivity and perpetuating a downward spiral into ill-health. This paper presents an overview of the bidirectional links between agriculture and health with a focus on the developing world. It develops a conceptual framework that brings together the various links between agriculture and health into a single broad framework. The framework comprises the core components of the agricultural supply chain (producers, systems and outputs), key health concerns and the mechanisms of common interaction between the agricultural and health components: income, labour, environment and access -- all key social determinants of health. These links between agriculture and health present an opportunity for the two sectors to work together to find solutions to each other's problems. Yet the health and agricultural sectors remain poorly coordinated. Leadership from global health and agricultural institutions is needed to build policies and good governance to facilitate integration, while capacity building is needed at all levels to help translate the conceptual links into comprehensive action on the ground. Health and agricultural researchers likewise need to work more closely together to achieve common goals.

Essential medicines and human rights: what can they learn from each other?

Abstract: Most countries have acceded to at least one global or regional covenant or treaty confirming the right to health. After years of international discussions on human rights, many governments are now moving towards practical implementation of their commitments. A practical example may be of help to those governments who aim to translate their international treaty obligations into practice. WHO's Essential Medicines Programme is an example of how this transition from legal principles to practical implementation may be achieved. This programme has been consistent with human rights principles since its inception in the early 1980s, through its focus on equitable access to essential medicines. This paper provides a brief overview of what the international human rights instruments mention about access to essential medicines, and proposes five assessment questions and practical recommendations for governments. These recommendations cover the selection of essential medicines, participation in programme development, mechanisms for transparency and accountability, equitable access by vulnerable groups, and redress mechanisms. Bulletin of the World Health Organization 2006;84:371-375.

Medical ethics manual.

Abstract: Getting health reform right: a guide to improving performance and equity Authors: Marc J Roberts, William Hsiao, Peter Berman, Michael R Reich. Publisher: Oxford University Press, Oxford; 2003 ISBN: 0-19-516232-3; hardcover, 332 pages; price 29.99 [pounds sterling] The Director-General of WHO, Dr LEE Jong-wook, identifies comprehensive engagement with, and strengthening of, health systems as necessary starting points for managing global public health challenges. Addressing health systems issues and strengthening the health systems within which health programmes operate, rather than investing in programmes alone, will improve programme effectiveness and the chances of sustainability. This book has a number of strengths. First, it is written by an eminent group of scholars who have hands-on experience of health reforms in a range of settings. Second, it seamlessly links theory and practice and elegantly blends concepts with practical examples to paint a picture of reforms and their associated complexities. Third, it offers a number of analytical frameworks to enable those involved in designing, implementing or evaluating reforms to consider critically the value system within which the reforms take place. Fourth, it describes health system "control knobs" (health system financing, payment, regulation, organization and behaviour) which policy-makers can use to achieve their set goals and objectives. Fifth, it establishes the continuum between outcomes, objectives and interventions (control knobs) to enable policy-makers to consider health reform as a whole rather than separately. The book consists of two parts: Part I concentrates on health system analysis, emphasizing that ethical and political economy considerations are the starting points for reforms; and Part II describes the five control knobs available to policy-makers, with the final chapter linking analysis with execution. The authors argue that a clear understanding of the context, and in particular the value system within a given country, is critical for understanding and shaping the goals and objectives of health reforms. Distinguished are three value systems which shape societal and political preferences in terms of health system goals, objectives and elements: utilitarianism, liberalism and communitarianism. Two variants of each of these value systems are s 2) libertarians, who want minimal interference from the state to pursue their own life (and health) preferences and egalitarians, who eschew positive rights, emphasizing that people should be given the "opportunity" to realize rights, such as health; and 3) universal communitarians (who share a common value system and espouse this) and relative communitarians (who celebrate diversity). …

Understanding Enrolment in Community Health Insurance in Sub-Saharan Africa: A Population-Based Case-Control Study in Rural Burkina Faso/Motifs De la Souscription D'une Assurance-Maladie Communautaire Par Les Habitants De l'Afrique Sub-Saharienne: Etude Cas-Temoin En Population Rurale Menee Au Burkina Faso/Analisis De la Decision De Acogerse a Un Seguro Medico Comunitario En El Africa

Abstract: Introduction Community health insurance (CHI) is receiving increased attention as a means of health financing in low- and middle-income countries. In countries with limited ability to develop and sustain national health insurance programmes, CHI has emerged as a valuable alternative to user fees since, by pooling risks and resources at the community level, it promises to ensure better access to health services and greater financial protection against the costs of illness for traditionally excluded and disadvantaged populations. (1-3) In practice, however, CHI often falls short of achieving its potential, primarily because it fails to secure satisfactory levels of participation.(4-7) Although the inability to secure satisfactory enrolment rates among target populations remains a major concern across all low- and middle-income countries, (4,8-10) the problem assumes acute proportions in sub-Saharan Africa, where schemes rarely attain 10% coverage among target populations. (7) For this reason, they often cease to exist within a few years of their inception. (4,7,11) Although the problem of low enrolment has long dominated the policy debate, rigorous scientific evaluations of the factors affecting the decision to enrol in CHI in sub-Saharan Africa are still very scarce. (6,12) While several studies have documented voluntary health insurance experiences in Asia, (8,10,13-16) only a limited number of evaluations have explored the factors influencing the decision to enrol or not to enrol in CHI in sub-Saharan countries. (17-19) The literature on CHI in sub-Saharan Africa has long been dominated by consultancy reports, which have focused on assessing the managerial and financial capacity of existing schemes rather than systematically exploring the factors motivating or discouraging enrolment. (20-23) Understanding the reasons behind low enrolment rates is therefore a relevant research question. Our study aimed to identify factors shaping the decision to enrol in CHI in a population-based study applying a case-control methodology. We hypothesized that the decision to enrol in CHI was shaped by a combination of household head, household and community characteristics. The study was conducted in the Nouna Health District, Burkina Faso, in 2004. Methods Research setting The Nouna Health District is located in the northwest of the country, about 300 km from the capital, Ouagadougou. A CHI scheme was initiated there at the beginning of 2004. The aim is to set up a district-wide scheme by progressively offering CHI to all the villages of the district and to all sectors of the district capital, the town of Nouna. Our study is limited to those parts of the district--12 villages and 3 town sectors--in which the first enrolment campaign took place between February and May 2004. The insurance product on offer was identical across the 15 communities. The unit of enrolment was the household. The yearly premium amounted to 1500 CFA francs (US$ 3) for each adult and 500 CFA francs (US$ 1) for each child (less than 15 years of age). The benefit package included a wide range of first-line and second-line services that were available at the health facilities within the district. It excluded reimbursement for all traditional healing practices. Decisions regarding the services that should be included and those that should be excluded from the benefit package were guided by the results of a study which explored community preferences for such a package prior to the implementation of the scheme. This study and details of the benefit package are described in detail elsewhere. (24,25) Depending on their geographic location, villages and town sectors were designated to receive primary care either at one of five rural first-line facilities or at the urban first-line facility located on the premises of the district hospital. If referred, all patients were entitled to receive secondary care at the district hospital. …

Accelerating reproductive and child health programme impact with community-based services: The Navrongo experiment in Ghana

Abstract: OBJECTIVE: To determine the demographic and health impact of deploying health service nurses and volunteers to village locations with a view to scaling up results. METHODS: A four-celled plausibility trial was used for testing the impact of aligning community health services with the traditional social institutions that organize village life. Data from the Navrongo Demographic Surveillance System that tracks fertility and mortality events over time were used to estimate impact on fertility and mortality. RESULTS: Assigning nurses to community locations reduced childhood mortality rates by over half in 3 years and accelerated the time taken for attainment of the child survival Millennium Development Goal (MDG) in the study areas to 8 years. Fertility was also reduced by 15%, representing a decline of one birth in the total fertility rate. Programme costs added 1.92 US Dollar per capita to the 6.80 US Dollar per capita primary health care budget. CONCLUSION: Assigning nurses to community locations where they provide basic curative and preventive care substantially reduces childhood mortality and accelerates progress towards attainment of the child survival MDG. Approaches using community volunteers, however, have no impact on mortality. The results also demonstrate that increasing access to contraceptive supplies alone fails to address the social costs of fertility regulation. Effective deployment of volunteers and community mobilization strategies offsets the social constraints on the adoption of contraception. The research in Navrongo thus demonstrates that affordable and sustainable means of combining nurse services with volunteer action can accelerate attainment of both the International Conference on Population and Development agenda and the MDGs.

Suicide, suicide attempts and pesticides: a major hidden public health problem

Abstract: In addition to its specific focus on self-directed violence, the paper by Eddleston et al. in this issue of the Bulletin highlights how intersectoral collaboration can be crucial to furthering the cause of public health. (1) With nearly 900 000 deaths from suicide every year, worldwide, (2) suicide takes more lives than homicides and wars combined; it is commonly acknowledged that this figure is an underestimation and that the real magnitude can barely be guessed. Added to these deaths are the many non-fatal suicide attempts, some of which are addressed by Eddleston et al. In the absence of national registries or reliable hospital-based systems for recording suicide attempts, a large-scale study was conducted by the WHO Regional Office for Europe to estimate the number of suicide attempts in several European cities of various sizes. (3) The findings were compared with corresponding national rates for completed suicides, and showed suicide attempt rates to be 10-40 times higher than rates for completed suicides. Projecting these figures to the global total of completed suicides would give the mind-boggling worldwide estimate of between 9-36 million suicide attempts every year. Whatever the real numbers, self-directed violence clearly constitutes a major public health challenge that health planners, policy-makers and practitioners simply cannot afford to ignore. Imprecision in recording efforts does not only affect the figures for suicide. For every real case of suicide that is misrecorded as something else (e.g. accident, stroke or cardiac arrest), another mortality category will be unduly inflated, thus distorting the entire system of mortality records. Individual studies on the reliability of suicide mortality recording have indicated that numbers of deaths may be underestimated by 30-200%. (W4) Reliable information on suicide mortality and suicide attempts is therefore not only useful for better planning and delivery of suicide prevention programmes, but will also help to provide a clearer picture of the mortality attributable to other causes, particularly those indicated above. Perhaps even less well understood is the specific link between suicide and pesticides, which is significant in rural areas generally and in Asian countries in particular. It is estimated that in the last 10 years between 60-90% of suicides in China, Malaysia, Sri Lanka, and Trinidad and Tobago were by pesticide ingestion. (W5) This led Gunnell & Eddleston to estimate that there are as many as 300 000 deaths each year from intentional pesticide poisoning in those parts of the world. (W6) More recently, WHO has received reports of a growing number of suicides due to pesticide ingestion in many other Asian countries and in Central and South American countries (e.g. Brazil, El Salvador, Guatemala, Guyana, Nicaragua and Paraguay). This may well mean that the global number of suicide deaths is considerably higher than currently estimated, and clearly makes pesticide ingestion the most common method of suicide on a worldwide basis. This new information provides clear indications of directions for action. …

Multicentre Study of Acute Alcohol Use and Non-Fatal Injuries: Data from the WHO Collaborative Study on Alcohol and Injuries/ Etude Multicentrique De la Relation Entre Abus D'alcool et Traumatismes Non Mortels : Donnees Fournies Par Une Etude Collective Menee Par l'OMS Sur le Theme Alcools et traumatismes/Estudio Multicentrico Sobre Consumo Agudo De Alcohol Y Traumatismos No Mortales: Datos De Un Estudio

Abstract: [TEXT NOT REPRODUCIBLE IN ASCII] Introduction Reports of alcohol use that used the case-crossover design have shown that alcohol use is a strong risk factor for all causes of non-fatal injuries among patients attending emergency departments. (1-4) These reports, along with others that have sampled patients in the general population, have concluded that alcohol use is associated with driving accidents, (5) violence, (6,7) suicide,(8) and injuries such as falls, trips and burns--that is, non-traffic injuries in general. (9-14) The unique feature of the case-crossover study is that this method allows the effect of acute alcohol use to be separated from chronic effects of consumption (such as those that occur in people who abuse alcohol or are dependent on it). (15) Both are matters of great interest to public health policy-makers, such as when trying to establish "safe limits" for drinking across various situations, (16) and in injury epidemiology. (17) The case-cross-over method seems especially appropriate when studying the risk of non-fatal injury among people who consume only low levels or moderate levels of alcohol, (18) when assessing differences in risk across modes of injury (1) and when determining whether alcoholics may have a different risk of non-fatal injury compared with non-dependent drinkers. (19) Although these issues have been pardally addressed in prior case-crossover reports, (1,4,20) which have found mixed results, an important factor in a detailed analysis of these issues is the small sample size used in most studies, which affects the power of the analysis of the effects on those who consume only small amounts of alcohol and the comparisons that are made across key modifiers of the effects. The WHO collaborative study on alcohol and injuries (21) is a large multicentre survey of injured patients presenting in hospitals worldwide; its data can be used to help circumvent these limitations. The goals of this paper are to report on the risk of non-fatal injury according to levels of acute use of alcohol; thus, looking at a dose-response relationship. We also seek to compare risk estimates for patients who are heavy drinkers and those who are chronic alcoholics across modes of injury. Methods Data from the WHO collaborative study on alcohol and injuries were collected in 2001-02 from emergency departments in Argentina, Belarus, Brazil, Canada, China, the Czech Republic, India, Mexico, Mozambique, New Zealand, South Africa and Sweden. The methods used were similar to those used previously in emergency department studies in a number of countries. (22) Probability samples were drawn from patients admitted within 6 hours of an injury at each site; each shift during each day of the week was represented equally in the sampling. The target sample size was 500 patients from each site. Patients were approached as soon as possible to obtain informed consent for participation in the study. The total sample size of participants aged 18 years or older was 5243 patients, representing a 91% response rate. In their interviews, researchers at two sites (Mozambique and South Africa) did not include the questions required for case-crossover analysis and their data were excluded, leaving a final sample size of 4320 participants. Interviewers were trained and supervised by study collaborators. Interviewers administered a standard 25-minute questionnaire. Further details on the sample have been presented elsewhere. (21) Interview The questionnaire was translated and then back-translated into each language; it included questions on whether the participant reported drinking during the 6 hours before the injury, an estimate of the amount of alcohol consumed during the same 6-hour period in the previous week, an estimate of the number of drinks consumed during each period, and the usual quantity of alcohol consumed and the frequency of alcohol use during the past year. …

Multicentre study of acute alcohol use and non-fatal injuries: data from the WHO collaborative study on alcohol and injuries.

Abstract: OBJECTIVES: To study the risk of non-fatal injury at low levels and moderate levels of alcohol consumption as well as the differences in risk across modes of injury and differences among alcoholics. METHODS: Data are from patients aged 18 years and older collected in 2001-02 by the WHO collaborative study on alcohol and injuries from 10 emergency departments around the world (n = 4320). We used a case-crossover method to compare the use of alcohol during the 6 hours prior to the injury with the use of alcohol during same day of the week in the previous week. FINDINGS: The risk of injury increased with consumption of a single drink (odds ratio (OR) = 3.3; 95% confidence interval = 1.9-5.7), and there was a 10-fold increase for participants who had consumed six or more drinks during the previous 6 hours. Participants who had sustained intentional injuries were at a higher risk than participants who had sustained unintentional injuries. Patients who had no symptoms of alcohol dependence had a higher OR. CONCLUSION: Since low levels of drinking were associated with an increased risk of sustaining a non-fatal injury, and patients who are not dependent on alcohol may be at higher risk of becoming injured, comprehensive strategies for reducing harm should be implemented for all drinkers seen in emergency departments.

Understanding enrolment in community health insurance in sub-Saharan Africa: a population-based case-control study in rural Burkina Faso

Abstract: OBJECTIVE: To identify factors associated with decision to enrol in a community health insurance (CHI) scheme. METHODS: We conducted a population-based case-control study among 15 communities offered insurance in 2004 in rural Burkina Faso. For inclusion in the study, we selected all 154 enrolled (cases) and a random sample of 393 non-enrolled (controls) households. We used unconditional logistic regression (applying Huber-White correction to account for clustering at the community level) to explore the association between enrolment status and a set of household head, household and community characteristics. FINDINGS: Multivariate analysis revealed that enrolment in CHI was associated with Bwaba ethnicity, higher education, higher socioeconomic status, a negative perception of the adequacy of traditional care, a higher proportion of children living within the household, greater distance from the health facility, and a lower level of socioeconomic inequality within the community, but not with household health status or previous household health service utilization. CONCLUSION: Our study provides evidence that the decision to enrol in CHI is shaped by a combination of household head, household, and community factors. Policies aimed at enhancing enrolment ought to act at all three levels. On the basis of our findings, we discuss specific policy recommendations and highlight areas for further research.

Systematic reviews and knowledge translation

Abstract: Proven effective interventions exist that would enable all countries to meet the Millennium Development Goals. However, uptake and use of these interventions in the poorest populations is at least 50% less than in the richest populations within each country. Also, we have recently shown that community effectiveness of interventions is lower for the poorest populations due to a "staircase" effect of lower coverage/access, worse diagnostic accuracy, less provider compliance and less consumer adherence. We propose an evidence-based framework for equity-oriented knowledge translation to enhance community effectiveness and health equity. This framework is represented as a cascade of steps to assess and prioritize barriers and thus choose effective knowledge translation interventions that are tailored for relevant audiences (public, patient, practitioner, policy-maker, press and private sector), as well as the evaluation, monitoring and sharing of these strategies. We have used two examples of effective interventions (insecticide-treated bednets to prevent malaria and childhood immunization) to illustrate how this framework can provide a systematic method for decision-makers to ensure the application of evidence-based knowledge in disadvantaged populations. Future work to empirically validate and evaluate the usefulness of this framework is needed. We invite researchers and implementers to use the cascade for equity-oriented knowledge translation as a guide when planning implementation strategies for proven effective interventions. We also encourage policy-makers and health-care managers to use this framework when deciding how effective interventions can be implemented in their own settings.