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Showing papers in "Bulletin of The World Health Organization in 2008"


Journal ArticleDOI
TL;DR: To demonstrate a method for using genetic epidemiological data to assess the needs for equitable and cost-effective services for the treatment and prevention of haemoglobin disorders, online databases, reference resources, and published articles are obtained.
Abstract: To demonstrate a method for using genetic epidemiological data to assess the needs for equitable and cost-effective services for the treatment and prevention of haemoglobin disorders. We obtained data on demographics and prevalence of gene variants responsible for haemoglobin disorders from online databases, reference resources, and published articles. A global epidemiological database for haemoglobin disorders by country was established, including five practical service indicators to express the needs for care (indicator 1) and prevention (indicators 2-5). Haemoglobin disorders present a significant health problem in 71% of 229 countries, and these 71% of countries include 89% of all births worldwide. Over 330,000 affected infants are born annually (83% sickle cell disorders, 17% thalassaemias). Haemoglobin disorders account for about 3.4% of deaths in children less than 5 years of age. Globally, around 7% of pregnant women carry b or a zero thalassaemia, or haemoglobin S, C, D Punjab or E, and over 1% of couples are at risk. Carriers and at-risk couples should be informed of their risk and the options for reducing it. Screening for haemoglobin disorders should form part of basic health services in most countries.

1,433 citations


Journal ArticleDOI
TL;DR: Substantial evidence revealed that the leading risk factors contributing to pneumonia incidence are lack of exclusive breastfeeding, undernutrition, indoor air pollution, low birth weight, crowding and lack of measles immunization.
Abstract: Childhood pneumonia is the leading single cause of mortality in children aged less than 5 years. The incidence in this age group is estimated to be 0.29 episodes per child-year in developing and 0.05 episodes per child-year in developed countries. This translates into about 156 million new episodes each year worldwide, of which 151 million episodes are in the developing world. Most cases occur in India (43 million), China (21 million) and Pakistan (10 million), with additional high numbers in Bangladesh, Indonesia and Nigeria (6 million each). Of all community cases, 7-13% are severe enough to be life-threatening and require hospitalization. Substantial evidence revealed that the leading risk factors contributing to pneumonia incidence are lack of exclusive breastfeeding, undernutrition, indoor air pollution, low birth weight, crowding and lack of measles immunization. Pneumonia is responsible for about 19% of all deaths in children aged less than 5 years, of which more than 70% take place in sub-Saharan Africa and south-east Asia. Although based on limited available evidence, recent studies have identified Streptococcus pneumoniae, Haemophilus influenzae and respiratory syncytial virus as the main pathogens associated with childhood pneumonia.

1,367 citations


Journal ArticleDOI
TL;DR: The results presented in this paper help to unearth a formerly hidden problem of public health dimensions and promote policy development and implementation, programmatic decision-making and corrective interventions, as well as stimulate research.
Abstract: Estimates of the prevalence of visual impairment caused by uncorrected refractive errors in 2004 have been determined at regional and global levels for people aged 5 years and over from recent published and unpublished surveys. The estimates were based on the prevalence of visual acuity of less than 6/18 in the better eye with the currently available refractive correction that could be improved to equal to or better than 6/18 by refraction or pinhole. A total of 153 million people (range of uncertainty: 123 million to 184 million) are estimated to be visually impaired from uncorrected refractive errors, of whom eight million are blind. This cause of visual impairment has been overlooked in previous estimates that were based on best-corrected vision. Combined with the 161 million people visually impaired estimated in 2002 according to best-corrected vision, 314 million people are visually impaired from all causes: uncorrected refractive errors become the main cause of low vision and the second cause of blindness. Uncorrected refractive errors can hamper performance at school, reduce employability and productivity, and generally impair quality of life. Yet the correction of refractive errors with appropriate spectacles is among the most cost-effective interventions in eye health care. The results presented in this paper help to unearth a formerly hidden problem of public health dimensions and promote policy development and implementation, programmatic decision-making and corrective interventions, as well as stimulate research.

963 citations


Journal ArticleDOI
TL;DR: In low-income countries, infectious diseases still account for a large proportion of deaths, highlighting health inequities largely caused by economic differences, and vaccination can cut health-care costs and reduce these inequities.
Abstract: In low-income countries, infectious diseases still account for a large proportion of deaths, highlighting health inequities largely caused by economic differences. Vaccination can cut health-care costs and reduce these inequities. Disease control, elimination or eradication can save billions of US dollars for communities and countries. Vaccines have lowered the incidence of hepatocellular carcinoma and will control cervical cancer. Travellers can be protected against "exotic" diseases by appropriate vaccination. Vaccines are considered indispensable against bioterrorism. They can combat resistance to antibiotics in some pathogens. Noncommunicable diseases, such as ischaemic heart disease, could also be reduced by influenza vaccination. Immunization programmes have improved the primary care infrastructure in developing countries, lowered mortality in childhood and empowered women to better plan their families, with consequent health, social and economic benefits. Vaccination helps economic growth everywhere, because of lower morbidity and mortality. The annual return on investment in vaccination has been calculated to be between 12% and 18%. Vaccination leads to increased life expectancy. Long healthy lives are now recognized as a prerequisite for wealth, and wealth promotes health. Vaccines are thus efficient tools to reduce disparities in wealth and inequities in health.

882 citations


Journal ArticleDOI
TL;DR: Screening criteria were defined to guide the selection of conditions that would be suitable for screening, based, among other factors, on the capacity to detect the condition at an early stage and the availability of an acceptable treatment.
Abstract: In their landmark publication, the authors were fundamentally preoccupied with the notion that:“The central idea of early disease detec-tion and treatment is essentially simple. However, the path to its successful achievement (on the one hand, bring-ing to treatment those with previously undetected disease, and, on the other, avoiding harm to those persons not in need of treatment) is far from simple though sometimes it may appear de-ceptively easy.”For this reason, Wilson and Jungner at-tempted to define screening criteria to guide the selection of conditions that would be suitable for screening, based, among other factors, on the capacity to detect the condition at an early stage and the availability of an acceptable treatment (Box 1). They considered these criteria “especially important when case-finding is carried out by a public health agency, where the pitfalls may be more numerous than when screening is performed by a personal physician”.Just as forty years ago, Wilson and Jungner wrote their treatise amidst a great deal of controversy surrounding the early detection of disease, there are now similar debates with respect to genetic screening. A growing number of diseases can now be detected in the pre-clinical stage, and even in the pre-pathological stage, using molecular and non-molecular diagnostic techniques.Large-scale screening for genetic conditions began around the time of the Wilson and Jungner publication. There was newborn screening for inborn errors of metabolism such as phenylketonuria, later followed by prenatal screening for Down syndrome and neural tube defects using ultrasound and biochemical mark-ers. Once individual disease genes started to be identified using novel molecular techniques, pilot screening programmes were established for several rare genetic conditions such as Tay Sachs disease and cystic fibrosis. With the advances in genetic technology, the rate at which new disease genes are being identified is out-pacing the ability of professionals and

749 citations


Journal ArticleDOI
TL;DR: The focus of this paper is the conflict between individual and public health in the ethics of research on humans and it is demonstrated that, while concern for the individual has predominated over the needs of public health since World War Two, in recent years there has been some movement towards redressing this imbalance.
Abstract: Determining the optimal relationship between public health and individual health is a major ethical challenge for health systems and providers. In theory, there should be no conflict between the two – the public consists of individuals and public health can be considered as the sum of the health of all those individuals. However, the situation is not quite that simple. Conflicts do exist – over issues including funding, treatment, duties, rights and preferences. The focus of this paper is the conflict between individual and public health in the ethics of research on humans. I will use the World Medical Association (WMA)’s Declaration of Helsinki (DoH) to demonstrate that, while concern for the individual has predominated over the needs of public health since World War Two, in recent years there has been some movement towards redressing this imbalance. The DoH was first adopted at the 1964 WMA General Assembly in Helsinki. Its purpose was to provide guidance to physicians engaged in clinical research and its main focus was the responsibilities of researchers for the protection of research subjects. The advancement of medical science and the promotion of public health, although recognized as important objectives of medical research, were clearly subordinate to the well-being of individual research subjects. The reasons for this emphasis on protection of research subjects are not difficult to discern. The DoH, like its well-known predecessor, the Nuremberg Code, was intended to prevent mistreatment of research subjects such as had been practised by Nazi physicians. In the absence of external constraints like legal frameworks and research ethics committees, it placed the responsibility to protect research subjects on medical researchers, who at that time were mostly physicians. It drew heavily on traditional medical ethics, as summarized in documents such as the WMA Declaration of Geneva which requires of the physician that: “The health of my patient will be my first consideration.”1 In relation to the Nuremberg Code, however, the 1964 DoH represented a subtle shift in the balance between the responsibilities of the researcher to individual research participants and “to further scientific knowledge and to help suffering humanity”, i.e. for public health. This shift is most evident in the requirement to obtain the informed consent of participants. This requirement was absolute in the Nuremberg Code but was softened in the DoH to allow research on children, especially for vaccines, and on incompetent or ‘captive’ populations, such as prisoners and military personnel.2 Still, the 1964 DoH was composed mainly of restrictions on medical research designed to safeguard the interests of individual participants. The first revision of the DoH was adopted in 1975. In the wake of revelations that serious abuses of research ethics were relatively commonplace, the WMA made explicit what had only been implicit in the 1964 version that “In research on man, the interest of science and society should never take precedence over considerations related to the well-being of the subject” (paragraph III. 4, 1975 version). As important as the needs of public health may be, they must not override the rights of individuals who take part in medical research. Since it appeared that some researchers could not be trusted to protect research participants, new requirements were added to the DoH, including advance review of projects by an independent committee and adherence to the principles of the DoH as a condition for publication of the results of the research. Minor amendments to the DoH were adopted in 1983, 1989 and 1996.3 These did not alter the predominance of the individual research subject’s interests over those of society. In contrast, the version that was adopted at the 2000 WMA General Assembly represented a major revision and expansion of the document. Although the emphasis on the primacy of the individual was retained, the following amendments indicate an increased awareness of the needs of public health: The 2000 version did away with the distinction between ‘therapeutic’ and ‘non-therapeutic’ research that had been a hallmark of the DoH since 1964. This distinction was based on the premise that much medical research is therapeutic, i.e. is intended to benefit the research subject: “The physician can combine medical research with professional care, the objective being the acquisition of new medical knowledge, only to the extent that medical research is justified by its potential diagnostic or therapeutic value for the patient” (paragraph II. 6, 1996 version). In contrast, the purpose of research in the 2000 version is the advancement of knowledge for the benefit of future patients; double-blinded clinical trials clearly demonstrate this purpose and its limitations for the health needs of research subjects. The 2000 version introduced an entirely new concept – the responsibility of researchers and sponsors to provide benefits to populations: “Medical research is only justified if there is a reasonable likelihood that the populations in which the research is carried out stand to benefit from the results of the research” (paragraph 19). Although the nature and extent of these benefits is not specified, the amendment clearly adds a significant public-health component to research ethics. In May 2007 the WMA Council authorized a new review of the DoH.4 A call for suggested amendments was distributed widely during 2007; the responses were collated and presented to the WMA Medical Ethics Committee in October 2007. Following that meeting a set of draft amendments was prepared by a working group and distributed for comment. A revised draft was considered by the Medical Ethics Committee in May 2008 and another consultation took place during the summer. The working group’s final recommendations will be considered at the 2008 WMA General Assembly. Although it will be up to the General Assembly to decide what, if any, changes will be made to the DoH, the working group’s draft amendments suggest a continuation of the trend, noted in the 2000 version, towards a greater concern for public-health, as follows: Specific mention is made of epidemiological research, which by its nature aims at the improvement of public health and health systems rather than the health of individual research subjects. Another suggested amendment calls for appropriate access to participation in research for populations that have previously been underrepresented, such as children and pregnant women. The statement on risks and burdens is expanded to include their application to the communities as well as to the individuals involved in the research. However, the statement that “considerations related to the well-being of the human subject should take precedence over the interests of science and society” is essentially unchanged.

713 citations


Journal Article
TL;DR: In this article, the authors presented a systematic, extensive and comprehensive literature review of published information and developed a methodological approach that is transparent and consistent across different diseases and conditions to produce estimates of the major causes of childhood deaths.
Abstract: Introduction The Millennium Development Goals (MDGs) were adopted in 2000 with the aim of reducing the severe gaps between rich and poor populations Most countries have endorsed Goal 4 of the MDGs to "reduce by two thirds [between 1990 and 2015] the mortality rate among children under-five" (1,2) Reliable information on the magnitude, patterns and trends of causes of death of children aged less than 5 years helps decision-makers to assess programmatic needs, prioritize interventions and monitor progress It is also crucial for planning and evaluating effectiveness of health services and interventions Yet, data are very scarce in low-income settings where they are most needed and estimations are necessary for these areas In the 1980s, Snyder and Merson3 generated one of the earliest attempts to estimate the worldwide burden of diarrhoeal diseases, demonstrating the substantial health onus due to diarrhoeal diseases on mortality among children aged less than 5 years In the following decades, subsequent reviews updated these initial estimates using similar methods of assessment (4,5) These initial estimates were based on average values derived from a limited set of studies without taking into account the epidemiological variations across different regions Responding to international demand and to the need for better evidence-based cause-specific mortality, the Child Health Epidemiology Reference Group (CHERG)--an independent group of technical experts jointly coordinated by WHO and the United Nations Children's Fund (UNICEF)--was established in 2001 CHERG has undertaken a systematic, extensive and comprehensive literature review of published information and developed a methodological approach that is transparent and consistent across different diseases and conditions to produce estimates of the major causes of childhood deaths (6-10) This study is an essential part of the overall CHERG efforts Its main objective is to provide estimates of deaths from diarrhoea in 2004 at all levels, mainly for countries with incomplete or non-existing civil registration data Methods Data sources Common sources of data for cause-specific mortality include vital registration systems, sample registration systems, nationally representative household surveys, sentinel Demographic Surveillance Sites (DSS) or epidemiological studies of cause-specific mortality In countries that account for 98% of under-5 deaths worldwide, there is very limited or virtually no functioning vital registration system in place to support attribution of causes of deaths (11-14) A sample registration system, which reports causes of death on a regular basis, is currently available only in China and its coverage and quality for under-5 deaths is challenging (15) Nationally representative household surveys such as Demographic Health Surveys (DHS) and UNICEF's Multiple Indicator Cluster Surveys (MICS) do not usually report on causes of death, and DSS data were not available until very recently (16) Epidemiological studies currently constitute the main source of data available and were therefore used in this review for estimating diarrhoea-specific mortality Search strategy Studies included in the analysis were identified through a systematic search of the scientific literature published since 1980 Medline was searched using the terras: "developing countries", "mortality/death", different spellings of "diarrhoea" and combinations of these terms No restriction was placed on publication language The search identified a total of 804 papers of which 207 were kept for review of abstracts The reference sections of the studies retrieved were reviewed to identify additional papers Studies were then assessed to ensure that they met the main inclusion criteria: (i) direct or derivable diarrhoea-specific proportional mortality data; (ii) a minimum of 25 total deaths; (iii) a maximum of 25% of unknown or undetermined causes of death; (iv) community-based studies with at least 1 year of follow-up; and (v) follow-up time multiple of 12 months to minimize seasonal effects …

621 citations


Journal ArticleDOI
TL;DR: The incidence of typhoid varied substantially between sites, being high in India and Pakistan, intermediate in Indonesia, and low in China and Viet Nam, and underscore the importance of evidence on disease burden in making policy decisions about interventions to control this disease.
Abstract: Objective To inform policy-makers about introduction of preventive interventions against typhoid, including vaccination. Methods A population-based prospective surveillance design was used. Study sites where typhoid was considered a problem by local authorities were established in China, India, Indonesia, Pakistan and Viet Nam. Standardized clinical, laboratory, and surveillance methods were used to investigate cases of fever of ³ 3 days’ duration for a one-year period. A total of 441 435 persons were under surveillance, 159 856 of whom were aged 5–15 years. Findings A total of 21 874 episodes of fever were detected. Salmonella typhi was isolated from 475 (2%) blood cultures, 57% (273/475) of which were from 5–15 year-olds. The annual typhoid incidence (per 100 000 person years) among this age group varied from 24.2 and 29.3 in sites in Viet Nam and China, respectively, to 180.3 in the site in Indonesia; and to 412.9 and 493.5 in sites in Pakistan and India, respectively. Altogether, 23% (96/413) of isolates were multidrug resistant (chloramphenicol, ampicillin and trimethoprim-sulfamethoxazole). Conclusion The incidence of typhoid varied substantially between sites, being high in India and Pakistan, intermediate in Indonesia, and low in China and Viet Nam. These findings highlight the considerable, but geographically heterogeneous, burden of typhoid fever in endemic areas of Asia, and underscore the importance of evidence on disease burden in making policy decisions about interventions to control this disease.

596 citations


Journal ArticleDOI
TL;DR: It is concluded that risk of pneumonia in young children is increased by exposure to unprocessed solid fuels by a factor of 1.8, and greater efforts are now required to implement effective interventions.
Abstract: Reduction of indoor air pollution (IAP) exposure from solid fuel use is a potentially important intervention for childhood pneumonia prevention. This review updates a prior meta-analysis and investigates whether risk varies by etiological agent and pneumonia severity among children aged less than 5 years who are exposed to unprocessed solid fuels. Searches were made of electronic databases (including Africa, China and Latin America) without language restriction. Search terms covered all sources of IAP and wide-ranging descriptions of acute lower respiratory infections, including viral and bacterial agents. From 5317 studies in the main electronic databases (plus 307 African and Latin American, and 588 Chinese studies, in separate databases), 25 were included in the review and 24 were suitable for meta-analysis. Due to substantial statistical heterogeneity, random effects models were used. The overall pooled odds ratio was 1.78 (95% confidence interval, CI: 1.45-2.18), almost unchanged at 1.79 (95% CI: 1.26-2.21) after exclusion of studies with low exposure prevalence (< 15%) and one high outlier. There was evidence of publication bias, and the implications for the results are explored. Sensitivity subanalyses assessed the impact of control selection, adjustment for confounding, exposure and outcome assessment, and age, but no strong effects were identified. Evidence on respiratory syncytial virus was conflicting, while risk for severe or fatal pneumonia was similar to or higher than that for all pneumonia. Despite heterogeneity, this analysis demonstrated sufficient consistency to conclude that risk of pneumonia in young children is increased by exposure to unprocessed solid fuels by a factor of 1.8. Greater efforts are now required to implement effective interventions.

560 citations


Journal ArticleDOI
TL;DR: Planning and evaluation of interventions to control diarrhoea deaths and to reduce under-5 mortality is obstructed by the lack of a system that regularly generates cause-of-death information, so country-level estimates provided here provide alternative information for planning in settings without adequate data.
Abstract: OBJECTIVE: The major objective of this study is to provide estimates of diarrhoea mortality at country, regional and global level by employing the Child Health Epidemiology Reference Group (CHERG) standard. METHODS: A systematic and comprehensive literature review was undertaken of all studies published since 1980 reporting under-5 diarrhoea mortality. Information was collected on characteristics of each study and its population. A regression model was used to relate these characteristics to proportional mortality from diarrhoea and to predict its distribution in national populations. FINDINGS: Global deaths from diarrhoea of children aged less than 5 years were estimated at 1.87 million (95% confidence interval, CI: 1.56-2.19), approximately 19% of total child deaths. WHO African and South-East Asia Regions combined contain 78% (1.46 million) of all diarrhoea deaths occurring among children in the developing world; 73% of these deaths are concentrated in just 15 developing countries. CONCLUSION: Planning and evaluation of interventions to control diarrhoea deaths and to reduce under-5 mortality is obstructed by the lack of a system that regularly generates cause-of-death information. The methods used here provide country-level estimates that constitute alternative information for planning in settings without adequate data.

538 citations


Journal ArticleDOI
TL;DR: It was showed that pesticide suicide and firearm suicide replaced traditional methods in many countries, and the present evidence indicates that restricting access to the means of suicide is more urgent and more technically feasible than ever.
Abstract: OBJECTIVE: Accurate information about preferred suicide methods is important for devising strategies and programmes for suicide prevention. Our knowledge of the methods used and their variation across countries and world regions is still limited. The aim of this study was to provide the first comprehensive overview of international patterns of suicide methods. METHODS: Data encoded according to the International Classification of Diseases (10th revision) were derived from the WHO mortality database. The classification was used to differentiate suicide methods. Correspondence analysis was used to identify typical patterns of suicide methods in different countries by providing a summary of cross-tabulated data. FINDINGS: Poisoning by pesticide was common in many Asian countries and in Latin America; poisoning by drugs was common in both Nordic countries and the United Kingdom. Hanging was the preferred method of suicide in eastern Europe, as was firearm suicide in the United States and jumping from a high place in cities and urban societies such as Hong Kong Special Administrative Region, China. Correspondence analysis demonstrated a polarization between pesticide suicide and firearm suicide at the expense of traditional methods, such as hanging and jumping from a high place, which lay in between. CONCLUSION: This analysis showed that pesticide suicide and firearm suicide replaced traditional methods in many countries. The observed suicide pattern depended upon the availability of the methods used, in particular the availability of technical means. The present evidence indicates that restricting access to the means of suicide is more urgent and more technically feasible than ever.

Journal ArticleDOI
TL;DR: The prevalence of HSV-2 is relatively easy to measure since infection is lifelong and has a specific serological test, and the burden of disease is less easy to quantify.
Abstract: OBJECTIVE: To estimate the global prevalence and incidence of herpes simplex virus type 2 (HSV-2) infection in 2003. METHODS: A systematic review was undertaken of published seroprevalence surveys describing the prevalence or incidence of HSV-2 by age and gender. For each of 12 regions, pooled prevalence values by age and gender were generated in a random-effect model. HSV-2 incidence was then estimated from these pooled values using a constant-incidence model. Values of the HSV-2 seroprevalence from the model fits were applied to the total population to estimate the numbers of people infected. FINDINGS: The total number of people aged 15-49 years who were living with HSV-2 infection worldwide in 2003 is estimated to be 536 million, while the total number of people who were newly infected with HSV-2 in 2003 is estimated to be 23.6 million. While the estimates are limited by poor availability of data, general trends are evident. For example, more women than men were infected, and the number infected increased with age. Although prevalence varied substantially by region, predicted prevalence was mostly higher in developing regions than developed regions. CONCLUSION: The prevalence of HSV-2 is relatively easy to measure since infection is lifelong and has a specific serological test. The burden of disease is less easy to quantify. Despite the often sparse data on which these estimates are based, it is clear that HSV-2 infection is widespread. The dramatic differences in prevalence between regions are worthy of further exploration.

Journal ArticleDOI
TL;DR: In most African countries, the health financing system is too weak to protect households from health shocks and formal prepayment schemes could benefit many households, and an overall social protection network could help to mitigate the long-term effects of ill health on household well-being and support poverty reduction.
Abstract: OBJECTIVE: To explore factors associated with household coping behaviours in the face of health expenditures in 15 African countries and provide evidence for policy-makers in designing financial health protection mechanisms. METHODS: A series of logit regressions were performed to explore factors correlating with a greater likelihood of selling assets, borrowing or both to finance health care. The average partial effects for different levels of spending on inpatient care were derived by computing the partial effects for each observation and taking the average across the sample. Data used in the analysis were from the 2002-2003 World Health Survey, which asked how households had financed out-of-pocket payments over the previous year. Households selling assets or borrowing money were compared to those that financed health care from income or savings. Those that used insurance were excluded. For the analysis, a value of 1 was assigned to selling assets or borrowing money and a value of 0 to other coping mechanisms. FINDINGS: Coping through borrowing and selling assets ranged from 23% of households in Zambia to 68% in Burkina Faso. In general, the highest income groups were less likely to borrow and sell assets, but coping mechanisms did not differ strongly among lower income quintiles. Households with higher inpatient expenses were significantly more likely to borrow and deplete assets compared to those financing outpatient care or routine medical expenses, except in Burkina Faso, Namibia and Swaziland. In eight countries, the coefficient on the highest quintile of inpatient spending had a P-value below 0.01. CONCLUSION: In most African countries, the health financing system is too weak to protect households from health shocks. Borrowing and selling assets to finance health care are common. Formal prepayment schemes could benefit many households, and an overall social protection network could help to mitigate the long-term effects of ill health on household well-being and support poverty reduction.

Journal ArticleDOI
TL;DR: This low-cost brief intervention may be an important part of suicide prevention programmes for underresourced low- and middle-income countries.
Abstract: Resumen Eficacia de una intervencion de informacion y contactos en los casos de intento de suicidio: ensayo controlado aleatorizado en cinco paises Objetivo Determinar si una intervencion de informacion breve y contactos es una medida eficaz para reducir la mortalidad posterior por suicidio entre quienes han intentado suicidarse en los paises de ingresos bajos y medios.Metodos Un total de 1867 personas que habian intentado suicidarse seleccionadas por personal medico en los servicios de urgencia de ocho hospitales colaboradores en cinco lugares con distinto contexto cultural (Campinas, Brasil; Chennai, India; Colombo, Sri Lanka; Karaj, Republica Islamica del Iran; y Yuncheng, China) participaron entre enero de 2002 y octubre de 2005 en un ensayo controlado aleatorizado para someterse bien al tratamiento habitual, o bien al tratamiento habitual mas una intervencion consistente en una sesion breve de informacion y educacion del paciente y una serie de contactos de seguimiento (I+C). Globalmente, finalizaron el estudio el 91% de los pacientes. La variable principal de medicion del resultado del estudio fue la muerte por suicidio en los 18 meses de seguimiento.Resultados En el grupo sometido a I+C se observo una tasa de defunciones por suicidio significativamente menor que en el grupo tratado de la forma habitual (0,2% frente al 2,2%, respectivamente; c² = 13,83,

Journal ArticleDOI
TL;DR: Early patient losses were increasingly common when programmes were scaled up and were associated with a fee for service and advanced immunodeficiency at baseline, and measures to maximize ART programme retention are required in resource-poor countries.
Abstract: Objective To analyse the early loss of patients to antiretroviral therapy (ART) programmes in resource-limited settings. Methods Using data on 5491 adult patients starting ART (median age 35 years, 46% female) in 15 treatment programmes in Africa, Asia and South America with ³ 12 months of follow-up, we investigated risk factors for no follow-up after treatment initiation, and loss to follow-up or death in the first 6 months. Findings Overall, 211 patients (3.8%) had no follow-up, 880 (16.0%) were lost to follow-up and 141 (2.6%) were known to have died in the first 6 months. The probability of no follow-up was higher in 2003–2004 than in 2000 or earlier (odds ratio, OR: 5.06; 95% confidence interval, CI: 1.28–20.0), as was loss to follow-up (hazard ratio, HR: 7.62; 95% CI: 4.55–12.8) but not recorded death (HR: 1.02; 95% CI: 0.44–2.36). Compared with a baseline CD4-cell count ³ 50 cells/µl, a count < 25 cells/µl was associated with a higher probability of no follow-up (OR: 2.49; 95% CI: 1.43–4.33), loss to follow-up (HR: 1.48; 95% CI: 1.23–1.77) and death (HR: 3.34; 95% CI: 2.10–5.30). Compared to free treatment, fee-for-service programmes were associated with a higher probability of no follow-up (OR: 3.71; 95% CI: 0.97–16.05) and higher mortality (HR: 4.64; 95% CI: 1.11–19.41). Conclusion Early patient losses were increasingly common when programmes were scaled up and were associated with a fee for service and advanced immunodeficiency at baseline. Measures to maximize ART programme retention are required in resource-poor countries.

Journal Article
TL;DR: In this article, the authors investigated the effect of maintaining long-term contact with high suicide-risk psychiatric patients refusing further treatment, which was associated with a significant reduction in suicide rates for at least 2 years after discharge from the in-patient setting.
Abstract: Introduction Suicide is a preventable cause of death. After about two centuries of research in suicide prevention, the effectiveness of a number of interventions has been demonstrated and various risk factors have been placed in perspective. Thus, "it is no longer acceptable to state blandly that there is no convincing evidence for the effectiveness of suicide prevention measures ..." and, even more importantly, "... the unacceptable rate of suicide worldwide can be reduced." WHO estimated that 877 000 deaths were due to suicide in the year 2002, (2) the majority of which (85%) occurred in low- and middle-income countries. (3) Attempted suicide can be up to 40 times more frequent than completed suicide. (4,5) Many of those who attempt suicide require medical attention and they are at high risk for completed suicide. (6-8) Self-inflicted injuries represented 1.4% of the global burden of disease in 20022 and are expected to increase to 2.4% by 2020. As suicide is among the top three causes of death in the population aged 15-34 years, (9) there is a massive loss to societies of young people in their productive years of life. Suicide mortality statistics are available at: http://www.who.int/mental_health! prevention/suicide/country_reports/en/ index.html. There have been several recent reviews of interventions that may be considered effective in reducing suicides. (1,10-12) Under the framework of universal, selective, and indicated interventions, (13) the general population is targeted by universal interventions (e.g. restricting access to means of suicide) and selective interventions focus on high-risk subgroups (e.g. people with mental disorders), whereas those who have attempted suicide are considered high-risk individuals and are therefore addressed with indicated interventions, which include a range of behavioural therapies and approaches such as cognitive therapy. (14) Among indicated interventions, various approaches have been tested to prevent subsequent suicidal behaviour by suicide attempters; extensive review articles are available. (15,16) Usually, the primary outcome measure used for these interventions was repeated suicide attempts. It is suggested that extrapolation from attempted to completed suicide is valid. (17) As completed suicide is a rare outcome in statistical terms, large numbers of suicide attempters would be needed to demonstram the effectiveness of an intervention in terms of a reduction of completed suicides. The multisite study presented here tried to tackle this challenge by combining data from different sites that had applied the same research protocol. Previously, completed suicides were used as an outcome measure in a study that investigated the maintenance of long-term contact (i.e. a total of 5 years and 24 contacts) with high suicide-risk psychiatric patients refusing further treatment. (18-20) The contact comprised regular short letters expressing concern for the person's well-being and inviting them to respond. This was associated with a significant reduction in suicide rates for at least 2 years after discharge from the in-patient setting. In addition, a "tele-help/tele-check" service (i.e. an alarm system that can be activated to call for help and a service that contacts a person twice a week for assessment of their needs and to provide emotional support) could significantly reduce the number of suicide deaths in the elderly, who typically have an elevated risk of suicide compared with an age-adjusted number for the general population. (21,22) These two examples demonstrate that it is possible to reduce the suicide rate in populations at risk by keeping in regular contact with patients. Brief interventions for alcohol problems are another promising type of intervention that have not been previously applied to suicidal behaviours. (23-25) These are designed to address the specific behaviour of drinking with information, feedback, health education and practical advice and focus in order to raise awareness of the problem and advise change. …

Journal ArticleDOI
TL;DR: Socioeconomic inequality in childhood malnutrition existed throughout the developing world, and was not related to the average malnutrition rate, so policies should take into account the distribution of childhood malnutrition across all socioeconomic groups.
Abstract: Objective The objectives of this study were to report on socioeconomic inequality in childhood malnutrition in the developing world, to provide evidence for an association between socioeconomic inequality and the average level of malnutrition, and to draw attention to different patterns of socioeconomic inequality in malnutrition. Methods Both stunting and wasting were measured using new WHO child growth standards. Socioeconomic status was estimated by principal component analysis using a set of household assets and living conditions. Socioeconomic inequality was measured using an alternative concentration index that avoids problems with dependence on the mean level of malnutrition. Findings In almost all countries investigated, stunting and wasting disproportionately affected the poor. However, socioeconomic inequality in wasting was limited and was not significant in about one third of countries. After correcting for the concentration index’s dependence on mean malnutrition, there was no clear association between average stunting and socioeconomic inequality. The latter showed different patterns, which were termed mass deprivation, queuing and exclusion. Although average levels of malnutrition were higher with the new WHO reference standards, estimates of socioeconomic inequality were largely unaffected by changing the growth standards. Conclusion Socioeconomic inequality in childhood malnutrition existed throughout the developing world, and was not related to the average malnutrition rate. Failure to tackle this inequality is a cause of social injustice. Moreover, reducing the overall rate of malnutrition does not necessarily lead to a reduction in inequality. Policies should, therefore, take into account the distribution of childhood malnutrition across all socioeconomic groups.

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TL;DR: It is argued that collaborative partnership, including democratic deliberation, offers the context and process by which many of the ethical challenges in international herbal medicine research can be resolved and should be resolved.
Abstract: Governments, international agencies and corporations are increasingly investing in traditional herbal medicine research. Yet little literature addresses ethical challenges in this research. In this paper, we apply concepts in a comprehensive ethical framework for clinical research to international traditional herbal medicine research. We examine in detail three key, underappreciated dimensions of the ethical framework in which particularly difficult questions arise for international herbal medicine research: social value, scientific validity and favourable risk-benefit ratio. Significant challenges exist in determining shared concepts of social value, scientific validity and favourable risk-benefit ratio across international research collaborations. However, we argue that collaborative partnership, including democratic deliberation, offers the context and process by which many of the ethical challenges in international herbal medicine research can, and should be, resolved. By "cross-training" investigators, and investing in safety-monitoring infrastructure, the issues identified by this comprehensive framework can promote ethically sound international herbal medicine research that contributes to global health.

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TL;DR: Improved stillbirth and neonatal mortality rates observed indicate that community health workers (i.e. LHWs and Dais) can be effective in implementing a community and outreach package that leads to improved home care practices by families, increased care-seeking behaviour and greater utilization of skilled care providers.
Abstract: OBJECTIVE: This pilot study investigated the feasibility of delivering a package of community-based interventions for improving perinatal care using lady health workers (LHWs) and traditional birth attendants (Dais) in rural Pakistan. METHODS: The intervention was implemented in four of eight village clusters (315 villages, total population 138 600), while four served as a comparison group. The LHWs in intervention clusters received additional training focused on essential maternal and newborn care, conducted community education group sessions, and were encouraged to link up with local Dais. The intervention was delivered within the regular government LHW programme and was supported by the creation of voluntary community health committees. FINDINGS: In intervention villages, there were significant reductions from baseline in stillbirth (from 65.9 to 43.1 per 1000 births, P < 0.001) and neonatal mortality rates (from 57.3 to 41.3 per 1000 live births, P < 0.001). The proportion of deliveries conducted by skilled attendants at public sector facilities also increased, from 18% at baseline to 30%, while the proportion of home births decreased from 79% to 65%. A household survey indicated a higher frequency of key behaviours (e.g. early and exclusive breastfeeding, delayed bathing and cord care) in intervention villages. CONCLUSION: The improved stillbirth and neonatal mortality rates observed indicate that community health workers (i.e. LHWs and Dais) can be effective in implementing a community and outreach package that leads to improved home care practices by families, increased care-seeking behaviour and greater utilization of skilled care providers. These preliminary observations require confirmation in an adequately powered trial.

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TL;DR: Developing locally appropriate transplant programmes, effective use of nongovernmental sources of funding, service planning and cost containment, use of generic drugs and local manufacture of dialysis consumables have the potential to make life-saving renal replacement therapy available to many more in need.
Abstract: There is a significant emerging burden of chronic and end-stage kidney disease in low- and middle-income countries, driven by population ageing and the global epidemic of type 2 diabetes. Sufferers of end-stage kidney disease require ongoing dialysis or kidney transplantation to survive; however, in many low- and middle-income countries, treatment options are strictly limited or unaffordable. Low numbers of maintenance dialysis patients and transplant recipients reflect profound economic and service provision challenges for health-care systems in low- and middle-income countries in sustaining renal replacement therapy programmes. Underdeveloped organ donor and transplant programmes, health system and financing issues, ethical regulation of transplantation and the cost of pharmaceuticals commonly pose additional barriers to the delivery of efficient and cost-effective renal replacement therapy. Development of locally appropriate transplant programmes, effective use of nongovernmental sources of funding, service planning and cost containment, use of generic drugs and local manufacture of dialysis consumables have the potential to make life-saving renal replacement therapy available to many more in need. Select low- and middle-income countries demonstrate more equitable provision of renal replacement therapy is possible outside high-income countries. For other low- and middle- income countries, education, the development of good public policy and a supportive international environment are critical. Prevention of end-stage kidney disease, ideally as part of an integrated approach to chronic vascular diseases, must also be a key objective.

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TL;DR: This document provides a standardized case definition and classification scheme for APP into categories of probable, possible and unlikely/unknown cases and is intended to be applicable worldwide to contribute to identification of the scope of existing problems and thus promote action for improved management and prevention.
Abstract: Cases of acute pesticide poisoning (APP) account for significant morbidity and mortality worldwide. Developing countries are particularly susceptible due to poorer regulation, lack of surveillance systems, less enforcement, lack of training and inadequate access to information systems. Previous research has demonstrated wide variability in incidence rates for APP. This is possibly due to inconsistent reporting methodology and exclusion of occupational and non-intentional poisonings. The purpose of this document is to create a standard case definition to facilitate the identification and diagnosis of all causes of APP, especially at the field level, rural clinics and primary health-care systems. This document is a synthesis of existing literature and case definitions that have been previously proposed by other authors around the world. It provides a standardized case definition and classification scheme for APP into categories of probable, possible and unlikely/unknown cases. Its use is intended to be applicable worldwide to contribute to identification of the scope of existing problems and thus promote action for improved management and prevention. By enabling a field diagnosis for APP, this standardized case definition may facilitate immediate medical management of pesticide poisoning and aid in estimating its incidence.

Journal Article
TL;DR: In this paper, the authors apply a practical, comprehensive and widely accepted ethical framework to international traditional herbal medicine research and examine in detail difficult questions related to social value, scientific validity and favorable risk-benefit ratio.
Abstract: Introduction Traditional herbal medicines are naturally occurring, plant-derived substances with minimal or no industrial processing that have been used to treat illness within local or regional healing practices Traditional herbal medicines are getting significant attention in global health debates In China, traditional herbal medicine played a prominent role in the strategy to contain and treat severe acute respiratory syndrome (SARS) (1) Eighty per cent of African populations use some form of traditional herbal medicine, (2,3) and the worldwide annual market for these products approaches US$ 60 billion (2) Many hope traditional herbal medicine research will play a critical role in global health China, India, Nigeria, the United States of America (USA) and WHO have all made substantial research investments in traditional herbal medicines (2) Industry has also invested millions of US dollars looking for promising medicinal herbs and novel chemical compounds (4,5) This is still a relatively modest investment compared to the overall pharmaceutical industry; however, it raises interesting ethical questions, some of which are not faced in more conventional drug development As attention and public funding for international traditional herbal medicine research collaborations grows, more detailed analysis of ethical issues in this research is warranted Scant literature has addressed selected issues such as informed consent and independent review related to traditional herbal medicine research (6,7) Here we apply a practical, comprehensive and widely accepted ethical framework to international traditional herbal medicine research (80 We examine in detail difficult questions related to social value, scientific validity and favourable risk--benefit ratio We conclude with implications for future research in this area, focusing on the importance of collaborative partnership Case A government agency from a developed country is conducting an HIV-treatment trial in Africa A traditional herbal medicine, Africa Flower, has been used for decades to treat wasting symptoms associated with HIV Local traditional medicine healers believe Africa Flower is an effective antiviral It is already widely used for immune boosting in AIDS In vitro pharmacokinetic studies suggest potential interference with vaccines, and animal models show liver toxicity at very high doses There are no systemic side-effects reported for humans in the literature A few case series have shown mixed results Local leaders are requesting the government agency conduct a large, randomized controlled trial (RCT) of Africa Flower to test its efficacy as a novel adjunctive therapy to slow progression to MDS Ethical framework Cases like these present challenging questions related to the role of traditional herbal medicines in public health In general, international research on traditional herbal medicines should be subject to the same ethical requirements as all research related to human subjects (9) An ethical framework previously outlined by Emanuel et al and revised for international research (8) offers a useful starting point for thinking about the ethics of international traditional herbal medicine research This framework includes eight ethical requirements for clinical research (Table 1) (8) These ethical requirements are universal and comprehensive but must be adapted to the particular social context in which the research is implemented (8) Of these, fair subject selection, independent review, informed consent, and respect for enrolled subjects have been discussed previously in the literature on the ethics of global health research and raise few issues unique to international traditional herbal medicine research (8) However, social value, scientific validity, and favourable risk--benefit ratio raise specific challenges in international herbal medicine research that have not been adequately discussed …

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TL;DR: It is argued that enough is already known to justify accelerated action on surgery in low- and middle-income countries and that impact would have on global health disparities, and how does this compare with other interventions.
Abstract: Surgery is an essential component of health systems but has generally been neglected within global public health. This is despite growing evidence documenting the cost-effectiveness of essential surgical care in low- and middle-income countries (LMICs).1 The overall burden of disease that may be cured, palliated or treated with surgical intervention is large and (probably) rapidly growing, and this concept must therefore be revisited. There are major gaps in knowledge related to surgery in LMICs. What exactly is the burden and distribution of surgical conditions in LMICs? What is the unmet surgical need? What resources (human, financial, physical) are required to improve access to surgical care? What impact would this have on global health disparities, and how does this compare with other interventions? How can essential surgical services be integrated into health systems’ surveillance and evaluation? This paper outlines a research agenda and argues that enough is already known to justify accelerated action.

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TL;DR: The analysis suggests that South Africa has made the least progress in addressing fragmentation, while Ghana appears to be pursuing a universal coverage policy in a more coherent way.
Abstract: The World Health Assembly of 2005 called for all health systems to move towards universal coverage, defined as " access to adequate health care for all at an affordable price" . A crucial aspect in achieving universal coverage is the extent to which there are income and risk cross-subsidies in health systems. Yet this aspect appears to be ignored in many of the policy prescriptions directed at low- and middle-income countries, often resulting in high degrees of health system fragmentation. The aim of this paper is to explore the extent of fragmentation within the health systems of three African countries (Ghana, South Africa and the United Republic of Tanzania). Using a framework for analysing health-care financing in terms of its key functions, we describe how fragmentation has developed, how each country has attempted to address the arising equity challenges and what remains to be done to promote universal coverage. The analysis suggests that South Africa has made the least progress in addressing fragmentation, while Ghana appears to be pursuing a universal coverage policy in a more coherent way. To achieve universal coverage, health systems must reduce their reliance on out-of-pocket payments, maximize the size of risk pools, and resource allocation mechanisms must be put in place to either equalize risks between individual insurance schemes or equitably allocate general tax (and donor) funds. Ultimately, there needs to be greater integration of financing mechanisms to promote universal cover with strong income and risk cross-subsidies in the overall health system.

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TL;DR: Removing or reducing user fees was found to increase the utilization of curative services and perhaps preventive services as well, but may have negatively impacted service quality, although quality improvements may have helped maintain utilization in some cases.
Abstract: OBJECTIVE: To assess the effects of user charges on the uptake of health services in low- and middle-income countries. METHODS: A systematic search of 25 social science, economics and health literature databases and other sources was performed to identify and appraise studies on the effects of introducing, removing, increasing or reducing user charges on the uptake of various health services in low- and middle-income countries. Only experimental or quasi-experimental study designs were considered: cluster randomized controlled trials (C-RCT), controlled " before and after" (CBA) studies and interrupted time series (ITS) studies. Papers were assessed in which the effect of the intervention was measured in terms of changes in service utilization (including equity outcomes), household expenditure or health outcomes. FINDINGS: Sixteen studies were included: five CBA, two C-RCT and nine ITS. Only studies reporting effects on health service utilization, sometimes across socioeconomic groups, were identified. Removing or reducing user fees was found to increase the utilization of curative services and perhaps preventive services as well, but may have negatively impacted service quality. Introducing or increasing fees reduced the utilization of some curative services, although quality improvements may have helped maintain utilization in some cases. When fees were either introduced or removed, the impact was immediate and abrupt. Studies did not adequately show whether such an increase or reduction in utilization was sustained over the longer term. In addition, most of the studies were given low-quality ratings based on criteria adapted from those of the Cochrane Collaboration's Effective Practice and Organisation of Care group. CONCLUSIONS: There is a need for more high-quality research examining the effects of changes in user fees for health services in low- and middle-income countries.

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TL;DR: In this paper, a decision tree model and probabilistic sensitivity analysis applied to outpatients presenting at rural health facilities with suspected malaria was used to evaluate the relative cost-effectiveness in different sub-Saharan African settings of presumptive treatment, field standard microscopy and rapid diagnostic tests (RDTs) to diagnose malaria.
Abstract: Objective To evaluate the relative cost-effectiveness in different sub-Saharan African settings of presumptive treatment, field-standard microscopy and rapid diagnostic tests (RDTs) to diagnose malaria. Methods We used a decision tree model and probabilistic sensitivity analysis applied to outpatients presenting at rural health facilities with suspected malaria. Costs and effects encompassed those for both patients positive on RDT (assuming artemisinin-based combination therapy) and febrile patients negative on RDT (assuming antibiotic treatment). Interventions were defined as cost-effective if they were less costly and more effective or had an incremental cost per disability-adjusted life year averted of less than US$ 150. Data were drawn from published and unpublished sources, supplemented with expert opinion. Findings RDTs were cost-effective compared with presumptive treatment up to high prevalences of Plasmodium falciparum parasitaemia. Decision-makers can be at least 50% confident of this result below 81% malaria prevalence, and 95% confident below 62% prevalence, a level seldom exceeded in practice. RDTs were more than 50% likely to be cost-saving below 58% prevalence. Relative to microscopy, RDTs were more than 85% likely to be cost-effective across all prevalence levels, reflecting their expected better accuracy under real-life conditions. Results were robust to extensive sensitivity analysis. The cost-effectiveness of RDTs mainly reflected improved treatment and health outcomes for non-malarial febrile illness, plus savings in antimalarial drug costs. Results were dependent on the assumption that prescribers used test results to guide treatment decisions. Conclusion RDTs have the potential to be cost-effective in most parts of sub-Saharan Africa. Appropriate management of malaria and non-malarial febrile illnesses is required to reap the full benefits of these tests. Bulletin of the World Health Organization 2008;86:101–110.

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TL;DR: The type of policy intervention needed to alleviate projected shortages, such as increasing health-care training or adopting measures to discourage migration, depends on the type of shortage projected.
Abstract: OBJECTIVE: Global achievements in health may be limited by critical shortages of health-care workers. To help guide workforce policy, we estimate the future demand for, need for and supply of physicians, by WHO region, to determine where likely shortages will occur by 2015, the target date of the Millennium Development Goals. METHODS: Using World Bank and WHO data on physicians per capita from 1980 to 2001 for 158 countries, we employ two modelling approaches for estimating the future global requirement for physicians. A needs-based model determines the number of physicians per capita required to achieve 80% coverage of live births by a skilled health-care attendant. In contrast, our economic model identifies the number of physicians per capita that are likely to be demanded, given each country's economic growth. These estimates are compared to the future supply of physicians projected by extrapolating the historical rate of increase in physicians per capita for each country. FINDINGS: By 2015, the global supply of physicians appears to be in balance with projected economic demand. Because our measure of need reflects the minimum level of workforce density required to provide a basic health service that is met in all but the least developed countries, the needs-based estimates predict a global surplus of physicians. However, on a regional basis, both models predict shortages for many countries in the WHO African Region in 2015, with some countries experiencing a needs-based shortage, a demand-based shortage, or both. CONCLUSION: The type of policy intervention needed to alleviate projected shortages, such as increasing health-care training or adopting measures to discourage migration, depends on the type of shortage projected.

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TL;DR: Use of maternity care services was higher in the study areas than national averages, but a tremendous use-inequity persists, and interventions to overcome financial barriers are recommended to address inequity in maternal health.
Abstract: OBJECTIVE: To explore use-inequity in maternal health-care services in home-based skilled-birth-attendant (SBA) programme areas in Bangladesh. METHODS: Data from a community survey, conducted from February to May 2006, were analysed to examine inequities in use of SBAs, caesarean sections for deliveries and postnatal care services according to key socioeconomic factors. FINDINGS: Of 2164 deliveries, 35% had an SBA, 22.8% were in health facilities and 10.8% were by caesarean section. Rates of uptake of antenatal and postnatal care were 93% and 28%, respectively. There were substantial use-inequities in maternal health by asset quintiles, distance, and area of residence, and education of both the woman and her husband. However, not all inequities were the same. After adjusting for other determinants, the differences in the use of maternal health-care services for poor and rich people remained substantial [adjusted odds ratio (OR) 2.51 (95% confidence interval, CI: 1.68-3.76) for skilled attendance; OR 2.58 (95% CI: 1.28-5.19) for use of caesarean sections and OR 1.53 (95% CI: 1.05-2.25) for use of postnatal care services]. Complications during pregnancy influenced use of SBAs, caesarean-section delivery and postnatal care services. The number of antenatal carevisits was a significant predictor for use of SBAs and postnatal care, but not for caesarean sections. CONCLUSION: Use of maternity care services was higher in the study areas than national averages, but a tremendous use-inequity persists. Interventions to overcome financial barriers are recommended to address inequity in maternal health. A greater focus is needed on the implementation and evaluation of maternal-health interventions for poor people.

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TL;DR: In the 72 poorest countries, US$ 11-15 billion (30%-40%) of the overall resource needs are unmet if the GIVS goals are to be reached, providing a roadmap of financing gaps that need to be filled to scale up immunization by 2015.
Abstract: OBJECTIVE: To estimate the cost of scaling up childhood immunization services required to reach the WHO-UNICEF Global Immunization Vision and Strategy (GIVS) goal of reducing mortality due to vaccine-preventable diseases by two-thirds by 2015. METHODS: A model was developed to estimate the total cost of reaching GIVS goals by 2015 in 117 low- and lower-middle- income countries. Current spending was estimated by analysing data from country planning documents, and scale-up costs were estimated using a bottom-up, ingredients-based approach. Financial costs were estimated by country and year for reaching 90% coverage with all existing vaccines; introducing a discrete set of new vaccines (rotavirus, conjugate pneumococcal, conjugate meningococcal A and Japanese encephalitis); and conducting immunization campaigns to protect at-risk populations against polio, tetanus, measles, yellow fever and meningococcal meningitis. FINDINGS: The 72 poorest countries of the world spent US$ 2.5 (range: US$ 1.8-4.2) billion on immunization in 2005, an increase from US$ 1.1 (range: US$ 0.9-1.6) billion in 2000. By 2015 annual immunization costs will on average increase to about US$ 4.0 (range US$ 2.9-6.7) billion. Total immunization costs for 2006-2015 are estimated at US$ 35 (range US$ 13-40) billion; of this, US$ 16.2 billion are incremental costs, comprised of US$ 5.6 billion for system scale-up and US$ 8.7 billion for vaccines; US$ 19.3 billion is required to maintain immunization programmes at 2005 levels. In all 117 low- and lower-middle-income countries, total costs for 2006-2015 are estimated at US$ 76 (range: US$ 23-110) billion, with US$ 49 billion for maintaining current systems and $27 billion for scaling-up. CONCLUSION: In the 72 poorest countries, US$ 11-15 billion (30%-40%) of the overall resource needs are unmet if the GIVS goals are to be reached. The methods developed in this paper are approximate estimates with limitations, but provide a roadmap of financing gaps that need to be filled to scale up immunization by 2015.

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TL;DR: The quality of the data collected and the retention of patients in ART treatment programmes are unsatisfactory for many sites involved in the scale-up of ART in resource-limited settings, mainly because of insufficient staff trained to manage data and trace patients lost to follow-up.
Abstract: OBJECTIVE: To describe the electronic medical databases used in antiretroviral therapy (ART) programmes in lower-income countries and assess the measures such programmes employ to maintain and improve data quality and reduce the loss of patients to follow-up. METHODS: In 15 countries of Africa, South America and Asia, a survey was conducted from December 2006 to February 2007 on the use of electronic medical record systems in ART programmes. Patients enrolled in the sites at the time of the survey but not seen during the previous 12 months were considered lost to follow-up. The quality of the data was assessed by computing the percentage of missing key variables (age, sex, clinical stage of HIV infection, CD4+ lymphocyte count and year of ART initiation). Associations between site characteristics (such as number of staff members dedicated to data management), measures to reduce loss to follow-up (such as the presence of staff dedicated to tracing patients) and data quality and loss to follow-up were analysed using multivariate logit models. FINDINGS: Twenty-one sites that together provided ART to 50 060 patients were included (median number of patients per site: 1000; interquartile range, IQR: 72-19 320). Eighteen sites (86%) used an electronic database for medical record-keeping; 15 (83%) such sites relied on software intended for personal or small business use. The median percentage of missing data for key variables per site was 10.9% (IQR: 2.0-18.9%) and declined with training in data management (odds ratio, OR: 0.58; 95% confidence interval, CI: 0.37-0.90) and weekly hours spent by a clerk on the database per 100 patients on ART (OR: 0.95; 95% CI: 0.90-0.99). About 10 weekly hours per 100 patients on ART were required to reduce missing data for key variables to below 10%. The median percentage of patients lost to follow-up 1 year after starting ART was 8.5% (IQR: 4.2-19.7%). Strategies to reduce loss to follow-up included outreach teams, community-based organizations and checking death registry data. Implementation of all three strategies substantially reduced losses to follow-up (OR: 0.17; 95% CI: 0.15-0.20). CONCLUSION: The quality of the data collected and the retention of patients in ART treatment programmes are unsatisfactory for many sites involved in the scale-up of ART in resource-limited settings, mainly because of insufficient staff trained to manage data and trace patients lost to follow-up.