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Certificate Course In Evidence Based Diabetes Management: Capacity Building of Primary Care Physicians in Diabetes Care, India.

Author(s) Shivangi Vats1, K Srinath Reddy2, V Mohan3, Sandeep Bhalla 4
Affiliation(s) 1Training, PHFI, Delhi, India, 2PHFI, PHFI, New Delhi, India, 3Dr Mohan’s Diabetes Specialities Centre, Dr Mohan’s Diabetes Specialities Centre, Chennai, India, 4CCEBDM, PHFI, New Delhi, India.
Country - ies of focus India
Relevant to the conference tracks Education and Research
Summary CCEBDM is a pan India program for the capacity building of primary care physicians in the field of diabetes. As the country is becoming the diabetic capital with a lack of trained physicians in this field this program is launched in 2010. An evaluation was done to assess the short impact of the program and it was found that the program was effective and the skills of the physicians improved after attending the training program.
Background Diabetes is considered one of the major contributors to the global burden of disease. It exemplifies management challenges because of long latency, chronicity, multi-organ involvement and long term care. In India, health system is constrained in term of trained manpower and limited institutional capacities for diabetes management. A balanced approach to equip primary care physicians with advanced and newer evidence based knowledge for better diabetes management is fundamental.
Objectives This article/paper is aimed to assess the impact and effectiveness of PAN INDIA Certificate Course in Evidence Based Diabetes Management (CCEBDM).
Methodology CCEBDM is an evidence based diabetes management course with the objective of improving the treatment outcomes for patients by serving as an evidence based guidance for clinical decision making in risk assessment, diagnosis, prognosis and management of diabetes. Improvement in knowledge of physicians was assessed by quantitative and qualitative methods. For quantitative analysis pre and post test scores were used and for qualitative analysis, end-line evaluation as a cross-sectional survey was conducted with 100 and 125 randomly selected physicians from CCEBDM Cycle-I and cycle-II respectively using pre tested scheduled questionnaires two months after completion of cycles.
Results Pre-post test scores of 2776 physicians were assessed for the knowledge improvement and it was found that there is significant improvement (P value < 0.05) in knowledge regarding basics of diabetes, pharmacological treatment, acute and chronic complications with management. Once the course was completed the frequency of treating diabetic patient/physician/month increased (38% 501 to 1,500 patients per month and 44% stated that they treated about 101 to 500 patients per month), and the confidence level of physician increased in the field of diabetes diagnoses and management. Frequency of physicians who were confident to manage diabetic complications like hypoglycaemia (73%), peripheral neuropathy (94%), skin complication (82%), sexual dysfunction (78%), diabetic foot (74%) and nephropathy (71%) increased. 90% were confident about managing patients on insulin independently.
While assessing the clinic structure it was found that 66% of physicians had provision for laboratory facilities routine blood screenings, 53% had on-site dieticians who help the diabetic patients, 35% had a counsellor to guide the patients, 49% were using DBMS, 79% had full time nurses on duty, and 76% used various forms of Patient Education Resources to elicit awareness about diabetes. The majority of the physicians agreed that the course contributed significantly to their knowledge of diabetes management and added value to their treatment skills. All agreed that curriculum was up-to-date with latest advances and guidelines and faculty’s personal clinical experience added to their teaching were very useful as now they can consult the diabetic experts anytime for references.
Conclusion CCEBDM is an evidence based course and uses recent clinical findings in developing clinical guidelines for better management of diabetic patients and is very effective in improving the knowledge of physicians and clinical practices in diabetes management. Also by building the capacity of primary care physicians in diabetes management, it seems to be a solution to control the increasing burden of diabetes and to improve the productivity of people who are living with diabetes.

Scaling up family medicine and primary health care in Africa.

Author(s) Jan De Maeseneer1, Maaike Flinkenflögel2
Affiliation(s) 1Department Family Medicine and Primary Health Care, Ghent University, Gent, Belgium, 2Department of Family Medicine and Primary Health Care, Ghent University, Gent, Belgium.
Country - ies of focus Global
Relevant to the conference tracks Health Workforce
Summary Increasingly, there is an emphasis upon the need for scaling up the capacity of primary health care. The Primafamed-network (www.primafamed.ugent.be), at its workshop in November 2012 formulated a statement on human resources for primary health care. They formulated a plan that will lead to 30.000 new family physicians in sub-saharan Africa by 2020. There is an increasing need for skilled primary health care providers, and also family physicians at the primary health care level in Africa. Until now, in different African countries only a small number of family physicians have been trained. There is a huge problem of recruitment of family physicians in the medical faculties.
Background Accessible and comprehensive primary health care is a key factor to solve the health problems of the developing countries, also in Africa. There is a need to scale up both quality and capacity of family medicine in the context of primary health care teams in Africa. The actual programs have only been able to train a very limited number of family physicians. Increasingly, countries and ministries of health recognised the importance of this discipline to strengthen health systems.
Objectives To formulate a policy statement to scale up family medicine and primary health care in Africa and to develop a strategy accordingly.
Methodology At the recent Primafamed-workshop in Vic Falls (Zimbabwe), a gathering of African representatives from 20 African countries discussed the different strategic options in order to scale up the capacity of family medicine and primary health care. The result was a statement published in the African Journal of Primary Health Care and Family Medicine (http://www.phcfm.org).
Results Starting from reports from various countries, with a diverse scale of strategic approaches to capacity building in family medicine, a debate formulated a statement on scaling up. Important choices are related to the duration of the training, increasing the recruitment from undergraduate curriculum, and utilising appropriate educational strategies to train family physicians in the communities. Increasing exposure in undergraduate training to family and community service is essential to improve recruitment. Although some countries are in favour of a 4-years training, probably a 2-years program will be able to contribute to the achievement of the needed scaling up to capacity.
Conclusion The participants agreed that, if the strategy could lead to the fact that 50% of the graduates would be trained in family medicine from 2013 onwards, this will lead to 30.000 new family physicians in sub-saharan Africa by 2020 in a 2-year program.

Social inequalities in overall and cause specific mortality in Seychelles.

Author(s) Silvia Stringhini1, Valentin Rousson2, Bharathi Viswanathan3, Jude Gedeon 4, Fred Paccaud 5, Pascal Bovet6.
Affiliation(s) 1IUMSP, CHUV, Lausanne, Switzerland, 2IUMSP, CHUV, Lausanne, Switzerland, 3Ministry of Health, Ministry of Health, Victoria, Seychelles, 4Ministry of Health, Ministry of Health, Victoria, Seychelles, 5IUMSP, CHUV, Lausanne, Switzerland, 6IUMSP, CHUV, Lausanne, Switzerland.
Country - ies of focus Seychelles
Relevant to the conference tracks Social Determinants and Human Rights
Summary Low socioeconomic status is associated with higher risk of overall and cause specific mortality in a country of the African Region.
Background Low socioeconomic status (SES) is consistently associated with higher mortality in high income countries. Only few studies have assessed this association in low and middle income countries, mainly because of sparse reliable mortality data.
Objectives This study explores SES differences in overall and cause-specific mortality in the Seychelles, a rapidly developing small island state.
Methodology All deaths have been medically certified for more than two decades. SES and other health risk factors were assessed in a total of 3246 participants from three independent population-based surveys conducted in 1989, 1994 and 2004. Vital status was ascertained using linkage with vital statistics. Occupational position was assessed using the same questions in the three surveys.
Results During a mean follow-up of 15.0 years (range 0-23 years), 523 participants died (overall mortality rate 10.8 per 1000 person-years). The main causes of death were cardiovascular disease (CVD) (219 deaths) and cancer (142 deaths). Participants in the low SES group had a larger mortality risk overall (HR=1.80; 95% CI: 1.24-2.62), CVD (HR=1.95; 1.04-3.65) and larger non-cancer/non-CVD (HR=2.14; 1.10-4.16) mortality compared to participants in the high SES group. Cancer mortality also tended to be patterned by SES (HR=1.44; 0.76-2.75). Major lifestyle-related risk factors (smoking, heavy drinking, obesity, diabetes, hypertension, hypercholesterolemia) explained 25%, 11% and 19% of the associations between low SES and all-cause, CVD, and non-cancer/non-CVD mortality, respectively.
Conclusion In this population-based study assessing social inequalities in mortality in the African region, low SES was strongly associated with overall, CVD and non-cancer/non-CVD mortality. Our findings support the view that the burden of non-communicable diseases may disproportionally affect the poor in low and middle income countries.

Family Planning Practice in Unintended Pregnancy: Rural Women in Bangladesh

Author(s) Forhana Noor1, Ubaidur Rob2
Affiliation(s) 1Reproductive Health, Population Council, Dhaka, Bangladesh, 2Reproductive Health, Population Council, Dhaka, Bangladesh.
Country - ies of focus Bangladesh
Relevant to the conference tracks Women and Children
Summary This article explores how family planning methods have contributed to unintended pregnancy among the rural women in Bangladesh. The study was a cross-sectional survey of 3,300 women. Findings suggest that among the respondents about 29 percent of the pregnancies were unintended. Analysis was found that those who did not use contraceptive methods before their last pregnancy had reduced odds (OR=0.22) of experiencing unintended pregnancy compared to those who used modern contraceptive methods. Advocacy is needed to promote longer acting and permanent methods among the eligible couples to avoid unintended pregnancy.
Background In Bangladesh most of the reproductive health programs are directed towards improving maternal health and family planning. These efforts lead to the decline of maternal mortality by 40% from 322 deaths in 2001 to 194 deaths in 2010 per 100000 live births, which may be attributable to remarkable progress in fertility decline, from a high level of 6.3 births per woman in the mid-1970s to 2.3 births per woman in 2011. Contraceptive use rate has also increased from only 8 in 1975 to 61 in 2011. Despite these recent achievements, maternal mortality still remains one of the prime challenges and also unintended pregnancy remained same for last three decades. Unintended pregnancy is typically exposed to the risk of abortion. In Bangladesh, abortion-related complications contribute to about one-fourth of all maternal deaths. Besides this, the rate of unintended pregnancy is also one of the most basic measures of the situation of women's reproductive health, and of the level of women’s autonomy and capacity for self-determination. It signifies a woman’s capacity to determine whether and when to have pregnancies.
Objectives According to 2011 Bangladesh Demographic and Health Survey (BDHS), in Bangladesh, 30 percent of pregnancies were unintended. The total intended fertility rate was 1.6 which is quite lower than the total fertility rate (TFR) 2.3. This means that if all unintended pregnancies could be eliminated, the TFR would drop below the replacement level of fertility immediately. High discontinuation rate, low use of long acting and permanent methods, erroneous use of family planning methods and unmet needs of family planning, in part or combined all contribute to the incidence of unintended pregnancies. Considering the situation, this article explores how family planning methods have contributed to unintended pregnancy among the rural women in Bangladesh.
Methodology This article used data from the follow-up survey of evaluation of the Reproductive Health Voucher Evaluation project in Bangladesh. It was a quasi-experimental research design with pre and post studies in intervention and control areas and the assignment to the intervention was non random. It was conducted in 22 sub-districts where 11 sub-districts were selected as intervention areas. The other 11 sub-districts were selected as control areas. In this study a baseline survey was conducted in 2010 and a follow-up survey was conducted in 2012. A total of 3,300 women of 18-49 years of age were interviewed who gave birth in the previous 12 months from the starting date of data collection. Respondents’ socioeconomic and demographic characteristics as well as service utilization and perception of each service were collected by using a structured questionnaire in this survey. In this article, both bi-variate and multivariate analyses were used to examine strength of the relationship between the unintended pregnancy and use of family planning methods.
Results Findings suggest that among the respondents (women) 68 percent wanted to become pregnant, 20 percent women wanted to wait or mistimed and another 12 percent did not want children any more. In other words, about 32 percent of the pregnancies were unintended. It was found that almost fifty percent (49 percent) of respondents were using a contraceptive method before their last pregnancy. Among them only one percent used a traditional method and rest 48 percent used a modern contraceptive method. Interestingly, the women who used (49 percent) any contraceptive before their last pregnancy, among them 46 percent experienced unintended pregnancy. On the other hand, non-users (51 percent) of contraceptive methods reported relatively lower proportion of unintended pregnancy (20 percent). The rate of unintended pregnancy also varied according to the use of contraceptive methods. The proportion of unintended pregnancy was comparatively higher among injectable users (51 percent) as compared to other method users.Logistic regression analysis was used to examine the odds of unintended pregnancy for each of the risk factors controlling for the others. It was found that those who did not use contraceptive methods before their last pregnancy had a reduced odds (OR=0.22) of experiencing unintended pregnancy compared to those who used modern contraceptive methods. Among contraceptive users, the likelihood of reporting unintended pregnancy was 1.6 times higher among the women who used traditional method as compared to modern contraceptive method users.
Conclusion Findings suggest that the unintended pregnancy rate was higher among the contraceptive users before their last pregnancy than non-users. Again, the rate was higher among traditional and temporary modern method users as compared to longer acting modern method users. From several studies it has been explored whether the incidence of unintended pregnancy might decline more slowly than expected, and might even rise for a while, as countries move through the fertility transition. So, it can be assumed that the improvement of quality of family planning services is likely to decrease the level of unintended pregnancies in the future and advocacy is needed to promote longer acting and permanent methods among eligible couples to avoid unintended pregnancy.

Integration and Convergence in the context of National AIDS Program Planning in Resource-constrained Settings.

Author(s) Nabeel M K1
Affiliation(s) 1Education, Research, and Evidence-informed Advocacy, Public Health Organizations, New Delhi, India, 2, , , ,
Country - ies of focus Global,India
Relevant to the conference tracks Health Systems
Summary Using the principles of public health ethics, particularly resource allocation ethics, this paper conducts a conceptual analysis of Integration and Convergence in the light of National AIDS Program Planning in Resource-constrained Settings. Sustaining and maximizing current achievements equitably in a resource constrained environment is indeed a challenge. Resorting to a fair and legitimate priority setting framework is the bare minimum that countries ought to do, without which the AIDS programs stand a serious risk of implosion. By undertaking an exercise of meaningful deliberative democracy, there are potential substantive benefits beyond procedural ones.
Background HIV is now referred to as a chronic manageable condition – a class of conditions under which diabetes and hypertension are included. With the advent of ART and other advances in treatment, care, and support, and with the increasing number of persons newly infected with HIV, the number of people requiring prolonged care and treatment continues to grow. Thus there is a clear need to continue investments in order to consolidate and sustain the successes so far, as well as ensure that the successes of the global and national efforts are equitably distributed. Convergence and Integration have been advocated as means to achieve the above two goals. The Planning Commission of India working group on AIDS has also made remarks on similar lines that “one of the critical challenges is to move towards more effective and efficient approaches through convergence and integration of programme components such as basic HIV services, comprehensive care, support and treatment with National Rural Health Mission (NRHM) and general health systems to the extent possible” (Planning Commission Working Group on AIDS, 2011). Apart from reducing the costs of interventions, convergence and integration have the potential to strengthen overall health systems as well (Shakarishvili, G et al, 2011; 2010).
Objectives The objective of this paper is to analyse India's National AIDS Program planning through a lens of integration and a prism of resource allocation. The National AIDS Control Organization (NACO) – now a separate department under the central ministry of health and family welfare in India – conducted a series of consultations with stakeholder groups for planning the next phase of the National AIDS Control Program (NACP). Different reviews of the current phase of NACP indicate success against the set benchmarks on several fronts. The program is on track and will achieve the targets set for most of the indicators (NACO E-Consultation, 2011). The fourth phase of the program (NACP-IV) is projected as the logical next step in India’s efforts to halt and reverse the epidemic, which is also in line with the Millennium Development Goals (MDG). It is envisaged to build on the different achievements of its predecessor - NACP-III – in order to reverse the epidemic through enhanced prevention as well as reinforced care, support, and treatment. However, NACP officials themselves have stressed the need for concerted attention in future for “consolidating the gains and ensuring quality and coverage”. (NACO E-Consultation, 2011) In addition, there have been concerns regarding the availability of resources in order to continue the existing beneficial interventions and to accelerate the achievements in alignment with the national goals and the Millennium Development Goals (MDG) to halt and reverse the HIV epidemic. Quoting the Planning Commission of India’s steering committee on Health, media reports talked about a proposal to ‘merge’ NACP with the National Rural Health Mission (NRHM) (Times of India, 2012). According to some members of the steering committee, it is about training the front line health workers similar to the Auxiliary Nurse Midwives (ANMs) in the  AIDS program. However, officials from the Ministry of Health and NACO publicly expressed their unhappiness and emphasized that the NACP deals with a specialized issue and a clientele different from that of ANMs. (Times of India, 2012) It appears prima facie that this proposal for a “merger” originates with the objective to streamline the health programs. This most recent media debate does not mention the proverbial ‘elephant in the room’ which are the resource constraints faced by the AIDS program.
Methodology The analysis in this paper is based on the Modified Accountability for Reasonableness Framework. Whereas ethics can guide policy makers and program planners on “what ought to be done”, economic analysis and research evidence can substantially help in setting the priorities in a resource constrained environment. Scientific and research evidence informs us of the effectiveness of particular interventions in order to guide resource allocation decisions and economics tries to find out the efficiency of interventions from a population-health point of view. (Gibson J et al, 2005). While there has been concerted efforts to incorporate evidence and economics into the priority setting process, decision makers often feel a gap in ensuring the ethics  of decision making are addressed. (Gibson J et al, 2005). It is in this context that a framework like the Accountability for Reasonableness (A4R) becomes handy for decision makers to ensure a fair and legitimate process in priority setting (Daniels N, 2000). The A4R framework has demonstrated the potential benefits of ethical considerations to deal with the “how” part in the decision making process of allocating scarce resources. The further addition of a fifth condition of empowerment to the original four conditions further strengthens the framework (Gibson J et al, 2005). This addition is an important step in respecting autonomy by virtue of citizens and groups who are empowered to participate in the process.
Results The results of the analysis is described under the following five conditions of the A4R+E framework: Condition 1: Relevance
As per the Relevance condition, the decisions need to be made on the basis of reasons that ‘fair-minded’ stakeholders can agree upon as criteria for decision making. The reasoning must comprise evidence, principles, and values.Condition 2: PublicityThis condition stipulates that the decisions along with the rationale for decisions should be transparent and publicly accessible. Condition 3: Revision and Appeals
As per this condition, NACP-IV planning process must have built-in opportunities to revisit and revise decisions in light of further evidence or arguments and there should be a mechanism for challenge and dispute resolution.Condition 4: Enforcement
As per this condition "enforcement" is necessary to ensure that the above three process-oriented conditions are met.Condition 5: Empowerment
According to this condition, there must be “efforts to optimize effective opportunities for participation in priority setting and to minimize power differences in the decision making context”.Further, the following also needs to be kept in mind based on the results of conceptual research on Convergence and Integration. Convergence and Integration have different meanings – former being more of a programmatic high level consideration and the latter as a grass-roots level service delivery consideration. Yet, these two terms have traditionally been used synonymously to broadly refer to the concepts discussed in the above two paragraphs. However, the term ‘Merger’ is relatively new in this context and connotes a more radical approach where one entity will lose its identity once the process of merger is completed. In the context of health care organizations, mergers have raised difficult ethical issues from the perspective of clients and patients, and service providers (Shaw D, 2003). Even though mostly in the context of hospitals, there have been instances where the mergers achieved neither cost-reduction nor quality-improvement (Weil T, 2010). Thus, mergers, especially those done in haste, have the potential to harm the program and its beneficiaries. Even in the case of integration of HIV related services with general health systems, there are cautions against blanket integration as opposed to carefully planned integration of select interventions.
Conclusion The analysis in this paper reveals that issues related to resource allocation have not been acknowledged and addressed adequately in the planning process of NACP-IV. As a result, the planning process, even though participatory in nature, did not have a resource allocation framework to adhere to. Neither was it able to consult the stakeholders with possible options and rationales for decision making in the context of shrinking resources. In addition, the concepts of integration and convergence have not been dealt with in detail leaving room for speculations and misinterpretations as mergers. It does not seem to be a problem exclusive to India that resource allocation within and between sectors related to health gets inadequate if not neglected attention. Critiquing the report of the Commission on Social Determinants of Health, Bayoumi in 2009 has stated that the Commission missed an opportunity by being “largely silent” on the issue of resource allocation. However, the Commission’s report did in fact show skepticism towards the current trends of health care reform which gives a very narrow focus on economic efficiency; as opposed to a broader attention to priority measures (Bayoumi A, 2009). It is still not too late for India to adopt a framework like the modified version of the Accountability for Reasonableness framework with empowerment as an additional condition (Gibson J et al, 2005). Certainly, this framework cannot stand in isolation but must form a broader frame on which evidence and economic analysis form superimposing rubrics for decision making (Gibson J et al, 2006). For this to happen, first there should be an explicit acknowledgement of the ‘elephant in the room’, rather than silence about resource constraints. Sustaining and maximizing the current achievements equitably in a resource constrained environment is indeed a challenge. Resorting to a fair and legitimate priority setting framework is the bare minimum that India ought to do, without which the AIDS program stands a serious risk of implosion. By undertaking an exercise of meaningful deliberative democracy, there are potential substantive benefits apart from procedural ones (Gutmann A, 1997).

Impact of Voucher Scheme: Delivery Care Services in Rural Bangladesh.

Author(s) Forhana Noor1, Ubaidur Rob2.
Affiliation(s) 1Reproductive Health, Population Council, Dhaka, Bangladesh, 2Reproductive Health, Population Council, Dhaka, Bangladesh.
Country - ies of focus Bangladesh
Relevant to the conference tracks Women and Children
Summary This paper examined the impact of the intervention of a demand-side financing scheme on the utilization of services as well as out-of-pocket expenses incurred by women for availing of delivery care services. A quasi-experimental research design was conducted for this study. Findings reveal that there was a significant (p<0.0001) increase in the utilization of delivery care at public facilities in the intervention areas compared to the control areas. The average out-of-pocket cost or money required for a normal or caesarean delivery decreased over thirty percent over the time period. Demand-side financing had a positive effect on both utilization and cost.
Background In rural Bangladesh, around 71% of births take place at home. Home delivery is preferred as it is associated with low cost and delivery care at facilities are only considered for emergency obstetric care (EmOC). Bangladesh is predominantly a rural, low income country with a vast majority of its people living in poverty. The utilization of skilled attendants at delivery was almost three times less in rural areas compared to urban areas and also it is seven times less among the poorest (9%) compared to the richer (63%) households. Borrowing, using household savings, and financial assistance from relatives were also found to be important sources in paying for the delivery care.
In the health sector of Bangladesh, the primary source of finance is out of pocket (OOP) expenditure and it is primarily spent in the private sector. Here 64% of total health care expenditure is paid by individuals and the rest by the government. In many situations, OOP payments for health care can cause households to incur catastrophic expenditures, which in turn can push them into poverty. Bangladesh has one of the highest rates of catastrophic illnesses which drives 3.8% of the population into poverty every year.
Objectives To address this equity issue, the Government of Bangladesh piloted a demand-side financing (DSF) scheme (popularly known as the maternal health voucher program) in 21 upazilas (sub-districts) from 2006 and expanded to 33 upazilas in 2007. The selected poor women under DSF scheme receive a package of essential maternal health care services, as well as treatment of pregnancy and delivery related complications. This program also provides supply side financing to service providers. This program has been expanded to another 11 upazilas in 2010. Population Council, with funding from the Bill and Melinda Gates Foundation, has been evaluating the impact of voucher programs in five countries including Bangladesh. As part of evaluation activities, Population Council conducted a baseline survey in 2010 and a follow-up survey in 2012 in new 11 DSF (intervention) and 11 non DSF areas (control). This article used information from the baseline and follow-up survey to examine the impact of this intervention on utilization as well as out-of-pocket expenses incurred by women for availing delivery care services at facility.
Methodology A quasi-experimental research design with pre and post studies in intervention and control areas was conducted to evaluate the impact of demand side financing vouchers on maternal health care services. The assignment to the intervention was non random. A baseline survey was conducted in 2010 with a follow-up survey in 2012. The study was conducted in 22 sub-districts where 11 sub-districts were selected as intervention areas where demand-side financing scheme was implemented. The other 11 sub-districts were selected as control areas where the demand-side financing scheme was not implemented. To draw a sample population, the national facility-based births figure was considered for baseline and follow-up survey and a total of 3300 women with 1650 experimental subjects and 1650 control subjects were selected. From each sub district, three of nine unions and three villages from each union were selected through probability proportional to size and finally, from each selected village, required numbers of respondents were interviewed. Women from 18-49 years of age were interviewed who had given birth in the previous 12 months from the starting date of data collection. Respondents’ socio-economic and demographic characteristics as well as service utilization and cost of each service were collected by using a structured questionnaire. Following the same sampling procedure, we interviewed the same numbers of respondents in the follow-up survey.
Out-of-Pocket Expenses: To examine the expenditure pattern, women were requested to report expenses on card/registration fees, consultation fees, laboratory examination, medicine, round trip transportation and any other associated costs to avail maternity care services. These expenses have been divided into three broad categories: medical cost at the facility, medical cost outside the facility, and transportation cost. “Medical cost at the facility” or internal medical cost includes card/ registration fee, consultation fee (unofficial), laboratory charges, drug cost (unofficial), tips to support staff for expediting services, and attendant expenditures for staying at the facility. Expenditures to purchase drugs and get laboratory services from the other private sector are considered as “medical cost outside the facility” and the actual cost women pay to transport providers is calculated as “transportation cost”.
Results Information on the utilization of delivery presented in Table 1 indicates an increase in the proportion of the deliveries that occurred at the facility from 19 percent in 2010 to 31 percent in 2012 in the intervention areas with the control sites experiencing almost the same increase. Use of public-sector facilities for delivery services increased in intervention sites while control sites experienced greater increase in using the private sector. It has emerged from the 2010 & 2012 expenditure pattern that all delivery services involved OOP payments and the average volume of expenditure is higher in control than in intervention. Findings illustrated  the average cost of different OOP expenses for receiving normal delivery services from public health facility. Cost incurred outside the facility (purchasing drugs and laboratory services) is the largest component (about half) of OOP expenditure for normal and cesarean delivery services in both areas. For that reason total average cost for normal delivery decreased a little bit in control areas also. Commonly, transportation cost increased in both intervention and control for normal or cesarean delivery.In the intervention group there has been a decline in the OOP cost for cesarean delivery that women incurred as medical cost both inside and outside the facility while an increase was reported for control. Reduction in both internal and external cost implies a positive impact of demand side financing benefits on women in receiving cesarean deliveries. With a mixed pattern of expenditure, the differences in OOP expenses between intervention and control that women incurred in 2012 cannot be explained with the effect of the DSF program.In the intervention areas, the average OOP cost for receiving normal delivery service reduced by 44% (from $40 to $22), and money required for a caesarean delivery decreased by 30% (from $115 to $80). Comparisons within public and private and voucher non-voucher has been made only in DSF upazillas.  For the women external medical costs at private facilities were double compared to public facilities. Internal medical cost was four times higher at private facilities than at public facilities. In a two-year period, this expense remained same for public facilities while it increased three times for private facilities. Again, voucher clients spent much less money than non-voucher clients.
Conclusion The recent shift in program development has taken place from being supply-side driven to being demand-side driven which improves the situation of non-accessibility of poor pregnant mother to the health facility. Findings reveal that there was a significant increase in the utilization of delivery care at the facility but it was also observed that the use of public-sector facilities for delivery services increased in only intervention sites while control sites experienced greater increase in the use of the private sector. The demand-side incentive package for the poor covers essential costs for maternal health care services and related to transportation cost also, while other costs like the purchase of additional medicine, unofficial provider fees and incidental costs incurred at facility are not covered under the program. Therefore, in DSF upazillas, there is no woman who did not incur any cost to utilize delivery services. Findings suggest the average volume of expenditure in receiving normal or cesarean deliveries is higher in control than in intervention areas. So, cost implies a positive impact of DSF benefits on women and this leads to the conclusion that DSF may have contributed to lower OOP payments. These findings necessitate the allocation of resources to subsidize the cost women incur to purchase medicine and undergo laboratory services that are not available in government facilities. Increased transportation expenses strongly justifies the need to increase the existing amount of financial assistance the government provides to poor clients. Without making normal delivery fully subsidized, it will be difficult to increase the institutional delivery rate  as women still spends a large share of their family income for receiving normal delivery services.Besides this, implementing programs at the upazila hospital alone cannot raise the rate of delivery in rural areas. Additionally, for optimum utilization of the existing health structure in rural areas, other govt. facilities need to incorporate it. It was also observed that a large proportion of women are receiving services from private health facilities. Therefore, the national health financing strategies should engage the private health sector in a way that enables poor women to receive services from the private sector more easily. With the right types of interventions, maternal health-related MDG may not be very difficult to achieve in Bangladesh.

Hospital waste management in Rawalpindi: A threat to urban environmental sustainability.

Author(s) Shahid Mehmood1, Audil Rashid2, Irfan Khawar3, Fakhra Rashid 4
Affiliation(s) 1Urban Health Division, City coordination, Punjab Local Government, Pakistan, Lahore, Pakistan, 2EcoHealth Research Group, Department of Environmental Sciences, PMAS Arid Agriculture University, Rawalpindi, Pakistan, 3Haemotology Department , Holy Family Hospital, Rawalpindi, Pakistan, 4EcoHealth Research Group, Department of Environmental Sciences, PMAS Arid Agriculture University, Rawalpindi, Pakistan.
Country - ies of focus Pakistan
Relevant to the conference tracks Environment and Sustainability
Summary One of the constraints in hospital waste management in Pakistan is ineffective legislation and the improper training about the collection, transportation and disposal of waste. In addition, unavailability of appropriate equipment for disposal (incinerators, autoclaves etc.) and insufficient budget to meet the expenses of waste management has led to many hospitals burning their waste in open environments. Lack of professional waste management teams, both at upper and lower levels, is another cause of hospital waste management failures in Pakistan. Unfortunately, scarce data is available on this issue therefore, this study has provided some of the baisc facts needed to improve hospital waste management.
Background Open dumping of hospital waste is one of the biggest threats to the urban environments in Pakistan. Unprecedented risks are posed to public health when infectious hospital waste is openly burnt along with municipal waste. This has undermined the sustainability of breathing air quality in Rawalpindi city where population has been complaining about this issue but no proper action has been initiated to solve the problem.
Objectives This study aimed to evaluate the waste generation, collection, segregation, transportations and disposal from major hospitals of Rawalpindi and its effect on the urban environment. An effort was made to document the effects of hospital waste burning on urban populations in order to find out the relation between ill-health effects faced by the people directly exposed to hospital waste burning.
Methodology Primary data was collected through comprehensive surveys which included questionnaire form, personal observations, formal and informal meetings. Secondary data was collected from hospital records. Logistic Regression analysis was performed to evaluate the first hand response obtained during surveys and the presence/absence of any ill-health effect was analyzed in the context of exposure extent.
Results The result indicated that approximately one sweeper is used for the cleaning of six beds and average daily waste generation rate was 1.55 kg day each bed,  which contains 71% non-infectious and 14% infectious waste with 91% average bed occupancy rate. Three of the studied hospitals have separates waste bins for infectious and non-infectious waste collection. But unfortunately, the segregation of waste is only at the point of generation. Two of the studied hospital had wheel trolleys for waste collections while other used manpower for waste collection. Two of the studied hospitals had no proper place for the temporary storage of waste and none of the hospital had refrigerators/cooling room for the storage of pathological waste. Out of 254 responses collected during  the questionnaire survey, 85% regarded themselves as directly exposed to waste burning fumes. Among ill-health effects attributed to hospital & municipal burning exposure includes in respiratory tract infections (Odds ratio = 3.18; 95% confidence interval 1.17 – 7.89) and eye irritations (Odds ratio = 2.66; 95% confidence interval 1.37 – 8.11).
Conclusion Open burning of hospital and municipal waste must be immediately stopped as it appears to be an urban health issue. A well-managed waste administration team is required for all hospitals in Rawalpindi city to develop a multidirectional co-operation from all stakeholders, including federal and provincial governments, public, private hospitals and waste disposal staff.

Community Pharmacists’ Knowledge, Practices and Attitudes towards the Medication Use Review in Qatar

Author(s) Ahmed Babiker1, Louise Carson2, Ahmed Awaisu3.
Affiliation(s) 1Pharmacy & Drug Control Department, Supreme Council of Health, Doha, Qatar, 2School of Pharmacy, Queen's University Belfast, Belfast, United Kingdom, 3College of Pharmacy, Qatar University, Doha, Qatar.
Country - ies of focus Qatar
Relevant to the conference tracks Advocacy and Communication
Summary Medication use review (MUR) is a service provision with accredited pharmacists undertaking structured adherence-centered reviews with patients on multiple medications, particularly those receiving medications for long-term conditions. The overall goal of MUR is to maximize an individual patient’s benefit from their medication regimen and prevent drug-related problems. MUR service is not yet established in community pharmacies in Qatar and nothing is known about pharmacists' knowledge, attitude, and practice pertaining to this service.
Background In Qatar, most patients currently receive their medications from the 8 public hospitals under Hamad Medical Corporation (HMC). In spite of being secondary and tertiary hospitals, most patients prefer to obtain their care including outpatient pharmacy services from these hospitals. Owing to this preference and attitude, there is unwarranted overcrowding in most hospitals and their outpatient pharmacies within HMC. One of the goals of Qatar’s National Health Strategies 2011-2016 is to improve the health services to international standards. Under this premise, Qatar envisions to provide world-class health care standard services and the best healthcare in the Middle East region (NHS 2011-2016). Within this goal, there is a community pharmacy strategy project aiming to adopt and implement international community pharmacy services and best practices as benchmark. Medication use review (MUR,) is one of these services. MUR service is not yet established in community pharmacies in Qatar and nothing is known about pharmacists' knowledge, attitude, and practice pertaining to this service. To our knowledge, the current study is the first one carried out to investigate the potential impact of implementing MUR services.
Objectives The overall aim of this research was to evaluate the perception of community pharmacists towards establishing MUR service as an extended role in patient care. The specific objectives of the study are to: 1) Assess the availability of facilities to support MUR implementation in community pharmacies in Qatar; 2) Evaluate pharmacist's self-perceived competence in providing MUR service; 3) Assess the knowledge of community pharmacists on MUR; 4) Assess the practices of the community pharmacists pertaining to MUR.
Methodology A cross-sectional study using self-administered questionnaires as a research tool was conducted among community pharmacists in Qatar from December 2012 to January 2013. The survey evaluated the pharmacists' self-perceived competence and attitudes towards providing MUR services in Qatar. The study involved pharmacists practicing in the private community pharmacy setting. There are approximately a total of 500 community pharmacists practicing in Qatar. In order to achieve a confidence level of 95% and 5% margin of error, a random sample of 220 community pharmacists currently practicing as community pharmacists in different cities and different pharmacies, including chains and independent pharmacies, in Qatar were selected to participate in the study. Inclusion criteria for potential respondents was: 1) being licensed as a practicing pharmacist in Qatar; 2) Currently working as a community pharmacist and; 3) working in a community pharmacy in Qatar for at least 12 months. The research instrument was developed via review of the literature pertaining to MUR, consultation with experienced researchers, experts, and licensed community pharmacists involved in the service. The data collected were analyzed using IBM Statistical Package for Social Science (IBM SPSS® Statistics) version 20 for analysis. Both descriptive and inferential statistics were used for data analysis. The study was approved by the Institutional Review Board of the Supreme Council of Health, Qatar.
Results One hundred and twenty-three community pharmacists responded to the survey, but 116 were included in the analysis (useable rate 94%; 116/123). The mean total knowledge score was 71.4% ± 14.7%. Although, nearly all of the participants (97%) were able to identify the scope of MUR in relation to chronic illnesses and in enhancing the quality use of medicines, only 43.4% knew that acute conditions are not the principal focus of MUR services. Over 80% of the community pharmacists were able to identify patients of priority for inclusion in an MUR program. At least 95% of the participants acknowledged that provision of MUR services is a great opportunity for the extended role of community pharmacists and that MUR makes excellent use of the pharmacist's professional skills in the community. Participants generally reported concerns about time, dedicated consultation areas, and support staff being significant barriers towards MUR. A large proportion of the participants (95%) indicated that training and education should be conducted for community pharmacists before implementing MUR program.
Conclusion The current findings suggest that community pharmacists in Qatar had sufficient knowledge about the concept of MUR and its scope, but there were still important areas of deficiencies and misconception of the practice that warrant education and training. The findings have important implications for policy and practice, particularly pertaining to the implementation of MUR services as an extended role of pharmacists and as part of Qatar's National Health Strategy 2011-2016 agenda to move primary health care forward in Qatar.

Best Practices for Building an Integrated National Health Information System: Rwanda.

Author(s) Caricia Catalani1, Angela Hoth2, Dawn Seymour3, Tyler Nelson 4, Felix Kayigamba 5, Richard Gakuba6
Affiliation(s) 1Innovative Support to Emergency, Disease, & Disaster (InSTEDD) & University of California, Berkeley, School of Public Health, San Francisco, United States, 2Innovative Support to Emergency, Disease, & Disaster (InSTEDD), Berkeley, United States, 3Rwanda Health Information Exchange, Regenstrief Institute, Kigali, Rwanda, 4Maternal Health & RapidSMS, The Access Project, Kigali, Rwanda, 5The Access Project, Kigali, Rwanda, 6 Rwanda Health Information Exchange , Kigali, Rwanda
Country - ies of focus Rwanda
Relevant to the conference tracks Innovation and Technologies
Summary The Rwanda Health Information Exchange (RHIE) is among the world’s first efforts to establish an integrated national health information system in a low-resource setting. Global decision-makers and implementers can benefit from both RHIE's open source tools and knowledge of leading and managing innovation for integration. This study assesses best practices in the design, development, and deployment of RHIE from the perspective of key stakeholders. Themes from the analysis of semi-structured interviews with funders, leaders, and implementers include recommendations on governance of country-owned initiatives, technological design and development, and deployment in a low-resource setting.
Background RHIE is a cloud-based system that supports quality of care and continuity of care over time, across geographies, and across different care delivery sites. RHIE’s vision is to improve health and wellbeing by ensuring that critical information follows patients when and where they need it, despite the dozens of different information systems used nationwide. In 2010, RHIE was designed and developed under the leadership of Rwanda’s Ministry of Health by the Open Health Information Exchange (OpenHIE), a global open-source technology community including partners at PEPFAR, Canadian International Research Development Center, Rockefeller Foundation, Regenstrief Institute, InSTEDD, Jembi Health Systems, IntraHealth, and others. RHIE’s national rollout began in 2012 and entailed working across sites with minimal infrastructure and among providers with little computer experience to configure hardware, install software, build local capacity, and manage technical support . Today, and as scale-up continues, RHIE facilitates the movement of health information across Rwanda with the primary aim of improving maternal and child health and the treatment and prevention of HIV/AIDS.
Objectives The Open Health Information Exchange builds free and open-source tools to enable other national leaders, policymakers, and implementers to improve the integration of health data and systems through the establishment of health information exchanges. Today, the partnership is collaborating with national leaders from six countries, providing technical support required to spearhead this effort. However, more than just tools and technical support, decision-makers need practical insights into the process of leading and managing innovation of this kind. As such, this study aims to describe the best practices in design, development, and deployment of a health information exchange, based on the RHIE experience. Researchers conducted key stakeholder interviews among RHIE funders, leaders, and implementers with a range of expertise from computer engineering to health systems management to clinical care. From their critical reflections of the RHIE initiative, its three years of history, and its pathways forward, stakeholders provide recommendations on approaches to governance of country-owned initiatives, strategies for technological design and development, and tactics for managing deployment of technological innovation in low-resource settings.
Methodology Qualitative semi-structured interviews were conducted with RHIE key stakeholders. Stakeholders included Ministry of Health leaders & implementers, project managers & strategists, technology architecture designers & developers, and funders & other institutional partners. Semi-structured interviews guided a conversational interview, providing the interviewers with key points of discussion without requiring strict adherence to a set order of questioning or phrasing of the questions. As such, interviewees provide descriptions of their experiences, ideas, and critiques in an open and guided discussion. Interview were conducted by two trained interviewers via phone, audio-recorded, and documented through detailed notes. Interview duration ranged from 45-75 minutes. Analysis was conducted using Dedoose Mixed Methods Analysis Software, a cloud-based research and analysis application. A modified grounded theory approach was used in the analysis of qualitative data. This approach facilitated the detailed and systematic examination of data regularities in the relationships between and within codes, and for variations and contrasts within codes. Major themes emerged from the codes and a descriptive framework formed.
Results Key stakeholder interviews included 14 participants from 7 organizations and 4 countries. Several key themes emerged across the major phases, spanning partnership building, design, development, deployment, and evaluation. First, eHealth is a new field without established guidelines for management and leadership and, as such, most found it challenging to partner without clearly articulated governance rules. Terms of governance, they argued, provide guidance for decision-making, roles and responsibilities, accountability, and transparency. The RHIE experience confirmed for most that country-ownership of the initiative should be established early and embedded into the partnership’s governance structures.Second, most partners commented on the difficulty of collaboration when key contributors were spread across several countries and time-zones. They explained that in a low-resource setting, it is often necessary to look for eHealth integration expertise and capacity from people based in other countries. Cross-cultural, cross-national, and cross-disciplinary communication was immensely difficult, although building an integrated system required a well-integrated team. Stakeholders found that it was critical to have a shared commitment to regular communication and ample budget for in-person meetings.Third, experts were adamant that an eHealth integration initiative should start by looking at existing, tested, and ideally open-source tools that might serve as customizable building blocks for their own solution. While identifying these tools, most argued that the team must create a shared standard of assessment so that they can transparently evaluate tools in a world where business interests may sway these decisions. Many stakeholders shared the opinion that eHealth solutions must be simple, tested, and even boring, although “the siren song is to do something new, bold, and innovative.”Finally, most partners found that the health and human development objectives of the project were obfuscated by the technological objectives of the project. RHIE contributors spent the vast majority of their efforts on designing and developing the technology, often without a shared vision of how the system would ultimately impact health services, morbidity, and mortality. One expert argued that it should have been the opposite and that “in a sociotechnical system, the technical should be 10% and the rest of the money and time should be spent focusing on implementing.”
Conclusion The health systems integration experts involved in RHIE shared a common sense of the challenges and opportunities inherent in partnering, designing, developing, and deploying a health information exchange. Several best practices emerge from these findings: establish rules of governance to guide the partnership; plan for regular and in-person communications to facilitate collaboration among diverse contributors; build on existing, tested, and open-source technologies before considering anything new; and, create a shared strategic and practical vision for how a new eHealth tool will impact health. As the OpenHIE expands beyond Rwanda and into new country implementations, these findings can be used to guide policy-makers, implementers, and other experts. Worldwide, country leaders are struggling to take advantage of the digitization of health information while managing innovation within health centers and protecting patient privacy. In an era of big data, health information exchange is one way to integrate and manage health information across disparate systems. Health information exchange tools and best practices may improve health and wellbeing by ensuring that critical information follows patients when and where they need it, despite the dozens of different health information devices, tools, and systems emerging worldwide.

How well do we know the “users” of health interventions? The example of (non-)enrolment in voluntary community-based health insurance schemes in Mali.

Author(s) Alexander Schulze1.
Affiliation(s) 1Global Health, Novartis Foundation for Sustainable Development, Basel, Switzerland.
Country - ies of focus Mali
Relevant to the conference tracks Social Determinants and Human Rights
Summary For health interventions to be successful, not only the health system needs to be considered, but also the patients understood. However, often in health research this understanding is reduced to their socio-economic status.
The present empirical study, focusing on the reasons for (non-) enrolment in voluntary health insurance schemes in rural Mali, expands the analysis of household characteristics to sociocultural orientations and intra-familial structures, including decision-making patterns.
The results reveal that the socio-economic status of households does not explain membership in a health insurance scheme, whereas the attitudes heads and family decision making patterns clearly do.
Background Systematic, quantitative evidence on user characteristics of health interventions is mostly limited to socio-demographic features and economic status. Yet, as research in medical anthropology has revealed, the acceptance of health related innovations is not only dependent on these factors.The example of (non-)enrolment in voluntary health community-based insurance schemes in sub-Saharan Africa mirrors this research gap. These schemes are characterized by modest enrolments rates and do not tap their potential in an already limited catchment area. In order to increase their coverage, the reasons for (non-)enrolment need to be better understood.However, to date, research has focused on the supply side, i.e. features of the insurance schemes and their contracted providers. On the demand side, comparative studies of enrolled and non-enrolled households have mainly concentrated on their socioeconomic status.Three research gaps remain which are not unique to the analysis of community-based health insurance: 1) sociocultural features are not analyzed in a quantifiable manner as socio-economic characteristics are. 2) household and family structures and their decision making patterns are not considered. Thirdly, significant factors are not explained and related to each other.
Objectives The present empirical study aims to fill the following research gaps:1) to expand the analysis of household characteristics beyond households’ socio-economic status by also taking account of their sociocultural orientations and intra-familial structures, including decision-making patterns. The main hypothesis underlying this approach is that socio-economic differences have been overestimated regarding their importance in determining the uptake of innovations, i.e. in the presented case membership in health insurance schemes, whereas attitudes and values, such as openness to or mistrust of social innovations, have been underestimated.2) A further goal is to systematically bring together and interrelate influencing factors that are meaningful beyond statistical significance, in order to ultimately reveal different lifestyle patterns associated with membership in, or refusal to join, a health insurance scheme.3) A further aim of this study is to present an analytical framework that links the socio-economic characteristics of households with their sociocultural orientations as well as with household and family structures.
Methodology A mixed methods approach, with different instruments employed sequentially, was developed. The central rationale behind a mixed-methods approach of this type was the idea to use qualitative methods of data collection not only in the exploratory phase but also at a later stage, to enhance interpretation of results from quantitative statistical data analysis and to develop explanatory patterns.The core element of the mixed methods approach chosen was household surveys on lifestyle patterns and social protection strategies. A total of 600 heads of households were interviewed in two localities. Of these, in each locality 200 had no insurance, while 100 did have insurance. In a second survey round, half of these household heads were again interviewed about their social protection strategies. In each study area this round covered 100 households with insurance and 50 households with no insurance.Households were the focus of research for two reasons: on the one hand, they are the unit of membership in the community-based health insurance schemes being studied. On the other hand, households are important repositories of lifestyle patterns within society and have a great degree of influence on the activities of their members. This is manifested, for example, in the transmission of values between generations and in the sharing of resources. Moreover, households are units of decision-making in different areas of life.Comparison of two rural areas in Mali had been considered useful insofar as community-based health insurance schemes are being advocated for peasant populations, primarily in French-speaking Africa. Furthermore, the two localities differ in terms of climate and in socio-economic and sociocultural terms but have a very similar health insurance scheme. Comparison of two areas also made it possible to examine to what extent social differences exist in rural Mali.

The household surveys were preceded by an exploratory phase including group and individual discussions, which primarily served to identify locally relevant categories of social differentiation. Following the household surveys, preliminary results were presented to representatives from the municipalities. These discussions brought out new points of view that were of use in further data collection and analysis. Following this, 20 group discussions and 24 individuals from selected families were interviewed in order to obtain insights into household and family decision-making patterns.

Results The results reveal that the socio-economic status of households does not explain membership in a community-based health insurance scheme, whereas the attitudes of household heads and family decision-making patterns clearly do. For instance, households of the lower socioeconomic tercile were even slightly more likely to be members than those of the middle tercile (p-value: 0.669; CI: .63-2.02; OR: 1.13).Households that are single households or are not part of a large family have greater freedom in decision-making. Moreover, heads of households with insurance appreciate different social changes (e.g. existence of new, formal organizations including community-based health insurance schemes), take on responsible roles in their communities and plan in a manner where the benefit is unsure or not immediately given, significantly more often than heads of uninsured households. For instance, those heads of household who only utter negative social changes are significantly less likely to be insured than those who also mention positive changes (p-value: 0.000; CI: .21-.57; OR: .35).Based on the results, a typology of households and their lifestyle patterns was empirically determined in both study areas. Each of the two study areas, two different household types were identified that are distinct not by their socio-economic status but by family structure and sociocultural orientation. The existence of different household types in both areas underscores the clear social differences that exist in rural Mali.
Conclusion The findings from this research on the reasons for (non-)enrolment of households in community-based health insurance schemes in rural Mali reveal that limiting the "users" of health interventions to their socio-economic status in many circumstances does not sufficiently explain why people "lack access to" or do not take up the services offered through health interventions.In order to better target potential users of health interventions and increase coverage, a more comprehensive but systematic analysis of their characteristics must be done. This includes socio-cultural features such as attitudes towards social innovations and change, leading values, consumption priorities as well as decision making patterns at household and family level.In other words, for health interventions to be successful, not only the heath system and its actors need to be considered, but also the patients. However, they must not be reduced to people living in poverty. Rather research must acknowledge that they are characterised by different livelihood patterns that expand beyond the issue of poverty.