Geneva Health Forum Archive

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Detecting Malaria in Refugees living in Non-Endemic Area: South Africa

Author(s) Joyce Tsoka-Gwegweni1, Uchenna Okafor2.
Affiliation(s) 1Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa, 2Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa.
Country - ies of focus South Africa
Relevant to the conference tracks Infectious Diseases
Summary The study presents findings from a research conducted in a refugee population in South African city known to be non-endemic to malaria transmission.
Background It is reported that 64% of malaria cases in South Africa are imported. This is expected given the high influx of refugees into the cities and reports by United Nations High Commission for Refugees that South Africa carries the highest number of asylum seekers globally. Although South Africa has planned to eliminate malaria by 2018, current interventions and research only take place in malaria endemic areas, which are remote and rural.
Objectives The aim of this study is to determine prevalence of malaria infection among a refugee population living in a malaria non-endemic city of KwaZulu-Natal province, South Africa.
Methodology After obtaining relevant approvals and consent, adult refugee participants were recruited from a faith-based facility offering social services in a city of KwaZulu-Natal province. The participants were screened for malaria using rapid diagnostic tests and confirmed with microscopy. Demographic data for the participants were obtained using a closed ended questionnaire.
Results Data were obtained for 303 participants consisting of 52% females and 48% males ranging from 19 to 64 years old. Of these 303 participants, 289 originated from different African countries, mainly central Africa. Two hundred and ninety participants provided a blood sample for screening of malaria. Of these, 3.8% tested positive for rapid diagnostic test and 5.2% for microscopy. The majority of malaria infections were due to Plasmodium falciparum.
Conclusion The study confirms important findings that include the prevalence of asymptomatic malaria infections detected in a refugee population and residing in an urban area of KwaZulu-Natal province that is not endemic for malaria. These findings have important implications for both public health and malaria control in South Africa, particularly since the country has decided to eliminate malaria by 2018. To achieve this goal, South Africa needs to expand research, surveillance and elimination activities to include non-endemic areas and marginalized communities. The findings further emphasize the importance of integrating services such as malaria surveillance into other public health intervention programmes, and provide refugees with full access to public health services. Other implications of the findings and possible challenges threating the success of the malaria elimination process and health service provision in South Africa are discussed.

Towards The Elimination Of New Pediatric HIV Infections.

Author(s) Olatunji Adetokunboh1.
Affiliation(s) 1Community Health, Stellenbosch University, Cape Town, South Africa.
Country - ies of focus South Africa
Relevant to the conference tracks Infectious Diseases
Summary In 2009, UNAIDS called for the virtual elimination of Mother to Child Transmission. In 2011, the Global Plan started and it covers all low and middle-income countries, but focuses on the 22 countries with the highest estimated numbers of pregnant women living with HIV. The data used were obtained from 2012 progress reports submitted by countries to UNAIDS and Spectrum software 2012 country files were used in monitoring the progress of these countries. From this study, Kenya, Namibia, South Africa, Swaziland and Zambia were the top progressing countries while India, Congo Democratic Republic, Nigeria, Angola, Chad and Mozambique were in the rear.
Background In 2009, the Joint United Nations Programme on HIV/VIGS (UNAIDS) called for the virtual elimination of Mother to Child Transmission, a call that has since been embraced by many agencies, regional coordinating bodies and national governments.
In 2011, at the United Nations General Assembly High Level Meeting on AIDS, global leaders made commitment with a plan towards the elimination of new HIV infections among children by 2015 and to keeping their mothers alive. This plan covers all low and middle-income countries, but focuses on the 22 countries with the highest estimated numbers of pregnant women living with HIV.
Objectives The objective of this study was to access the progress of the priority countries involved in Global Plan towards the elimination of new HIV infections in children and keeping their mothers alive.
Methodology Research question:
What is the progress made by the priority countries towards the elimination of new HIV infections in children and keeping their mothers alive.Methods:
The data used were obtained from 2012 progress reports submitted by countries to UNAIDS and Spectrum software 2012 country files. The study looked at the overall target 1 which is geared towards reducing the number of new HIV infections among children by 90%. The study also looked at Prong 3: Targets 3.1 - reducing mother-to-child transmission of HIV to 5% , Target 3.2 - having 90% of mothers receiving Perinatal antiretroviral therapy or prophylaxis and Target 3.3 - having 90% of breastfeeding infant-mother pairs receiving antiretroviral therapy or prophylaxis. The 2009 data serves as the baseline for this study.
Results For the overall target 1, the countries were categorized into 3 categories with 8 countries achieving rapid decline ( > 30%), 7 countries had moderate decline (20 -30%) while 5 countries had slow or no decline (10%) The percentage difference in reduction of mother-to-child transmission rate (%) (2009-2011), 9 countries (5 - 10%) and 5 countries (90%, 50-90% and < 50% in 3, 12 and 7 countries respectively.
By 2011, the percentages of mother-infant pairs receiving antiretroviral drugs to reduce transmission during breastfeeding were >50%, 21-50% and ≤20% in 3, 6 and 11 countries respectively. From this study, Kenya, Namibia, South Africa, Swaziland and Zambia were the top progressing countries while India, Congo Democratic Republic, Nigeria, Angola, Chad and Mozambique were in the rear. Notably, by 2009 Botswana had achieved some of the targets. Some of the countries did not provide adequate data for proper assessment.
Conclusion There was some level of progress among the priority countries in different areas geared towards reaching the elimination of new HIV infections in children, however some countries are still far behind. The performance in the area of mother - infant pairs receiving antiretroviral drugs is generally not encouraging. There is need for more drastic measures in the slowly progressing countries and keeping pace with the others. This research will be published in open access journals and presented to the research communities.

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.

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.