Geneva Health Forum Archive

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Strengthening the competencies and skills of nurses in mental health: Experiences from Bosnia and Herzegovina

Author(s) Selma Kukic1, Zvjezdana Stjepanovic2.
Affiliation(s) Mental health, Mental health Project in BH, Sarajevo, Bosnia and Herzegovina, Mental Health, Mental Health Project in BH, Banja Luka, Bosnia and Herzegovina.
Country - ies of focus Bosnia and Herzegovina
Relevant to the conference tracks Health Workforce
Summary The mental health reform in BiH was launched in 1996 focusing on community-based care and so far has made significant progress in the development of a large network of community mental health centers. In the centers multidisciplinary teams operate, however nurses are the largest and least skilled professional category of professionals and have the highest fluctuation rate within health system. The reform project in BiH (Mental Health Project in Bosnia and Herzegovina) is focused on the informal education of nursing staff with the objective of professional development, empowering and providing networking as a first steps toward a systematic re-profiling of nurses in mental health.
What challenges does your project address and why is it of importance? In 2008/09 the survey "Situation analysis and assessment of community-based mental health services in Bosnia-Herzegovina“ (Mental Health in SEE Project 2009) was undertaken. The findings of the 2008/09 survey were used as the baseline for the Mental Health Project in BiH to monitor changes and improvements made with the project's support. A self-assessment of the middle-level nursing staff in this survey revealed that the staff believed they were under-trained. 46% of nurses believed they had not received enough training to work in a mental health centre, and the MHC team members believed that the work of the nursing staff was not recognised by other health professionals and that there were prejudices caused by vaguely defined job descriptions for the nursing staff working in a MHC team. A new concept of nursing, as well as the empowerment of nurses within the system of community mental health, requires well trained nurses, whose knowledge is closely linked to psychological, sociological, philosophical, educational, medical and expert training. This would improve the ability of nurses to assume new tasks. This can be achieved through formal education, non-formal education, continuing professional education, as well as initiative and creativity in the field of nursing.
How have you addressed these challenges? Do you see a solution? The adequate re-profiling of nurses in mental health is optimally achieved through formal education. This project presented informal education as the first step to a systematic aproach. Education has garnered excellent results in terms of narrowing the gap of professional training, but the benefits of education are more reflected in the development of contacts, exchange of experiences and formal networking of these professional groups that did not previously exist in the form of professional associations. The results indicate that associated advocacy for the development of nursing legislation on education and employment in mental health is required.
How do you know whether you have made a difference? The results of the performance evaluation of the Conducted Educations suggested key improvements in the work of this professional group. 96 % of respondents felt that the education contributed to providing quality services to patients and their families through individual or team work. Particular emphasis was upon the acquisition and use of new knowledge, skills and techniques in work (88%), the rights and obligations of medical professionals and patients (66%) and combating the stigma of mentally ill patients in society (32%). 90 % of respondents observed changes in the area of respect for the professional attitudes of mental health nurses by other team members. Particular emphasis was on the experience exchanges among colleagues (65%), the level of self- confidence in the process of presenting opinions to their superiors (64%) and an additional level of competence to work within a multidisciplinary team (53%). With continous collaboration with mental health staff in MHCs there is greater viability for the initiatives taken by nurses to process their difficulties in work.
Have you or the project mobilized others and if so, who, why and how? The key project holders and implementers were the Ministries of Health, and their key responsibility was to make the entire process a success by ensuring the participation of nursing stuff and relevant experts and key stakeholders in the implementation of activities, as well as to provide further support to the continuing education of nursing staff.
When your donor funding runs out how will your idea continue to live? Sustainability is ensured through cooperation with other projects whose main goal is to work on legislation that would provide a legal framework for the employment of nurses in mental health, including formal education, by providing needed information and support.

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.

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.

Securing WHO FCTC Article 11 Compliance Through Legislative Advocacy: the Philippines

Author(s) Patricia Miranda1, Diana Cecilia Trivino2, Karla Mae Rocas3, Evita Mariz Ricafort4.
Affiliation(s) 1Legal Team, HealthJustice Philippines, Antipolo City, Philippines, 2Legal Team, HealthJustice, Quezon City, Philippines, 3Legal Team, HealthJustice Philippines, Quezon City, Philippines, 4Legal Team, HealthJustice Philippines, Quezon City,Philippines.
Country - ies of focus Philippines
Relevant to the conference tracks Governance and Policies
Summary Under the WHO FCTC, the Philippines obligated itself to require effective health warnings on cigarette packs by 2008. That deadline has long passed. Thus, HealthJustice Philippines (HJ) and Social Weather Stations (SWS) conducted a nationwide survey entitled "Usage and Attitudes of Filipino Youth Towards Tobacco" to gauge the behavioral response of Filipino youth towards graphic health information (GHI) on cigarette packages. The results show, among others, that 82% of current smokers believe that GHI shall be effective in preventing the increase of smokers. The survey is one of the launching points of HJ's legislative advocacy to ensure the passage of a GHI law in the 16th Congress.
What challenges does your project address and why is it of importance? The biggest challenge to the GHI legislative advocacy plan is the strong pro-tobacco lobby of the Northern Luzon Alliance (NLA), a legislative bloc composed mostly of representatives of tobacco-growing districts in Northern Luzon. The NLA has been known to deliver a "solid vote" against tobacco control measures in the Philippines. Currently, the Philippines is implementing Republic Act No. 9211, otherwise known as the Tobacco Regulation Act of 2003 (RA 9211), which provides for text-only warnings at the bottom portion of only one side of the pack. The contents of the warnings have not changed since the enactment of RA 9211 in 2003. Notably, RA 9211 does not comply with Philippine obligations under the WHO FCTC. Under this treaty, the Philippines is obligated enact effective measures requiring the placement of GHI on tobacco product packages by 2008. Thus, the Philippines has breached its international obligations when it missed its deadline to comply with the WHO FCTC. As a member of the family of nations, the Philippines agreed to be bound by generally accepted rules for the conduct of its international relations.
How have you addressed these challenges? Do you see a solution? It is urgent and necessary that Congress pass a law or laws guaranteeing that all our policies are in compliance with the WHO FCTC. One such legislative measure is the passage of a law requiring the placement of graphic health GHI on tobacco product packages, and banning the use of misleading descriptors thereon.HJ is currently with individual lawmakers and lawmaking bodies to gain support for GHI. As part of its legislative advocacy plan, HJ has prepared the following documents:
(a) brief on implementing Article 11 of the WHO FCTC in the Philippines;
(b) draft model bill incorporating the requirements of the WHO FCTC and its Implementing Guidelines;
(c) legislator's toolkit containing reports, surveys and studies relating to the effectivity of GHI in other countries; and
(d) presentation containing data which includes the results of the HJ-SWS nationwide survey entitled "Usage and Attitudes of Filipino Youth Towards Tobacco."At the time of this writing, there are currently seven Graphic Health Information bills. In the Senate, there are two bills filed by Senate President Franklin Drilon and Senator Pia Cayetano. In the House of Representatives, there are currently five bills on GHI, filed by Representatives Marcelino Teodoro of Marikina City, Niel Tupas of Iloilo, Joseph Violago of Nueva Ecija, Leah Paquiz of Ang Nars Party List, and Eric Singson of Ilocos Sur. All of these bills have been read on First Reading and are pending in their respective committees on health and/or trade. It should be noted that Eric Singson is a member of the Northern Luzon Alliance (NLA), a legislative bloc composed mostly of representatives of tobacco-growing districts in Northern Luzon. This may prove to be a sign that there is public clamor for more health promotive policies, particularly one requiring the placement of graphic health GHI on tobacco product packages. Hence, the solution lies in pushing for the passage of a law requiring GHI, particularly because of the presence and commitment of dedicated champions, the recent re-filing of the bills in both Houses of Congress, and the filing of a bill from a member of the NLA.
How do you know whether you have made a difference? One can only hope to make a difference, since the passage of any tobacco control measure in the Philippines entails coordination and teamwork between public health advocates. This is because the Philippines has the strongest tobacco lobby in Asia. Thus, one crucial gauge to determine if tobacco control advocates have made a difference in pushing for WHO FCTC compliant measures is to determine the number of tobacco control measures passed.
Have you or the project mobilized others and if so, who, why and how? The HJ Project Team is still currently mobilizing legislators and government agencies. Hence, the results of the "Usage and Attitudes of Filipino Youth Towards Tobacco," as well as the contents of the draft WHO FCTC-compliant bill, is being made available to the public.
When your donor funding runs out how will your idea continue to live? While donor funding may have been useful in drafting the documents submitted to the legislators in the Senate and Congress, these documents are also made available to the public. Hence, even if donor funding runs out, the documents meant to promote standardized tobacco product packaging and labeling in accordance with the Article 11 Guidelines would still be available to other tobacco control advocates, both public and private partners, to use and disseminate as they fit. The end goal would be amending RA 9211 to ensure its compliance with the WHO FCTC. The Department of Health, the Civil Service Commission, and the Metropolitan Manila Development Authority are government agency partners of HJ. These agencies have shown a strong support for the implementation of tobacco control policies in the Philippines.

‘Source’ Country Perspectives on the Migration of Highly Trained Health Workers: Findings from Jamaica

Author(s) Benjamin Waysome1, Gail Tomblin Murphy2, Adrian MacKenzie3, Rowena Palmer 4, Joan Guy-Walker 5, Annette Elliott Rose6, Ivy Bourgeault7, Ronald Labonte8
Affiliation(s) 1Strategic Human Resource Management, Jamaica Ministry of Health, Kingston, Jamaica, 2WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, Halifax, Canada, 3WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, Halifax, Canada, 4Strategic Human Resources Planning, Jamaica Ministry of Health, Kingston, Jamaica, 5Human Resource Management and Development, Jamaica Ministry of Health, Kingston, Jamaica, 6WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, Halifax, Canada, 7School of Health Sciences, University of Ottawa, Ottawa, Canada, 8Faculty of Medicine, University of Ottawa, Ottawa, Canada
Country - ies of focus Global, Jamaica
Relevant to the conference tracks Advocacy and Communication
Summary Although migration of human resources for health (HRH) is common, the consequences of it for ‘source’ countries are poorly understood, as are the range of strategies implemented to manage these consequences. A study of ‘source’ country perspectives on HRH migration, funded by the Canadian Institutes of Health Research, was conducted in India, Jamaica, the Philippines and South Africa to address this gap. This paper reports the findings from Jamaica, where HRH migration is common, and the causes of it are numerous, long-standing, and systemic. Several strategies have been implemented to address the consequences of HRH emigration from Jamaica, however their impacts have not been studied.
Background The migration of highly skilled health professionals from developing to developed nations has increased dramatically in the last ten years in response to a range of social, economic and political factors. The consequences of this shift in human resources for health (HRH) can be of critical importance to the overall sustainability of health systems in many of these ‘source’ countries, and have become much more salient in the ongoing debate about the reliance of some high-income countries on health workers who migrate from low- and middle-income countries. Few studies have examined these trends and their consequences from a comparative approach; those that have typically focus on ‘macro-‘level health indicators which do not allow for a broader investigation of the range of impacts HRH migration may have on patients, providers and health systems. Further, existing evidence is almost exclusively limited to physicians and nurses without considering the roles of other highly skilled health professionals who are also critical to the sustainability of developing health systems. Research to date has also given less attention to the range of responses that various policy decision-makers can and have undertaken to stem the tide of emigrating workers, and on their respective impacts.
Objectives To help to address the above gaps in evidence, a study was undertaken to examine the causes, consequences and responses to HRH migration from four ‘source’ countries – India, Jamaica, the Philippines, and South Africa. Although designed, initiated and overseen by a team of Canadian researchers, the study was largely driven by partners ‘on the ground’ in each of the four participating countries.The research questions the study sought to answer include:
(1) What is the present picture of /recent historic trends in the migration of highly skilled health personnel from Jamaica, the Philippines, India, and South Africa? (a) Who is migrating, how, and why? (b) What are the levels and impacts of return migration? (2) What, according to various stakeholders ‘on the ground’ in these source countries, are the most critical consequences of the migration of highly skilled health workers? (3) What is the range of policy responses that have been considered, proposed and implemented to address the critical causes and consequences of health worker migration from these countries, and what have been some of the outcomes of these responses?In addition to physicians and nurses, each participating country selected two additional categories of HRH to be the focus of their investigations. The purpose of this presentation is to share the study’s findings from Jamaica, where the additional professions selected were midwives and dental auxiliaries
Methodology The study built on a long-standing successful HRH research partnership between Dalhousie University and the Jamaica Ministry of Health. There were three data collection activities used to address the research questions: a scoping review, key informant interviews, and a survey of Jamaica’s dental auxiliaries, midwives, nurses and physicians. The scoping review identified and synthesized the published peer-reviewed and grey literature on Jamaica as it pertained to the research questions. The initial draft of the scoping review was completed by Canadian members of the research team, reviewed by Jamaican stakeholders for completeness and accuracy, and then updated to address identified gaps. Twenty seven key informants, representing Jamaica’s Ministry of Health, regional health authorities (RHAs), professional colleges and associations, private and public hospitals, universities, the Pan American Health Organization, and the Statistical Institute of Jamaica, were interviewed by the Jamaican study coordinator. The interviews were transcribed, validated by the interviewees, and then subjected to thematic analysis with NVivo 10. The survey of health care professionals was administered using both web  and paper based versions. Respondents could choose their desired format. Survey data were subjected to descriptive and regression analysis using SAS 9.2.Preliminary findings from the scoping review and qualitative and quantitative analyses were presented at a deliberative forum at the University of the West Indies (UWI) campus outside Kingston, Jamaica. Participants represented Jamaica’s Ministry of Health, Ministry of Labour and Social Security, Ministry of National Security, and Ministry of Foreign Affairs, each of the four targeted health professions, the RHAs, UWI, private hospitals, Passport and Immigration Services, the Statistical Institute of Jamaica and the Planning Institute of Jamaica. Participants validated the study findings and deliberated several potential strategies to mitigate the negative impacts of migration on Jamaica’s health care system. These findings were subsequently shared with representatives of the other participating countries at an international forum to identify common challenges and potential solutions.
Results Data on HRH migration are not systematically captured in Jamaica. Migration rates for physicians are estimated at between 31% and 58%, and 66% for nurses. Over one third of respondents from each profession reported that it was very likely they would emigrate within the next five years.Asked why they would emigrate, the top three working conditions-related reasons were income, infrastructure at work, and lack of opportunity for advancement. The top three living conditions-related reasons for migrating were cost of living, public infrastructure, and the quality of consumer goods. Interviewees frequently cited an outdated cadre system as being a barrier to employing necessary personnel, and to advancement for those who are employed. Twenty two percent of respondents reported experiencing some unemployment in the past five years. Fifteen percent of respondents described their current economic situation as “Good” or better and 23% described it as “Poor”. Regression analyses indicated that, after controlling for respondents’ age, gender, profession, years in practice, source of funding for training, and main sector of work (public vs. private), only age was a significant predictor of respondents’ intention to migrate. Older respondents were less likely to report an intention to migrate.Respondents reported being much more likely to receive or make inquiries about working abroad through colleagues in other countries than through recruitment agencies. One third of respondents reported having applied to write the licensing exam for their profession in another country.

Eleven percent of respondents reported having worked in their profession in another country, mostly other Caribbean countries, and returning. Most of these respondents reported being unsure whether their returns were permanent.

Interviewees reported that HRH who migrate tend to be more experienced, which reduces the leadership and mentoring skills available to those who remain. Respondents described international HRH migration as having a more negative impact than rural to urban or public to private sector migration. Eighty percent of respondents said they would send money home to Jamaica if they did migrate. Remittances from all Jamaicans living abroad are estimated at $2B USD or 1/7th of Jamaica’s GDP.

Jamaica has implemented a number of domestic and international strategies to mitigate the negative impacts of HRH migration. However, the impacts of these programs are unknown.

Conclusion Although its current health information systems preclude a precise quantification of the extent of HRH migration, it is clear that migration is very common among Jamaica’s health care personnel. It is also clear from published literature as well as the study participants that the causes of migration in Jamaica are numerous, long-standing, and systemic. Unfortunately, deeper understanding of the causes and consequences of migration, as well as the various strategies implemented to mitigate those consequences, is hindered by a variety of factors. These include weak health information systems (HIS) and infrequent policy evaluation. Recent efforts by Jamaica’s Ministry of Health, in collaboration with other partners, to strengthen its HIS, update its HRH cadre, and increase its capacity for HRH research and policy evaluation may help to address these issues.The study was limited by a low response rate to the survey of health personnel. There were 361 respondents to the survey. Although accurate data on the number of licensed health personnel currently in Jamaica are not available, the estimated size of the potential respondent pool across the four targeted professions is just under 6,000. This makes for a response rate of less than 10%. That said, the findings of the study were validated by a range of Jamaican stakeholders as being consistent with their experience. Further, it was noted by participants at the international forum that many of the findings from Jamaica were consistent with those from the other participating ‘source’ countries. This indicates that its results have national and global validity, strengthening the case for their incorporation into Jamaica’s HRH policy.

Understanding the Growing Complexity of Governing Immunization Services in Kerala, India.

Author(s) Joe Varghese1, Raman Kutty2, Ligia Paina3, Taghreed Adam 4
Affiliation(s) 1D 43 NCD Lifespan Training Program, Centre for Chronic Disease Control , New Delhi, India, 2Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Science and Technology , Thiruvananthapuram, India, 3International Health, Johns Hopkins University School of Public Health, Baltimore, United States, 4Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland.
Country - ies of focus India
Relevant to the conference tracks Advocacy and Communication
Summary This study tries to understand the complex phenomena related to the governance of immunization services in Kerala, India where, after basic immunization reached high coverage in the late 1990s, started to decline in some of the regions. The study applied system thinking lens and used a qualitative case study approach to explore the underlying phenomena governing vaccination coverage in two districts in Kerala, one with high and one with low coverage. The study identified four phenomena that influenced change in vaccination coverage.
Background Governing immunization services in a way that achieves and maintains desired population coverage levels is complex as it involves interactions of multiple actors and contexts. The conventional approaches often fail to take this complexity into account and expect that technically sound programs ensure successes when necessary management processes are in place. In India, the Universal Immunization Program (UIP), introduced in 1985, targets around 27 million infants and 30 million pregnant women every year and is one of the largest in the world. In one of the high performing Indian states, Kerala, after basic immunization had reached high coverage in the late 1990s, it started to decline in some of the regions.
Objectives We applied a systems thinking lens to understand the contexts, processes and complex phenomena which led to changes in vaccination coverage over the past three decades in Kerala and the reasons underlying these changes. The analysis expands our understanding of the governance of immunization programs operating in a complex system and thus, enables an understanding of, not only for Kerala but also for the other contexts, where public health programs are showing similar complex behavior.
Methodology We used a qualitative case study approach to explore the underlying phenomena governing vaccination coverage in two districts in Kerala, one with high and one with low immunization coverage. Data collection included in-depth interviews with private and public providers; beneficiaries and other stakeholders, as well as focus group discussions with mothers of under-five children and observations of vaccination-related activities. Content analysis for the qualitative data aimed to identify and describe the complex, adaptive phenomena resulting from immunization programs in our study area. Causal loop diagrams were developed to depict the phenomena, key actors, and their interactions.
Results We identified several complex phenomena that influenced change in vaccination coverage levels in the two districts. For example, we identify a phase transition from acceptability to resistance of receiving vaccination services due to the involvement of new actors. The causal loop diagram illustrated several balancing and reinforcing feedback loops that resulted from actions of actors attempting to regain vaccine acceptability and others who counteracted these actions. For instance, mothers who played a major role in decision making during the acceptance phase were replaced by the male members of the household during the resistance phase. The male members were influenced mainly through media which used a negative incident related to child vaccination to create a polemic that influenced their behavior and stance with respect to child vaccination all together. The conventional public health approach that is designed to target mothers through health information and female community health workers did not manage to counteract the influence of media since they are not designed to directly target the male members of the household.Path dependence is another phenomenon where new events influenced the way the decision to vaccinate by households was shaped in two different regions and the speed by which this happened. For instance, the special vaccination campaigns where the entire state machinery mobilized its resources to increase smooth operations were seen as a soft target by groups among naturopathy and homeopathy systems that traditionally opposed vaccination and propagated their misgivings against immunization programs. Finally, the emergence of social networks and their power to influence the change in either direction was detected. Health Worker’s status as a local woman known to the other members of the community gives her special advantage in influencing community perceptions on immunization issues
Conclusion This study offered a rich understanding of the interactions between multiple actors and contexts and the various phenomena that resulted from these interactions, influencing households' decision to vaccinate their children. Understanding these interactions, including the power exercised by each actor at different points in time, the factors determining the exchange of information, and the norms guiding the institutional mechanisms for immunization functions, clarified how the societal actions changed from acceptance to resistance to vaccinate. Understanding vaccination coverage using a systems thinking lens offered a robust framework to explore the underlying complex mechanisms and contexts that influence policies. The framework also emphasized the importance of considering all the actors beyond health systems. It can be applied in other public health contexts to define problems and guide the analysis.

Take a Step for Diabetes

Author(s) Beatriz Yáñez1, Martijn Pakker2, Marie-Hélène Charles3, Lorenzo Piemonte 4, Leonor Guariguata 5, Aneta Tyszkiewicz6.
Affiliation(s) 1Programmes and Policy, International Diabetes Federation, Brussels, Belgium, 2Programmes and Policy, International Diabetes Federation, Brussels, Belgium, 3External Relations, International Diabetes Federation, Brussels, Belgium, 4External Relations, International Diabetes Federation, Brussels, Belgium, 5Programmes and Policy, International Diabetes Federation, Brussels, Belgium, 6Programmes and Policy, International Diabetes Federation, Brussels, Belgium.
Country - ies of focus Belgium
Relevant to the conference tracks Advocacy and Communication
Summary Diabetes is a global epidemic that has traditionally lacked proper attention, a situation the International Diabetes Federation (IDF) is working to revert through integrated advocacy and communication efforts. IDF pushed for a UN High-Level Meeting on Non-communicable Diseases, held in 2011 and resulted in a Political Declaration on NCD prevention and control, placing diabetes high on the global health agenda. IDF also implements campaigns such as “Take a Step for Diabetes” to raise awareness on diabetes to an increasingly broader audience thanks to social media. The combined advocacy and communications efforts result in campaigns to help reduce risk factors and raise awareness on diabetes.
Background Diabetes and Noncommunicable Diseases (NCDs) are the leading cause of death and disability worldwide - accounting for 34.5 million of the 52.8 million global deaths in 2010 (65%). They exact a heavy and growing toll on physical health, economic security and human development.A global epidemic at crisis levels, diabetes affected 371 million people in 2012 and the number is due to increase to 552 million in 2030.The United Nations Political Declaration on NCD Prevention and Control raised diabetes/NCDs to the top of the international agenda and led to the adoption by the 66th World Health Assembly (WHA) of the Global Monitoring Framework (GMF). This sets out 25 indicators to monitor progress towards the achievement of nine voluntary global targets by 2025 – including halting the rise in diabetes and obesity.

Therefore, advocating for health strategies and promoting social mobilisation to decrease NCD risk factors is vital. This can be achieved through awareness-raising communications that will have a positive effect on improving both diabetes/NCDs management and preventing the rise of new cases of diabetes and NCDs.

Objectives Despite its consequences, diabetes continues to lack proper attention: half of all people with diabetes in 2012 – a shocking 186 million – were undiagnosed and type 2 diabetes is increasing worldwide at an alarming rate. Raising awareness of the risk factors and promoting healthier lifestyles have the double impact of improving diabetes management and halting its rise.
The International Diabetes Federation (IDF) – whose mission is to promote diabetes care, prevention and a cure worldwide – has two objectives to revert the present situation: advocate for political commitments and increase public awareness.INFLUENCING POLICY
In 2009 IDF, the Union for International Cancer Control, the World Heart Federation and the International Union Against Tuberculosis and Lung Disease formed the NCD Alliance (NCDA), a highly influential civil society force focused on placing non-communicable diseases (NCDs) on the political agenda.
IDF and NCDA have engaged in high-level advocacy to achieve this effect. IDF and NCDA campaigned for a UN High-Level Meeting on NCDs, held in September 2011 which was a major milestone in the history of diabetes and other NCDs. During the Summit IDF and NCDA influenced political negotiations to secure strong outcomes for diabetes and NCDs. The unanimously adopted Political Declaration on NCD Prevention and Control, opened the door for further advocacy efforts towards a Global Monitoring Framework (GMF). This was finally endorsed by the World Health Assembly in 2013. The GMF has 25 indicators to monitor progress to the achievement of nine voluntary global targets by 2025 – including halting the rise in diabetes and obesity.
IDF and NCDA’s work does not finish with the adoption of these global targets. IDF, its Member Associations and NCDA continue to work to monitor the progress governments make on their promises and to press the case for including NCDs in a global development framework post-2015.SOCIAL MOBILISATION
Despite the political will to stop the current diabetes epidemic that is reflected in the adoption of these nine voluntary global targets, there must be more advances. There will be no change unless both people with diabetes, and those at risk of developing the condition, are aware of the risk factors and willing to adopt healthier lifestyles. With that objective IDF has set in motion the social mobilisation campaign “Take a step for diabetes”, as part of the 5-year World Diabetes Day theme “Diabetes: education and prevention”.
Methodology Over the last four years World Diabetes Day has focused on raising awareness of the warning signs and risk factors of diabetes, highlighting the serious global threat that it poses, promoting simple and cost-effective measures to prevent the further rise of type 2 diabetes and the importance of diabetes education from a young age.With the goal of keeping the global commitments on diabetes made during the 2011 UN Summit on NCDs on the global health agenda, IDF launched the 2013 campaign “Take a Step for Diabetes” in March 2013, marking the final year of the “Diabetes: education and prevention” campaign.Conceived as a new way of raising awareness, inspiring local communities and promoting membership “Take a Step for Diabetes” has been designing as an innovating, engaging programme. It encourages people to make a symbolic donation of steps accrued through activities that help promote diabetes awareness, improve the lives of people with diabetes, promote healthy lifestyles or reduce one’s individual risk of developing diabetes. A total of 32 activities – ranging from wearing blue to running a marathon – can be done repeatedly. The aim is to reach 371 million steps – one for each person with diabetes in the world.

The main target groups are IDF member associations, other diabetes-related organisations, young leaders in diabetes, health professionals and community groups promoting healthy nutrition and physical activity. However, everyone – individuals and groups - is invited to register on the campaign website (steps.worlddiabetesday.org) and submit steps, providing a short description of the activities performed. The steps are collected on an online platform that displays the total number of steps submitted and the gap to the 371 million target.

This campaign is widely promoted through all IDF communication channels: website, social media (Facebook, Twitter, YouTube), newsletters (IDF, World Diabetes Day, World Diabetes Congress) and events where IDF has a stand. Specific communication materials have also been developed for the campaign including web banners, promotional videos, posters promoting key messages, a smartphone application, merchandise and an online toolkit providing information and resources on diabetes.

The “Take a Step for Diabetes” campaign will be widely promoted in the run up to and on World Diabetes Day – November 14 – and will officially end at the World Diabetes Congress Melbourne 2013 – 2-6 December.

Results The IDF campaign “Take a Step for Diabetes” has been designed to reach not only people and organisations strongly connected with diabetes – IDF regions and member associations, other diabetes-related organisations, community groups active in promoting healthy lifestyles, young leaders in diabetes, health professionals – but everyone who is interested in promoting the diabetes cause and furthering IDF’s mission.One of the campaign’s goals is to involve as many people as possible. The use of social media – mainly Facebook and Twitter – is essential in reaching a broad audience and engaging new publics in constructive dialogue. With more than 21.000 fans on Facebook and 13.000 followers in Twitter informed daily about the campaign, “Take a Step for Diabetes” has proven to be a powerful instrument for social mobilisation.More traditional means of drawing attention to the campaign are also used: the WDD newsletter had over 25.000 subscribers in September 2013 and, since the launch of the campaign in March the WDD website had achieved more than 100.000 views.

By the end of September 2013 over 450 individuals and groups had registered on the campaign online platform and performed around 8000 activities, accruing more than 332 million steps. The achievement of 90% of the target, 371 million steps by December 2013 which is 3 months in advance of the deadline, reflects the campaign’s impact and success.

However, as IDF is encouraging its member associations and other organisations and groups to organise WDD awareness activities – particularly during the month of November and WDD (November 14), a significant hike in the submitted number of steps is expected around those dates. Considering that the initial 371 million steps target will possibly be achieved before then (October), and the campaign does not end officially until the World Diabetes Congress 2013 in December, it is likely that IDF may increase the current steps to make the goal more ambitious.

Once the target is achieved and the campaign is over, IDF will send an open letter to the United Nations Secretary General Ban Ki-Moon on behalf the “Take a Step for Diabetes” participants. The great social mobilisation achieved through this campaign will be used to advocate for the global commitments on diabetes made during the 2011 UN Summit on NCDs to be kept on the global health agenda.

Conclusion Diabetes is a massive global burden with brutal health and socio-economic consequences. Although type 2 diabetes – which accounts for the vast majority of the cases worldwide – is largely preventable, the number of affected people is increasing in every single country. Tackling the current situation is a health priority for which interdisciplinary collaboration is imperative.Advocacy and communication are two inextricably linked working areas with the common objective of raising awareness. While advocacy is focused on influencing governments and key authorities to develop more comprehensive policies and strategies, communication promotes dialogue by delivering a series of messages to the general public. Both of them have a big role to play in overcoming the diabetes epidemic.The foundation of the NCD Alliance, of which IDF is founding member, was a clear advocacy milestone in combatting the NCDs and diabetes outbreak. As a network of more than 2,000 organisations, the NCDA is using its powerful voice to press governments into giving urgent response to NCDs as was shown by the UN High Level Meeting in 2011. The adoption of the GMF with its nine voluntary global targets to achieve by 2015 is another NCDA victory.

Political commitments on diabetes and NCDs are of great importance but would have little impact if the population is not aware of the risk factors to which we all are exposed. Communication campaigns such as “Take a Step on Diabetes” are perfect tools to promote healthy lifestyles and raise awareness on those risk factors. Social media has meant a revolution in this discipline, as now it is possible to reach a much broader audience than previously. In addition, an engaged population is another influential force for holding governments accountable for their political commitments.

Advocacy and communication are continuously interacting and frequently the outcome of one discipline can be used as a tool by the other. On the occasion of the achievement of the “Take a Step for Diabetes” campaign target a letter will be sent to the UN Secretary General Ban Ki-Moon, to continue advocacy efforts on keeping diabetes and the NCDs high on the political agenda. The constant feedback between advocacy and communication is a mechanism that needs to be continuously strengthened, to ensure the best outcomes in the fight against diabetes and NCDs.

MOTHER: A Mobile-Based Voice Health Alert Tool to Create Awareness on Young Child Feeding Habits.

Author(s) Suneetha Sapur1, Kathiresan Chinnusamy2, Girija Vadlamudi3
Affiliation(s) 1Nutrition, AkkshayaFoundation Society, Hyderabad, India, 2Indian Development Gateway, Center for Development of Advanced Computing, Hyderabad, India, 3Health, Health Management Reaserch Institute, Hyderabad, India, 4
Country - ies of focus India
Relevant to the conference tracks Advocacy and Communication
Summary Background: Malnutrition in Children is extensively prevalent in India. Poor feeding practices may lead to the burden of malnutrition, infant and child mortality.Objectives: To create awareness and demand generation in the community of government health services for infant and child feeding practices with the help of Information Communication Technology (ICT)Methods: Centre for Development of Advanced Computing and the Ministry of Communications and Information has developed the ‘MOTHER’ tool to capitalize the mobile phone’s core utility of ‘voice calls’ to create health awareness among the illiterate rural community. The project was taken up where the 80% of the population owned mobile phones.
What challenges does your project address and why is it of importance? •Registration and updating of the beneficiary records in the ‘MOTHER’ system directly from remote locations was a big challenge owing to poor internet connectivity. Our field workers started collecting the beneficiary details manually in the prescribed registration forms and in the evening, records were updated online from the Mandal Headquarters.• Voice alerts are being pushed from the system to the beneficiary mobiles and it is unilateral communication (Push Method). Beneficiary can’t call back and interact with the system. To facilitate the beneficiaries queries the phone numbers of health officials of the PHCs have been circulated to the beneficiaries during registration.
•In many families, mobile phones are only with husbands who receive the voice alerts. Most of the husbands are not interested in knowing about the basic support that can be provided to women during pregnancy and child care. They feel that it is the duty of the women. Sensitizing the husbands was one of the major challenges faced by our team. As part of MOTHER project, we organized village level awareness meetings to sensitize the men to listen to the voice alerts and pass the information to their wives.
•Compared to SMS, voice calls are costlier.
How have you addressed these challenges? Do you see a solution? Challenge: Registration and updating of the beneficiary records in the ‘MOTHER’ system directly from remote locations was a big challenge owing to poor internet connectivity. The solution was that our field workers started collecting the beneficiary details manually in the prescribed registration forms and in the evening, records were updated online from the Mandal HeadquartersChallenge: Voice alerts are being pushed from the system to the beneficiary mobiles and it is unilateral communication (Push Method). Beneficiary can’t call back and interact with the system.Solution: To facilitate the beneficiaries queries the phone numbers of health officials of the PHCs have been circulated to the beneficiaries during registrationChallenge: In many families mobile phones are only with husbands who receive the voice alerts. Most of the husbands are not interested in knowing about the basic support that can be provided to women during pregnancy and child care. They feel that it is the duty of the women. Sensitizing the husbands was one of the major challenges faced by our team.
Solution: We organized village level awareness meetings to sensitize the men to listen to the voice alerts and pass the information to their wives.
Challenge: Compared to SMS, voice calls are costlier. Moreover, service providers charge based on call duration and number of calls made per month.
Solution: We designed the voice alerts such a way that each call will be less than one minute and each alert will be sent two times in a day. Only critical alerts (such as expected date of delivery) will be repeated more than 3 times.
How do you know whether you have made a difference? Who were targeted:
• pregnant women, husbands of beneficiaries, fathers of children, health care providers,
Why:
• To create demand for the health services in the community, better utilization of health services by the beneficiaries and timely monitoring by the health officials.
How was this delivered:
• Apart from better infant and child feeding practices as presented in the abstract we observed positive changes after implementations of the project.
• Repeated voice calls sensitized the family members, particularly husbands, to understand the importance of pregnancy and the care to be taken at critical stages. Improved participation of husbands and fathers in health care activities was observed.
Have you or the project mobilized others and if so, who, why and how? The project mobilized community participation and awareness created by the project helped to create demand for health services, especially for immunization as the Mother call voice alert reaches the beneficiary (pregnant women, Mother's of below 18 months) on the days of immunisation schedule as well as nutritional supplementation through the Integrated Child development Surveillance program. Beneficiaries were demanding the village health workers for immunization and the food supplements such as Egg, fruit and calorie and protein mix.It also helped to improve health workers participation as it increased the responsibility of Health workers to follow-up with registered members. The number of visits by health workers to the beneficiary house reduced, in turn helping them to effectively utilize their time in other productive works. As to corruption, beneficiaries were sensitized about the entitlements and monetary benefits from health department along with voice health alerts. The better utilization of health as well as monetary benefits was observed.There was online monitoring of the beneficiaries details by higher government health authorities especially about high risk cases of pregnancy.
When your donor funding runs out how will your idea continue to live? In spite of a few limitations and challenges faced by the Mother tool implementation, the Mother project is a successful program that creates awareness on infant and child feeding habits. The Mother pilot project has been initiated with the goal of being integrated into the national level health services, so the pilot has been implemented by involving State National Rural health Mission and the antenatal and child data collection formats used in mother project were also of National Rural health Mission (NRHM) as these formats are common across the country. The NRHM people were involved at each step of the implementation program which helped the Mother project to be taken up by the state NRHM. The scale up of the Mother project to state level has been assisted by the NRHM officials involved witnessing the effectiveness of this innovative tool to create awareness across community, in particular to rural illiterate women. At the National level NRHM is considering a scale up to entire nation in a phased manner. Considering the level of mobile penetration in India and literacy level among rural women, voice calls (MOTHER) is the best model to reach-out towards the target beneficiaries directly at an affordable cost.  The projected has been scaled up to the state level and National Rural Health Mission is adopting this tool and scaling up to the different states in phases at national level. This project has been awarded "eIndia 2012’ Public Choice Award under Health category.

Understanding Policy Development of an NCD Benefit Package: Philippines

Author(s) Raoul Bermejo1, Pura Angela Wee2, Wim Van Damme3.
Affiliation(s) 1Department of Public Health, Institute of Tropical Medicine -Antwerp, Manila, Philippines, 2Zuellig Center for Asian Business Transformation, Asian Institute of Management, Manila, Philippines, 3Department of Public Health, Institute of Tropical Medicine -Antwerp, Antwerp, Belgium.
Country - ies of focus Philippines
Relevant to the conference tracks Governance and Policies
Summary There is increasing global attention on Non-Communicable Diseases (NCDs). In the Philippines, the burden of NCDs is growing but government response remains weak. The study is a policy research that looks at the development of a new benefit package for non-communicable diseases within the Philippine social health insurance program (Philhealth). We investigated how the interaction between the context, actors and processes contributed in shaping the policy. The push for Universal Healthcare, the increasing fiscal space, the growing burden of NCDs, and the increasing demand for access to quality medicines are important contextual discourses that help push the development of the benefit.
Background There has been increasing attention to non-communicable disease (NCDs) globally since the run-up to the high-level summit at the United Nations in September 2011 (Beaglehole 2011). In the Philippines, the burden of NCDs is growing (Shaw 2010). Although the government has started to develop policies and programs to address NCDs, there is still poor financing especially for prevention activities and comprehensive primary care services, lack of health human resource and weak political support (Higuchi 2010; Dans 2011). At the community level, the implementation of NCD programs, comprising mainly of healthy lifestyle clubs and occasional screening activities, remain weak (Lorenzo 2011). Overall, there is an inadequate response considering increasing burden of disease (Bermejo 2011; Van Olmen 2011).The improvement of the health financing mechanisms and particularly of the national health insurance agency, PhilHealth, is seen as a key in decreasing inequities and improving access (Romualdez 2011). One of the new Philhealth benefit packages that is ready to be piloted is the “Outpatient Medicines Benefit Package For Hypertension, Diabetes And Dyslipidemia” also known as the "Primary Care Benefit 2" (PCB2).
Objectives The study is essentially a policy research which looks at the development of a new benefit package for non-communicable diseases within the Philippines social health insurance program (Philhealth). We investigated how the interaction between the context, actors and processes contributed to shaping the policy. The study will also identify different streams in the discourse around PCB2 and analyze how and why this specific policy window emerged.Philhealth is emerging to be one of largest purchasers of healthcare services in the Philippines. It is an agency attached to the Department of Health and is increasingly seen as one of the institutions that shape the healthcare landscape in the country. This research will help to gain insight into its policy making processes, what and who these affect and how these are influenced. This study will help us identify opportunities for improvement of the policy processes at Philhealth and develop recommendations to inform current health policy.
Methodology Study design
A case study methodology was done using both qualitative and quantitative methodologies. Documents and issuances related to the development of PCB2 including Administrative Orders, Philhealth Circulars, other legal issuances, and reports of key meetings and events were reviewed. Key informant interviews were conducted among an initial list of actors involved in the development of this new benefit package to gain insight into the key decision made, why these decisions were made and how such decisions were arrived at. The snowballing technique was employed to identify other potential interviewees. The study aimed for theoretical saturation. A trend analysis on quantitative data from the Philhealth database on inpatient claims for NCDs was performed to enrich the contextual description of the case.Sampling
A total of 28 key informant Interviews were conducted with actors involved in the development of PCB2, including:
1. Philhealth decision-makers (e.g. the former and current president of Philhealth, technical personnel within the Primary Care Benefit Team);
2. Program managers and decision-makers at the Department of Health specifically those who are concerned with primary care, NCDs, access to medicines and local health systems development;
3. Members of the academe and researchers consulted on PCB2;
4. Representatives of advocacy groups on Universal Health Care and NCDs;
5. Health officers and representatives of local governments selected as pilot sites;
6. Representatives of the private pharmaceutical sector in the Philippines.Analysis
The policy triangle (Walt and Gilson 1994) and Kingdon’s policy window theory (Kingdon 1995; Guldbrandsson 2009) was applied to analyze the case. The researchers reconstructed the story of the development of PCB2 and identified key strategic decision-making points in the development process. We analyzed how the policy was shaped by the interaction between the context, actors and process. We enriched the contextual description with the time trend analyses of Philhealth population coverage, NCD-related inpatient claims, and reserve funds. The study also identified different streams in the discourse around PCB2, including the discussions on Universal Health Care, NCDs, primary care, strengthening local health systems, and analysed how and why this specific policy window emerged. The research approach was iterative. Each set of data analyzed were used to construct and test the theory.
Results We identified four key elements in the new outpatient benefit package of Philhealth: 1) only for sponsored program members or the bottom poor enrolled into the program by the national and local governments, 2) use of the WHO Package of Essential Noncommunicable (PEN) Disease Intervention guidelines for screening and risk scoring, 3) access to full monthly regiments of 8 firstline NCD medications which were 4) made available through contracted private pharmacies.The focus on the bottom poor is consistent with the overall poverty reduction strategy of the government. The strategy is to concentrate poverty alleviation interventions (e.g. Conditional Cash Transfers, enrolment in social health insurance) among the bottom poor (20% of the population) identified through a national household targeting system for poverty reduction.The use of the PEN guideline for screening and risk scoring was a result of consultation with the World Health Organization (WHO) and with the health managers of the City of Pateros where the guidelines were being piloted. Setting risk scores was seen by the insurance managers as a good way to have control over the cost exposure of Philhealth on this new benefit package. This was further validated by expert consultants in Medicine.The first line generic medications included in the list covered by the benefit package was arrived at with the technical team validating the evidence around NCD drugs included in the Philippine National Drug Formulary. By law, all government agencies, including Philhealth, can only pay or procure medicines that are included in the formulary. The position of Philhalth is to promote rational drug use and is directed at the common practice of many physicians who prefer originator drugs. Representatives of pharmaceutical companies, public health centers and specialist doctors actively raised the issue of the "very limited" list of medicines covered by the package.

The decision to make the NCD medicines available through contracted pharmacies is to be consistent with the Pharmacy Law but also largely depoliticizes access to drugs and link it as a clear benefit of being a Philhealth member. Access to medcines made available through public primary care facilities are often politicized.

The push for Universal Healthcare, the increasing fiscal space, the growing burden of NCDs, and the increasing demand for access to quality medicines are important contextual discourses that help push the development of the benefit.

Conclusion Health policies, programs and and agendas do not exist in separate silos from each other. PhilHealth’s “Outpatient Medicines Benefit Package For Hypertension, Diabetes And Dyslipidemia" or "Primary Care Benefit Package 2" (PCB2) is one such policy whose development was shaped by policy development processes, actors pushing for their specific agenda and by the context. The actual policy is a product of the dynamic interplay of these factors.

The Use of Traditional Medicine: A study in Bangladesh.

Author(s) Rumana Huque1
Affiliation(s) 1Department of Economics, University of Dhaka, Dhaka, Bangladesh.
Country - ies of focus Bangladesh
Relevant to the conference tracks Advocacy and Communication
Summary The present study aimed to examine the determinants of using traditional medicine by different socio-economic groups of people, assess the marketing strategies of providers of traditional medicines, and look at the existing policies that regulate the production, marketing and supply of traditional medicines. Household survey, exit client survey and key informants interview were employed to collect data. The findings suggest that though traditional medicine is popular in both rural and urban areas, inadequate monitoring and poor implementation leads to improper preparation of medicine with low quality or even the manufacturing of such medicines without legal permission.
Background Traditional medicine is the sum total of knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures that are used to maintain health, as well as to prevent, diagnose, improve or treat physical and mental illnesses. In Bangladesh, traditional health care providers (ayurvedic, homeopathic, unanie/kabiraji and others) are common and popular in rural areas leading to low utilisation of public facilities. It is evident that the non-availability of drugs and commodities, poor access to services by the poor, imposition of unofficial fees, lack of trained providers, a rural-urban imbalance in health providers’ distribution, weak referral mechanisms and unfavourable opening hours are contributing to low use of public facilities in Bangladesh. This indicates that though the health care seeking behaviour is partly associated with the socio-economic status of the population, the supply side problems existing within the health system also influence service utilization. In this context, the present study aimed to examine the determinants of using traditional medicine, assess the marketing strategies of providers of traditional medicines and to look at the existing policies to regulate traditional medicine.
Objectives The present study aimed to examine the determinants of using traditional medicine by different socio-economic groups of people and assess the marketing strategies of providers of traditional medicines. The specific objectives are to:• Assess the perception of people about safety, efficacy and quality of traditional medicine
• Identify the reasons for preferring traditional medicines by their types and by different socio-economic groups of people, and the types of services received
• Explore the level of satisfaction of users by socio- economic category, age, and gender
• Investigate the marketing strategies of providers for selling traditional medicines
• Identify the national policy and existing regulatory mechanisms for traditional medicines
Methodology The study followed a cross sectional survey approach where both quantitative and qualitative data was collected from exit clients, providers and at the household level at a single point of time. The study was carried out in two districts: Tangail and Munshiganj. Two upazilas from each district had been chosen randomly. Household surveys were carried out to assess the extent to which people from different socio-economic groups prefer traditional medicine and the reasons for preferring traditional medicine. Household surveys gave an overall understanding of the preference for traditional medicine among the population. A total of 800 households were surveyed from the four upazilas, taking 200 from each upazila. Among the households, 400 households were selected from rural poor areas and 400 from urban/peri urban non-poor areas to include samples from different socio-economic groups. A multi-stage stratified systematic random sampling approach was adopted. Wards were selected as Primary Sampling Units (PSU) through a systematic random sampling procedure from the list of wards as documented in Community Series Population Census 2001, published by Bangladesh Bureau of Statistics. After selecting the sample wards as the PSUs, we again adopted a systematic random sampling technique to draw sample households from the wards. We followed a cluster randomization approach for selecting the households within the sample frame. A semi-structured questionnaire was used for the household survey. Randomly selected 20 exit clients of each type of traditional medicine users (160 clients from eight facilities/providers) were interviewed to assess their knowledge, attitude and practice regarding traditional medicine usage, and their level of satisfaction. This contributed to the gathering of a more specific understanding of the preference for traditional medicine among the users. A semi-structured questionnaire was used to collect data. We interviewed three policy makers within the Directorate General of Health Services and one academic. A total of 18 traditional medicine providers were also interviewed for the study. The quantitative data were analyzed by using both descriptive and analytical statistics. Transcribed qualitative data were analyzed with respect to context, process, and outcomes.
Results Traditional medicine was popular among households in study areas. Overall, 48% of the households sought treatment from traditional providers in the recent past for themselves or for any one of their family members in the study areas, while the proportion was relatively higher in Tangail (54%) as compared to Munshigonj (42.5%). It was also found that the proportion of households who used traditional medicines were higher in Sadar upazilas (51%) as compared to the remote upazilas (45%). It was evident that 47% of households who had sought treatment from traditional providers were poor defined as those whose monthly household income was less than 10,000 Taka. Households sought treatment from traditional providers generally for women and children, who suffered from fever, pain, common colds and general ailments such as anemia, helminthiasis and nutrition, eye infection, common dental diseases and ear problems. The percentage of households inclined to take treatment from traditional providers for the elderly was relatively low in both areas (15% in Tangail and 11% in Munshigonj), and a few of them sought treatment for non – communicable diseases such as diabetes, cardio-vascular disease, hypertension, heart diseases and hypertrophy of the heart. The major reasons for seeking care from traditional providers were low cost, no side effects, prompt services and most importantly the close location of the service centre which makes the service easily accessible. It was found that illiterate and little learned persons were the main clients of traditional medicine. A considerable number of exit clients were found to be familiar with traditional medicine and had been using it for quite a long period. Therefore, from the view point of effectiveness, the clients were satisfied with traditional medicine. Most of the clients of both districts claimed that they never had any side effect for using traditional medicine. Providers also distributed leaflets in popular public places, did promotion on TV through cable operators and made miking and wall paintings to attract less-educated and middle income group people. It was evident that though there exists law and policy regarding production and practice of traditional medicine in Bangladesh, the poor implementation of the law and inadequate monitoring leads to improper preparation of medicine with low quality or even the manufacturing of medicines without legal permission due to the unavailability of proper medicine testing laboratories for traditional medicines.
Conclusion Traditional medicines are believed to be made of natural products and therefore are safe and have no side effects. However, traditional medicines and practices can be harmful if the medicines are inappropriately prepared and consumed. For mainstreaming the traditional medicine into the public health system, the followings measures need to be adopted:• A proper regulatory framework is required for the quality production and safe use of traditional medicine in Bangladesh. Given the heterogeneity of the service provision by the traditional providers, a monitoring and regulation mechanism needs to be developed to ensure quality of service provision. Governments should take the necessary measures to strengthen drug administration to ensure the quality of traditional medicine.• An appropriate medicine testing laboratories service must be introduced to ensure the quality of Unani, Ayurbedic and Homeopathic medicine.• Government needs to establish training centres for service providers and manufacturers of traditional medicine.

• Initiative should be taken by government and NGOs to increase awareness among the population about the service variety and quality of traditional medicine.

• Further research should be done on the cost-effectiveness of traditional medicines, pharmacology of natural products, characterization of natural products, synthesis of natural products, product development and possibility of commercialization of traditional medicine.