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Health as an indicator of sustainable development: How health can contribute to and benefit from sustainable policies.

Author(s) Natalie Mrak1, Callum Brindley2
Affiliation(s) 1Development studies, The Graduate Institute for International and Development Studies, Geneva, Switzerland, 2Development Studies , The Graduate Institute for International and Development Studies, Geneva, Switzerland.
Country - ies of focus Switzerland
Relevant to the conference tracks Environment and Sustainability
Summary This study highlights how health can be a cross-sectoral indicator for the proposed 2015 sustainable development goals. The impacts of environmental changes on human wellbeing have been clearly established but insufficient work has been done to show how sustainable policies can also benefit health. This study recommends health indicators that can be used to measure sustainable progress in the sectors of water, food, energy, housing and transportation within the urban environment. It also provides suggestions on accountability and governance mechanisms that should put be in place at local, national and global levels to ensure that everyone takes responsibility for sustainable development.
Background Growing concerns about the impact of environmental changes on health have emerged as middle-income countries have adopted the consumption and greenhouse gas emission behaviours of high-income countries. The same economic trajectory that has created a global marketplace dependent on increasing volumes of production, consumption and the long-distance transport of goods, has also led to the overexploitation of finite natural resources, energy shortages and the overburdening of the natural environment. The affects from this trajectory not only pose challenges to the sustainability of the environment but to human health as well. About 24 per cent of the global burden of disease and 23 per cent of deaths are attributable to environmental causes and around 36 per cent of the disease burden in children is caused by environmental factors. Despite this information, health has been an omitted aspect in climate policies. The collective health benefits that can be gained from a low carbon economy have been overlooked when they can actually be motivation for further cutting greenhouse emissions. Emphasizing the joint benefits could make reducing greenhouse emissions attractive since they serve as a means towards achieving both public health and climate goals.
Objectives The primary objective of this study is to demonstrate how health is a cross-sectoral theme of sustainable development that can be used to motivate behaviour change. The secondary objective is to show how human wellbeing will be impacted if sustainable approaches to development are not pursued. Since the MDGs were established in 2000, tremendous progress has been made to improve health outcomes but this progress will become compromised if measures are not taken to improve the current state of the environment. Everyone will be impacted but particularly the poorest and most vulnerable whose already scarce access to public goods could be further compromised as governments grapple with economic devastation as result of changes in the climate and environment. Urban areas will continue to grow, unable to accommodate their expanding population, which could lead to increased food insecurity as dry arable rural lands become incapable of producing crops. Prolonged drought conditions and increased occurrence of natural disasters could also lead to water insecurity. This situation, combined with poor housing conditions, unsustainable energy sources and carbon-motorized transport will negatively impact health and the environment. The tertiary objective is to show how policies across diverse sectors can improve human wellbeing and the environment. Health can be used to measure the effectiveness of policies in various sectors as well as benefit from policies that also improve the environment. In order to tackle the health risks that environmental changes pose, an integrated, cross-sectoral approach needs to be taken since human wellbeing is not only affected by such factors as health systems as but also other factors like pollutants and physical activity. The additional objective is to analyse the opportunities and challenges to promoting more sustainable behaviour. Everyone can contribute to a sustainable future from healthcare workers to businesses as well as governments and civil society. The post-2015 development agenda provides an opportunity to implement accountability mechanisms that do not currently exist. As cities become centres of human settlement, there is also a need to implement environmental-friendly policies that enhance rather than detract from economic growth.
Methodology The main question of this study is to see how health is a cross-sectoral indicator of sustainable development. The study was conducted between June and September 2013. The search strategy sourced reports and articles primarily published by the United Nations, especially the WHO, UNICEF and UNEP as well as the below leading health and development journals. We reviewed only articles published in English and concentrated on the period from 1990 to 2012. Our principal search terms were: “health” AND “sustainable development”; “environmental burden of disease”; “healthy environment”; “urban health”; “healthy cities”; “health” and “results-based management”; “health indicators.” In total, we closely reviewed over 100 reports and articles. To analyse the literature, the following questions were posed:• How can health and sustainable development be linked?
• How is health positioned in the post-2015 development agenda and the sustainable development goals debate?
• What are the strengths and limitations of indicators
• What current health indicators exist and what are their merits?
• What lessons can be drawn from the WHO’s Healthy Cities programme?
• How can inter-sectoral cooperation be promoted?The study looks at sustainable development within the context of urban areas, focusing on five key areas – food, water, energy, households and transport. Cities were selected as the geographic area of focus since their populations are expected to continue to increase over the course of this century. The five areas of focus were selected on the basis of their strong cross-sectoral communications with health and the burden of disease from their associated risk factors. The study demonstrates how the relationship between health and sustainable development can be thought of in three ways: health contributes to the achievement of sustainable goals, health can benefit from sustainable development and health is a way to measure progress across all three pillars of sustainable development policy.
Results The results of the study clearly demonstrate that health is an integral part of sustainable development whose contributions should be considered more seriously in the post-2015 development agenda discussions. First, climate change is contributing to the increased incidence of natural disasters and disease outbreaks, increasing the global burden of disease. Second, urban areas will endure great burdens as a result of climate change, which will be primarily due to the increased migration to cities. Third, there are measures that can be implemented across sectors, which can reduce greenhouse gas and pollutant emissions as well as improve human well-being. Last, this study also found that while there is an abundance of data on health as an indicator of sustainable development and the distinctiveness of each country’s context make it difficult to discern which existing indicators are most practical and useful, there are a series of assessments that can be carried out to develop a fit-for-purpose complement of indicators. The below tool outlines the method for conducting these assessments by focusing on a country’s:• Burden of disease
• Level of economic and social development, and
• Environmental condition and pressuresTables of indicators by income-level for the health-sustainable development nexus were created. It was found that each indicator has the following four strengths;

• Relates closely to both health and sustainable development
• Relies on data that is easily accessible and reliable
• Communicates clearly a development challenge
• Facilitates practical policy interventions

The primary limitation of this study was the lack of first-hand qualitative data which is due to the top-down approach of the study. A complementary bottom-up study containing ethnographic work could help confirm these findings and provide a people centered-approach to seeing how health is an integral part of sustainable development.

Conclusion Health can be a useful focal point to promote inter-sectoral cooperation at the local level but there is unfortunately no set of health indicators that are relevant to all contexts. A drawback to the work that has been done on health as an indicator of sustainable development in urban settings has been the emphasis on the quantitative aspect of indicators. This has made it difficult to single out a set of best practices and to actually see whether these interventions improve well-being. As urban populations continue to expand in the coming decades, new approaches to urban planning need to be taken which engage a variety of stakeholders and adapt to the dynamic nature of cities. Small-scale interventions in urban areas can be key to providing insights into what does and does not work. To ensure the work on health and sustainable development continues, health needs to be an integral component of the post-2015 development agenda. The sustainable development goals of the post-2015 agenda will not be achieved if a concerted effort is not made to assist low and middle-income countries in developing and implementing renewable energy techniques as their populations and economies continue to grow in the coming decades. Mechanisms should be created that not only transfer funds but knowledge and technology as well. Governance mechanisms need to be set in place, which marry policy and scientific evidence and impose accountability. Increasing public awareness of the intricate relationship between public health and the environment could help promote sustainable behaviour and raise attention to the need of holding all stakeholders accountable. Ultimately, there needs to be commitment at all levels of government and society in order for sustainable development to become a reality.

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.

Lessons from the Commercial Sector: How Integration Can Transform Public Health Supply Chains

Author(s) Carmit Keddem1, Nadia Olson2, Carolyn Hart3, Joseph McCord4.
Affiliation(s) 1Center for Health Logistics, John Snow, Inc., Boston, United States, 2USAID | DELIVER PROJECT, John Snow, Inc., Washington, DC, United States, 3Center for Health Logistics, John Snow, Inc., Washington, DC, United States, 4USAID | DELIVER PROJECT, John Snow, Inc., Washington, DC,United States.
Country - ies of focus Global
Relevant to the conference tracks Health Systems
Summary Successful health programs require an uninterrupted supply of health products provided by a well-designed, well-operated and well maintained supply chain. By applying a new approach to end-to-end integration, adapted from the commercial sector, health managers can ensure that public health supply chains deliver an adequate supply of essential health commodities to the clients who need them.
What challenges does your project address and why is it of importance? Health programs can succeed only if people have access to the essential health products they need. Although many countries have strengthened their public health supply chains and, thus, improved product availability in recent years, they continuously face new challenges. Countries are under increasing pressure to deliver a rising volume of products to support expanding health programs and respond to greater demand from donors for accountability and sustainability. New technology and commercial sector approaches can help countries build dynamic supply chains that respond to these changes and yield health and development benefits.
How have you addressed these challenges? Do you see a solution? JSI has researched and applied commercial sector approaches to public health supply chains, including supply chain integration, and has seen significant results. While public health systems in resource-limited settings are very different than private companies, public health supply chain managers face many of the same challenges as commercial supply chain managers did many years ago. Over the past few decades, commercial sector supply chains of major corporations, including Apple, Proctor & Gamble, Wal-Mart, and Dell, have undergone a major transformation to become cost-effective, agile, and responsive to consumer needs. This occurred in an environment where consumers were expecting wider choice and better service from retailers, and increasing globalization encouraged companies to build international, outsourced supply chains with increased management complexity. With the right approach, integration can be as transformative for public health as it has been in the commercial sector – leading to more cost-effective and reliable supply chains that effectively deliver health products to clients and contribute to better health outcomes.When adapted for public health, supply chain integration involves linking the actors managing health products from the top to the bottom of the supply chain, or from end-to-end, into one cohesive organization, which oversees all supply chain functions, levels, and partners, ensuring an adequate supply of products to clients. Lessons from the commercial sector teach us that integration is more than merging health program supply chains - for example putting malaria and HIV and AIDS products on the same truck. JSI has worked to design and strengthen various public health supply chains according to the principles of supply chain integration by better linking people, information, and activities from where products are made to the people who need them.
How do you know whether you have made a difference? In Zimbabwe, after applying supply chain integration principles to integrate key products into a well-functioning family planning supply chain, stockout rates for nevirapine tablets decreased from 33 percent to 2 percent and supply chain costs were reduced. This, ultimately, resulted in 35 percent more mothers treated to prevent mother-to-child transmission of HIV.
Have you or the project mobilized others and if so, who, why and how? JSI, through various supply chain projects, works with government, civil society, academic and funder organizations to strengthen public health supply chains worldwide. We have incorporated supply chain integration concepts into our system strengthening approaches in various countries – from a supply chain orientation of animal health specialists in Indonesia, to pre-service training in Tanzania, to guiding the supply chain system design process for essential medicines in Nigeria.
When your donor funding runs out how will your idea continue to live? Strengthening supply chain systems requires significant investment and resources, but can reap significant long-term benefits for health programs and the broader health system. While supply chains required sustained investment, designing public health supply chains according to the principles of supply chain integration will improve their efficiency and effectiveness in the long-term, protecting the investment in commodities and the supply chain system and leading to more sustainable health solutions.

The Effectiveness of Holistic Care Unit by Using Rate of Patients Revisiting Emergency Department within 3 Days in Taiwan

Author(s) Meng-Chieh Wu1, Li-Sheng Chang2, Hsin-Kai Huang3, Tzu-Chieh Weng 4, Chun-Cheng Zhang 5, Kao-Chang Lin6.
Affiliation(s) 1Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 2Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 3Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 4Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 5Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 6Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan.
Country - ies of focus Taiwan
Relevant to the conference tracks Clinical Practice and Hospitals
Summary Owing to the convenience of health insurance, the numbers of community hospitals has declined in past 20 years in Taiwan. Many patients directly visited medical centers for aid and waited for admission through the gate of emergency department. Overcrowding situations affecting the quality of care at Emergency Departments is an important issue in the Taiwan medical system. The overloading pressure induced the shortage of emergency physicians and nurses. A new department, holistic care unit, was established in Chi-Mei Medical Center in Taiwan in August 2012, to bridge ER and wards in order to provide the continuum of patients care and safety. To our knowledge, it is the first approach in Taiwan.
Background The word 'holistic health' was defined in PubMed database as follows: “Health as viewed from the perspective that humans and other organisms function as complete, integrated unit rather than as aggregate of separate parts”. The definition of a holistic view was that all aspects of people's psychological, physical and social needs be taken into account and seen as a whole. The term is sometimes confused with alternative medicine. Owing to the convenience of health insurance, the numbers of community hospitals has declined in past 20 years in Taiwan. Many patients directly visited medical centers for assistance and waited for admission at emergency departments (ER). In the ER the waiting time was prolonged and more difficult for patients to have beds available. It also influenced the effectiveness of medical treatment. A new department, holistic care unit (HCU), was established in Chi-Mei Medical Center in Taiwan since August 2012, to bridge the gap between ER and wards in order to provide the continuum of patients care and safety.
Objectives Overcrowding situations affect the quality of care at Emergency Departments and is an important issue in  the Taiwan medical system. Many health care workers, including physicians and nurses, are under a lot of working pressure. Many health care workers have retired from emergency department and critical medicine. The shortage of physicians in emergency medicine has significantly decreased the quality of health care. Accordingly, holistic care units were established to improve the quality of medical care. To realize the effectiveness of Holistic Care Units, we evaluated the waiting time for hospitalization and revisits to the Emergency department within 3 days after discharge.
Methodology This Holistic Care Unit was set up close to the Emergency Department to reduce the workload of emergency physicians who were responsible for patients waiting for admission. This newly created unit was composed of seven experienced medical attending staff who would to take care of patients in 8 hours rotations in collaboration with emergency physicians, radiologists, nurses, social workers and cases manager who constituted the team. This team had similar three domains of responsibility: education and training programs, living together in same place, and sharing the medical devices and resources. Each morning there were meetings focused around subspecialties to discuss the constellations with the exception of difficult or surgical cases which ere referred. The case manager followed the condition of post-discharge patients from Holistic Care Unit in order to assure smooth and regular compliance in the transition home without the need for readmittance into the wards. The case manager tracked patients of Holistic Care Unit from January 2013. We used the waiting time period and the rate of revisits to the Emergency Department within 3 days in a proper statistics evaluation of the effectiveness of Holistic Care Unit in our hospital.
Results From February to July 2012 and August to January 2013, before and after the establish of Holistic Care Unit, the rate of waiting period for more than 24 hours for admission at ER declined from 8.55% to 5.4% and from 2.71% to 1.27% for more than 48 hours. The overcrowding conditions at Emergency Departments were largely improved after the establishment of the Holistic Care Unit. The numbers of patients treated at the Emergency Department was 86712 persons from January 2013 to August 2013. The rate of patients revisiting emergency department within 3 days was 3.6% from January 2013 to August 2013. The rate included the patients of Holistic Care Unit. The rate of revisiting Emergency Department within 3 days was 6.1 % among the patients who were discharged from the Holistic Care Unit. The rate of revisiting the Emergency Department within 3 days was 3.2% after eliminating the patients who were discharged against medical advice (DAMA).
Conclusion Overcrowding situations affect the quality of care at Emergency Department and is an important issue in Taiwan medical system. The overloading pressure and the fear of liability has created a shortage of emergency physicians and nurses. A new department, Holistic Care Unit, was established to improve the overcrowding situation and our preliminary results indicate that it has worked effectively. The rate of revisiting emergency department within 3 days is lower if physicians from the Holistic Care Unit suggested early discharge from hospital. However, the overcrowding situation still influences the quality of care. If patients were discharged against medical advice of physicians from the Holistic Care Unit, the rate of revisits to the Emergency Department within 3 days is higher. The major reason for discharges against medical advice is the unavailability of beds and long waiting times for wards. More attention needs to be paid to the long waiting time to admit patients. To our knowledge, this project was the first approach in Taiwan to establish a new department nearby Emergency Department to intervene in the earlier take over patients who waited for admission for advanced and continued care. Beyond above benefits, the mutual interaction bridging Holistic Care Unit and Emergency Department will also cultivate an interdisciplinary teamwork that can achieve the same goals of patients care, education, quality and safety outcomes.

Decentralized nurse training in rural Zambia – triplicating the output of trained nurses.

Author(s) Martina Weber1, Toddy Sinkamba2, Klaus Thieme3.
Affiliation(s) Zambia, SolidarMed, Chongwe, Zambia, 2 St. Luke's School of Nursing, Mpanshya, Zambia, 3 SolidarMed, Chongwe, Zambia.
Country - ies of focus Zambia
Relevant to the conference tracks Health Workforce
Summary The SolidarMed pilot project decentralized practical nurse training in rural Zambia started in 2012 with St. Luke’s School of Nursing in Mpanshya. The project aims at providing nurses for rural districts of Zambia by triplicating the annual student intake, and by delivering quality theoretical and decentralised practical training to meet quality standards. It is a pilot project presented as a valuable model for nurse training in Zambia to the Ministry of Health and other interested stakeholders. The project is based on the recommendations of WHO Global Policy Recommendations (2010) on Improving access to health workers in remote and rural areas through improved retention.
What challenges does your project address and why is it of importance? Zambia, like many other low income countries in the region, faces considerable challenges in providing sufficient human resources for health. In Zambia only about half of the health facility workforce are trained. Nurses and midwives are crucial in an already struggling health system, and not having enough key staff like nurses weakens the health system. Zambia has a shortfall of 9’000 nurses which is approximately 60% of its requirement. Rural hospitals particularly illustrate a drastic gap between the planned medical staff and the actual staffing situation. Historically, Zambia has not invested enough in its health training institutions. The under-funding of health institutions, poor training and accommodation facilities, inadequate equipment and study materials, as well as inadequate teaching staff have resulted in high attrition rates from pre-service training (like nursing), fewer graduates and an overall deterioration in the quality of outputs.
How have you addressed these challenges? Do you see a solution? The SolidarMed pilot project tries to target all these recommendations in the partnership with St. Luke’s School of Nursing at St. Luke’s Mission Hospital in rural Mpanshya / Zambia. The school had 30 students in 2009. The project target is to double the output of students by decentralisation of practical training. The first external practical training site is Sacred Heart Mission Hospital in Katondwe – a small hospital in a very rural and remote part of the Province. Experiencing clinical practice is essential for the student nurses to understand their professional future. Nurses are likely to find themselves as one of the few health professionals within a rural health institution. If they have never experienced the reality of rural practice and learnt to deal and adapt to its challenges, the outlook for their retention in the rural areas is not good. Given the limitations of a rural posting, where there is likely to be staff and equipment shortages as well as crumbling infrastructure, nurses need to be trained for this. And this kind of training is only possible if you actually train within a rural, peripheral context. The second external practical training site will be Chongwe District Hospital. This Level 1 District hospital is quite close to Lusaka, in the District capital of Chongwe and here nursing students supplement their experience of clinical practice in a remote rural area with practical training in a more urban hospital. Patient numbers are high, which is also valuable preparation for their professional future. In addition, being based in Chongwe allows nursing students easier access to Chainama Hills Hospital where they complete a practical rotation in mental health. Two clinical instructors are placed at all three practical training sites. The combination of learning and experience available at these three quite different hospitals provides a balanced mix of exposures to various professional settings. This allows nursing students to experience as many aspects of their practical work as possible, and thus gives them the best possible training for their future career.
How do you know whether you have made a difference? The project is on-going. The overall goal is to improve the provision of nurses for rural health care in rural districts of Zambia. In order to achieve this goal, SolidarMed invested in infrastructure and equipment at the decentralised training sites by building a student hostel and staff houses for the clinical instructors at Sacred Heart Mission Hospital in Katondwe and at Chongwe District Hospital, as well as staff houses for the clinical instructors at St. Luke’s School of Nursing in Mpanshya. Additionally, teaching and learning equipment is constantly upgraded. Furthermore, SolidarMed is supporting the training of one nurse tutor and six clinical instructors, incentivising the latter and supporting St. Luke’s Nursing School by placing them on the payroll of the individual practical training sites. To ensure cooperation between the Nursing School and the decentralised sites works smoothly, a comprehensive Framework Agreement is drawn up to define roles and responsibilities. The relevant Ministry of Health and Ministry of Community Development, Mother, Child Health are very interested in both the negative and positive outcomes of this pilot project. It is seen as a way of increasing the output of trained nurses in a relatively cost effective way with the additional benefits for the participating decentralised practical hospitals. Since the start of the project the intake of nurse students has been increased to 103 in 2013. This triples the number of students since the Nursing School started.
Have you or the project mobilized others and if so, who, why and how? This project is a pilot project for the Zambian training system for medical personnel. As well as the training institution, St. Luke’s School of Nursing and its Hospital involved other parties at the decentralized training sites at Katondwe Sacred Heart Mission Hospital and Chongwe District Hospital. All lessons learnt are shared with all stakeholders – e.g. the General Nursing Council of Zambia, the Ministry of Health and the Ministry of Community Development and Mother & Child Health and all other training institutes interested in scaling up their output. The involvement of the General Nursing Council is crucial for the success of this pilot project. This professional body registers nurses and midwives and regulates their professional conduct and education while also registering nursing and midwifery schools. It also has an advisory role in the Ministry of Health on matters relating to nurses and midwives. With regard to nursing and midwifery schools, the General Nursing Council sets the monitoring and evaluation standards, decides whether facilities are suitable for training, conducts supportive supervision visits and evaluates the training programmes offered at individual institutions. Furthermore, the General Nursing Council also develops and reviews curricula, teaching and learning materials, evaluates the implementation of these curricula and conducts knowledge and skills updates for teaching and clinical staff. The lessons learnt could be applicable for other job training institutions in Zambia that focus on topics other than health.
When your donor funding runs out how will your idea continue to live? The design of the SolidarMed project is that the decentralized nurse training can continue after funding runs out. The nursing school benefits from investment in its infrastructure and faculty and will be strengthened in the area of quality assurance. SolidarMed experienced that the practical training sites hosting the students benefited from their participation in nursing training. Nurses in training are a form of additional manpower in the context of a human resource crisis. SolidarMed has not created separate cadres of health professionals or designed its own brand of training, but rather supports Zambian training programmes, tailored to Zambian requirements. The project supports local ownership of human resource for health strategies. So it is fully consistent with Zambia’s national health priorities and strategies as defined in the Government of the Republic of Zambia’s Fifth National Development Plan 2006 -2010 as well as the Ministry of Health’s National Health Strategic Plan 2006 -2010, and the Human Resources for Health Strategic Plan 2011-2015. Preliminary drafts of the Sixth National Development Plan 2011-2015 suggest that this project is in line with Zambia’s future national health priorities and strategies. Local ownership is key to sustainability. SolidarMed supports Zambian solutions to Zambian problems, and this project is fully in line with this strategy. In doing so, SolidarMed recognises that a home-grown solution is more likely to be effective in addressing context-specific challenges, and more efficient and affordable. SolidarMed seeks out local knowledge and expertise to achieve its aims and contributes its own experience to build capacities and strengthen its partners.

An Integrated Approach to Management of Diabetes and Hypertension in Western Kenya

Author(s) Simon Manyara1, Jemima Kamano2, Diama Menya3, Jeremiah Laktabai4, Benjamin Andama5, Evans Tenge6, FlorenceSituma7, SonakPastakia8
Affiliation(s) 1Pharmacy, Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya, 2Department of Medicine, Moi Teaching and Referral Hospital, Eldoret, Kenya, 3Epidemiology and Nutrition, School of Public Health, Moi University, Eldoret, Kenya, 4Family Medicine, Moi University, Webuye,Kenya, 5Family Preservation Initiative, Academic Model Providing Access to Medicines, Eldoret, Kenya, 6Family Preservation Initiative, Academic Model Providing Access To Healthcare, Eldoret, Kenya, 7Home Glucose Monitoring, Webuye District Hospital, Webuye, Kenya, 8Purdue University College of Pharmacy, Purdue University, Eldoret, Kenya
Country - ies of focus Kenya
Relevant to the conference tracks Chronic Diseases
Summary This pilot project seeks to establish whether the provision of intensive, self and peer management trainings to patients combined with the integration of income generating incentives leads to enhanced diabetes and hypertension control for resource-constrained patients in rural western Kenya. Patients are placed into peer support groups where they receive group care and are trained on various aspects of diabetes and hypertension self-care. These groups also double as microfinance groups that offer capital to patients to start up income generating activities. The groups are further incentivised to compete against each other based on both clinical and non clinical parameters.
What challenges does your project address and why is it of importance? Developing countries are facing an increasing burden of non communicable diseases (NCDs). While there has been increased emphasis in addressing communicable diseases by the international community, the vast majority of NCDs have been neglected, leaving patients with very poor outcomes and limited prospects for a healthy life. Due to their chronic nature, NCDs strain the already scarce resources of healthcare systems and families in resource constrained settings. Furthermore, NCDs are no longer associated with the wealthy or elderly, for they also affect poorer rural dwellers and younger members of the society who are expected to be economically productive. This adversely affects economic development in these populations, further propagating the vicious cycle of poverty. The prevalence of diabetes in Kenya is 4.7%, while that of hypertension has been reported to be as high as 23.7% in some urban settings. Patients with chronic diseases in Kenya face several barriers to care, including lack of access to essential services and inadequate information. This project uses a holistic approach which directly addresses barriers related to the socioeconomic status of patients with diabetes and hypertension, while encouraging positive health seeking behaviors.
How have you addressed these challenges? Do you see a solution? Bridging Income Generation with Provision of Incentives for Care (BIGPIC) uses an integrated approach that capitalizes and builds on the AMPATH’s (Academic Model Providing Access To Healthcare) existing infrastructure and years of experience in managing patients with HIV/AIDS throughout western Kenya. We focus on the following points of intervention:
1) Peer Groups.
Following community-based screening, positively diagnosed patients are placed into peer groups where they receive intensive training on self-management strategies for diabetes and/ or hypertension. They are given targets for their management which will be evaluated upon completion of the pilot. Targets will comprise of both process metrics such as clinic attendance, medication refills, fulfillment of ordered tests and clinical outcome metrics including blood pressure and sugar control. Patients receive group care and are provided with essential services like clinical consultations, selected portable laboratory tests and medication at affordable prices. They are expected to pay for each service and all the money collected is used to restock supplies.
2) Incentivization.
Patients are instructed on the incentives that can be earned through participation in this program. Their care is evaluated after 6 months to document the progression of their glucose and/or blood pressure control using standardized laboratory assessments. They receive points based on the set targets and these points can be used to earn various predetermined rewards. Incentives are awarded at two levels of participation – the group level where the top three groups with the most improved outcomes will receive rewards, and at the individual level where each participant attaining pre-set goals receives a reward.
3) Economic empowerment
The economic component of the project is facilitated by the Family Preservation Initiative (FPI), which is AMPATH’S income generation program. This will be achieved by the incorporation of a micro finance component which provides interest-bearing loans to members while offering a limited form of financial insurance. Participants mobilize and manage their own savings. They can therefore access affordable loans and get advice from FPI agribusiness officers on sustainable income generating activities. BIGPIC combines the socioeconomic benefits of FPI activities with the care strategy utilized by our diabetes program to synergistically enhance the outcomes and retention in both programs.
How do you know whether you have made a difference? While AMPATH has enjoyed immense success in the management of patients with both communicable and non communicable diseases, a lot of effort still needs to be put into retention of new patients to care. Data from the chronic disease management team shows that only 30% of patients who screened positive for diabetes and hypertension ever returned to a health facility for care. Preliminary data from this project shows that out of the 902 patients that were screened, 157 patients screened positive for either diabetes or hypertension. Of those that screened positive, 67.5% (n=106) came back to the health centre for confirmatory screening. Currently, 70.3% (n=71) of all those who confirmed positive for diabetes or hypertension are enrolled into the peer groups and are receiving care. The pilot will be completed in December and the final results will be presented at the conference
Have you or the project mobilized others and if so, who, why and how? This project draws expertise from a multidisciplinary team and intricately incorporates several aspects of patient care. The chronic disease management team provides the necessary platform for the management of diabetes and hypertension, from facilitation of screening activities to capacity building through staff training at health facilities. The Primary Healthcare team at AMPATH provides valuable insights into community strategies and engagement both at the macro and micro levels. One of the key approaches has been the use of community health workers (CHWs) for the purposes of finding patients, linking them to health facilities and raising awareness on chronic diseases within the community. The peer groups are also led by the CHWs who we train intensively on diabetes and hypertension self-care and on the operations of the GISE groups. The project taps into AMPATH’s Family Preservation Initiative’s GISE project. Through the microfinance groups, we strive to empower our patients economically through access to capital and giving them advice on viable business ventures. These microfinance groups have been shown to have high retention rates of its members, an outcome that we hope to achieve by incorporating the microfinance element into healthcare. This project is further strengthened by AMPATH’s pharmacy team which has a revolving fund pharmacy project that provides quality medicines to its patients at affordable prices. The revolving fund pharmacy works by procuring quality controlled medication in bulk and availing it to patients at a price that is almost at cost. Through this project, we have been able to provide quality, low cost essential antidiabetic and antihypertensive medicines to our patients. The biggest piece of the puzzle is the government health management team which is responsible for the implementation of all health initiatives within a district. This team facilitates all our activities on the ground. Part of the activities that we engage in include capacity building of the existing infrastructure by carrying out refresher courses on good practices in the management of diabetes and hypertension and mentoring the staff in the lower level facilities like dispensaries and health centres.
When your donor funding runs out how will your idea continue to live? BIGPIC offers a sustainable means of ensuring access to healthcare while at the same time promoting economic empowerment, leading to a healthier, more productive labor force. The project is modeled around the existing healthcare system and infrastructure in Kenya. Care for diabetes and hypertension at the facility level is enhanced through capacity building by training of the existing government healthcare workers. This is followed by close mentorship by the chronic disease management team at AMPATH, ensuring that patients can access quality care even in our absence. The microfinance groups have been shown to have a high retention rate of its members, and we believe that this model will maintain the members of the peer groups long after completion of the initial six months of our involvement. This will promote self-care within the members hence leading to improved patient outcomes. Patients are also empowered economically through these groups where they can access capital from their own savings. The groups create their own constitutions that guide their operations, and we only facilitate income generation through our agribusiness advisors. This ensures that they own the project and that the groups can continue independent of our support. Provision of drugs through the revolving fund pharmacy ensures continuity of drug supply since patients pay for the drugs and the money collected is solely used to purchase more drugs. Furthermore, antihypertensive and antidiabetic medicines are not supplied to dispensaries and health centres and the provision of these drugs at this level ensures accessibility while promoting the use of lower level facilities, with only complicated cases being referred to higher level facilities. Patients are expected to pay for every service that is provided through group care. The money collected from this model of care makes its continuity sustainable. The information provided to the community through the CHWs and the patients participating in the project will also go a long way in preventing NCDs by averting common risk factors such as poor diets, physical inactivity, unhealthy use of alcohol and cigarette smoking. This project therefore draws its strengths from a multidisciplinary team and integrates proven, sustainable interventions to achieve a holistic care model for diabetes and hypertension within a resource-constrained setting.

mTB by Front Line Workers in a Tribal District in India: A Pilot Study

Author(s) Archana Trivedi1, Sarabjit Chadha2, Nevin Wilson3, Sunita Prasad4, Sanjay Kumar5
Affiliation(s) 1Public Health, USEA, The Union, New Delhi, India, 2Health, Communicable Diseases, USEA, The Union, New Delhi, India, 3Health Communicable and Non Communicable Diseases, USEA The Union, New Delhi, India, 4CSR, Lilly Foundation Grant in association with Lilly MDR TB partnership, New Delhi, India, 5IT, USEA, The Union, New Delhi, India.
Country - ies of focus India
Relevant to the conference tracks Innovation and Technologies
Summary The Union through a community engagement process has mapped and trained Rural Health Care providers who are “first point of contact” for marginalized and vulnerable population. The trainings have contributed to imparting knowledge about TB and referrals of TB symptomatics to the National TB Control Programme. A paper based referral mechanism is established to capture data on quality of referrals made. However, providers often lack information about referred TB symptomatics – results and follow-up. Through the mobile phone application, this project is demonstrating the use of mobile technology in establishing a mechanism to impart knowledge and continued engagement with TB symptomatics.
What challenges does your project address and why is it of importance? Background and Challenges to implementation: Front Line Workers/Rural Health Care Providers (RHCPs) are most often the first point of contact for curative services in many villages, especially in tribal and remote geographic areas. A paper based mechanism is used to capture the data on referrals made including the results of their sputum examination and the management of those diagnosed with TB.However, Front Line Workers including RHCP’s and Lab Technicians (LTs) often lack information about referred cases with chest symptoms. Validating the referrals at designated microscopic centers is resource intensive, time consuming and difficult. It is also difficult to attribute the contributions made by FLWs towards strengthening National TB Control Programme.
How have you addressed these challenges? Do you see a solution? The intervention being implemented to address the challenges is ‘CommCare’ (mobile platform), an easily customizable mobile platform that tracks the referred cases, supports FLWs and creates a central database on a real-time basis.The CommCare application is being piloted in three blocks namely Torpa, Murhu and Khunti of Khunti, a tribal district in Jharkhand, India covering a population of 2,55,372 (80% district population). Two ComCare applications have been developed. One application is being used by RHCP and NGO supervisor, and one by LTs.FLWs are provided with 30 Lava Android phones. ComCare aids FLWs with guidance on key counselling points. Each counselling point is reinforced by images and audio clips that FLW uses to engage their clients. Messages are displayed regardless of the result of sputum examination and are focused on “Shared Air, Safe Air.”
How do you know whether you have made a difference? Results and Lessons Learnt: ComCare is a management system that assists in the follow up of referred chest symptoms by FLWs for the purpose of efficient diagnosis and treatment of tuberculosis. It reduces the delay in communication of the test results and saves resources by reducing the number of visits of the FLWs to the diagnostic centres. It helps to assess the contribution of FLWs in total chest symptoms examined and TB cases diagnosed. This application provides data lost follow up cases and creates a real-time central database which in turn helps with the retrieval of cases.In three months ninety symptomatics have been referred by using this application.  From these, 17 were diagnosed as  sputum positive TB and 6 sputum negative TB. All of these 23 diagnosed Tuberculosis patients are put on DOTS and are regularly being counselled through the mobile application. The outcome of patients who are being regularly counselled will be assessed upon completion of treatment.
Have you or the project mobilized others and if so, who, why and how? Mobilisation of other stake holders: The Project has explored possibilities for sustainability and scaling up of the use of mobile technology to promote TB care and control through collaboration under the World Bank Project by the matching of 25 additional mobiles in Jharkhand (tribal state, Khunti).These mobiles have been initiated to be used in one of the Global fund Round 9 project districts in Jharkhand. The project has moved beyond pilot to scale it up and illustrates the impact of implementing innovative technologies to address the challenge of tracking referred symptomatics by front line workers.Due to the positive impact of intervention, procurement of 50 additional mobiles has occurred and expansion is being initiated in one more district of Ghazipur in Uttar Pradesh, with additional mobiles at Khunti in Jharkhand. In this implementation mobiles are given to LTs of 3 respective districts who work in close collaboration with front line workers. This implementation is being appreciated by RNTCP officials.
When your donor funding runs out how will your idea continue to live? Potential framework for sustainability when donor funding runs out: Implementation of pilot project on use of CommCare application to track TB symptomatics is initiated in a tribal district and POC grant from Dimagi (USAID fund) for 1 year and expansion has been initiated in Ghazipur (UP), Khunti (Jharkhand) and one other tribal district in Jharkhand.
Scaling up the use of the mobile application is being anticipated well in advance so that project is not restricted to a pilot study only.Proposed Partners will be Identified partners under the implementation of the Axshya Project (Global Fund Round 9) in 300 districts and Dimagi representatives.
Roles & ResponsibilitiesSelection of front line workers for the use of mobile technology application and selection of geographical areas for implementation of mobile application can be done through the Implementing NGO partners. Training of front line workers and NGO Supervisors on the use of CommCare application can be done through projects that train these front line workers by USEA, The Union. Follow up implementation of these applications is carried out by NGO supervisors of identified NGOs in implementing districts.Who Pays? Recurring costs of implementation will be carried out by linking NGOs with districts upon the take up of the NGO PP RNTCP schemes.

We intend to develop trust of the government health system and the community as to the benefits of the application and slowly encourage government investment in the project.

Vaccination against Human Papillomavirus: Knowledge, attitudes, and beliefs of Medical Students in Sth Africa.

Author(s) Muhammad Hoque1, Sam Monokoane2, Guido Van Hal3.
Affiliation(s) 1Graduate School of Business and Leadership, University of KwaZulu-Natal, Durban, South Africa, 2Obstetrics and Gynaecology, University of Limpopo (Medunsa Campus), Pretoria, South Africa, 3Medical Sociology and Health Policy, University of Antwerp, Antwerp, Belgium.
Country - ies of focus South Africa
Relevant to the conference tracks Women and Children
Summary The majority of the medical students in South Africa intend to prescribe human papillomavirus vaccines even though they have little knowledge of the human papillomavirus vaccine.
Background In South Africa cervical cancer is one of the leading causes of death among women. Currently there are two vaccines available in South Africa. These vaccines are currently being considered for a national vaccination programme. A nationwide vaccination programme in South Africa will almost certainly make a significant difference in the cervical pre-cancer and cancer incidence in the future.
Objectives The purposes of the study are to investigate the knowledge, attitude and beliefs of medical students in South Africa concerning vaccination against the human papillomavirus.
Methodology This was a cross-sectional study conducted among 100 medical students using a self-administered questionnaire.
Results More than two-thirds (71%) of the respondents were aware of HPV and among them 81.2% mentioned vaccination against HPV. The majority (81.7%) were aware that persistent HPV infection is a necessary cause of cervical cancer. The fact that between 60 – 80% of cervical cancer incidents are caused by HPV types 16 and 18 is only known by 14.5% of the medical students. Overall, knowledge regarding HPV infection was low among the medical students as the average score was 3.23 (possible range was 0 to 9). The majority (87.7%) of the students reported that they have not received sufficient information regarding HPV infection. The majority of the students (72.9%) indicated that the vaccine should be given to girls before the onset of sexual activity. More than 90% of the students believe that physicians will support HPV vaccination and adolescents and young adults will accept HPV vaccination and 82.9% intend to recommend HPV vaccination if it is publicly funded. Overall, 86.7% of respondents intend to prescribe HPV vaccines.
Conclusion HPV vaccination is a relatively new concept for the primary prevention of cervical cancer. Overall, knowledge regarding HPV vaccination among the medical students is low, but there was a positive attitude towards it. There is a strong need to provide more education for medical students about the relationship of HPV infection and cervical cancer and the benefits of vaccinating adolescent girls to prevent cervical cancer in the future.

Economic Benefits of Antiretroviral Therapy for HIV/AIDS Patients in Nigeria.

Author(s) Kingsley Nnanna Ukwaja1.
Affiliation(s) 1Department of Medicine, , Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria, Abakaliki, Ebonyi State, Nigeria 2
Country - ies of focus Nigeria
Relevant to the conference tracks Infectious Diseases
Summary Little is known about the economic benefits of antiretroviral therapy (ART) for HIV/AIDS-patients and their households. We conducted a descriptive study among 1176 HIV/AIDS patients on ART to assess their present status of employment, household poverty and its determinants. About 88% of the patients had stable jobs. Employment rates increased with duration on ART (P=0.033). Overall, poverty rates were 86% of households of HIV-patients ≤1 year on ART while 39% for HIV-patients >1 year on ART (P <0.001). Poverty rates decreased with increasing duration of ART use (P <0.001). ART use decreases poverty among households of HIV/AIDS patients in Nigeria.
Background Although clinical, immunologic, and virologic effects of antiretroviral therapy (ART) for people living with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) are well-documented, far less is known about the economic benefits of treatment of HIV/AIDS for patients and their households. ART use has been shown to improve work performance, reduce absenteeism and increase employment rates following job loss due to HIV/AIDS. Furthermore, recent longitudinal studies indicated that ART use resulted in a rapid increase in employment and income for patients. The findings of these studies were limited by high attrition rates. Secondly, in low-income countries, ART is started after a substantial drop in the immunity of HIV patients. These studies mainly compared the economic indices of healthy ART-naïve HIV patients with those of immune-depressed patients on ART. Healthy ART-naïve HIV patients are more likely to be employed, maintain productivity, and decrease absenteeism, while ill HV-patients may require some time to become strong enough to work. Thus it is still not clear if these improvements in economic indices from ART and its sustained use in the long-term translate to poverty reduction among HIV/AIDS patients and their households.
Objectives The primary objective of this study was to investigate the rates of employment and poverty among HIV/AIDS patients receiving antiretroviral therapy and their households and to explore the relationships between household poverty and duration of antiretroviral therapy among HIV/AIDS patients in Nigeria.
Methodology A cross-sectional survey was conducted from April to May 2013 with 1,176 HIV/AIDS patients at a large tertiary hospital providing antiretroviral treatment services in South East, Nigeria. Socio-economic and clinical characteristics of the respondents were collected using in-depth interviews with structured questionnaires. Monthly household income was self-reported including all sources of each household member’s income such as salary, wages, pensions, relatives’ supports, interests and revenues. Other characteristics like patient employment status, duration on antiretroviral therapy, adherence to ART, e.t.c. were also obtained. Households earning below the national minimum wage were classified as poor. Also, the economic indices of HIV-patients on ART for one year or less were compared with those of patients who had been on ART for more than one year. Statistical analyses were conducted using Epi Info 3.5.2. Descriptive analyses were presented and multivariable logistic regression analysis was performed to identify independent determinants of household poverty.
Results We interviewed 1176 patients, accounting for 20% of total HIV patients in the study site. Mean age was 35.3 (standard deviation [SD] = 10) years, 71.4% were female, 92.9% had at least a formal education (six years of schooling), 53% were resident in the rural area, and the overall mean duration on ART was 33.2 (SD = 28.2) months. Almost 88% had stable jobs and the mean monthly household income was US$ 156 (SD = 183). The median duration on ART for HIV-patients was significantly associated with the likelihood of being employed (employed (31 months) versus unemployed (19months) using the Kruskal-Wallis test 4.56, P=0.033). Also 624 (53%) were from poor households. Overall 86% of households of HIV-patients who were one year or below on ART were poor, while 39% of households with HIV patients on ART for more than a year were poor (Chi-square 218; P
Conclusion Rates of employment increased and poverty rates decreased with increasing duration of ART among HIV/AIDS patients and their households in Nigeria. Integration of education about sustained use and improved ART adherence counselling, as well as social and financial protection services for HIV-patients belonging to the identified at risk-groups could further reduce poverty among their households and should be implemented. Overall, this study provides evidence that effective delivery of ART services in resource-constrained settings could improve employment rates of HIV patients and reduce poverty among their households. The study findings have important implications for policy. Low-income countries, especially those with high burden of HIV, must further decentralize HIV/AIDS care services to rural and remote communities, for example through integration with primary health care services as an intervention to reduce poverty in people living with HIV/AIDS. Future studies to assess the impact of these interventions are urgently needed in resource-limited settings.

The Effect of Unintended Pregnancy on Maternal Health Care Service Utilisation in South Asia.

Author(s) S. M. Mostafa Kamal1, Che Hashim Hassan2.
Affiliation(s) 1Department of Mathematics, Islamic University, Kushtia-7003, Bangladesh, 2Unit for the Enhancement of Academic Performance, University of Malaya, Kuala Lumpur, Malaysia 3.
Country - ies of focus Bangladesh
Relevant to the conference tracks Social Determinants and Human Rights
Summary This study examines the effect of unintended pregnancy on maternal health care services utilization among women of four South Asian countries using nationally representative survey data conducted between 2005 and 2011. The prevalence of unintended pregnancy ranges from 25% in India to 32% in Bangladesh. Overall, the Indian women sought more skilled services for maternity care than the women of other study countries. The multivariable binary logistic regression yielded that, except for Pakistan, the women with unintended pregnancy were significantly less likely to seek skilled maternal health care services than women who reported that their last child was planned/wanted.
Background Of the estimated annual 210 million pregnancies occurring worldwide, approximately two-fifths are unintended which include mistimed and unwanted pregnancies, out of which 22% end in unsafe and illegal abortions. Unintended pregnancy is a major cause of unsafe abortion. Ninety-five percent of unsafe abortions occur in the developing countries. Worldwide, unsafe abortion accounts for approximately 13% of the total maternal deaths. Millions more suffer long-term life threatening complications caused by unsafe abortion. The pernicious consequences due to unintended pregnancies are well documented. Evidences show that unintended childbearing can cause adverse health outcomes such as depression, anxiety, poor psychological well-being, poor utilization of antenatal care services, low use of supplements, vaccination and nutrition. However, most of these findings are from developed countries. Such evidence is limited in developing countries.
Objectives This study aims to examine the effect of unintended pregnancy on maternal health care service utilization among women of four South Asian countries: Bangladesh, India, Nepal and Pakistan.
Methodology Data used in this study were collected by the most recent and nationally representative Demographic and Health Survey (DHS) conducted in Bangladesh, India, Nepal and Pakistan. The surveys are based on a two-stage stratified sample of households. It accumulated information from married women of reproductive age inclusive of rural and urban areas. The survey obtained various information related to demographic and health issues including fertility, marriage, use of family planning methods, pregnancy intention status, maternal and child health, use of maternal and health care services etc. The surveys collected information of live births that occurred in the five years preceding the survey.Outcome measures.The outcome measures of the study are: (i) skilled antenatal care (ANC) seeking; (ii) adequate ANC (≥4 ANC) visits; (iii) seeking assistance from skilled birth assistants (SBA); and (iv) delivery at facility place. The skilled MHCS has been defined as receiving care from a medically-trained services provider. The facility for childbirth includes a medically equipped health care service centre.Exposure variables.Along with the principal exposure variable ‘unintended pregnancy’, we additionally included socioeconomic and demographic variables which may influence the utilization of MHCS. The list, definitions and measurement of the covariates included for analysis are provided in Table 1.

Statistical analyses.

Both bivariate and multivariable statistical analyses were adopted in this study. Differences of the use of MHCS according to the desirability of pregnancy and other socioeconomic factors were assessed by chi-square (χ2) tests. To assess the net effects of the exposure variables on the outcome measures, four different multivariable binary logistic models were designed for outcome interests. The checking of multi co-linearity results in its non-existence. The results of the logistic regression analyses are presented by odds ratios (ORs) with 95% confidence intervals (CIs). The level of significance was set at 0.10. The statistical analyses were performed by IBM SPSS v21 (SPSS Inc., Chicago, IL, USA).

Results Prevalence of unintended pregnancy.The prevalence of unintended pregnancy was highest in Bangladesh (32%), followed by Pakistan (30%), Nepal (30%) and India (25%). The prevalence of unintended pregnancy differed significantly by place of residence, age at first marriage, maternal age, birth order and wealth index.Prevalence and differentials of MHCS utilisation.A slightly over half of the Bangladeshi women (51.8%) visited at least once for ANC services. The corresponding figures for women in India, Nepal and Pakistan were respectively 76%, 58.3% and 64.8%. The proportion of women who received adequate ANC services was highest in Nepal (50.1%), followed by India (37.3%), Pakistan (28.8%) and Bangladesh (23.9%). Exactly half of the Nepalese women received adequate ANC services. Seeking assistance from SBA was reported to be highest among women of India (46.7%), followed by Pakistan (39.2%), Nepal (36.0%) and Bangladesh (27.7%) respectively. The prevalence of delivery at hospital was highest among Indian women (38.7%), followed by Nepal (45.3%), Pakistan (34.6%) and Bangladesh (24.9%). Pregnancy desireability exhibited a significant difference in the use of four indicators of MHCS. Except in Pakistan, the prevalence of use of MHCS was lowest among those who reported their last child as unwanted.

Results of multivariate regression

The multivariate logistic regression analysis reveals that, when other variables were controlled for, except for Pakistan, the women, experiencing unintended pregnancy were significantly reluctant to seek skilled MHCS than women with wanted pregnancy. For instance, the women of Bangladesh who opined that their last child was unintended, the risk of seeking ANC, SBA and use of facility place for delivery decreased by the factors 0.85 (95% CI=(0.75-0.96), 0.87 (95% CI=0.77-0.99), 0.86 (95% CI=0.76-0.98) respectively as compared to that those with wanted pregnancy. Almost similar results were obtained for India and Nepal. Surprisingly, the Pakistani women experiencing unintended pregnancy were more likely to seek ANC services, but were less likely to go for delivery at hospital than those whose last child was reported as wanted. The other variables that showed to have significant effect on the utilization of MHCS for the study countries are maternal age, age at first marriage, birth order, women’s education, pregnancy termination and wealth index.

Conclusion Overall, the study results provide important insights into the association of unintended pregnancy with four indicators of MHCS utilization. To our knowledge, this study is the first multi-country study of the association of pregnancy intention status and use of maternity care services. All of these outcomes have been previously associated with a variety of factors, including place of residence, education, and standard of living index or wealth quintiles. However, study findings reveal a high prevalence of unintended pregnancy in the study countries which adds another layer of vulnerability over and above these background characteristics on MHCS utilisation. In the study countries, unintended pregnancy is not only a concern from the perspective of fertility, but is also a cause for concern from the point of view of public health, particularly regarding the use of MHCS. Therefore, greater attention is required to curb the high levels of unintended pregnancies in South Asia. Family planning programmes can play a vital role in averting unintended births and in reducing the burden of unintended pregnancy. Improving access to quality contraception may be an important intervention. Awareness should be created as to the long term benefits of using skilled MHCS through information, education and communication (IEC) programmes.