Health Policy and Planning - recent issues

Pandemic influenza preparedness in Africa is a profound challenge for an already distressed region: analysis of national preparedness plans

Ortu, G., Mounier-Jack, S., Coker, R. — 2008-04-18

A new highly pathogenic strain of influenza virus, H5N1, has emerged causing severe outbreaks in poultry and high mortality rates when humans are infected. The threat of a new influenza pandemic has prompted countries to draft national strategic preparedness plans to prevent, contain and mitigate the next human influenza pandemic.

To evaluate preparedness for an influenza pandemic in the African region we analysed African national preparedness plans available in the public domain. A data extraction tool, based on a World Health Organization checklist for influenza epidemic preparedness, was designed in consultation with pandemic influenza planning experts and experts on the region's public health challenges.

Thirty-five plans were identified and available from 53 African countries. Most plans are relatively robust in addressing detection and containment of influenza in animals but strategic preparedness to respond to pandemic human influenza is weak. In most plans communication strategies have been developed with the aim to raise awareness of transmission factors and promote hygiene measures. By contrast, the human health care sector is ill-prepared. Case management, triage procedures, identification of health care facilities for patient treatment (including home care and provisions for the distribution and administration of pharmaceuticals) are poorly addressed by most plans. The maintenance of essential services in the event of a pandemic is absent from most plans.

Whilst many African countries have strategic pandemic influenza preparedness plans, most are developmental in nature and lack operational clarity, or focus principally on the containment of avian influenza rather than pandemic human influenza. Clear strategies, that are operational, need to be developed that reflect the realities of national context and resource constraints and that meet national objectives. These objectives need also to be coherent with international imperatives such that the global threat of pandemic influenza can be met effectively and efficiently.

Malaria overdiagnosis: is patient pressure the problem?

2008-04-18

Objective In Africa antimalarials are often prescribed when malaria is unlikely, a problem that is becoming critical as more expensive antimalarials replace established drugs. However, little is known about what drives the overuse of antimalarials. We conducted this study to explore to what extent current prescribing behaviour in hospitals is driven by patient demand.

Methods Consultations were observed followed by exit interviews with patients or caretakers. Five district hospitals where microscopy was routinely available were selected in areas of low (n = 3) and high (n = 2) malaria transmission in north-eastern Tanzania. All outpatient consultations during the study period were observed (n = 669). Those sent for a malaria blood slide or treated with antimalarials presumptively were interviewed (n = 326). At the end of the study, clinicians were interviewed for their opinions on the use of antimalarials.

Findings Patients were not observed to demand antimalarials from clinicians, but occasionally asked for a malaria slide. Patient satisfaction on exit was similar between those prescribed antimalarials and those not prescribed antimalarials, but more patients or carers expressed satisfaction when the patient had been tested than when not. Clinicians rarely reported perceiving patient demand for antimalarials and asserted that such demand for medication would not affect their prescribing behaviour.

Conclusions Patient demand was not found to be driving the over-prescription of antimalarials found in the hospitals in our setting. To the contrary, the involvement of patients may provide an opportunity to improve prescribing practice if their expectations for testing and treatment in line with test results can be effectively communicated to clinicians.

Community health workers and the response to HIV/AIDS in South Africa: tensions and prospects

Schneider, H., Hlophe, H., van Rensburg, D. — 2008-04-18

After a decline in enthusiasm for national community health worker (CHW) programmes in the 1980s, these have re-emerged globally, particularly in the context of HIV. This paper examines the case of South Africa, where there has been rapid growth of a range of lay workers (home-based carers, lay counsellors, DOT supporters etc.) principally in response to an expansion in budgets and programmes for HIV, most recently the rollout of antiretroviral therapy (ART). In 2004, the term community health worker was introduced as the umbrella concept for all the community/lay workers in the health sector, and a national CHW Policy Framework was adopted. We summarize the key features of the emerging national CHW programme in South Africa, which include amongst others, their integration into a national public works programme and the use of non-governmental organizations as intermediaries. We then report on experiences in one Province, Free State. Over a period of 2 years (2004–06), we made serial visits on three occasions to the first 16 primary health care facilities in this Province providing comprehensive HIV services, including ART. At each of these visits, we did inventories of CHW numbers and training, and on two occasions conducted facility-based group interviews with CHWs (involving a total of 231 and 182 participants, respectively). We also interviewed clinic nurses tasked with supervising CHWs. From this evaluation we concluded that there is a significant CHW presence in the South African health system. This infrastructure, however, shares many of the managerial challenges (stability, recognition, volunteer vs. worker, relationships with professionals) associated with previous national CHW programmes, and we discuss prospects for sustainability in the light of the new policy context.

Targeting the poor in times of crisis: the Indonesian health card

Sparrow, R. — 2008-04-18

This paper looks at targeting performance of the Indonesian health card programme that was implemented in August 1998 to protect access to health care for the poor during the Indonesian economic crisis. By February 1999, 22 million people had received a health card. The health card provided a user fee waiver for public health care. Targeting of the health card was pro-poor, but with considerable leakage to the non-poor. Utilization of the health card for outpatient care was also pro-poor, but conditional on ownership, the middle quintiles were more likely to use the card.

Targeting of the health card followed a decentralized design combining geographic targeting with community-based targeting instruments. This design facilitated the rapid implementation of the programme, but targeting performance suffered from a lack of information on the regional impact of the crisis, while at local level not all barriers to accessing health care services were overcome by the health card. Indirect and direct costs of seeking health care seem to be the main deterrent to using the health card, and are higher in more remote areas.

Micro-simulations show that geographic targeting can contribute considerably to improving targeting performance, but most of the targeting gains are to be made at the local level, with district programme management and public health care providers.

This study highlights the need for adequate and up-to-date social welfare indicators. In addition, further research would need to focus on how local knowledge can be utilized for signalling poverty dynamics and local barriers to access.

Price Elasticity Estimates for Tobacco Products in India

John, R. M — 2008-04-18

The tax base of tobacco in India is heavily dependent on about 14% of tobacco users, who smoke cigarettes. Non-cigarette tobacco products accounting for 85% of the tobacco consumption contributes only 15% of the total tobacco taxes. Though taxation is an important tool to regulate consumption of tobacco, there have been no estimates of price elasticities for different tobacco products in India to date, which can guide tax policy on tobacco. This paper, for the first time in India, examines the price elasticity of demand for bidis, cigarettes and leaf tobacco at the national level using a representative cross-section of households. This study found that own-price elasticity estimates of different tobacco products in India ranged between –0.4 to –0.9, with bidis (an indigenous hand-rolled smoked tobacco preparation in India) and leaf tobacco having elasticities close to unity. Cigarettes were the least price elastic of all. With some assumptions, it is shown that the tax on bidis can be increased to Rs. 100 per 1000 sticks compared with the current Rs. 14 and the tax on an average cigarette can be increased to Rs. 3.5 per stick without any fear of losing revenue. The paper argues that the current system of taxing cigarettes in India based on the presence of filters and the length of cigarettes has no justification on health grounds, and should be abolished, if reducing tobacco consumption and the consequent disease burden is one of the objectives of tobacco taxation policy. It also argues that attempts to regulate tobacco use without effecting significant tax increases on bidis may not produce desired results.

The appropriateness of use of coronary angiography in Lebanon: implications for health policy

2008-04-18

Background Lebanon, characterized by a free-market health care system, has one of the highest reported per capita rates of cardiac catheterization facilities and coronary angiographies in the world. The aim of this study is to evaluate the appropriateness of performance of coronary angiography procedures in Lebanon.

Methods Data derived from the 2004 Lebanese Interventional Coronary Registry (LICOR) included 5418 patients aged 30 years and older who had not undergone prior percutaneous coronary intervention or coronary artery bypass grafting. Appropriateness was evaluated based on the Class I indications of the ACC/AHA guidelines for coronary angiography.

Findings The overall rate of appropriate procedures was 54.7% (95% CI 53.3–56.0%). Appropriateness varied significantly by gender and across administrative regions. Compared with females, males were more likely to be referred appropriately for coronary angiography (OR = 1.28, 95% CI = 1.15–1.44). Appropriateness was lowest (OR = 0.89, 95% CI = 0.71–1.12) in the region where the per capita density of cardiac catheterization labs increased by six-fold in the latter 2 years. The majority of the patients (84.3%) were not evaluated by any of the non-invasive tests prior to angiography, with only 10.8%, 4% and 1.5% of the patients referred for an exercise stress test, stress echocardiography and thallium stress tests, respectively.

Discussion Findings indicate a high rate of procedures conducted without appropriate indications and a low utilization rate of pre-interventional non-invasive testing. This may be attributed to three factors: a surplus of catheterization facilities in certain regions, the insignificant cost gradient between non-invasive testing and coronary angiography, and the wide case-based reimbursement of coronary angiography, unlike non-invasive testing, by public insurance schemes.

10 best resources on ... mental health

Patel, V. — 2008-04-18

Review of corruption in the health sector: theory, methods and interventions

Vian, T. — 2008-02-16

There is increasing interest among health policymakers, planners and donors in how corruption affects health care access and outcomes, and what can be done to combat corruption in the health sector. Efforts to explain the risk of abuse of entrusted power for private gain have examined the links between corruption and various aspects of management, financing and governance. Behavioural scientists and anthropologists also point to individual and social characteristics which influence the behaviour of government agents and clients. This article presents a comprehensive framework and a set of methodologies for describing and measuring how opportunities, pressures and rationalizations influence corruption in the health sector. The article discusses implications for intervention, and presents examples of how theory has been applied in research and practice. Challenges of tailoring anti-corruption strategies to particular contexts, and future directions for research, are addressed.

Has donor prioritization of HIV/AIDS displaced aid for other health issues?

Shiffman, J. — 2008-02-16

Advocates for many developing-world health and population issues have expressed concern that the high level of donor attention to HIV/AIDS is displacing funding for their own concerns. Even organizations dedicated to HIV/AIDS prevention and treatment have raised this issue. However, the issue of donor displacement has not been evaluated empirically.

This paper attempts to do so by considering donor funding for four historically prominent health agendas—HIV/AIDS, population, health sector development and infectious disease control—over the years 1992 to 2005. The paper employs funding data from the Organization for Economic Cooperation and Development's (OECD) Development Assistance Committee, supplemented by data from other sources.

Several trends indicate possible displacement effects, including HIV/AIDS’ rapidly growing share of total health aid, a concurrent global stagnation in population aid, the priority HIV/AIDS control receives in US funding, and HIV/AIDS aid levels in several sub-Saharan African states that approximate or exceed the entirety of their national health budgets. On the other hand, aggregate donor funding for health and population quadrupled between 1992 and 2005, allowing for funding growth for some health issues even as HIV/AIDS acquired an increasingly prominent place in donor health agendas. Overall, the evidence indicates that displacement is likely occurring, but that aggregate increases in global health aid may have mitigated some of the crowding-out effects.

Saving newborn lives in Asia and Africa: cost and impact of phased scale-up of interventions within the continuum of care

Darmstadt, G. L, Walker, N., Lawn, J. E, Bhutta, Z. A, Haws, R. A, Cousens, S. — 2008-02-16

Background Policy makers and programme managers require more detailed information on the cost and impact of packages of evidenced-based interventions to save newborn lives, particularly in South Asia and sub-Saharan Africa, where most of the world's 4 million newborn deaths occur.

Methods We estimated the newborn deaths that could be averted by scaling up 16 interventions in 60 countries. We bundled the interventions in a variety of existing maternal and child health packages according to time period of delivery and service delivery mode, and calculated the additional running costs of implementing these interventions at scale (90% coverage) in sub-Saharan Africa and South Asia. The phased introduction and expansion of interventions was modelled to represent incremental strategies for scaling up neonatal care in developing country health systems.

Results Increasing coverage of 16 interventions to 90% could save 0.59–1.08 million lives in South Asia annually at an additional cost of US$0.90–1.76 billion. In sub-Saharan Africa, 0.45–0.80 million lives saved would cost US$0.68–1.32 billion. Additional costs for increased antenatal interventions are low, but given relatively high baseline coverage and lower impact, fewer additional newborn lives can be saved through this package (5–10%). Intrapartum care has higher impact (19–34% of deaths averted) but is costly (US$1.66–3.25 billion). Postnatal family-community care, with potential for high impact at low cost (10–27%, US$0.38–0.75 billion), has been neglected. A first phase of scaling up care in 36 high (NMR 30–45) and 15 very high (NMR >45) mortality countries would cost approximately US$0.56–1.10 and US$0.09–0.17 billion annually, respectively, and would avert 15–32% and 13–29% of neonatal deaths, respectively, in these countries. Full coverage with all interventions in the 51 high and very high mortality countries would cost US$2.23–4.37 billion, and avert 38–68% of neonatal deaths (1.13–2.05 million), at an extra cost per death averted of US$1100–3900.

Conclusions Low-cost, effective newborn health interventions can save millions of lives, primarily in South Asia and sub-Saharan Africa. Modelling costs and impact of intervention packages scaled up incrementally as health systems capacity increases can assist programme planning and help policy makers and donors identify stepwise targets for investments in newborn health.

Hierarchical linear modelling of smoking prevalence and frequency in China between 1991 and 2004

Pan, Z., Hu, D. — 2008-02-16

This study uses the hierarchical linear modelling (HLM) growth curve technique to explore predictors of the change in the prevalence and frequency of cigarette smoking in China between 1991 and 2004. Using nationally representative data, the study introduces a number of previously unanalysed variables at both the individual and the community level. The findings show that a number of factors are associated with the change in both the prevalence and frequency of smoking in China. In addition, there is a trend of decreasing prevalence of smoking in China after the effects of other covariates are adjusted. Finally, the free market cigarette price has an inconsistent relationship with the change in the prevalence and frequency of smoking, which further reveals the daunting task of tobacco control for public health scholars and policymakers in China.

Comparison of cost-of-illness with willingness-to-pay estimates to avoid shigellosis: evidence from China

2008-02-16

Previous studies have shown that cost of illness (COI) measures are lower than the conceptually correct willingness-to-pay (WTP) measure of the economic benefits of disease prevention. We compare COI with stated preference estimates of WTP associated with shigellosis in a rural area of China. COI data were collected through face-to-face interviews at 7 and 14 days after culture-confirmed diagnosis. WTP to avoid an episode similar to the one the respondent just experienced was elicited using a sliding-scale payment card. In contrast to previous studies’ findings, average COI estimates (2002 PPP adjusted US$28.2) approximate an upper bound estimate of WTP, rather than a lower bound. One explanation for the similarity between COI and WTP is that preventive expenditures and disutility due to pain and suffering are low for shigellosis. WTP to avoid additional cases in children aged 0–5 years is higher than in adults. Also, average COI (2002 PPP adjusted US$28.4) for children is similar to a lower bound estimate of WTP (2002 PPP adjusted US$16.4) and lies within the WTP range. Because the monetary loss associated with another episode in children is small, caregivers’ higher WTP may be attributable to the disutility of illness due to the children's pain and suffering. These findings suggest that for some diseases, COI may approximate more comprehensive measures of economic benefits.

The crisis in human resources for health care and the potential of a 'retired' workforce: case study of the independent midwifery sector in Tanzania

Rolfe, B., Leshabari, S., Rutta, F., Murray, S. F — 2008-02-16

The human resource crisis in health care is an important obstacle to attainment of the health-related targets for the Millennium Development Goals. One suggested strategy to alleviate the strain upon government services is to encourage new forms of non-government provision. Detail on implementation and consequences is often lacking, however. This article examines one new element of non-government provision in Tanzania: small-scale independent midwifery practices. A multiple case study analysis over nine districts explored their characteristics, and the drivers and inhibitors acting upon their development since permitted by legislative change.

Private midwifery practices were found concentrated in a ‘new’ workforce of ‘later life entrepreneurs’: retired, or approaching retirement, government-employed nursing officers. Provision was entirely facility-based due to regulatory requirements, with approximately 60 ‘maternity homes’ located mainly in rural or peri-urban areas. Motivational drivers included fear of poverty, desire to maintain professional status, and an ethos of community service. However, inhibitors to success were multiple. Start-up loans were scarce, business training lacking and registration processes bureaucratic. Cost of set-up and maintenance were prohibitively high, registration required levels of construction and equipping similar to government sector dispensaries. Communities were reluctant to pay for services that they expected from government. Thus, despite offering a quality of basic maternity care comparable to that in government facilities, often in poorly-served areas, most private maternity homes were under-utilized and struggling for sustainability.

Because of their location and emphasis on personalized care, small-scale independent practices run by retired midwives could potentially increase rates of skilled attendance at delivery at peripheral level. The model also extends the working life of members of a professional group at a time of shortage. However, the potential remains unrealized. Successful multiplication of this model in resource-poor communities requires more than just deregulation of private ownership. Prohibitive start-up expenses need to be reduced by less emphasis on facility-based provision. On-going financing arrangements such as micro-credit, contracting, vouchers and franchising models require consideration.

Public social policy development and implementation: a case study of the Ghana National Health Insurance scheme

Agyepong, I. A., Adjei, S. — 2008-02-16

The public social policy and programme decisions that are made in low-income countries have critical effects on human social and development outcomes. Unfortunately, it would appear that inadequate attention is paid to analysing, understanding and factoring into attempts to reshape or change policy, the complex historical, social, cultural, economic, political, organizational and institutional context; actor interests, experiences, positions and agendas; and policy development processes that influence policy and programme choices. Yet these can be just as critical as the availability of research or other evidence in influencing decision making on policies and their accompanying programmes and the resulting degree of success or failure in achieving the original objectives. Ghana, a low-income developing country in sub-Saharan Africa, embarked on a national policy process of replacing out-of-pocket fees at point of service use with national health insurance in 2001. This paper uses a case study approach to describe and reflect on the complex interactions of context with actors and processes including political power play; and the effects on agenda setting, decision making and policy and programme content. This case study supports observations from the literature that although availability of evidence is critical, major public social policy and programme content can be heavily influenced by factors other than the availability or non-availability of evidence to inform content decision making. In the low-income developing country context there can be imbalances of policy decision-making power related to strong and dominant political actors combined with weak civil society engagement, accountability systems and technical analyst power and position. Efforts at major reform need to consider and address these issues alongside efforts to provide evidence for content decision-making. Without an analysis and understanding of the politics of reform and how to work within it, researchers and other technical actors may find their information to support reform is not applied effectively. Similarly, without an appreciation of the need for critical technical analysis to support decision making rather than an indiscriminate use of political approaches, political actors may find that even with the best of intentions, desired policy objectives may not be attained.

The effectiveness of contracting-out primary health care services in developing countries: a review of the evidence

Liu, X., Hotchkiss, D. R, Bose, S. — 2007-12-21

The purpose of this study is to review the research literature on the effectiveness of contracting-out of primary health care services and its impact on both programme and health systems performance in low- and middle-income countries. Due to the heightened interest in improving accountability relationships in the health sector and in rapidly scaling up priority interventions, there is an increasing amount of interest in and experimentation with contracting-out. Overall, while the review of the selected studies suggests that contracting-out has in many cases improved access to services, the effects on other performance dimensions such as equity, quality and efficiency are often unknown. Moreover, little is known about the system-wide effects of contracting-out, which could be either positive or negative. Although the study results leave open the question of how contracting-out can be used as a policy tool to improve overall health system performance, the results indicate that the context in which contracting-out is implemented and the design features of the interventions are likely to greatly influence the chances for success.

Detention of insolvent patients in Burundian hospitals

Kippenberg, J., Sahokwasama, J. B., Amon, J. J — 2007-12-21

Between February and June 2006, Human Rights Watch and the Association for the Promotion of Human Rights and Detained Persons conducted an investigation into the detention of insolvent hospital patients in Burundi. Of 11 hospitals visited, nine were found to be holding former patients in detention for being unable to pay their hospital bills. Thirty-seven detained patients, and key informants in government, hospital administration and health services, were interviewed. The detention of insolvent hospital patients was described as a routine practice, dating from the 1990s. Conditions of detention included overcrowding, insufficient food and water, and withholding of further medical treatment. Seventy-two per cent of patients interviewed had been detained for 1 month or longer at the time of interview. Mechanisms designed to exempt or reimburse the health fees of low-income and indigent people failed to protect patients from becoming detained. The detention of insolvent patients is a clear violation of rights established under international law, including the right not to be arbitrarily detained or detained as debtors and the right to accessible health care. The abolition of user fees for women giving birth and for small children in May 2006 has reduced the number of detained patients, but in June 2006 we visited two hospitals and found 77 detained men, older children and women with other health problems. Burundi, with the support of the international community, must immediately stop the detention of patients and address the urgent financing needs of health facilities.

Cost and cost-effectiveness of nationwide school-based helminth control in Uganda: intra-country variation and effects of scaling-up

Brooker, S., Kabatereine, N. B, Fleming, F., Devlin, N. — 2007-12-21

Estimates of cost and cost-effectiveness are typically based on a limited number of small-scale studies with no investigation of the existence of economies to scale or intra-country variation in cost and cost-effectiveness. This information gap hinders the efficient allocation of health care resources and the ability to generalize estimates to other settings. The current study investigates the intra-country variation in the cost and cost-effectiveness of nationwide school-based treatment of helminth (worm) infection in Uganda. Programme cost data were collected through semi-structured interviews with district officials and from accounting records in six of the 23 intervention districts. Both financial and economic costs were assessed. Costs were estimated on the basis of cost in US$ per schoolchild treated, and an incremental cost-effectiveness ratio (cost in US$ per case of anaemia averted) was used to evaluate programme cost-effectiveness. Sensitivity analysis was performed to assess the effect of discount rate and drug price. The overall economic cost per child treated in the six districts was US$0.54 and the cost-effectiveness was US$3.19 per case of anaemia averted. Analysis indicated that estimates of both cost and cost-effectiveness differ markedly with the total number of children who received treatment, indicating economies of scale. There was also substantial variation between districts in the cost per individual treated (US$0.41–0.91) and cost per anaemia case averted (US$1.70–9.51). Independent variables were shown to be statistically associated with both sets of estimates. This study highlights the potential bias in transferring data across settings without understanding the nature of observed variations.

'What if they ask how I got it?' Dilemmas of disclosing parental HIV status and testing children for HIV in Uganda

Rwemisisi, J, Wolff, B, Coutinho, A, Grosskurth, H, Whitworth, J — 2007-12-21

Background Limited research has been conducted outside Western settings on how HIV-positive parents decide to test and disclose their own HIV status to children. We conducted a qualitative study in 2001 and 2005 to assess parent attitudes and current counselling policy and practice regarding child testing and parental disclosure in Uganda prior to the roll-out of antiretroviral therapy.

Methods Parent perspectives were obtained through extended in-depth interviews with 10 HIV-positive parents recruited from The AIDS Support Organization (TASO), Entebbe branch. Counselling policy and practice were explored through key informant interviews with directors and two counsellors from each of five Ugandan counselling institutions with national or regional coverage.

Results Respondents had 51 children ranging from 4 to 36 years with a median age of 13. Five of 10 parents had disclosed their status to their children, usually to all, and four of these had tested one child for HIV. All those who tested any child had also disclosed their status to some or all of their children. Parents regularly worried that their children may be infected, but all preferred to wait for emergence of symptoms before considering HIV tests, citing fear of children's emotional reaction and lack of perceived benefits from knowing status. Counselling policy directors confirmed the absence of policy and training guidelines on the subject of parent-child disclosure. Counsellors reported improvising and giving inconsistent advice on this common concern of clients.

Conclusions Concerns over disclosure to children of parent's HIV status and testing children for HIV represent a major psychological burden for HIV-positive parents. Further research is needed, but current counselling practice could be improved now by adapting lessons learned from existing research.

Direct observation and adherence to tuberculosis treatment in Chongqing, China: a descriptive study

Hu, D., Liu, X., Chen, J., Wang, Y., Wang, T., Zeng, W., Smith, H., Garner, P. — 2007-12-21

Introduction China has an estimated 5 million people with tuberculosis (TB). Official policy is that treatment of all patients is directly observed by health workers; completion rates are reported to be in excess of 90%, and drugs should be supplied for free. However, some research suggests there is a gap between the official policies and practice.

Methods Survey of TB patients in four counties of one municipality; record assessment at one TB centre; patient and village doctor in-depth interviews.

Results Sixteen per cent (64/401) reported being directly observed every time they took treatment; less than 5% of TB patients (17/401) were observed by health staff. Overall, 12.5% (50/401) reported they had not taken any TB drugs in the previous week, but this varied between the four counties (range 6.2 to 21.7%). We used survival analysis with medical records at one centre: 74.1% of new patients collected their drugs for their sixth month of treatment, and 50.3% attended the final visit at 6 months. Qualitative research indicated direct observation is neither well understood nor thought to be necessary, and that patients reported being charged expensive fees for ancillary treatments, such as liver protection drugs.

Conclusion In China, direct observation is not well implemented and may not be a feasible policy option. Official completion rates are higher than we found in this study. The concept of free treatment has become blurred, with charges for additional tests and drugs, especially liver protection drugs. The government is already actively tackling these issues, and involvement of managers and others in this process will be helpful.

Effectiveness of training supervisors to improve reproductive health quality of care: a cluster-randomized trial in Kenya

2007-12-21

Health facility supervisors are in a position to increase motivation, manage resources, facilitate communication, increase accountability and conduct outreach. This study evaluated the effectiveness of a training intervention for on-site, in-charge reproductive health supervisors in Kenya using an experimental design with pre- and post-test measures in 60 health facilities. Cost information and data from supervisors, providers, clients and facilities were collected. Regression models with the generalized estimating equation approach were used to test differences between study groups and over time, accounting for clustering and matching. Total accounting costs per person trained were calculated. The intervention resulted in significant improvements in quality of care at the supervisor, provider and client–provider interaction levels. Indicators of improvements in the facility environment and client satisfaction were not apparent. The costs of delivering the supervision training intervention totalled US$2113 per supervisor trained. In making decisions about whether to expand the intervention, the costs of this intervention should be compared with other interventions designed to improve quality.

Midwifery provision in two districts in Indonesia: how well are rural areas served?

Makowiecka, K., Achadi, E., Izati, Y., Ronsmans, C. — 2007-12-21

Attention has focused recently on the importance of adequate and equitable provision of health personnel to raise levels of skilled attendance at delivery and thereby reduce maternal mortality. Indonesia has a village-based midwife programme that was intended to increase the rate of professional delivery care and redress the urban/rural imbalance in service provision by posting a trained midwife in every village in the country. We present findings on the distribution of midwifery provision in our study area: 10% of villages do not have a midwife but a nurse as a midwifery provider; there is a deficit in midwife density in remote villages compared with urban areas; those assigned to remote areas are less experienced; midwives manage few births and this may compromise their capacity to maintain professional skills; over 90% of non-hospital deliveries take place in the woman's (64%) or the midwife's (28%) home; three-quarters of midwives did not make regular use of the fee exemption scheme; midwives who live in their assigned village spend more days per month on clinical work there. We conclude that adequate provider density is an important factor in effective health care and that efforts should be made to redress the imbalance in provision, but that this can only contribute to reducing maternal mortality in the context of a supportive professional environment and timely access to emergency obstetric care.

Implementation of a new birth record in three hospitals in Jordan: a study of health system improvement

Khresheh, R., Barclay, L. — 2007-12-21

This study tested the introduction of a new integrated clinical record in Jordan where currently no clinical report links antenatal, birth and postnatal care for women. As a result, no continuity of information is provided to clinicians nor are there national statistics on trends, or performance of hospitals around birth. Our study was conducted in the Jordanian Ministry of Health, the maternity wards and registration departments of three hospitals in Jordan and in the Maternal and Child Health Centres located near these hospitals. We used an exploratory, descriptive design and practice-research engagement to investigate and report on the process of change to improve and implement the new birth record. Through engaging practitioners in research, care improved, the quality of reporting changed, managers developed more effective measures of hospital performance and policy makers were provided with information that could form the basis of a national maternity data monitoring system. Quantitative and qualitative audit data demonstrated improved clinical reporting, organizational development and sustained commitment to the new record from clinicians, managers and policy leaders.