Catastrophic payments for health care in Asia

Out-of-pocket (OOP) payments are the principal means of financing health care throughout much of Asia. We estimate the magnitude and distribution of OOP payments for health care in fourteen countries and territories accounting for 81% of the Asian population. We focus on payments that are catastrophic, in the sense of severely disrupting household living standards, and approximate such payments by those absorbing a large fraction of household resources. Bangladesh, China, India, Nepal and Vietnam rely most heavily on OOP financing and have the highest incidence of catastrophic payments. Sri Lanka, Thailand and Malaysia stand out as low to middle income countries that have constrained both the OOP share of health financing and the catastrophic impact of direct payments. In most low/middle-income countries, the better-off are more likely to spend a large fraction of total household resources on health care. This may reflect the inability of the poorest of the poor to divert resources from other basic needs and possibly the protection of the poor from user charges offered in some countries. But in China, Kyrgyz and Vietnam, where there are no exemptions of the poor from charges, they are as, or even more, likely to incur catastrophic payments

Dinâmicas comunitárias em deslocados e não deslocados residentes em áreas de exclusão social em Barranquilla (Colômbia)

El sentido de comunidad, la participación y el empoderamiento permiten comprender el proceso de desplazamiento y reasentamiento en el contexto de recepción, así como las consecuencias derivadas de ambos fenómenos. Los objetivos de la investigación son a) evaluar los tres constructos mencionados, b) analizar la sinergia que existe entre estos y c) proponer estrategias para aumentar su capacidad de influencia en los procesos de toma de decisiones. Llevamos a cabo una investigación exploratoria y transversal con población desplazada (n=30) y no desplazada (n=32) en dos localidades de bajos ingresos en Barranquilla (Colombia). Existe retroalimentación positiva entre los procesos evaluados, aunque no se observan diferencias significativas entre el grupo de desplazados y el de no desplazados. La dimensión Pertenencia (sentido de comunidad) es la que mejor explica la varianza del empoderamiento y de la participación en ambos grupos. Presentamos iniciativas para reforzar el sentido de comunidad y facilitar el acceso a los recursos socio-comunitarios en población desplazada.The sense of community, participation and empowerment enable us to understand the process of displacement and resettlement in the context of reception, as well as the consequences of both phenomena. Our objectives are a) to assess the three constructs mentioned above, b) to analyze the synergy existing among them and c) to propose strategies for increasing their capacity to influence the decision-making processes. We carried out a cross-sectional exploratory study with displaced (n=30) and non-displaced (n=32) people in two low-income districts of Barranquilla (Colombia). There is positive feedback between the processes evaluated, although no significant differences are observed between the displaced and the non-displaced groups. The dimension of belonging (sense of community) is the one that best explains the variance of empowerment and participation in both groups. Finally, we present a set of initiatives to reinforce the sense of community and to facilitate access to the community’s social resources for the displaced population.O sentido de comunidade, a participação e o empoderamento permitem compreender o processo de deslocamento e reassentamento no contexto de recepção bem como as consequências derivadas de ambos os fenômenos. Os objetivos desta pesquisa são: a) avaliar os três construtos mencionados; b) analisar a sinergia que existe entre estes e c) propor estratégias para aumentar sua capacidade de influência nos processos de tomada de decisões. Realizamos uma pesquisa exploratória e transversal com população deslocada (n=30) e não deslocada (n=32) em duas localidades de baixa renda em Barranquilla (Colômbia). Existe retroalimentação positiva entre os processos avaliados, embora não se observem diferenças significativas entre o grupo de deslocados e o de não deslocados. A dimensão Pertencimento (sentido de comunidade) é a que melhor explica a variância do empoderamento e da participação em ambos os grupos. Apresentamos iniciativas para reforçar o sentido de comunidade e facilitar o acesso aos recursos sociocomunitários em população deslocada

The Sustainable Development Oxymoron: Quantifying and Modelling the Incompatibility of Sustainable Development Goals

In 2015, the UN adopted a new set of Sustainable Development Goals (SDGs) to eradicate poverty, establish socioeconomic inclusion and protect the environment. Critical voices such as the International Council for Science, however, have expressed concerns about the potential incompatibility of the SDGs, specifically the incompatibility of socio-economic development and environmental sustainability. In this paper we test, quantify and model the alleged inconsistency of SDGs. Our analyses show which SDGs are consistent and which are conflicting. We measure the extent of inconsistency and conclude that the SDG agenda will fail as a whole if we continue with business as usual. We further explore the nature of the inconsistencies using dynamical systems models, which reveal that the focus on economic growth and consumption as a means for development underlies the inconsistency. Our models also show that there are factors which can contribute to development (health programs, government investment in education) on the one hand and ecological sustainability (renewable energy) on the other, without triggering the conflict between incompatible SDGs

Using Telemedicine to Diagnose Surgical Site Infections in Low- and Middle-Income Countries:Systematic Review

BACKGROUND: A high burden of preventable morbidity and mortality due to surgical site infections (SSIs) occurs in low- and middle-income countries (LMICs), and most of these SSIs occur following discharge. There is a high loss to follow-up due to a wide geographical spread of patients, and cost of travel can result in delayed and missed diagnoses.OBJECTIVE: This review analyzes the literature surrounding the use of telemedicine and assesses the feasibility of using mobile phone technology to both diagnose SSIs remotely in LMICs and to overcome social barriers.METHODS: A literature search was performed using Medline, Embase, CINAHL, PubMed, Web of Science, the Cochrane Central Register of Controlled Trials and Google Scholar. Included were English language papers reporting the use of telemedicine for detecting SSIs in comparison to the current practice of direct clinical diagnosis. Papers were excluded if infections were not due to surgical wounds, or if SSIs were not validated with in-person diagnosis. The primary outcome of this review was to review the feasibility of telemedicine for remote SSI detection.RESULTS: A total of 404 articles were screened and three studies were identified that reported on 2082 patients across three countries. All studies assessed the accuracy of remote diagnosis of SSIs using predetermined telephone questionnaires. In total, 44 SSIs were accurately detected using telemedicine and an additional 14 were picked up on clinical follow-up.CONCLUSIONS: The use of telemedicine has shown to be a feasible method in remote diagnosis of SSIs. Telemedicine is a useful adjunct for clinical practice in LMICs to decrease loss to postsurgical follow-up.</p

Essays on farm household credit constraint, productivity and consumption inequality in Malawi

Credit has proven to be a necessary tool for economic development affecting positively the welfare of households and individuals. However, one major area in which rural households lack is access to financial markets including credit. The studies included in this thesis contribute to the access to credit literature and the credit constraint/unconstraint impact on some welfare outcomes. The first empirical study examined farm households' access to credit in rural Malawi. Unlike previous empirical studies, particular attention is given to discouraged borrowers who are mostly ignored in such studies. Using the 2010/2011 household survey data from Malawi the study determines the demographic and socio-economic characteristics that distinguish farm households who need credit, who are the discouraged borrowers and who are rejected applicants. A three-step sequential estimation model following a trivariate probit model with double sample selection was adopted. The findings revealed that there were over 7 times more discouraged borrowers than denied applicants. Women were more likely to be discouraged from applying for credit but, if they applied, they were more likely to be successful in obtaining credit than males. This shows that when examining farm households' access to credit discouraged borrowers should be given special consideration. Capturing discouraged borrowers as also credit constrained, the second empirical study employed a switching model to estimate the impact of credit constraint status on farm productivity for each credit constraint regime. The study further compared the expected production under actual and counterfactual conditions for a household being credit constrained or unconstrained. The findings suggest that a household that is constrained is less productive than a randomly selected household from the sample would but that for the unconstrained household is inconclusive, however, the counterfactual arguments as seen from the analysis shows that being credit unconstrained was beneficial to the increase in productivity. Studies have shown that undeveloped financial markets have been a major contributing factor increasing inequality, especially in developing countries. The third empirical study examined the impact of household credit constraint on the consumption inequality of rural households in Malawi. Factors that explain the within and between credit constrained and unconstrained status of consumption inequality were examined. The General Entropy (GE) Index and the Regression-Based Inequality Decomposition Methods, Field's (2003) and Blinder-Oaxaca Decomposition were employed. The findings show that inequality was more prominent within the groups than between them. Also, the size of households and the value of assets were the major contributors to the within-group inequalities for credit constrained and unconstrained households. Further, only the endowment component was important in explaining the consumption inequality gap between the credit constrained and unconstrained households. Adjusting the level of endowments of constrained households to that of the unconstrained households increased their welfare by 15.7 percent

Interventions for promoting the initiation of breastfeeding

Background: Despite the widely documented risks of not breastfeeding, initiation rates remain relatively low in many high-income countries, particularly among women in lower-income groups. In low- and middle-income countries, many women do not follow World Health Organization (WHO) recommendations to initiate breastfeeding within the first hour after birth. This is an update of a Cochrane Review, first published in 2005.Objectives: To identify and describe health promotion activities intended to increase the initiation rate of breastfeeding.To evaluate the effectiveness of different types of breastfeeding promotion activities, in terms of changing the number of women who initiate breastfeeding.To evaluate the effectiveness of different types of breastfeeding promotion activities, in terms of changing the number of women who initiate breastfeeding early (within one hour after birth).Search methods: We searched Cochrane Pregnancy and Childbirth's Trials Register (29 February 2016) and scanned reference lists of all articles obtained.Selection criteria: Randomised controlled trials (RCTs), with or without blinding, of any breastfeeding promotion intervention in any population group, except women and infants with a specific health problem.DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial reports for inclusion, extracted data and assessed trial quality. Discrepancies were resolved through discussion and a third review author was involved when necessary. We contacted investigators to obtain missing information.Main results: Twenty-eight trials involving 107,362 women in seven countries are included in this updated review. Five studies involving 3,124 women did not contribute outcome data and we excluded them from the analyses. The methodological quality of the included trials was mixed, with significant numbers of studies at high or unclear risk of bias due to: inadequate allocation concealment (N = 20); lack of blinding of outcome assessment (N = 20); incomplete outcome data (N = 19); selective reporting (N = 22) and bias from other potential sources (N = 17).Healthcare professional-led breastfeeding education and support versus standard careThe studies pooled here compare professional health workers delivering breastfeeding education and support during the prenatal and postpartum periods with standard care. Interventions included promotion campaigns and counselling, and all took place in a formal setting. There was evidence from five trials involving 564 women for improved rates of breastfeeding initiation among women who received healthcare professional-led breastfeeding education and support (average risk ratio (RR) 1.43, 95% confidence interval (CI) 1.07 to 1.92; Tau² = 0.07, I² = 62%, low-quality evidence) compared to those women who received standard care. We downgraded evidence due to design limitations and heterogeneity. The outcome of early initiation of breastfeeding was not reported in the studies under this comparison.Non-healthcare professional-led breastfeeding education and support versus standard careThere was evidence from eight trials of 5712 women for improved rates of breastfeeding initiation among women who received interventions from non-healthcare professional counsellors and support groups (average RR 1.22, 95% CI 1.06 to 1.40; Tau² = 0.02, I² = 86%, low-quality evidence) compared to women who received standard care. In three trials of 76,373 women, there was no clear difference between groups in terms of the number of women practicing early initiation of breastfeeding (average RR 1.70, 95% CI 0.98 to 2.95; Tau² = 0.18, I² = 78%, very low-quality evidence). We downgraded the evidence for a combination of design limitations, heterogeneity and imprecision (wide confidence intervals crossing the line of no effect).Other comparisonsOther comparisons in this review also looked at the rates of initiation of breastfeeding and there were no clear differences between groups for the following comparisons of combined healthcare professional-led education with peer support or community educator versus standard care (2 studies, 1371 women) or attention control (1 study, 237 women), breastfeeding education using multimedia (a self-help manual or a video) versus routine care (2 studies, 497 women); early mother-infant contact versus standard care (2 studies, 309 women); and community-based breastfeeding groups versus no breastfeeding groups (1 study, 18,603 women). None of these comparisons reported data on early initiation of breastfeeding.Authors' conclusions: This review found low-quality evidence that healthcare professional-led breastfeeding education and non-healthcare professional-led counselling and peer support interventions can result in some improvements in the number of women beginning to breastfeed. The majority of the trials were conducted in the USA, among women on low incomes and who varied in ethnicity and feeding intention, thus limiting the generalisability of these results to other settings.Future studies would ideally be conducted in a range of low- and high-income settings, with data on breastfeeding rates over various timeframes, and explore the effectiveness of interventions that are initiated prior to conception or during pregnancy. These might include well-described interventions, including health education, early and continuing mother-infant contact, and initiatives to help mothers overcome societal barriers to breastfeeding, all with clearly defined outcome measures.</p

Neurosurgical Randomized Trials in Low- and Middle-Income Countries

BACKGROUND The setting of a randomized trial can determine whether its findings are generalizable and can therefore apply to different settings. The contribution of low- and middle-income countries (LMICs) to neurosurgical randomized trials has not been systematically described before. OBJECTIVE To perform a systematic analysis of design characteristics and methodology, funding source, and interventions studied between trials led by and/or conducted in high-income countries (HICs) vs LMICs. METHODS From January 2003 to July 2016, English-language trials with >5 patients assessing any one neurosurgical procedure against another procedure, nonsurgical treatment, or no treatment were retrieved from MEDLINE, Scopus, and Cochrane Library. Income classification for each country was assessed using the World Bank Atlas method. RESULTS A total of 73.3% of the 397 studies that met inclusion criteria were led by HICs, whereas 26.7% were led by LMICs. Of the 106 LMIC-led studies, 71 were led by China. If China is excluded, only 8.8% were led by LMICs. HIC-led trials enrolled a median of 92 patients vs a median of 65 patients in LMIC-led trials. HIC-led trials enrolled from 7.6 sites vs 1.8 sites in LMIC-led studies. Over half of LMIC-led trials were institutionally funded (54.7%). The majority of both HIC- and LMIC-led trials evaluated spinal neurosurgery, 68% and 71.7%, respectively. CONCLUSION We have established that there is a substantial disparity between HICs and LMICs in the number of published neurosurgical trials. A concerted effort to invest in research capacity building in LMICs is an essential step towards ensuring context- and resource-specific high-quality evidence is generated

Assessing health facility performance in Indonesia using the Pabón-Lasso model and unit cost analysis of health services

Total health care costs have dramatically increased in Indonesia, and health facilities consume the largest share of health resources. This study aims to provide a better understanding of the characteristics of the best-performing health facilities. We use 4 national Indonesian datasets for 2011 and analysed 200 hospitals and 95 health centres. We first apply the Pabón-Lasso model to assess the relative performance of health facilities in terms of bed occupancy rate and the number of admissions per bed; the model gathers together health facilities into 4 sectors representing different levels of productivity. We then use a step-down costing method to estimate the cost per outpatient visit, inpatient, and bed days in hospitals and health centres. We combined both ratio analysis and applied bivariate and multivariate analyses to identify the predictors of the best-performing health facility; 37% of hospitals and 33% of health centres were located in the high-performing sector of the Pabón-Lasso model. The wide variation in unit costs across health facilities presented a basis for benchmarking and identifying relatively efficient units. Combining the unit cost analysis and Pabón-Lasso model, we find that health facility performance is affected by both internal (size and capacity, financing, type of patients, ownership, accreditation status, and staff availability) and external factors (economic status, population education level, location, and population density). Our study demonstrates that it is feasible to identify the best-performing health facilities and provides information about how to improve efficiency using simplistic methods

Human rights, health and the state in Bangladesh

BACKGROUND: This paper broadly discusses the role of the State of Bangladesh in the context of the health system and human rights. The interrelation between human rights, health and development are well documented. The recognition of health as a fundamental right by WHO and subsequent approval of health as an instrument of welfare by the Universal Declaration of Human Rights (UDHR) and the International Covenant on Social, Economic and Cultural Rights (ICSECR) further enhances the idea. Moreover, human rights are also recognized as an expedient of human development. The state is entrusted to realize the rights enunciated in the ICSECR. DISCUSSION: In exploring the relationship of the human rights and health situation in Bangladesh, it is argued, in this paper, that the constitution and major policy documents of the Bangladesh government have recognized the health rights and development. Bangladesh has ratified most of the international treaties and covenants including ICCPR, ICESCR; and a signatory of international declarations including Alma-Ata, ICPD, Beijing declarations, and Millennium Development Goals. However the implementation of government policies and plans in the development of health institutions, human resources, accessibility and availability, resource distribution, rural-urban disparity, the male-female gap has put the health system in a dismal state. Neither the right to health nor the right to development has been established in the development of health system or in providing health care. SUMMARY: The development and service pattern of the health system have negative correlation with human rights and contributed to the underdevelopment of Bangladesh. The government should take comprehensive approach in prioritizing the health rights of the citizens and progressive realization of these rights

Investigating sex differences in the accuracy of dietary assessment methods to measure energy intake in adults:a systematic review and meta-analysis

BACKGROUND: To inform the interpretation of dietary data in the context of sex differences in diet-disease relations, it is important to understand whether there are any sex differences in accuracy of dietary reporting. OBJECTIVE: To quantify sex differences in self-reported total energy intake (TEI) compared with a reference measure of total energy expenditure (TEE). METHODS: Six electronic databases were systematically searched for published original research articles between 1980 and April 2020. Studies were included if they were conducted in adult populations with measures for both females and males of self-reported TEI and TEE from doubly labeled water (DLW). Studies were screened and quality assessed independently by 2 authors. Random-effects meta-analyses were conducted to pool the mean differences between TEI and TEE for, and between, females and males, by method of dietary assessment. RESULTS: From 1313 identified studies, 31 met the inclusion criteria. The studies collectively included information on 4518 individuals (54% females). Dietary assessment methods included 24-h recalls (n = 12, 2 with supplemental photos of food items consumed), estimated food records (EFRs; n = 11), FFQs (n = 10), weighed food records (WFRs, n = 5), and diet histories (n = 2). Meta-analyses identified underestimation of TEI by females and males, ranging from -1318 kJ/d (95% CI: -1967, -669) for FFQ to -2650 kJ/d (95% CI: -3492, -1807) for 24-h recalls for females, and from -1764 kJ/d (95% CI: -2285, -1242) for FFQ to -3438 kJ/d (95% CI: -5382, -1494) for WFR for males. There was no difference in the level of underestimation by sex, except when using EFR, for which males underestimated energy intake more than females (by 590 kJ/d, 95% CI: 35, 1,146). CONCLUSION: Substantial underestimation of TEI across a range of dietary assessment methods was identified, similar by sex. These underestimations should be considered when assessing TEI and interpreting diet-disease relations