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Setting: Research capacity is weakest in low and middle-income countries (LMICs) where operational research is highly relevant and needed. Structured Operational Research and Training Initiative (SORT IT) courses have been developed to train participants to conduct and publish operational research and influence policy and practice. Twenty courses were completed in Asia, Africa, Europe and the South Pacific between 2009 and 2014. Objectives: In the 20 completed SORT IT courses, to assess where the research was conducted, who was trained, who became facilitators in subsequent courses and course outcomes. Design: A cohort study of completed SORT IT courses Results: There were 236 participants (41% female) including 64 nationalities who conducted research in 59 countries, mostly from Asia and Africa (mean course duration = 9.7 months). Most participants (68%) were from government health programs and non-governmental agencies. A total of 213(90%) participants completed all milestones successfully with 41(19%) becoming subsequent course facilitators, 88% of whom were from LMICs. Of 228 manuscripts submitted to scientific journals, 197(86%) were either published or in press; in 86%, the principal investigator (first author) was a LMIC national. Papers were published in 23 scientific journals (impact factor 0.5–4.4) and covered 21 disease categories (median publication time = 5.7 months). Published papers (186) had 94,794 cumulative article views/downloads. Article views/downloads for immediate open access articles were double those from closed access journals. Conclusion: The SORT IT model has been effective in training personnel to produce relevant operational research in LMICs. It merits continued commitment and support for further scale-up and development. [ABSTRACT FROM AUTHOR]

Objective: This paper reflected on the prevalence of hypertension and diabetes in Bangladesh, which is spreading rapidly in low-income countries. The rationale of constructing more health centers for addressing NCDs was assessed in this paper by determining the relationship between prevalence of NCDs, particularly hypertension and diabetes, and distance to health facilities. Methods: From BDHS (Bangladesh Health and Demographic Survey) 2011 data set, 7544 samples were analyzed to demonstrate association between Non-communicable diseases (NCD) and distance from respondents’ home to health facilities like hospitals, community clinics, pharmacies or doctors’ chambers, and community facilities like market, post office or cinema hall. Bivariate analysis was conducted between accessibility to health facilities and prevalence of the diseases. The causal relationship between the spatial effects and the prevalence of the diseases were analyzed by applying Generalized Linear Mixed Model (GLMM) was fitted. Results: Fitting linear mixed effect models, we found that hypertension and diabetes react differently with various spatial effects. Distance from home to hospital had significant effect (P < 0.001) on hypertension showing people living further from the facilities or town centers seemed to be less hypertensive, whereas diabetes showed no such affiliation. Conclusion: Higher prevalence of diabetes (40.9%) over hypertension (26.5%) in people aging 35 or higher, have appeared to have caused the difference, which concluded that each non-communicable disease should be dealt to its own merit for policy making instead considering as a group of diseases. [ABSTRACT FROM AUTHOR]

Background: Resource allocation decisions for disease categories can be informed by proper estimates of the magnitude and distribution of total spending. In the backdrop of a high burden of Non-Communicable Diseases and Injuries (NCDI) in India, and a paucity of estimates on government spending on NCDI, this paper attempts to analyse public sector expenditure on NCDI spending in India. Methods: Various recent budget documents of the Centre and States/Union Territories have been used to extract expenditure on NCDI. The aggregates thus arrived at have been analysed to estimate aggregate and state level per capita spending. State level spending have been compared against disease burden using DALYs. Patterns of spending on NCDI across states were also analysed together with state level poverty to observe possible patterns. Findings: The total spending on NCDI by the government is low at less than 0.5% of GDP. NCDI spending is little more than one-fourth of total health spending of the country and most spending takes place at the state level (80%). The Ministry of Health and Family Welfare’s share in Central spending on NCDI is around 65%, and currently it spends 20% of its total health spending on NCDI. The gap between spending and DALYs is the most for the economically vulnerable states. Also, the states with high poverty levels also have low per capita expenditure on NCDI Interpretation: India does not depend on donor funding for health. It will have to step up domestic funding to address the increasing disease burden of NCDIs and to reduce the high out-of-pocket expenditure on NCDI. Policies on NCDI need to focus on UHC, service integration and personnel gaps. [ABSTRACT FROM AUTHOR]

This paper examines the relationship between body composition and earnings in a developing country setting. We use body mass index, waist circumference and hip circumference. Exploiting the panel structure of our longitudinal survey, we find that along with BMI, waist circumference is related to higher earnings in Indonesia. [ABSTRACT FROM AUTHOR]

Objective: To explore intersections of social determinants of maternal healthcare utilization using the Classification and Regression Trees (CART) algorithm which is a machine-learning method used to construct prediction models. Methods: Institutional review board approval for this study was granted from Public Health Service—Ethical Review Board (PHS-ERB) and from the Health Ministry Screening Committee (HMSC) facilitated by Indian Council for Medical Research (ICMR). IRB review and approval for the current analyses was obtained from University of California, San Diego. Cross-sectional data were collected from women with children aged 0–11 months (n = 5,565) from rural households in 25 districts of Uttar Pradesh, India. Participants were surveyed on maternal healthcare utilization including registration of pregnancy (model-1), receipt of antenatal care (ANC) during pregnancy (model-2), and delivery at health facilities (model -3). Social determinants of health including wealth, social group, literacy, religion, and early age at marriage were captured during the survey. The Classification and Regression Tree (CART) algorithm was used to explore intersections of social determinants of healthcare utilization. Results: CART analyses highlight the intersections, particularly of wealth and literacy, in maternal healthcare utilization in Uttar Pradesh. Model-1 documents that women who are poorer, illiterate and Muslim are less likely to have their pregnancies registered (71.4% vs. 86.0% in the overall sample). Model-2 documents that poorer, illiterate women had the lowest ANC coverage (37.7% vs 45% in the overall sample). Model-3, developed for deliveries at health facilities, highlighted that illiterate and poor women have the lowest representation among facility deliveries (59.6% vs. 69% in the overall sample). Conclusion: This paper explores the interactions between determinants of maternal healthcare utilization indicators. The findings in this paper highlights that the interaction of wealth and literacy can play a very strong role in accentuating or diminishing healthcare utilization among women. The study also reveals that religion and women’s age at marriage also interact with wealth and literacy to create substantial disparities in utilization. The study provides insights into the effect of intersections of determinants, and highlights the importance of using a more nuanced understanding of the impact of co-occurring forms of marginalization to effectively tackle inequities in healthcare utilization. [ABSTRACT FROM AUTHOR]

Motivation: Proper management of fecal sludge has significant positive health and environmental externalities. Most research on managing onsite sanitation so far either simulates the costs of, or the welfare effects from, managing sludge in situ in pit latrines. Thus, designing management strategies for onsite rural sanitation is challenging, because the actual costs of transporting sludge for treatment, and sources for financing these transport costs, are not well understood. Methods: In this paper we calculate the actual cost of sludge management from onsite latrines, and identify the contributions that latrine owners are willing to make to finance the costs. A spreadsheet-based model is used to identify a cost-effective transport option, and to calculate the cost per household. Then a double-bound contingent valuation method is used to elicit from pit-latrine owners their willingness-to-pay to have sludge transported away. This methodology is employed for the case of a rural subdistrict in Bangladesh called Bhaluka, a unit of administration at which sludge management services are being piloted by the Government of Bangladesh. Results: The typical sludge accumulation rate in Bhaluka is calculated at 0.11 liters/person/day and a typical latrine will need to be emptied approximately once every 3 to 4 years. The costs of emptying and transport are high; approximately USD 13 per emptying event (circa 14% of average monthly income); household contributions could cover around 47% of this cost. However, if costs were spread over time, the service would cost USD 4 per year per household, or USD 0.31 per month per household—comparable to current expenditures of rural households on telecommunications. Conclusion: This is one of few research papers that brings the costs of waste management together with financing of that cost, to provide evidence for an implementable solution. This framework can be used to identify cost effective sludge management options and private contributions towards that cost in other (context-specific) administrative areas where onsite sanitation is widespread. [ABSTRACT FROM AUTHOR]

Background: For countries to contribute to Sustainable Development Goal 3.1 of reducing the global maternal mortality ratio (MMR) to less than 70 per 100,000 live births by 2030, identifying the drivers of maternal mortality is critically important. The ability of countries to identify the key drivers is however hampered by the lack of data sources with sufficient observations of maternal death to allow a rigorous analysis of its determinants. This paper overcomes this problem by utilising census data. In the context of Indonesia, we merge individual-level data on pregnancy-related deaths and households’ socio-economic status from the 2010 Indonesian population census with detailed data on the availability and quality of local health services from the Village Census. We use these data to test the hypothesis that health service access and quality are important determinants of maternal death and explain the differences between high maternal mortality and low maternal mortality provinces. Methods: The 2010 Indonesian Population Census identifies 8075 pregnancy-related deaths and 5,866,791 live births. Multilevel logistic regression is used to analyse the impacts of demographic characteristics and the existence of, distance to and quality of health services on the likelihood of maternal death. Decomposition analysis quantifies the extent to which the difference in maternal mortality ratios between high and low performing provinces can be explained by demographic and health service characteristics. Findings: Health service access and characteristics account for 23% (CI: 17.2% to 28.5%) of the difference in maternal mortality ratios between high and low-performing provinces. The most important contributors are the number of doctors working at the community health centre (8.6%), the number of doctors in the village (6.9%) and distance to the nearest hospital (5.9%). Distance to health clinics and the number of midwives at community health centres and village health posts are not significant contributors, nor is socio-economic status. If the same level of access to doctors and hospitals in lower maternal mortality Java-Bali was provided to the higher maternal mortality Outer Islands of Indonesia, our model predicts 44 deaths would be averted per 100,000 pregnancies. Conclusion: Indonesia has employed a strategy over the past several decades of increasing the supply of midwives as a way of decreasing maternal mortality. While there is evidence of reductions in maternal mortality continuing to accrue from the provision of midwife services at village health posts, our findings suggest that further reductions in maternal mortality in Indonesia may require a change of focus to increasing the supply of doctors and access to hospitals. If data on maternal death is collected in a subsequent census, future research using two waves of census data would prove a useful validation of the results found here. Similar research using census data from other countries is also likely to be fruitful. [ABSTRACT FROM AUTHOR]

Background: Leprosy remains a disease of concern in many countries including Nepal. To achieve the target of elimination, the WHO strategy promotes comprehensive education of patients, healthcare workers (HCWs), and the public on leprosy-related issues. However most educational programs are based on the concerns of HCWs and not on patients’ needs. The objective of this paper is to explore the educational needs of leprosy affected patients in Nepal and compare them to the needs perceived by HCWs. Methodology/principal findings: Semi directive interviews were conducted with patients and HCWs. The data was analyzed using the basic interpretative qualitative framework. The study was conducted in two leprosy referral centers, one university hospital and one primary health care center: Lalgadh Leprosy Hospital and Services Centre, Anandaban Hospital and its satellite clinic in Patan, B. P. Koirala Institute of Health Sciences in Dharan, and the Itahari primary health care centre. The results show that there remains a lack of knowledge regarding the disease (origins, manifestations, prevention and treatment) contributing to late care seeking behavior and high levels of stigma, with an important psychological and financial stress for patients. All of the HCWs displayed a good understanding of patients’ difficulties and needs and acknowledged the key role of patient education. However, they expressed several challenges in managing patients due to lack of time, human resources and training in patient education. Conclusions/significance: Further efforts need to be made to increase patients’ general knowledge of the disease in order to motivate them to seek healthcare earlier and change their perception of the disease to reduce stigma. HCWs need proper training in patient education and counseling for them to acquire the necessary skills required to address the different educational needs of their patients. The use of lay and peer counselors would be an option to address the workload and lack of time expressed by HCWs. [ABSTRACT FROM AUTHOR]

Introduction: Public health spending in India has been traditionally one of the lowest globally. Punjab is one of the states with highest proportion of out-of-pocket expenditures for healthcare in India. We undertook this study to produce the sub-national health accounts (SNHA) for Punjab state in India. Methodology: We used System of Health Accounts (SHA) 2011 framework for preparing health accounts for Punjab state. Data on health spending by government was obtained from concerned public sector departments both at state and central level. Estimates on Out-of-Pocket Expenditures (OOPE) expenditure were derived from National Sample Survey (NSS) 71st round data, Consumer Expenditure Survey (CES) data and Pharmatrac. Primary surveys were done for assessing health expenditure data by firms and non-governmental organizations. All estimates of healthcare expenditures reported in our paper pertain to 2013–14, and are reported in both Indian National Rupee (INR) and United States Dollar (US $),using average conversion rate of INR 60.50 per US $. Results: In 2013–14, the current health expenditures (CE) in Punjab was INR 134,680million (US $ 2245 million) which was 4.02% of its gross state domestic product (GSDP).However, public spending on health was 0.95% of GSDP i.e. 21% of the total health expenditure (THE), while 79% was private expenditure. In per capita terms, THE in Punjab was INR 4963 (US $ 82.03). In terms of functions, medical goods (41.6%) and curative care (37%) consumed larger share of expenditure in the Punjab state. Households spent 52% of expenditures for medicines and other pharmaceutical goods. Risk pooling mechanisms are being adopted to a lesser extent in the state. Conclusion: The healthcare in Punjab is largely financed through private OOPE. Currently, public health spending in Punjab is inadequate to meet the healthcare demands of population, which is less than 1% of state’s GSDP. Monitoring public resources is very important for better resource allocations. Health Accounts production is useful in order to assess future trends and impact of health financing policies on goals of universal health coverage and should be made a part of routine monitoring system both at national and sub-national level. [ABSTRACT FROM AUTHOR]

Waiting time for non-emergency medical care in developing countries is rarely of immediate concern to policy makers that prioritize provision of basic health services. However, waiting time as a measure of health system responsiveness is important because longer waiting times worsen health outcomes and affect utilization of services. Studies that assess socio-economic inequalities in waiting time provide evidence from developed countries such as England and the United States; evidence from developing countries is lacking. In this paper, we assess the relationship between social class i.e. caste of an individual and waiting time at health facilities—a client orientation dimension of responsiveness. We use household level data from two rounds of the Indian Human Development Survey with a sample size of 27,251 households in each wave (2005 and 2012) and find that lower social class is associated with higher waiting time. This relationship is significant for individuals that visited a male provider but not so for those that visited a female provider. Further, caste is positively related to higher waiting time only if visiting a private facility; for individuals visiting a government facility the relationship between waiting time and caste is not significant. In general, caste related inequality in waiting time has worsened over time. The results are robust to different specifications and the inclusion of several confounders. [ABSTRACT FROM AUTHOR]

This paper uses two nationally representative sets of medical claims data from medical assistance and universal public health insurance systems to examine how medical assistance system assignment affects short-term inpatient health care provision. In Japan, the medical assistance system, which is part of a public assistance system, provides medical care services for its beneficiaries without imposing any financial burdens, such as copayments or advance premium payments. These circumstances can lead to inpatient costs, as physicians may provide more treatments because there is a financial incentive. Because the assignment of public assistance in Japan is not random but is subject to means testing by the local government, I employ the instrumental variable model to control the potential correlation. I find that medical expenditure is significantly higher for medical assistance patients than for universal public health insurance patients, with an arc elasticity of approximately 0.20. This elasticity is slightly greater than that found for inpatient care in the randomized RAND Health Insurance Experiment and recent empirical studies on low-income populations. In addition, the elasticities for patients who receive medication, treatment and surgery are greater. [ABSTRACT FROM AUTHOR]

Background: The Philippines has built an extensive decentralised network of Animal Bite Treatment Centers (ABTCs) to help bite victims receive timely rabies post-exposure prophylaxis (PEP) at little cost. This study surveyed patients in the community and at ABTCs of three provinces to assess animal bite/scratch incidence, health-seeking behaviour and PEP-related out-of pocket expenses (OOPE). Methodology and principal findings: During community surveys in 90 barangays (neighbourhoods), 53% of households reported at least one animal bite /scratch injury over the past 3 years, similar across urban and rural barangays. Overall bite/scratch incidences in 2016–17 were 67.3, 41.9 and 48.8 per 1,000 population per year for Nueva Vizcaya, Palawan and Tarlac respectively. Incidences were around 50% higher amongst those under 15 years of age, compared to -those older than 15. Household awareness of the nearest ABTCs was generally over 80%, but only 44.9% sought proper medical treatment and traditional remedies were still frequently used. The proportion of patients seeking PEP was not related to the distance or travel time to the nearest ABTC. For those that did not seek medical treatment, most cited a lack of awareness or insufficient funds and almost a third visited a traditional healer. No deaths from bite/scratch injuries were reported. A cohort of 1,105 patients were interviewed at six ABTCs in early 2017. OOPE varied across the ABTCs, from 5.53 USD to 37.83 USD per patient, primarily dependent on the need to pay for immunization if government supplies had run out. Overall, 78% of patients completed the recommended course, and the main reason for non-completion was a lack of time, followed by insufficient funds. Dog observation data revealed that 85% of patients were not truly exposed to rabies, and education in bite prevention might reduce provoked bites and demand for PEP. An accompanying paper details the ABTC network from the health provider’s perspective. [ABSTRACT FROM AUTHOR]

Background: The Philippine government has an extensive network of 513 Animal Bite Treatment Centers (ABTCs) to supply rabies post exposure prophylaxis (PEP), reaching over 1 million bite victims in 2016. The network was evaluated using a review of existing national and provincial data, key informant interviews and surveys in sample ABTCs to determine the cost-effectiveness of this network in preventing human rabies deaths. Methodology and principal findings: One urban and one rural ABTC in each of three selected provinces were studied in more detail. PEP delivery generally followed national guidance based on best practices, but there was evidence of operational challenges in supplying all ABTCs with adequate biologics and recently trained staff. Funding was contributed by different levels of government and in some clinics, patients paid for a significant fraction of the total cost. From a health provider perspective including both fixed and variable costs, the average PEP course delivered cost USD 32.91 /patient across urban ABTCs (with higher patient throughput) and USD 57.21 /patient across rural ABTCs. These costs suggests that PEP provision in the Philippines cost USD 37.6 million in 2016, with a cost per life saved of USD 8,290. An analysis of the 2,239 suspected rabies deaths from 2008 to 2016 showed no significant decline, and from 2014–16 an average of 8,534 years of life were lost annually. The incidence of rabies deaths from 2014–16 was not clearly related to the provision of ABTCs (per 100,000 population) or human population density, but deaths were more common in higher income provinces. Conclusions/Significance: In the context of comprehensive rabies control (including dog vaccination and public awareness) ways to reduce this high expenditure on PEP should be explored, to most cost-effectively reach the elimination of human rabies deaths. This paper is accompanied by another containing data on the operation of ABTCs network from a patient perspective. [ABSTRACT FROM AUTHOR]

Background: Around 63% of total health care expenditure in Bangladesh is mitigated through out of pocket payment (OOP). Heavy reliance on OOP at the time of care seeking poses great threat for financial impoverishment of the households. Households employ different strategies to cope with the associated financial hardship. Objective: The aim of this paper is to understand the determinants of hardship financing in coping with OOP adopted for health care seeking of under five childhood illnesses in rural setting of Bangladesh. Methods: A community based cross sectional survey was conducted during August to October, 2014 in 15 low performing sub-districts of northern and north-east regions of Bangladesh. Of the 7039 mothers of under five children surveyed, 1895 children who suffered from illness and sought care for their illness episodes were reported in this study. Descriptive statistics and ordinal regression analysis were conducted. Results: A total number of 7,039 under five children reported to have suffered illness by their mothers. Among these children 37% suffered from priority illness. Care was sought for 88% children suffering from illnesses. Among them 26% went to a public or private sector medically trained provider. 5% of households incurred illness cost more than 10% of the household’s monthly expenditure. The need for assistance was higher among those compared to others (31% vs 13%). Different financing mechanisms adopted to meet OOP are loan with interest (6%), loan without interest (9%) and financial help from relatives (6%) Need for financial assistance varied from 19% among households in the lowest quintile to 9% in the highest wealth. Ordinal regression analysis revealed that burden of hardship financing increases by 2.17 times when care is sought from a private trained provider compared to care seeking from untrained provider (CI: 1.49, 3.17). Similarly, for families that incur a health care expenditure that is more than 10% of their total monthly expenditure (CI:1.46, 3.88), the probability of falling into more severe financial burden increases by 2.4 times. We also found severity of the hardship financing to be around half for households with monthly income of more than BDT 7500 (OR = 0.56, CI: 0.37, 0.86). The burden increased by 2.10 times for households with a deficit (CI: 1.53, 2.88) between their monthly income and expenditure. The interaction between family income and severity of illness showed to significantly affect the scale of hardship financing. Children suffering from priority illness belonging to poor households were found have two times (CI: 1.09, 3.47) higher risks of suffering from hardship financing. Conclusion and policy implications: Findings from this study will help the policy makers to identify the target groups and thereby design effective health financing programs. [ABSTRACT FROM AUTHOR]

This paper examines the effect of maternal socio-economic status in the household, such as their autonomy, ability, freedom and bargaining power, on child birth registration in India using the nationally representative India Human Development Survey-II (IHDS-II), 2011–12. We have estimated a multilevel mixed effects model which accounts for the hierarchical structure of the data and allows us to examine the effects of unobserved ‘district’ and ‘community’ characteristics along with individual child level characteristics on probability of birth registration. The results show that between-districts and between individuals differences share a considerably high and an almost equal proportion of the variations in probability of birth registration in India. At individual child level, mother’s socio-economic status such as her ability to move around independently and her exposure to outside world, significantly raise the probability of birth registration. More importantly, the marginal effects of the maternal autonomy indicators: mother’s ability to move around freely and her control over resources, on birth registration vary across districts in India. Other variables such as institutional birth, mother’s antenatal care seeking behaviour, caste, religion, household wealth and parental education are significant determinants of birth registration. [ABSTRACT FROM AUTHOR]

Background: No study of obesity risk for people in developed countries has conducted a multi-dimensional analysis of the association of socioeconomic status with obesity. In this paper, we investigated if education functions as either a confounder or an effect modifier in the association of another socioeconomic status indicator with obesity. Methods: This cross-sectional study analyzed data of an adult population sample (10,905 men and 14,580 women) from the Korea National Health and Nutrition Examination Survey (2010–2014). The study performed multivariate logistic regression analyses for three education levels and four indicators of socioeconomic status (i.e., marital status, residential area, occupation, and income). Results: The overall prevalence of obesity was 38.1% in men and 29.1% in women (p < 0.001). In men, while education functioned as an effect modifier in the association between marital status and obesity (p for interaction = 0.006), it functioned as both a confounder (p < 0.001) and an effect modifier (p for interaction < 0.001) in the association between residential area and obesity. In contrast, in women, education functioned as a confounder in the association of residential area with obesity (p = 0.010). However, it functioned as both a confounder (p < 0.001) and an effect modifier (p for interaction = 0.012) in the association between income and obesity. A prediction showed that unlike in women, education was positively associated with obesity risk for some socioeconomic indicator groups in men; for example, in a rural resident group, a higher level of education increased the probability of being obese by 19.7%. Conclusions: The present study suggests the need to examine sex-specific studies regarding the role of education on the association between other socioeconomic status indicators and obesity. This should be considered in planning education policies to reduce the risk of obesity. [ABSTRACT FROM AUTHOR]

This paper aimed to investigate the role of parental education in child disability in China. We used nationally representative data from China’s National Sample Survey on Disability, iterated twice, in 1987 and 2006, with data of 764,718 children aged 0–14 years. Logit models were used for statistical analysis. Results showed that the prevalence of child disability was significantly associated with each parent’s education. Maternal education was more important than paternal education in child disability in both surveys. The analysis of marginal effect indicated a one-year increase in maternal and paternal schooling led to an average decrease of 0.121% and 0.091% in the probability of child disability in 1987, and 19 years later, these figures had dwindled to 0.091% and 0.072%, respectively. [ABSTRACT FROM AUTHOR]

Background: While women and girls face special risks from lack of access to sanitation facilities, their ability to participate and influence household-level sanitation is not well understood. This paper examines the association between women's decision-making autonomy and latrine construction in rural areas of Odisha, India. Methods: We conducted a mixed-method study among rural households in Puri district. This included a cross sectional survey among 475 randomly selected households. These were classified as either having a functional latrine, a non-functional latrine or no latrine at all. We also conducted 17 in-depth interviews and 9 focus group discussions among household members of these three categories of households. Results: Decisions on the construction of household level sanitation facilities were made exclusively by the male head in 80% of households; in 11% the decision was made by men who consulted or otherwise involved women. In only 9% of households the decision was made by women. Households where women were more involved in general decision making processes were no more likely to build a latrine, compared to households where they were excluded from decisions. Qualitative research revealed that women’s non-involvement in sanitation decision making is attributed to their low socio-economic status and inability to influence the household’s financial decisions. Female heads lacked confidence to take decisions independently, and were dependent on their spouse or other male family members for most decisions. The study revealed the existence of power hierarchies and dynamics within households, which constrained female’s participation in decision-making processes regarding sanitation. Conclusions: Though governments and implementers emphasize women’s involvement in sanitation programmes, socio-cultural factors and community and household level dynamics often prevent women from participating in sanitation-related decisions. Measures are needed for strengthening sanitation policies and effective implementation of programmes to address gender power relations and familial relationships that influence latrine adoption and use. [ABSTRACT FROM AUTHOR]

Background: Exposure to armed conflict and/or war have been linked to an increase in intimate partner violence (IPV) against women. A substantial body of work has focused on non-partner rape and sexual violence in war and post-war contexts, but research about IPV is limited, particularly in Asian settings. This paper presents the finding of a study conducted in the Eastern Province of Sri Lanka. The study explored women’s experiences of and responses to IPV as well as how health and social service providers perceive the problem. It also explored the IPV-related services and supports available after the end of a 30-year civil war. Method: We conducted in-depth, qualitative interviews with 15 women who had experienced IPV and 15 service providers who were knowledgeable about IPV in the Eastern Province of Sri Lanka. Interviews were translated into English, coded and organized using NVivo8, and analyzed using inductive thematic analysis. Results: Participants described IPV as a widespread but hidden problem. Women had experienced various forms of abusive and controlling behaviours, some of which reflect the reality of living in the post-war context. The psychological effects of IPV were common, but were often attributed to war-related trauma. Some men used violence to control women and to reinstate power when their gender roles were reversed or challenged due to war and post-war changes in livelihoods. While some service providers perceived an increase in awareness about IPV and more services to address it, this was discordant with women’s fears, feelings of oppression, and perception of a lack of redress from IPV within a highly militarized and ethnically-polarized society. Most women did not consider leaving an abusive relationship to be an option, due to realistic fears about their vulnerability to community violence, the widespread social norms that would cast them as outsiders, and the limited availability of related services and supports. Implications: These findings revealed the need for more research about IPV in post-war contexts. Women’s experiences in such contexts are influenced and may be masked by a complex set of factors that intersect to produce IPV and entrap women in violence. A more nuanced understanding of the context-specific issues that shape women’s experiences of IPV- and community responses to it—is needed to develop more comprehensive solutions that are relevant to the local context. [ABSTRACT FROM AUTHOR]

Objective: The world population is aging rapidly and the well-being of older people is of great interest. Therefore, this study investigates the determinants of life satisfaction among the oldest-old (i.e. individuals aged 80 or over) in China. Materials and methods: We use the 2011/2012 Chinese Longitudinal Healthy Longevity Survey data (n = 6530) for this paper. Logistic regression is used to analyse the effects of socio-demographic, economic, health, instrumental activities of daily living, family and community factors on life satisfaction and depression among the oldest-old in China. Results: Our analysis confirms the significance of many factors affecting life satisfaction among the oldest-old in China. Factors that are correlated with life satisfaction include respondent’s sex, education, place of residence, self-rated health status, cognitive ability (using mini mental state examination), regular physical examination, perceived relative economic status, access to social security provisions, commercialized insurances, living arrangements, and number of social services available in the community (p<0.05 for all these variables). Although life satisfaction is negatively associated with instrumental activities of daily living (β = -0.068, 95%CI = -.093—.043), and depression (β = -0.463, 95%CI = -.644—.282), the overall effect of self-rated health status is positive (p<0.001). This confirms the primacy of health as the determinant of well-being among the oldest-old. Conclusions: Majority of the oldest-old in China rated their life satisfaction as good or very good. Our findings show that health and economic status are by far the most significant predictors of life satisfaction. Our finding on the primacy of health and relative income as determinants of well-being among the oldest-old, and the greater influence of self-rated health status over objective health measures is consistent with the findings of many past studies. Our results suggest that efforts should be directed at enhancing family support as well as health and social service provisions in the community to improve life satisfaction of older people. [ABSTRACT FROM AUTHOR]

Purpose: Diabetes mellitus (DM) is a global pandemic metabolic disorder. In recent years, the amount of medical resources required for the treatment of diabetes has increased as diabetes rates have gradually risen. The combined effects of individual and neighbourhood socio-economic status (SES) on DM survival rates are still not clear, especially in patients of working age. In this paper, we aim to analyze the combined effects of neighbourhood and individual SES on DM survival rates in patients of working age in Taiwan. Methods: The study of 23,781 people who were diagnosed with DM by using population—based study between 2002 and 2006. Each sample was followed up for 4 years or as a sensor case. We defined Individual SES and neighbourhood SES by each patient’s job category and household income which characterized as advantaged or disadvantaged. Then we compared the survival rates by SES group used Cox proportional hazards model for adjust risk factors. Results: The 4-year overall survival rates of diabetic patients were worst for those with low individual SES who living in advantaged neighbourhoods. After adjustment for patient characteristics, DM patients with high individual SES living in disadvantaged neighbourhoods had the same risk of mortality as those patients with high individual SES living in advantaged neighbourhoods (hazard ratio: 1.11; 95% confidence interval [CI]: 0.81–1.51). The study found that DM patients with low individual SES who live in disadvantaged areas had a greater risk of mortality than those with high SES (odds ratio: 2.57; 95% CI: 2.04–3.24). There were significant differences in survival rates between patients with high individual SES and patients with low individual SES. In contrast, the results did not statistically significant differences in survival rates between advantaged and disadvantaged neighbourhood SES groups. Conclusion: DM patients with low individual SES had the worst survival rate, regardless of whether they were living in a high or low SES neighbourhood area. The competitive cause of death, i.e., the fact that complications, rather than DM itself, are often the cause of death, may be the reason for the inverse relationship found between the effects of individual SES and neighbourhood SES on DM survival. We conclude that the socio-economic gradient in survival among DM patients may be the result of differences in access to medical treatment and attributes related to individual SES. [ABSTRACT FROM AUTHOR]

Out-of-pocket spending at out-patient departments (OPD) by households is relatively less analyzed compared to hospitalization expenses in India. This paper provides new evidence on the levels and drivers of expenditure on out-patient care, as well as choice of providers, using household survey data from 8 districts in 3 states of India. Results indicate that the economically vulnerable spend more on OPD as a proportion of per capita consumption expenditure, out-patient care remains overwhelmingly private and switches of providers—while not very prevalent—is mostly towards private providers. A key result is that choice of public providers tend to lower OPD spending significantly. It indicates that an improvement in the overall quality and accessibility of government facilities still remain an important tool that should be considered in the context of financial protection. [ABSTRACT FROM AUTHOR]

Objective: The paper examines whether out-of-pocket health care expenditure also has regional discrepancies, comparing to the equity between urban and rural areas, and across households. Method: Sampled data were derived from Urban Household Survey and Rural Household Survey data for 2011/2012 for Anhui Province, and 11049 households were included in this study. The study compared differences in out-of-pocket expenditure on health care between regions (urban vs. rural areas) and years (2011 vs. 2012) using two-sample t-test, and also investigated the degree of inequality using Lorenz and concentration curves. Result: Approximately 5% and 8% of total household consumption expenditure was spent on health care for urban and rural populations, respectively. In 2012, the wealthiest 20% of urban and rural population contributed 49.7% and 55.8% of urban and rural total health expenditure respectively, while the poorest 20% took only 4.7% and 4.4%. The concentration curve for out-of-pocket expenditure in 2012 fell below the corresponding concentration curve for 2011 for both urban and rural areas, and the difference between curves for rural areas was greater than that for urban areas. Conclusion: A substantial and increasing gap in health care expenditures existed between urban and rural areas in Anhui. The health care financing inequality merits ample attention, with need for policymaking to focus on improving the accessibility to essential health care services, particularly for rural and poor residents. This study may provide useful information on low income areas of China. [ABSTRACT FROM AUTHOR]

Background: A recent report by the Institute for Health Metrics and Evaluation (IHME) highlights that mental health receives little attention despite being a major cause of disease burden. This paper extends previous assessments of development assistance for mental health (DAMH) in two significant ways; first by contrasting DAMH against that for other disease categories, and second by benchmarking allocated development assistance against the core disease burden metric (disability-adjusted life year) as estimated by the Global Burden of Disease Studies. Methods: In order to track DAH, IHME collates information from audited financial records, project level data, and budget information from the primary global health channels. The diverse set of data were standardised and put into a single inflation adjusted currency (2015 US dollars) and each dollar disbursed was assigned up to one health focus areas from 1990 through 2015. We tied these health financing estimates to disease burden estimates (DALYs) produced by the Global Burden of Disease 2015 Study to calculated a standardised measure across health focus areas—development assistance for health (in US Dollars) per DALY. Findings: DAMH increased from USD 18 million in 1995 to USD 132 million in 2015, which equates to 0.4% of total DAH in 2015. Over 1990 to 2015, private philanthropy was the most significant source (USD 435 million, 30% of DAMH), while the United States government provided USD 270 million of total DAMH. South and Southeast Asia received the largest proportion of funding for mental health in 2013 (34%). DAMH available per DALY in 2013 ranged from USD 0.27 in East Asia and the Pacific to USD 1.18 in the Middle East and North Africa. HIV/AIDS received the largest ratio of funds to burden—approximately USD150 per DALY in 2013. Mental and substance use disorders and its broader category of non-communicable disease received less than USD1 of DAH per DALY. Interpretation: Combining estimates of disease burden and development assistance for health provides a valuable perspective on DAH resource allocation. The findings from this research point to several patterns of unproportioned distribution of DAH, none more apparent than the low levels of international investment in non-communicable diseases, and in particular, mental health. However, burden of disease estimates are only one input by which DAH should be determined. [ABSTRACT FROM AUTHOR]

While internal migration is widely occurring in countries across the world and older people are more likely to be left behind by family members who out-migrated to other locations, little attention has been paid to the cognitive health of those people who have been left behind (PLB). Understanding how these demographic patterns relate to older persons’ cognitive health may inform efforts to reduce the disease burden due to cognitive decline. Data came from the China Health and Nutrition Survey in 1997, 2000 and 2004. Participants aged 55 to 93 who participated in a cognitive function screening test (score range: 0–31) in two or more waves and provided information on family members’ migration (n = 1,267) were included in the analysis. A mixed linear model was used to investigate the association between being left behind by any members who had not resided in the household for at least 6 months at baseline and cognitive function. Approximately 10% of the participants had been left behind by family members who migrated out of their communities. A significant interaction was observed in relation to cognitive function between being left behind and the number of years from the first test. Specifically, there was a less steep decline in cognitive function of PLB compared to people not left behind. This longitudinal study showed that PLB tended to have a higher cognitive function compared to those not left behind due to their relatively stable transition in cognitive function during the study period. [ABSTRACT FROM AUTHOR]

Introduction: Tobacco smoking is often more prevalent among those with lower socio-economic status (SES) in high-income countries, which can be driven by the inequalities in initiation and cessation of smoking. Smoking is a leading contributor to socio-economic disparities in health. To date, the evidence for any socio-economic inequality in smoking cessation is lacking, especially in low- and middle-income countries (LMICs). This study examined the association between cessation behaviours and SES of smokers from eight LMICs. Methods: Data among former and current adult smokers aged 18 and older came from contemporaneous Global Adult Tobacco Surveys (2008–2011) and the International Tobacco Control Surveys (2009–2013) conducted in eight LMICs (Bangladesh, Brazil, China, India, Mexico, Malaysia, Thailand and Uruguay). Adjusted odds ratios (AORs) of successful quitting in the past year by SES indicators (household income/wealth, education, employment status, and rural-urban residence) were estimated using multivariable logistic regression controlling for socio-demographics and average tobacco product prices. A random effects meta-analysis was used to combine the estimates of AORs pooled across countries and two concurrent surveys for each country. Results: Estimated quit rates among smokers (both daily and occasional) varied widely across countries. Meta-analysis of pooled AORs across countries and data sources indicated that there was no clear evidence of an association between SES indicators and successful quitting. The only exception was employed smokers, who were less likely to quit than their non-employed counterparts, which included students, homemakers, retirees, and the unemployed (pooled AOR≈0.8, p<0.10). Conclusion: Lack of clear evidence of the impact of lower SES on adult cessation behaviour in LMICs suggests that lower-SES smokers are not less successful in their attempts to quit than their higher-SES counterparts. Specifically, lack of employment, which is indicative of younger age and lower nicotine dependence for students, or lower personal disposable income and lower affordability for the unemployed and the retirees, may be associated with quitting. Raising taxes and prices of tobacco products that lowers affordability of tobacco products might be a key strategy for inducing cessation behaviour among current smokers and reducing overall tobacco consumption. Because low-SES smokers are more sensitive to price increases, tobacco taxation policy can induce disproportionately larger decreases in tobacco consumption among them and help reduce socio-economic disparities in smoking and consequent health outcomes. [ABSTRACT FROM AUTHOR]

Background: Expanding public health insurance seeks to attain several desirable objectives, including increasing access to healthcare services, reducing the risk of catastrophic healthcare expenditures, and improving health outcomes. The extent to which these objectives are met in a real-world policy context remains an empirical question of increasing research and policy interest in recent years. Methods: We reviewed systematically empirical studies published from July 2010 to September 2016 using Medline, Embase, Econlit, CINAHL Plus via EBSCO, and Web of Science and grey literature databases. No language restrictions were applied. Our focus was on both randomised and observational studies, particularly those including explicitly attempts to tackle selection bias in estimating the treatment effect of health insurance. The main outcomes are: (1) utilisation of health services, (2) financial protection for the target population, and (3) changes in health status. Findings: 8755 abstracts and 118 full-text articles were assessed. Sixty-eight studies met the inclusion criteria including six randomised studies, reflecting a substantial increase in the quantity and quality of research output compared to the time period before 2010. Overall, health insurance schemes in low- and middle-income countries (LMICs) have been found to improve access to health care as measured by increased utilisation of health care facilities (32 out of 40 studies). There also appeared to be a favourable effect on financial protection (26 out of 46 studies), although several studies indicated otherwise. There is moderate evidence that health insurance schemes improve the health of the insured (9 out of 12 studies). Interpretation: Increased health insurance coverage generally appears to increase access to health care facilities, improve financial protection and improve health status, although findings are not totally consistent. Understanding the drivers of differences in the outcomes of insurance reforms is critical to inform future implementations of publicly funded health insurance to achieve the broader goal of universal health coverage. [ABSTRACT FROM AUTHOR]

Background: The aging of populations is rapidly accelerating worldwide. Especially, Japan has maintained the highest rate of population aging worldwide. As countermeasures, the Japanese government prioritized the promotion of local comprehensive care systems and collaboration in medical care and social (long-term) care. Development of a system to connect medical and social services in the community is necessary for the increasing older people, especially for the people in the stage of end of life. Objective: This study aimed to assess the effect of a multidisciplinary end-of-life educational intervention program on confidence in inter-professional collaboration and job satisfaction among health and social care professionals. Design: a cluster-randomized controlled trial Setting/Participants: Three professional groups (home care nurses, care managers, and heads of care workers) in an urban area participated in this trial. Intervention: We implemented a multidisciplinary end-of-life educational intervention program comprising two educational workshops and an educational booklet to support multidisciplinary care for end-of-life patients during the 7-month study period. Main outcome measure: Confidence in improved interactions among professionals and job satisfaction were assessed with the Face-to-Face Cooperative Confidence Questionnaire and the Minnesota Satisfaction Questionnaire at T1 (before intervention) and T2 (7 months after the intervention). Results: In total, 291 professionals participated in this study (experimental group n = 156; control group n = 135). Multivariate regression analyses showed significant between-group increases on all of seven subscales in participants’ face-to-face cooperative confidence over the study period; no effect was evident regarding job satisfaction. Conclusions: A multidisciplinary end-of-life educational intervention program increased confidence in multidisciplinary collaboration among health and social care professionals. Trial number: UMIN Clinical Trial Registry, Japan . [ABSTRACT FROM AUTHOR]

There has been growing recognition of menstrual hygiene management (MHM) as a significant public health issue. However, research has predominately focused on the experiences of adolescent girls in school settings. The purpose of this research is to examine detailed accounts of menstruation for women in rural Odisha, India at various life stages with a view toward improving international monitoring of MHM. Focus group discussions and in-depth interviews were conducted to understand women’s experiences of menstruation across four life stages (unmarried women, recently married women, married women, and older women). Thematic analysis was used to identify menstruation-related challenges and needs. We found women voiced needs that aligned with those captured by the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) definition for MHM: access to clean materials, privacy for changing materials, soap and water for bathing, and disposal facilities for materials. However, we also found women require materials that are not only clean but comfortable and reliable; soap and water for more than bathing; privacy for the full spectrum of menstruation-related practices, not just when changing; and disposal facilities that are private and safe, not just accessible. Additionally, we identified needs that extend beyond the existing definition: pain management, social support, and an enabling sociocultural environment. Overall, women representing all life stages discussed menstruation challenges, including bathing, pain, and washing, drying, and storing cloth materials. Cloth management challenges were most acute for unmarried and recently married women, who were concerned that practices could reveal their menstrual status and harm their reputations, thus informing their preference for disposable materials, if attainable. We propose a revised definition of adequate MHM for this population that more comprehensively captures their needs. This definition may also prove useful for other populations, future research, creating measures of assessment, and guiding interventions and program priorities. [ABSTRACT FROM AUTHOR]

Introduction: The National Rural Health Mission (NRHM) was launched in India in 2005 to address the health needs of under-served populations in rural areas, and to support universal access to care. Despite this initiative, unaccredited informal providers (IPs) often remain patients’ first point of contact, which has led to inconsistencies in treatment, and has compromised the quality of care. Aim: To explore the factors that influence patients’ decisions about healthcare providers in rural areas of central India. Methods: Nine focus group discussions (FGDs) were held in nine villages in central India. Framework analysis using an inductive approach was used to analyse the data. Results: The crosscutting theme across the discussions was not choice but need—the need for affordable and accessible health care regardless of the provider’s qualification. Results highlighted that IPs play a pivotal role in villagers’ lives. Formal healthcare services were accessed infrequently, and mainly when a condition was judged severe or possibly even fatal. Even then, affordability was carefully weighed. Villagers’ distance from formal providers contributed to high cost and low preference of formal providers. When opting for IPs, familiarity and trust were more important to villagers than qualifications. IPs have operated in rural communities in India for a long time and have adapted their services to meet the needs, preferences, social norms, and economic conditions of villagers. Conclusion: IPs have captured a niche and are often the first contact point in rural settings even when patients ultimately are diagnosed and treated by trained doctors. Merely tackling the undersupply of qualified doctors is not effective or sufficient to impact on the rural healthcare system: the strong and prevalent influence of IPs needs to be addressed also. [ABSTRACT FROM AUTHOR]

Background: The prevalence of overweightness in Bangladesh is increasing, while underweightness also continues to persist. A better understanding of the patterns and socioeconomic risk factors of both conditions, particularly among women, is critical in order to promote the development of interventions to improve maternal health in Bangladesh. This study therefore sought to assess the patterns of under- and overweightness between 2004 and 2014 and to examine the predictors of individual and community-level inequalities of under- and overnutrition in Bangladesh. Methods: Cross-sectional data of 10, 431, and 16,478 ever-married nonpregnant women aged between 15 and 49 years who did not give birth in the two months preceding the survey were extracted from the 2004 and 2014 Bangladesh Demographic and Health Surveys, respectively. Body mass index was used to measure weight status, and underweightness, at-risk for overweightness, overweightness, and obesity were the main outcome variables. Patterns of nutritional change over time was examined by considering the annual average rate of change. Multilevel multinomial logistic regression and quantile regression were used to identify the inequalities. Results: In 2014, the age-adjusted prevalence values of underweightness, at-risk for overweightness, overweightness, and obesity were 19.7%, 14.9%, 18.1% and 4.0%, respectively. A higher average annual rate of reduction of underweightness was found among wealthier, highly educated, and wealthier community–living women, while a rate of increase of overweightness was found among poorer, uneducated, and poor community–living women. Individual and community-level inequalities of malnutrition were observed among these populations. In comparison with women living in low wealth communities, women from wealthier communities were at an increased risk of being at-risk for overweightness [adjusted odds ratio (AOR): 1.53, 95% confidence interval (CI): 1.23–1.91], overweight (AOR: 1.60, 95% CI: 1.27–2.00), and obese (AOR: 2.12, 95% CI: 1.42–3.18). Conclusions: This study suggests the coexistence of a double burden of under- and overnutrition in Bangladesh and that the prevalence of overweightness surpasses that of underweightness. The burdens of under- and overnutrition are strongly associated with women’s individual socioeconomic positions and the nature of the community in which they live. [ABSTRACT FROM AUTHOR]

Background: As population health and well-being are influenced by multiple factors that cut across sectoral boundaries, an intersectoral approach that acknowledges and leverages the multiple determinants, actors and sectors at play is increasingly seen as critical for achieving meaningful and lasting improvements. In this study, we utilize social network analysis (SNA) to characterize the intersectoral collaboration between the organizations working on maternal & child health (MCH) and water & sanitation (WASH) before and immediately after the implementation of HCL Foundation (HCLF)-funded HCL Samuday Project (2015–2017) in a rural block of Uttar Pradesh state, India. While SNA has been used to examine public health issues, few have used it monitor stakeholder relationships, intervene, improve and facilitate project implementation involving intersectoral partnerships, particularly in the context of a low-and middle-income countries. Method: An organization-level SNA was conducted with 31 key informants from 24 organizations working on MCH and/or WASH in Kachhauna, Uttar Pradesh, India. Data were collected using face-to-face, semi-structured interviews between June and September 2017. Density, centrality and homophily were calculated to describe the network and a qualitative analysis was also conducted to identify the strengths and weaknesses of collaboration between organizations working on MCH and WASH. Results: Overall, our findings showed that the network of organizations working on MCH and WASH in Kachhauna grew in number since the implementation of Samuday. HCLF rapidly achieved centrality, thus positioning the organization to serve as a gatekeeper of information and enabling it to play a coordinator role within the network. Direct collaboration between other organizations working on MCH and WASH was low at both time points. Interviews with key informants indicated widespread interest in increasing interorganizational interactions and engagement throughout the network. Conclusion: This study demonstrates the feasibility and practical application of SNA for projects like Samuday that involve intersectoral collaboration. It also provides lessons about the use of SNA with organizations as the unit of analysis and in the context of rural India, including challenges, practical considerations, and limitations. [ABSTRACT FROM AUTHOR]

Background: Although most Indians live in rural settings, data on cardiovascular disease risk factors in these groups are limited. We describe the association between socioeconomic position and cardiovascular disease risk factors in a large rural population in north India. Methods: We performed representative, community-based sampling from 2013 to 2014 of Solan district in Himachal Pradesh. We used education, occupation, household income, and household assets as indicators of socioeconomic position. We used tobacco use, alcohol use, low physical activity, obesity, hypertension, and diabetes as risk factors for cardiovascular disease. We performed hierarchical multivariable logistic regression, adjusting for age, sex and clustering of the health sub-centers, to evaluate the cross-sectional association of socioeconomic position indicators and cardiovascular disease risk factors. Results: Among 38,457 participants, mean (SD) age was 42.7 (15.9) years, and 57% were women. The odds of tobacco use was lowest in participants with graduate school and above education (adjusted OR 0.11, 95% CI 0.09, 0.13), household income >15,000 INR (adjusted OR 0.35, 95% CI 0.29, 0.43), and highest quartile of assets (adjusted OR 0.28, 95% CI 0.24, 0.34) compared with other groups but not occupation (skilled worker adjusted OR 0.93, 95% CI 0.74, 1.16). Alcohol use was lower among individuals in the higher quartile of income (adjusted OR 0.75, 95% CI 0.64, 0.88) and assets (adjusted OR 0.70, 95% CI 0.59, 0.82). The odds of obesity was highest in participants with graduate school and above education (adjusted OR 2.33, 95% CI 1.85, 2.94), household income > 15,000 Indian rupees (adjusted OR 1.89, 95% CI 1.63, 2.19), and highest quartile of household assets (adjusted OR 2.87, 95% CI 2.39, 3.45). The odds of prevalent hypertension and diabetes were also generally higher among individuals with higher socioeconomic position. Conclusions: Individuals with lower socioeconomic position in Himachal Pradesh were more likely to have abnormal behavioral risk factors, and individuals with higher socioeconomic position were more likely to have abnormal clinical risk factors. [ABSTRACT FROM AUTHOR]

Persistent barriers to universal access to medicines are limited social protection in the event of illness, inadequate financing for essential medicines, frequent stock-outs in the public sector, and high prices in the private sector. We argue that greater coherence between human rights law, national medicines policies, and universal health coverage schemes can address these barriers. We present a cross-national content analysis of national medicines policies from 71 countries published between 1990–2016. The World Health Organization’s (WHO) 2001 guidelines for developing and implementing a national medicines policy and all 71 national medicines policies were assessed on 12 principles, linking a health systems approach to essential medicines with international human rights law for medicines affordability and financing for vulnerable groups. National medicines policies most frequently contain measures for medicines selection and efficient spending/cost-effectiveness. Four principles (legal right to health; government financing; efficient spending; and financial protection of vulnerable populations) are significantly stronger in national medicines policies published after 2004 than before. Six principles have remained weak or absent: pooling user contributions, international cooperation, and four principles for good governance. Overall, South Africa (1996), Indonesia and South Sudan (2006), Philippines (2011–2016), Malaysia (2012), Somalia (2013), Afghanistan (2014), and Uganda (2015) include the most relevant texts and can be used as models for other settings. We conclude that WHO’s 2001 guidelines have guided the content and language of many subsequent national medicines policies. WHO and national policy makers can use these principles and the practical examples identified in our study to further align national medicines policies with human rights law and with Target 3.8 for universal access to essential medicines in the Sustainable Development Goals. [ABSTRACT FROM AUTHOR]

Despite the efforts of community health workers to increase access to healthcare among ethnic minority groups in low- and -middle income countries, members of ethnic minorities are less likely than women from other ethnic groups to use maternal and child healthcare services. However, much less is known about the factors that limit access of ethnic minorities to healthcare services, including the services of community health workers in Nepal, who are known as Female Community Health Volunteers (FCHVs). To address this issue, we conducted a qualitative study to explore perceived barriers to accessing maternal and child healthcare services among ethnic minority groups in two different geographical locations (the hill and Terai regions- flatland bordering south India) with varying degrees of access to local healthcare centres. Between April 2014 and September 2014, semi-structured interviews were conducted with twenty FCHVs, 26 women service users and 11 paid local health workers. In addition, 15 FCHVs participated in four focus group discussions. A thematic analysis of the data identified five major themes underlying barriers to accessing available maternal and child healthcare services by ethnic minority groups such as Dalits, Madhesi, Muslim, Chepang and Tamang. These themes include: a) lack of knowledge among service users; b) lack of trust in volunteers; c) traditional beliefs and healthcare practices; d) low decision-making power of women; and e) perceived indignities experienced when using health centres. We conclude that community health programmes should focus on increasing awareness of healthcare services among ethnic minority groups, and the programmes should involve family members (husband and mothers-in-law) and traditional health practitioners. Both the FCHVs and local healthcare providers should be trained to communicate effectively in order to deliver respectful care among ethnic minorities if we want to achieve universal healthcare coverage for maternal and child health in low- and -middle income countries. [ABSTRACT FROM AUTHOR]

Background: Donor funding for HIV/AIDS services is declining in Cambodia, and domestic resources need to be mobilized to sustain and expand these services. However, the cost of delivering HIV/AIDS services is not well studied in Cambodia. This study aims to assess the costs of delivering HIV/AIDS services, identify the major components of costs, and sources of funding. Methods: Four of the six highest HIV burden provinces were selected at random for this study. Within each province, four health centers and two hospitals were selected for detailed data collection. A mix of top-down and bottom-up methods were used to assess the costs for HIV testing and antiretroviral therapy (ART) from the provider perspective. We assessed the differences in the quantity and prices of inputs between health facilities of the same type to identify cost-drivers. Results: The average cost per visit for HIV testing was $8.92 at health centers and $14.03 at referral hospitals. Differences in the number of visits per staff were the primary determinant of differences in the cost per visit. First-line ART costed about $250 per patient per year, and the number of patients per staff was an important cost driver. Second-line ART costed from $500 to $716 per patient per year, on average, across the types of facilities, with the quantity and mix of second-line antiretroviral drugs being an important cost driver. Inpatient care at referral and provincial hospitals in total represented less than 2 percent of costs of outpatient ART. Discussion: Costs are similar to neighboring countries, but over 50% of the costs of ART are financed by donors. Cambodia now is scaling up social health insurance coverage; the data from this study could serve as one input when setting reimbursement rates for HIV/AIDS services to help ensure that providers are adequately reimbursed for their services. [ABSTRACT FROM AUTHOR]

Background: Disclosure of HIV status is a critical gateway to HIV prevention. Despite many studies on this topic, there is a gap in knowledge regarding HIV status disclosure and risky sexual behavior in HIV-infected female migrant workers. The current study addressed this research gap, and focused on HIV-infected Shan female migrant workers in Northern Thailand. Methods: This study conducted in-depth interviews with 18 HIV-infected Shan female migrants (aged between 23–54 years old) and 29 healthcare workers in district hospitals in Chiang Mai. Content analysis was employed to identify particular themes related to HIV status disclosure, sexual risk behavior, and ART adherence. Results: We found that non-disclosure to husbands/partners was mostly related to fear of marital conflict and of losing social and financial support. Non-disclosure prevented Shan female migrant workers from negotiating condom use with their partners. Reasons for not disclosing to friends, family and other community members were mostly related to feared rejection and discrimination due to HIV-related stigma. Accounts of condomless sex in the context of HIV status disclosure suggest that gender norms and male dominance over women influenced decision-making for safe sex. Lastly, some female migrant workers perceived low risk of HIV transmission with good adherence to the ART. Conclusions: This study highlighted the complex challenges of HIV status disclosure among HIV-positive Shan female migrant workers and the link between disclosure/non-disclosure and condom use. There is a pressing need to create realistic disclosure mechanisms that take into account the socio-cultural barriers to disclosure including marital conflicts, stigma, and gender norms. Messages to encourage condom use should be delivered carefully so that knowledge of the HIV transmission reduction qualities of good ART adherence does not serve as a barrier to condom use. [ABSTRACT FROM AUTHOR]

Background: The iDSI reference case, originally published in 2014, aims to improve the quality and comparability of cost-effectiveness analyses (CEA). This study assesses whether the development of the guideline is associated with an improvement in methodological and reporting practices for CEAs using disability-adjusted life-years (DALYs). Methods: We analyzed the Tufts Medical Center Global Health CEA Registry to identify cost-per-DALY averted studies published from 2011 to 2017. Among each of 11 principles in the iDSI reference case, we translated all methodological specifications and reporting standards into a series of binary questions (satisfied or not satisfied) and awarded articles one point for each item satisfied. We then calculated methodological and reporting adherence scores separately as a percentage of total possible points, measured as normalized adherence score (0% = no adherence; 100% = full adherence). Using the year 2014 as the dissemination period, we conducted a pre-post analysis. We also conducted sensitivity analyses using: 1) optional criteria in scoring, 2) alternate dissemination period (2014–2015), and 3) alternative comparator classification. Results: Articles averaged 60% adherence to methodological specifications and 74% adherence to reporting standards. While methodological adherence scores did not significantly improve (59% pre-2014 vs. 60% post-2014, p = 0.53), reporting adherence scores increased slightly over time (72% pre-2014 vs. 75% post-2014, p<0.01). Overall, reporting adherence scores exceeded methodological adherence scores (74% vs. 60%, p<0.001). Articles seldom addressed budget impact (9% reporting, 10% methodological) or equity (7% reporting, 7% methodological). Conclusions: The iDSI reference case has substantial potential to serve as a useful resource for researchers and policy-makers in global health settings, but greater effort to promote adherence and awareness is needed to achieve its potential. [ABSTRACT FROM AUTHOR]

This study examined the burden of food insecurity in India’s un-notified slums, using an SDG framework to identify correlates of food insecurity. A convenience sampling approach was employed in selecting 38 slums from 675 un-notified slums across four geographic zones. Ten percent of the households in each slum site were selected from each zone, and one household member was interviewed, based on their availability and fulfilment of the eligibility criteria. Eligible individuals included those aged 18 years and above, who were resident in the selected slums and provided consent. Individuals with mental or physical challenges were excluded. A total sample of 907 study participants were included. Results showed that 43% (n = 393) of the participants were food insecure. More than half were females (73%, n = 285), who had not completed any schooling (51%, n = 202). One-third (n = 128) resided in the Northern Region of Delhi. SDG-related predictors of food insecurity included: household educational level (SDG 4 Quality education) (p = 0.03), coverage of health service needs (SDG 3 Good health and well-being) (p = 0.0002), electricity needs (SDG 7 affordable and clean energy) (p<0.0001), and employment needs (SDG 8 Decent and economic growth) (p = 0.003). Having healthcare needs that were partially or fully met was equally associated with higher food insecurity: this could be attributed to high healthcare costs and the lack of federal subsidies in un-notified slums, collectively contributing to high out-of-pocket health costs. Failure to fully meet employment needs was also significantly associated with higher food insecurity. However, met needs for electricity, finance, women’s safety and satisfactory family relationships, were associated with lower food insecurity. Household predictors of food insecurity included: number of household members, and the presence of physically disabled household members. Necessary interventions should include connecting food insecure households to existing social services such as India’s Public Distribution System, and multi-sector partnerships to address the existing challenges. [ABSTRACT FROM AUTHOR]

Background: In this study, we aim to establish the impact of the introduction of the Family Medicine Model patient satisfaction in the Turkish health system. Methods: We use data on data 69,028 primary health care (PHC) patients over the period 2010–2012. We estimate the impact of the Family Medicine Model in panel regressions with province fixed effects, exploiting the sequential introduction of this health systems transformation across Turkey's 81 provinces. We use principal component analysis to reduce the dimensionality of the data from the European Patients Evaluate General/Family Practice (EUROPEP) patient satisfaction survey, to focus on the fundamental dimensions of patient satisfaction and to decrease the need for multiple hypothesis testing. We identified two key principal components. The first captured primarily information on satisfaction with provider behavior and the second on satisfaction with the organization of care. We then use these two principal components as outcome variables in our panel analysis to estimate the causal impact of the introduction of the Family Medicine Model. Results: The Family Medicine Model significantly improved patient satisfaction across a range of dimensions. The coefficient results showed a positive and statistically significant impact (p-values<0.05) of the Family Medicine Model on the outcome variables representing the satisfaction dimensions clinical behaviour and the organization of care even after controlling for calendar time fixed effects. Conclusions: The introduction of the Family Medicine Model in Turkey, which was primarily aimed at achieving universal health coverage goals, substantially improved patient satisfaction. This study provides some of the first national-level evidence that the introduction of a Family Medicine Model can substantially improve patient satisfaction. [ABSTRACT FROM AUTHOR]

Introduction: Despite the global rise in waterpipe tobacco smoking (WTS), the effectiveness of waterpipe tobacco health warnings remain understudied, especially in countries with high WTS rates. Egypt has been employing waterpipe tobacco labelling for a decade, however, their effectiveness is unknown. Our overall aim was to measure the effectiveness of pictorial health warnings (PHWs) on waterpipe tobacco packs (WTPs) through participant memory recall and to investigate whether they induced behavioural responses in waterpipe smokers and deterred uptake of WTS in non-smokers, examining the differentials of effectiveness among socio-demographic subgroups. Subjects and methods: We conducted two surveys including 1490 adult current waterpipe smokers, 73 former waterpipe smokers, and 451 non-smokers in Cairo and a rural village in Egypt between 2015–2017. Participants who noticed PHWs on WTPs were asked questions about salience, communication of health risks, public support, cognitive processing, and self-reported behavioural responses (current waterpipe smokers: reduce consumption, forgo a smoke, quit attempts; former waterpipe smokers: quit; non-smokers: deter WTS initiation). Univariate and multivariable statistical analyses were performed. Results: Participants’ mean age was 35 years, mostly males (90.4%), waterpipe smokers (74.0%) and rural residents (59.3%). Approximately two-thirds of participants noticed PHWs on WTPs. Salience was significantly less among females, urban residents and participants with high literacy. More than three-quarters of participants reported that WTS health risks were communicated through the warnings. At least half of participants cognitively processed the warnings: 56.3% thought of the warnings when WTPs were out of sight; non-smokers understood the warnings (83.2%) and discussed them with others (90.3%) significantly more than current (76.0% and 72.5%, respectively) and former waterpipe smokers (81.0% and 61.9%, respectively). Participants reported that PHWs on WTPs motivated 58.5% of waterpipe smokers to think about quitting; 64.5% to reduce their consumption; 42.2% to forgo a smoke; 24.5% to attempt to quit; 57.1% of former waterpipe smokers to successfully quit; and 59.3% of non-smokers to remain smoke-free. Conclusions: Findings suggest that inserting PHWs on WTPs is an effective waterpipe tobacco labelling policy. Countries with similarly high rates of WTS should consider adopting WTP PHWs within a comprehensive regulatory framework. [ABSTRACT FROM AUTHOR]

The economic burden of noncommunicable diseases (NCDs), including treatment costs and income and productivity losses, is a growing concern in developing countries, where NCD medical expenditure may offset consumption of other essential commodities. This study examines the role of NCDs in household resource allocation in Bangladesh. We use the Bangladesh Household Income and Expenditure Survey (HIES) 2010 to obtain expenditure data on 11 household expenditure categories and 12 food expenditure sub-categories for 12,240 households. Household NCD status was determined through self-report of at least one of the six major NCDs within the household–heart disease, hypertension, diabetes, kidney diseases, asthma, and cancer. We estimated unadjusted and regression-adjusted differences in household expenditure shares between NCD and non-NCD households. We further investigated how consumption of different food sub-categories is related to NCD status, distinguishing between household economic levels. The medical expenditure share was estimated to be 59% higher for NCD households than non-NCD households, and NCD households had lower expenditure shares on food, clothing, hygiene, and energy. Regression results indicated that presence of NCDs was associated with lower relative expenditure on clothing and housing in all economic subgroups, and with lower expenditure on food among marginally poor households. Having an NCD was significantly associated with higher household spending on tobacco and higher-calorie foods such as sugar, beverages, meat, dairy, and fruit, and with lower spending on fish, vegetables, and legumes. The findings indicate a link between NCDs and the possibility of adverse economic effects on the household by highlighting the potential displacement effect on household consumption that might occur through higher medical expenditure and lower spending on essentials. The findings might also point to a need for raising awareness about the link between NCDs and diet in Bangladesh. [ABSTRACT FROM AUTHOR]

Hypertension is a rapidly growing problem in developing countries. At the same time, due to its asymptomatic nature, the afflicted population is largely unaware of being hypertensive. Due to a lack of resources, routine medical exams are very rare in developing countries and many sick individuals remain undiagnosed. Using a large sample of hypertensive individuals from Indonesia, we show the importance of being diagnosed. Diagnosed individuals exhibit lower systolic and diastolic blood pressure, and overall lower probability of remaining hypertensive than undiagnosed individuals. We also show the main channels through which this is achieved: taking medication, routinely monitoring one’s blood pressure, and engaging in moderate physical activities. We also point to channels through which additional benefits could be realized, but that are currently ineffective: dietary changes and maintaining a healthy body weight. Combined, these results point to the importance of directing public policy towards addressing the under-diagnosis problem and educating the public of the benefits of adopting a healthy life-style. [ABSTRACT FROM AUTHOR]

This study aimed to explore societal determinants of HIV vulnerability among the clients of female commercial sex workers (FCSWs) in Belu and Malaka districts, Indonesia. A qualitative inquiry using in-depth interviews was employed to collect data from participants (n = 42) recruited using a purposive and snowball sampling technique. Data analysis was guided by a qualitative data analysis framework. The study results revealed several societal determinants that supported vulnerability to HIV infection among the participants. They included low education level and sexual health literacy including the lack of knowledge and information about HIV transmission and prevention. Additional determinants identified were limited source of HIV/AIDS-related information, availability of and ease of accessibility of brothels and FCSWs, peer influence, and high mobility of the study participants. Findings of this study indicate the needs and call for interventions that aim to protect both FCSWs and their clients, through provision of HIV/AIDS and sexual health education and information and improvement in the availability and accessibility of condoms. [ABSTRACT FROM AUTHOR]

Objectives: The South Korean government required the submission of economic evidence when it implemented the Positive-List System in December 2006. This study investigates the key factors that influenced actual public insurance reimbursement decisions, including the role of economic evidence, after 10 years of decision practice under compulsory health technology assessment (HTA) for new drugs. Method: Logistic regression analysis was used to estimate the impact of the variables involved, including cost-effectiveness ratio as a key variable, on reimbursement decisions. The latter were defined as “yes” or “no” at a submitted price and indication. Only cases (n = 91) that present a cost-effectiveness ratio, and that have been reviewed based on this ratio from January 2007 to December 2016, were included in the analysis. Results: Cases with higher cost-effectiveness ratios were less likely to be accepted. In addition, drugs that were used to treat severe diseases and drugs with no substitute were more likely to be recommended. The probability of acceptance declined along with the level of uncertainty in the submitted evidence. The acceptance rate for severe-disease drugs has increased since 2013, when the government introduced several policies that lowered the existing barriers to positive reimbursement. However, such an increase was not statistically significant. Conclusions: Cost-effectiveness is one of the most influential factors in drug-reimbursement decisions. However, inclusion of other explanatory variables, in addition to the cost-effectiveness ratio, predicted the results of decisions more accurately. [ABSTRACT FROM AUTHOR]