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With the deepening of health insurance reform in China, the integration of social health insurance schemes was put on the agenda. This paper aims to illustrate the achievements and the gaps in integration by demonstrating the trends in benefits available from the three social health insurance schemes, as well as the influencing factors. Data were drawn from the three waves of the China Health and Nutrition Survey (2009, 2011, 2015) undertaken since health reforms commenced. χ2, Kruskal–Wallis test, and the Two-Part model were employed in the analysis. The overall reimbursement rate of the Urban Employee Basic Medical Insurance (UEBMI) is higher than that of Urban Resident Basic Medical Insurance (URBMI) or the New Rural Cooperative Medical Scheme (NRCMS) (p < 0.001), but the gap has narrowed since health reform began in 2009. Both the outpa-tient and inpatient reimbursement amounts have increased through the URBMI and NRCMS. Illness severity, higher institutional level, and inpatient service were associated with significant in-creases in the amount of reimbursement received across the three survey waves. The health reform improved benefits covered by the URBMI and NRCMS, but gaps with the UEBMI still exist. The government should consider more the release of health benefits and how to lead toward healthcare equity.

BACKGROUND: Four million people living in the Indian Sundarbans region in the state of West Bengal face a particularly high risk of drowning due to rurality, presence of open water, lack of accessible health systems and poor infrastructure. Although the World Health Organization has identified several interventions that may prevent drowning in rural low-and middle-income country contexts, none are currently implemented in this region. This study aims to conduct contextual policy analysis for the development of a drowning program. Implementation of a drowning program should consider leveraging existing structures and resources, as interventions that build on policy targets or government programs are more likely to be sustainable and scalable. METHODS: A detailed content review of national and state policy (West Bengal) was conducted to identify policy principles and/or specific government programs that may be leveraged for drowning interventions. The enablers and barriers of these programs as well as their implementation reach were assessed through a systematic literature review. Identified policies and programs were also assessed to understand how they catered for underserved groups and their implications for equity. RESULTS: Three programs were identified that may be leveraged for the implementation of drowning interventions such as supervised childcare, provision of home-based barriers, swim and rescue skills training and community first responder training: the Integrated Child Development Scheme (ICDS), Self-Help Group (SHG) and Accredited Social Health Activist (ASHA) programs. All three had high coverage in West Bengal and considered underserved groups such as women and rural populations. Possible barriers to using these programs were poor government monitoring, inadequate resource provision and overburdening of community-based workers. CONCLUSIONS: This is the first systematic analysis of both policy content and execution of government programs to provide comp

© 2020 The Author(s). Background: Mozambique has high maternal mortality which is compounded by limited human resources for health, weak access to health services, and poor development indicators. In 2011, the Mozambique Ministry of Health (MoH) approved the distribution of misoprostol for the prevention of post-partum haemorrhage (PPH) at home births where oxytocin is not available. Misoprostol can be administered by a traditional birth attendant or self-administered. The objective of this paper is to examine, through applying a human rights lens, the broader contextual, policy and institutional issues that have influenced and impacted the early implementation of misoprostol for the prevention of PPH. We explore the utility of rights-based framework to inform this particular program, with implications for sexual and reproductive health programs more broadly. Methods: A human rights, health and development framework was used to analyse the early expansion phase of the scale-up of Mozambique's misoprostol program in two provinces. A policy document review was undertaken to contextualize the human rights, health and development setting in Mozambique. Qualitative primary data from a program evaluation of misoprostol for the prevention of PPH was then analysed using a human rights lens; these results are presented alongside three examples where rights are constrained. Results: Structural and institutional challenges exacerbated gaps in the misoprostol program, and sexual and reproductive health more generally. While enshrined in the constitution and within health policy documents, human rights were not fully met and many individuals in the study were unaware of their rights. Lack of information about the purpose of misoprostol and how to access the medication contributed to power imbalances between the state, health care workers and beneficiaries. The accessibility of misoprostol was further limited due to dynamics of power and control. Conclusions: Applying a rights-ba

Over the last four decades, Bangladesh has made considerable improvements in population health, this is in part due to the use of evidence to inform policymaking. This systematic review aims to better understand critical factors that have facilitated the diffusion of scientific evidence into multiple phases of health policymaking in Bangladesh. To do this an existing policy framework designed by Shiffman and Smith in 2007, was used to extract and synthesize data from selected policy analyses. This framework was used to ensure the content, context and actors involved with evidence-informed policymaking were considered in each case where research had helped shape a health policy. The 'PRISMA Checklist' was employed to design pre-specified eligibility criteria for the selection of information sources, search strategy, inclusion and exclusion criteria, and process of data extraction and synthesis. Through our systematic search conducted from February to May 2017, we initially identified 1859 articles; after removal of duplicates, followed by the screening of titles, abstracts and full-Texts, 24 articles were included in the analysis. Health policy issues included the following topics: maternal and child health, tobacco control, reproductive health, infectious disease control and the impact and sustainability of knowledge translation platforms. Findings suggested that research evidence that could be used to meet key targets associated with the Millennium Development Goals (MDGs) were more likely to be considered as a political (and therefore policy) priority. Furthermore, avenues of engagement between research organizations and the government as well as collective action from civil-society organizations were important for the diffusion of evidence into policies. Through this article, it is apparent that the interface between evidence and policy formulation occurs when evidence is, disseminated by a cohesive policy-network with strong leadership and framed to deliver solu

Intimate partner violence (IPV) routine screening is widely implemented, yet the evidence for pathways to impact remain unclear. Of 32 abused women, interviewed 16 weeks after antenatal IPV screening, 24 reported positive impact, six reported nil positive impact and two reported negative impact. Using Qualitative Comparative Analysis, key conditions for positive impact were: care in asking, and support and validation from the midwife. Lack of these and of continuity of care were relevant to nil positive impact. Benefits included: naming the abuse, connection, unburdening, taking steps to safety and enabling informed care. Disclosure was not required for positive impact.

Living and geographical conditions in Bangladesh expose children to a high risk of drowning. Two programs operating in the Barishal Division of Bangladesh aim to reduce drowning risk through the provision of crèches (Anchal) and swim and rescue classes (SwimSafe). Anchal provides a safe environment with early childhood education to children aged 1–5 years old, while SwimSafe teaches children aged 6–10 years old basic swimming and rescue skills. Despite evidence for their effectiveness, it is unclear under which conditions these programs best operate. This protocol describes a project that seeks to conduct a process evaluation and gender analysis to identify implementation inefficiencies and contextual considerations for improved sustainability of the programs. A mixed-method approach using both qualitative and quantitative data will be used. Quantitative program data will be analysed to measure program utilisation, delivery and reach, while qualitative data will be collected via key informant in-depth interviews (IDIs), focus group discussions (FGDs) and observations. The process evaluation of the Anchal and SwimSafe programs provides an opportunity for implementers to identify practical strategies to improve program delivery and improve contextual adaptability of these programs. Furthermore, the findings may provide guidance to other implementers aiming to deliver community-based programs in rural lower-middle income contexts.

BACKGROUND AND OBJECTIVES: Young people are an important group to target with health promotion and preventive healthcare. This paper focuses on the engagement of migrant and refugee young people with sexual and reproductive healthcare in general practice. METHOD: Semi-structured first interviews (n = 27; 16 female, 11 male) and follow-up interviews (n = nine; six female, three male) were undertaken with migrant and refugee young people aged 16-24 years living in Sydney. RESULTS: The majority of participants had seen a general practitioner (GP) for general health issues. However, most were reluctant to discuss sexual health with a practitioner whom they described as their 'family doctor', primarily because of concerns about judgement and confidentiality. Most described negative experiences with GPs for sexual health matters, including not being listened to or being rushed through the appointment. DISCUSSION: There appears to be a lack of effective engagement with migrant and refugee young people by GPs in relation to sexual health. Building the skills and confidence of GPs to work with this group and promote sexual health and wellbeing should be considered, and efforts should be made to communicate confidentiality and trustworthiness.

BackgroundCataract is the leading cause of blindness in low- and middle-income countries (LMICs), and the prevalence is inequitably distributed between and within countries. Interventions have been undertaken to improve cataract surgical services, however, the effectiveness of these interventions on promoting equity is not known.ObjectivesTo assess the effects on equity of interventions to improve access to cataract services for populations with cataract blindness (and visual impairment) in LMICs.Search methodsWe searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 3), MEDLINE Ovid (1946 to 12 April 2017), Embase Ovid (1980 to 12 April 2017), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 12 April 2017), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 12 April 2017, ClinicalTrials.gov (www.clinicaltrials.gov); searched 12 April 2017 and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 12 April 2017. We did not use any date or language restrictions in the electronic searches for trials.Selection criteriaWe included studies that reported on strategies to improve access to cataract services in LMICs using the following study designs: randomised and quasi-randomised controlled trials (RCTs), controlled before-and-after studies, and interrupted time series studies. Included studies were conducted in LMICs, and were targeted at disadvantaged populations, or disaggregated outcome data by 'PROGRESS-Plus' factors (Place of residence; Race/ethnicity/ culture/ language; Occupation; Gender/sex; Religion; Education; Socio-economic status; Social capital/networks. The 'Plus' component includes disability, sexual orientation and age).Data collection and analysisTwo authors (JR and JP) independently selected studies, extracted data and assessed them

Background: In South Sudan, birth deliveries attended by unskilled birth attendants put the mothers and their newborns at increased risk of perinatal morbidity and mortality. The aim of this study was to identify factors associated with delivery by unskilled birth attendants or by unassisted delivery.Design: We examined data for 2,767 (weighted total) women aged 15–49 years who delivered at home 2 years prior to the South Sudan Household Health Survey 2010. Multinomial logistic regression analyses were used to identify factors associated with delivery by unskilled birth attendants or by unassisted delivery.Results: The prevalence of delivery by unskilled birth attendants was 19% [95% confidence interval (CI) 17.0, 20.5], by skilled birth attendants (SBAs) was 45% (95% CI 42.4, 47.0), and by unassisted delivery was 36% (95% CI 34.2, 38.6). After adjusting for potential confounders, the following factors were associated with the increased odds for unassisted delivery or delivery by an unskilled birth attendant: mothers with no schooling, who did not attend antenatal care (ANC) during pregnancy, who had lower quality of ANC services, from poor households, or who had no prior knowledge about obstetric danger signs.Conclusions: We found that non-utilization of maternal health care services, such as ANC, was significantly associated with unattended birth delivery or delivery by unskilled health providers. The increased uptake of SBAs at delivery will require easier access to ANC services, health promotion on the importance and benefits of SBAs for delivery, targeting both mothers and their families, and the training and deployment of more SBAs across the country.Keywords: skilled birth attendants; maternal health services; home birth; socio-economic factors; South Sudan

9 Background: Burden of disease (BoD) studies have been conducted in numerous international settings since the10 early 1990’s. Two national BoD studies have been undertaken in Australia, in 1998 and 2003, although neither study11 estimated the BoD specifically for Indigenous Australians. In 2005 the Australian Government Department of Health12 and Ageing Office for Aboriginal and Torres Strait Islander Health formally commissioned the University of13 Queensland to undertake, in parallel with the second national BoD study, the “Burden of Disease and Injury in14 Aboriginal and Torres Strait Islander Peoples” study, drawing on available data up to 2003. This paper is part of a15 broader NHMRC-funded project that examines the uptake of evidence to policy, using the 2007 Indigenous BoD16 (IBoD) study as a case study.17 This study aims to explore the policy context and narrative in the lead up to commissioning the IBoD study,18 focusing on relevant contextual factors and insights regarding the perspectives and anticipated value of the study19 by key stakeholders.20 Methods: A systematic review of the literature was undertaken in late 2013 and early 2014, and the findings21 triangulated with 38 key informant interviews with Indigenous and non-Indigenous academics, researchers, statisticians,22 policy advisors, and policymakers, conducted between 2011 and 2013.23 Findings: Contextual features which led to commissioning the IBoD study included widespread recognition of24 longstanding Indigenous disadvantage, lower life expectancy than non-Indigenous Australians, and the lack of25 an adequate evidence base upon which to determine priorities for interventions. Several anticipated benefits26 and expectations of key stakeholders were identified. Most informants held at least one of the following expectations27 of the study: that it would inform the evidence base, contribute to priority setting, and/or inform policy. There28 were differing or entirely contrasting views to

Sexual violence is recognised as a widespread consequence of armed conflict and other humanitarian crises. The limited evidence in literature on interventions in this field suggests a need for alternatives to traditional review methods, particularly given the challenges of undertaking research in conflict and crisis settings. This study employed a realist review of the literature on interventions with the aim of identifying the mechanisms at work across the range of types of intervention. The realist approach is an exploratory and theory-driven review method. It is well suited to complex interventions as it takes into account contextual factors to identify mechanisms that contribute to outcomes. The limited data available indicate that there are few deterrents to sexual violence in crises. Four main mechanisms appear to contribute to effective interventions: increasing the risk to offenders of being detected; building community engagement; ensuring community members are aware of available help for and responses to sexual violence; and safe and anonymous systems for reporting and seeking help. These mechanisms appeared to contribute to outcomes in multiple-component interventions, as well as those relating to gathering firewood, codes of conduct for personnel and legal interventions. Drawing on pre-existing capacity or culture in communities is an additional mechanism which should be explored. Though increasing the risk to offenders of being detected was assumed to be a central mechanism in deterring sexual violence, the evidence suggests that this mechanism operated only in interventions focused on gathering firewood and providing alternative fuels. The other three mechanisms appeared important to the likelihood of an intervention being successful, particularly when operating simultaneously. In a field where robust outcome research remains likely to be limited, realist methods provide opportunities to understand existing evidence. Our analysis identifies the importa

Objective: To identify the socioeconomic distribution of perceived oral health among adults in Tehran, Iran. Basic research design: A cross-sectional population study. Participants: A stratified random sample of 1,100 adults aged 18–84 years living in Tehran. Methods: Self-report data were obtained from the 2010 dental telephone interview survey. Oral health was evaluated using self-assessed non-replacedextracted teeth (NRET), and a three-item perceived dental health instrument. Socioeconomic status was measured by combining the variablesof education and assets using principal component analysis. Inequalities in oral health were examined using prevalence ratios andconcentration index. Results: The poorest quintile was 1.60 (95% confidence interval, CI, 1.30;1.98) times as likely to have any NRET compared with the richest quintile, indicating a disparity. Inequality was most pronounced in the 35–59 age group with prevalence ratio 2.01 (95%CI 1.26;3.05). The concentration index of NRET in adults in Tehran was -0.22 (95%CI -0.28;-0.16). No significant differenceswere found in perceived dental health between socioeconomic classes. Conclusions: Adults from lower socioeconomic classes experienced more disabilities due to missing their teeth, specifically in the middle-age group. Inequalities in perceived dental health were not apparent in the studied population.

The Republic of South Sudan continues to face considerable challenges in meeting maternal, newborn and child health (MNCH) care needs and improving health outcomes. Ongoing instability and population displacement undermine scope for development, and damaged infrastructure, low coverage of health services, and limited government capacity and human resource base have resulted in a fragmented health system. Despite considerable attention, effort and support, the issues and challenges facing South Sudan remain deep and sustained, and urban-rural disparities are considerable. There is a need to maintain investments in MNCH care and to support developing systems, institutions and programs. This paper review of the published literature provides an overview and summary of the current MNCH situation in South Sudan. It explores the barriers and challenges of promoting MNCH gains, and identifies priorities that will contribute to addressing the Millennium Development Goals and the emerging health priorities for the post-2015 development agenda.

Purpose: To examine gender, ethnic and socioeconomic differences in access to eye care services in marine fishing communities in Karachi, Pakistan. Methods: The Karachi Marine Fishing Communities Eye and General Health Survey was a door-to-door, cross-sectional survey conducted between March 2009 and April 2010 in fishing communities in Keamari, Karachi, located on the coast of the Arabian Sea. Adults aged e"50 years living in 3 Islands and 4 coastal areas were enrolled. They underwent a detailed interview regarding socio-demographics, eye problems and eye care use; presenting and best-corrected visual acuity testing with reduced logMAR chart and; detailed eye examination. Results: 700 people were planned to be included in the study; 638 (91.1%) were interviewed and examined. Most participants were extremely poor and had no formal education. Only 45.3 % (95% CI, 41.4-49.2) of participants reported having had an eye examination in the past; 12.1% (9.5-14.6) and 30.9 % (27.3-34.5) had seen an eye doctor within the last year or prior 5 years, respectively. In the multivariate analysis, ethnicity was the strongest independent predictor of eye care utilisation, followed by self-reported eye problems and diabetes. Ethnic Bengalis were 4.2 times less likely (adjusted OR 0.24, 95 % CI 0.15-0.38; P<0.001) to have had an eye examination in the past than Kutchis. Conclusions: Despite a high prevalence of visual impairment and blindness, eye care examination in fishing communities, especially among ethnic Bengalis, is disappointingly low. Such communities deserve particular attention in Vision 2020 and other national and international strategies and plans

Purpose: To examine self-reported barriers to eye care among marginalised, hard-to-reach fishing communities in Karachi, Pakistan. Methods: The Karachi Marine Fishing Communities Eye and General Health Survey was a cross-sectional survey conducted between March 2009 and April 2010 in fishing communities in Keamari, Karachi, located on the coast of the Arabian Sea. Adults aged ≥ 50 years living in 7 Islands and coastal areas underwent a detailed interview regarding socio-demographics, eye problems, eye care use and barriers to access; visual acuity testing with reduced logMAR chart and; detailed eye examination. Results: 700 people were planned to be included in the study; 638 (91.1%) were interviewed and examined. 93.9% participants lived in extreme poverty and 84.3% had no school-based education. 349 (54.7 %; 95% CI, 50.8-58.6) of them had never had an eye examination. The common barriers to access identified included: a perceived lack of or low need (176/349 or 50.4%), financial hardships (36.4 %), fears (8.6 %) and social support constraints (6.3 %). 21.9 % of those reporting a “lack of need” had significant visual loss. Financial hardships, fears and social support constraints were more prevalent among women than men. Bengalis and individuals with poor/fragile self-reported financial status of the household were more likely to cite financial hardships than their respective reference groups. Conclusions: Access to eye care in this marginalised population is substantially hindered by perceived lack of need, financial hardships and different fears despite a large unmet need. These barriers should be addressed while paying particular attention to gender, ethnic and socioeconomic differences.

IntroductionWomen in conflict-affected countries are at risk of mental disorders such as posttraumatic stress disorder and depression. No studies have investigated the association between experiences of abuse and injustice and explosive anger amongst women in these settings, and the impact of anger on women's health, family relationships and ability to participate in development.MethodsA mixed methods study including an epidemiological survey (n = 1513, 92.6% response) and qualitative interviews (n = 77) was conducted in Timor-Leste. The indices measured included Intermittent Explosive Disorder, posttraumatic stress disorder; severe distress; days out of role (the number of days that the person was unable to undertake normal activities); gender-specific trauma; conflict/violence; poverty; and preoccupations with injustice.ResultsWomen with Intermittent Explosive Disorder (n = 184, 12.2%) were more disabled than those without the disorder (for >5 days out of role, 40.8% versus 31.5%, X2(2) = 12.93 p = 0.0016). Multivariable associations with Intermittent Explosive Disorder, controlling for the presence of PTSD, psychological distress and other predictors in the model, included the sense of being sick (OR 1.73; 95% CI 1.08¿2.77); victimization as a result of helping the resistance movement (OR 2.33, 95% CI 1.48¿3.68); war-related trauma specific to being a woman (OR 1.95, 95%, CI 1.09¿3.50); ongoing family violence and community conflict (OR 1.88, 95% CI 1.27¿2.77); extreme poverty (OR 1.23, 95%, CI 1.08¿1.39); and distressing preoccupations with injustice (relating to 2/3 historical periods, OR 2.10, 95% CI 1.35¿3.28). In the qualitative study, women elaborated on the determinants of anger and its impact on their health, family and community functioning, child-rearing, and capacity to engage in development. Women reflected on the strategies that might help them overcome their anger.ConclusionsIntermittent Explosive Disorder is prevalent and disabling amongst women in

In 2007 Timor-Leste, a malaria endemic country, changed its Malaria Treatment Protocol for uncomplicated falciparum malaria from sulphadoxine-pyrimethamine to artemetherlumefantrine. The change in treatment policy was based on the rise in morbidity due to malaria and perception of increasing drug resistance. Despite a lack of nationally available evidence on drug resistance, the Ministry of Health decided to change the protocol. The policy process leading to this change was examined through a qualitative study on how the country developed its revised treatment protocol for malaria. This process involved many actors and was led by the Timor-Leste Ministry of Health and the WHO country office. This paper examines the challenges and opportunities identified during this period of treatment protocol change.

Objective In Australia, the poorer health status of the Indigenous population relative to the non-Indigenous population is well documented. Closing the gap in life expectancy between Indigenous and other Australians within a generation is central to national Indigenous reform policy (Closing the Gap). Over time, various methods of estimating Indigenous life expectancy and with that, the life expectancy gap, have been adopted with differing, albeit non-comparable results. We present data on the extent of the gap and elucidate the pattern of use and interpretations of the different estimates of the gap, between 2007 and 2012. MethodsAn extensive search was conducted for all peer-reviewed health publications citing estimates of and/or discussing the life expectancy of Indigenous Australians, for the period 2007-2012. ResultsFive predominant patterns of citation of the gap estimates were identified: 20 years, 17 years, 15-20 years, 13 years, and 11.5 years for males and 9.7 years for females. Other estimates of the gap also appear for some years. Some authors misinterpret the most recent estimates as reflecting improvement from the 17 year figure, rather than the result of different methods of estimation. Support for the direct methods used to calculate Indigenous life expectancy is indicated.Conclusions and ImplicationsA specific estimate of the life expectancy gap has not been established among stakeholders in Indigenous health. However, agreement on the precise magnitude of the gap is arguably needed in order to evaluate strategies aimed at improving health outcomes for Indigenous Australians. Moreover, measuring progress towards ¿closing the gap¿ depends on the availability of comparable estimates, using the same techniques of measurement to assess changes over time.

The health care system in Papua New Guinea is fragile, and surveillance systems infrequently meet international standards. To strengthen outbreak identification, health authorities piloted a mobile phone-based syndromic surveillance system and used established frameworks to evaluate whether the system was meeting objectives. Stakeholder experience was investigated by using standardized questionnaires and focus groups. Nine sites reported data that included 7 outbreaks and 92 cases of acute watery diarrhea. The new system was more timely (2.4 vs. 84 days), complete (70% vs. 40%), and sensitive (95% vs. 26%) than existing systems. The system was simple, stable, useful, and acceptable; however, feedback and subnational involvement were weak. A simple syndromic surveillance system implemented in a fragile state enabled more timely, complete, and sensitive data reporting for disease risk assessment. Feedback and provincial involvement require improvement. Use of mobile phone technology might improve the timeliness and efficiency of public health surveillance.

Sexual violence is highly prevalent in armed conflict and other humanitarian crises and attracting increasing policy and practice attention. This systematic review aimed to canvas the extent and impact of initiatives to reduce incidence, risk and harm from sexual violence in conflict, post-conflict and other humanitarian crises, in low and middle income countries. Twenty three bibliographic databases and 26 websites were searched, covering publications from 1990 to September 2011 using database-specific keywords for sexual violence and conflict or humanitarian crisis. The 40 included studies reported on seven strategy types: i) survivor care; ii) livelihood initiatives; iii) community mobilisation; iv) personnel initiatives; v) systems and security responses; vi) legal interventions and vii) multiple component interventions. Conducted in 26 countries, the majority of interventions were offered in African countries. Despite the extensive literature on sexual violence by combatants, most interventions addressed opportunistic forms of sexual violence committed in post-conflict settings. Only one study specifically addressed the disaster setting. Actual implementation of initiatives appeared to be limited as was the quality of outcome studies. No studies prospectively measured incidence of sexual violence, although three studies provided some evidence of reductions in association with firewood distribution to reduce women's exposure, as did one program to prevent sexual exploitation and abuse by peacekeeping forces. Apparent increases to risk resulted from lack of protection, stigma and retaliation associated with interventions. Multiple-component interventions and sensitive community engagement appeared to contribute to positive outcomes. Significant obstacles prevent women seeking help following sexual violence, pointing to the need to protect anonymity and preventive strategies. This review contributes a conceptual framework for understanding the forms, settings, and

Objective: To identify factors that have contributed to the systematic development of the Cambodian human resources for health (HRH) system with a focus on midwifery services in response to high maternal mortality in the context of fragile resource-constrained countries.Design: Qualitative case study. Review of published and grey literature and in-depth interviews with key informants and stakeholders using an HRH system conceptual framework developed by the authors (‘House Model’; Fujita et al, 2011). Interviews focused on the perceptions of respondents regarding their contributions to strengthening midwifery services and the other external influences which may have influenced the HRH system and reduction in the maternal mortality ratio (MMR). Focus was on the process towards outcomes, perceptions of respondents on their role and activities, results of their actions, and external influences. Setting and participants: Three rounds of interviews were conducted with a total of 49 senior and mid-level managers of the Ministries of Health (MoH) and Education, educational institutes and development partners. The interviewees were identified through a snowball sampling technique.Main outcome measures: Scaling up the availability of around the clock maternal health services at all health centers contributing to reduction of the maternal mortality ratio. Results: The incremental development of the Cambodian HRH system since 2005 focused on the production, deployment and retention of midwives in rural areas as part of a systematic strategy to reduce maternal mortality. The improved availability and access to midwifery services contributed to significant reduction of the maternal mortality ratio (MMR). Other contributing factors included improved mechanisms for decision-making and implementation; political commitment backed up with necessary resources; leadership from the top along with growing capacity of mid-level managers; increased MoH capacity to plan and coordinate; and

Background: Suicide in Sri Lanka is a major public health problem and in 1995 the country had one of the highest rates of suicide worldwide. Since then reductions in overall suicide rates have been largely attributed to efforts to regulate a range of pesticides. The evolution, context, events and implementation of the key policy decisions around regulation are examined.Methods: This study was undertaken as part of a broader analysis of policy in two parts—an explanatory case study and stakeholder analysis. This article describes the explanatory case study that included an historical narrative and in-depth interviews.Results: A timeline and chronology of policy actions and influence were derived from interview and document data. Fourteen key informants were interviewed and four distinct policy phases were identified. The early stages of pesticide regulation were dominated by political and economic considerations and strongly influenced by external factors. The second phase was marked by a period of local institution building, the engagement of local stakeholders, and expanded links between health and agriculture. During the third phase the problem of self-poisoning dominated the policy agenda and closer links between stakeholders, evidence and policymaking developed. The fourth and most recent phase was characterized by strong local capacity for policymaking, informed by evidence, developed in collaboration with a powerful network of stakeholders, including international researchers.Conclusions: The policy response to extremely high rates of suicide from intentional poisoning with pesticides shows a unique and successful example of policymaking to prevent suicide. It also highlights policy action taking place ‘under the radar’, thus avoiding policy inertia often associated with reforms in lower and middle income countries.

Background: In 2003, Timor-Leste successfully obtained its first Global Fund grant for a three-year programme for malaria control. The grant aimed to reduce malaria-related morbidity and mortality by 30% by the end of the implementation. Methods. A mixed-methods approach was used to assess the impact of the grant implementation. Fifty-eight in-depth interviews, eight group interviews, 16 focus group discussions, and on-site observations were used. Morbidity data reported to the Ministry of Health were also examined to assess trends. Results: The National Malaria Programme with funding support from the Global Fund grant and other development partners contributed considerably to strengthening malaria control and the general health system. It also brought direct and indirect benefits to pregnant women and to the community at large. However, it failed to achieve the stated objective of reducing malaria morbidity and mortality by 30%. The implementation was hampered by inadequate human resources, the rigidity of Global Fund rules, weak project management and coordination, and inadequate support from external stakeholders. Conclusion: Despite limitations, the grant was implemented until the agreed closing date. Considerable contributions to malaria control, health system, and the community have been made and the malaria programme was sustained. © 2012 Martins et al.; licensee BioMed Central Ltd.

Background: Better communication is often suggested as fundamental to increasing the use of research evidence in policy, but little is known about how researchers and policy makers work together or about barriers to exchange. This study explored the views and practice of policy makers and researchers regarding the use of evidence in policy, including: (i) current use of research to inform policy; (ii) dissemination of and access to research findings for policy; (iii) communication and exchange between researchers and policy makers; and (iv) incentives for increasing the use of research in policy. Methods: Separate but similar interview schedules were developed for policy makers and researchers. Senior policy makers from NSW Health and senior researchers from public health and health service research groups in NSW were invited to participate. Consenting participants were interviewed by an independent research company. Results: Thirty eight policy makers (79% response rate) and 41 researchers (82% response rate) completed interviews. Policy makers reported rarely using research to inform policy agendas or to evaluate the impact of policy; research was used more commonly to inform policy content. Most researchers reported that their research had informed local policy, mainly by increasing awareness of an issue. Policy makers reported difficulty in accessing useful research syntheses, and only a third of researchers reported developing targeted strategies to inform policy makers of their findings. Both policy makers and researchers wanted more exchange and saw this as important for increasing the use of research evidence in policy; however, both groups reported a high level of involvement by policy makers in research. Conclusion: Policy makers and researchers recognise the potential of research to contribute to policy and are making significant attempts to integrate research into the policy process. These findings suggest four strategies to assist in increasing the use

Background: Tuberculosis (TB) is a major public health problem in developing countries. Following the disruption to health services in East Timor due to violent political conflict in 1999, the National Tuberculosis Control Program was established, with a local non-government organisation as the lead agency. Within a few months, the TB program was operational in all districts. Methods and Findings: Using the East Timor TB program as a case study, we have examined the enabling factors for the implementation of this type of communicable disease control program in a post-conflict setting. Stakeholder analysis was undertaken, and semi-structured interviews were conducted in 2003 with 24 key local and international stakeholders. Coordination, cooperation, and collaboration were identified as major contributors to the success of the TB program. The existing local structure and experience of the local non-government organisation, the commitment among local personnel and international advisors to establishing an effective program, and the willingness of international advisers and local counterparts to be flexible in their approach were also important factors. This success was achieved despite major impediments, including mass population displacement, lack of infrastructure, and the competing interests of organisations working in the health sector. Conclusions: Five years after the conflict, the TB program continues to operate in all districts with high notification rates, although the lack of a feeling of ownership by government health workers remains a challenge. Lessons learned in East Timor may be applicable to other post-conflict settings where TB is highly prevalent, and may have relevance to other disease control programs. © 2006 Martins et al.

BACKGROUND: Tuberculosis (TB) is a major public health problem in developing countries. Following the disruption to health services in East Timor due to violent political conflict in 1999, the National Tuberculosis Control Program was established, with a local non-government organisation as the lead agency. Within a few months, the TB program was operational in all districts. METHODS AND FINDINGS: Using the East Timor TB program as a case study, we have examined the enabling factors for the implementation of this type of communicable disease control program in a post-conflict setting. Stakeholder analysis was undertaken, and semi-structured interviews were conducted in 2003 with 24 key local and international stakeholders. Coordination, cooperation, and collaboration were identified as major contributors to the success of the TB program. The existing local structure and experience of the local non-government organisation, the commitment among local personnel and international advisors to establishing an effective program, and the willingness of international advisers and local counterparts to be flexible in their approach were also important factors. This success was achieved despite major impediments, including mass population displacement, lack of infrastructure, and the competing interests of organisations working in the health sector. CONCLUSIONS: Five years after the conflict, the TB program continues to operate in all districts with high notification rates, although the lack of a feeling of ownership by government health workers remains a challenge. Lessons learned in East Timor may be applicable to other post-conflict settings where TB is highly prevalent, and may have relevance to other disease control programs.