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Towards the introduction of pneumococcal conjugate vaccines in Bhutan: A cost-utility analysis to determine the optimal policy option

Publication date: Available online 22 February 2018
Source:Vaccine

Author(s): Kinley Dorji, Sonam Phuntsho, Pempa, Suthasinee Kumluang, Sarayuth Khuntha, Wantanee Kulpeng, Sneha Rajbhandari, Yot Teerawattananon

Background Due to competing health priorities and limited resources, many low-income countries, even those with a high disease burden, are not able to introduce pneumococcal conjugate vaccines. Objective To determine the cost-utility of 10- and 13-valent pneumococcal conjugate vaccines (PCV10 and PCV13) compared to no vaccination in Bhutan. Methods A model-based cost-utility analysis was performed in the Bhutanese context using a government perspective. A Markov simulation model with one-year cycle length was used to estimate the costs and outcomes of three options: PCV10, PCV13 and no PCV programmes for a lifetime horizon. A discount rate of 3% per annum was applied. Results are presented using an incremental cost-effectiveness ratio (ICER) in United State Dollar per quality-adjusted life year (QALY) gained (USD 1 = Ngultrum 65). A one-way sensitivity analysis and a probabilistic sensitivity analysis were conducted to assess uncertainty. Results Compared to no vaccination, PCV10 and PCV13 gained 0.0006 and 0.0007 QALYs with additional lifetime costs of USD 0.02 and USD 0.03 per person, respectively. PCV10 and PCV13 generated ICERs of USD 36 and USD 40 per QALY gained compared to no vaccination. In addition, PCV13 produced an ICER of USD 92 compared with PCV10. When including PCV into the Expanded Programme on Immunization, the total 5-year budgetary requirement is anticipated to increase to USD. 3.77 million for PCV10 and USD 3.75 million for PCV13. Moreover, the full-time equivalent (FTE) of one health assistant would increase by 2.0 per year while the FTE of other health workers can be reduced each year, particularly of specialist (0.6–1.1 FTE) and nurse (1–1.6 FTE). Conclusion At the suggested threshold of 1xGDP per capita equivalent to USD 2708, both PCVs are cost-effective in Bhutan and we recommend that they be included in the routine immunization programme.





Categorías: Investigaciones

Designing evaluation studies to optimally inform policy: what factors do policy-makers in China consider when making resource allocation decisions on healthcare worker training programmes?

Abstract Background

In light of the gap in evidence to inform future resource allocation decisions about healthcare provider (HCP) training in low- and middle-income countries (LMICs), and the considerable donor investments being made towards training interventions, evaluation studies that are optimally designed to inform local policy-makers are needed. The aim of our study is to understand what features of HCP training evaluation studies are important for decision-making by policy-makers in LMICs. We investigate the extent to which evaluations based on the widely used Kirkpatrick model – focusing on direct outcomes of training, namely reaction of trainees, learning, behaviour change and improvements in programmatic health indicators – align with policy-makers’ evidence needs for resource allocation decisions. We use China as a case study where resource allocation decisions about potential scale-up (using domestic funding) are being made about an externally funded pilot HCP training programme.

Methods

Qualitative data were collected from high-level officials involved in resource allocation at the national and provincial level in China through ten face-to-face, in-depth interviews and two focus group discussions consisting of ten participants each. Data were analysed manually using an interpretive thematic analysis approach.

Results

Our study indicates that Chinese officials not only consider information about the direct outcomes of a training programme, as captured in the Kirkpatrick model, but also need information on the resources required to implement the training, the wider or indirect impacts of training, and the sustainability and scalability to other settings within the country. In addition to considering findings presented in evaluation studies, we found that Chinese policy-makers pay close attention to whether the evaluations were robust and to the composition of the evaluation team.

Conclusions

Our qualitative study indicates that training programme evaluations that focus narrowly on direct training outcomes may not provide sufficient information for policy-makers to make decisions on future training programmes. Based on our findings, we have developed an evidence-based framework, which incorporates but expands beyond the Kirkpatrick model, to provide conceptual and practical guidance that aids in the design of training programme evaluations better suited to meet the information needs of policy-makers and to inform policy decisions.

Categorías: Investigaciones

Creation, Implementation, and Assessment of a General Thoracic Surgery Simulation Course in Rwanda

Publication date: Available online 21 February 2018
Source:The Annals of Thoracic Surgery

Author(s): Adriana G. Ramirez, Nebil Nuradin, Fidele Byiringiro, Robinson Ssebuufu, George J. Stukenborg, Georges Ntakiyiruta, Thomas M. Daniel

Background The primary objective was to provide proof of concept of conducting thoracic surgical simulation in a low-middle income country (LMIC). Secondary objectives were to accelerate general thoracic surgery skills acquisition by general surgery residents and sustain simulation surgery teaching through a website, simulation models, and teaching of local faculty. Methods Five training models were created for use in a LMIC setting and implemented during on-site courses with Rwandan general surgery residents. A website <http://thoracicsurgeryeducation.com> was created as a supplement to the on-site teaching. All participants completed pre- and post-simulation course knowledge assessment and feedback/confidence surveys. Descriptive and univariate analyses were performed on participants’ responses. Results Twenty-three participants completed the simulation course. Eight (35%) had previous training with the course models. All training levels were represented. Participants reported higher rates of meaningful confidence – defined as moderate to complete on a Likert scale – for all simulated thoracic procedures (p<0.05). The overall mean knowledge assessment score improved from 42.5% pre-simulation to 78.6% post-simulation, (p<0.0001). When stratified by procedure, the mean scores for each simulated procedure showed statistically significant improvement except for ruptured diaphragm repair (p=0.45). Conclusions General thoracic surgery simulation provides a practical, inexpensive, and expedited learning experience in settings lacking experienced faculty and fellowship training opportunities. Resident feedback showed enhanced confidence and knowledge of thoracic procedures suggesting simulation surgery could be an effective tool in expanding the resident knowledge base and preparedness for performing clinically needed thoracic procedures. Repeated skills exposure remains a challenge for achieving sustainable progress.





Categorías: Investigaciones

Understanding nurses’ dual practice: a scoping review of what we know and what we still need to ask on nurses holding multiple jobs

Abstract Background

Mounting evidence suggests that holding multiple concurrent jobs in public and private (dual practice) is common among health workers in low- as well as high-income countries. Nurses are world’s largest health professional workforce and a critical resource for achieving Universal Health Coverage. Nonetheless, little is known about nurses’ engagement with dual practice.

Methods

We conducted a scoping review of the literature on nurses’ dual practice with the objective of generating hypotheses on its nature and consequences, and define a research agenda on the phenomenon. The Arksey and O’Malley’s methodological steps were followed to develop the research questions, identify relevant studies, include/exclude studies, extract the data, and report the findings. PRISMA guidelines were additionally used to conduct the review and report on results.

Results

Of the initial 194 records identified, a total of 35 met the inclusion criteria for nurses’ dual practice; the vast majority (65%) were peer-reviewed publications, followed by nursing magazine publications (19%), reports, and doctoral dissertations. Twenty publications focused on high-income countries, 16 on low- or middle-income ones, and two had a multi country perspective.

Although holding multiple jobs not always amounted to dual practice, several ways were found for public-sector nurses to engage concomitantly in public and private employments, in regulated as well as in informal, casual fashions. Some of these forms were reported as particularly prevalent, from over 50% in Australia, Canada, and the UK, to 28% in South Africa. The opportunity to increase a meagre salary, but also a dissatisfaction with the main job and the flexibility offered by multiple job-holding arrangements, were among the reported reasons for engaging in these practices.

Discussion and conclusions

Limited and mostly circumstantial evidence exists on nurses’ dual practice, with the few existing studies suggesting that the phenomenon is likely to be very common and carry  implications for health systems and nurses’ welfare worldwide. We offer an agenda for future research to consolidate the existing evidence and to further explore nurses’ motivation; without a better understanding of nurse dual practice, this will continue to be a largely ‘hidden’ element in nursing workforce policy and practice, with an unclear impact on the delivery of care.

Categorías: Investigaciones

Association of the client-provider ratio with the risk of maternal mortality in referral hospitals: a multi-site study in Nigeria

Abstract Background

The paucity of human resources for health buoyed by excessive workloads has been identified as being responsible for poor quality obstetric care, which leads to high maternal mortality in Nigeria. While there is anecdotal and qualitative research to support this observation, limited quantitative studies have been conducted to test the association between the number and density of human resources and risk of maternal mortality. This study aims to investigate the association between client-provider ratios for antenatal and delivery care and the risk of maternal mortality in 8 referral hospitals in Nigeria.

Methods

Client-provider ratios were calculated for antenatal and delivery care attendees during a 3-year period (2011–2013). The maternal mortality ratio (MMR) was calculated per 100,000 live births for the hospitals, while unadjusted Poisson regression analysis was used to examine the association between the number of maternal deaths and density of healthcare providers.

Results

A total of 334,425 antenatal care attendees and 26,479 births were recorded during this period. The client-provider ratio in the maternity department for antenatal care attendees was 1343:1 for doctors and 222:1 for midwives. The ratio of births to one doctor in the maternity department was 106:1 and 18:1 for midwives. On average, there were 441 births per specialist obstetrician. The results of the regression analysis showed a significant negative association between the number of maternal deaths and client-provider ratios in all categories.

Conclusion

We conclude that the maternal mortality ratios in Nigeria’s referral hospitals are worsened by high client-provider ratios, with few providers attending a large number of pregnant women. Efforts to improve the density and quality of maternal healthcare providers, especially at the first referral level, would be a critical intervention for reducing the currently high rate of maternal mortality in Nigeria.

Trial registration

Trial Registration Number: NCTR91540209. Nigeria Clinical Trials Registry. Registered 14 April 2016.

Categorías: Investigaciones

Tercera Edición del “Curso Internacional en Salud Sexual y Reproductiva para Adolescentes, con énfasis en la Prevención del Embarazo”

Noticias - El Salvador - Mar, 20/02/2018 - 11:18

En México, el Centro Nacional de Equidad de Género y Salud Reproductiva (CNEGSR) acorde con las políticas de salud establecidas a nivel federal, por la Presidencia de la República, entre ellas la Estrategia Nacional para la Prevención del Embarazo en la Adolescencia (ENAPEA), en la cual se considera que la salud sexual y reproductiva en adolescentes se ha convertido en prioridad. Ante esta situación, el gobierno de México y la Agencia de Cooperación Internacional del Japón (JICA) han sumado esfuerzos para realizar un programa de capacitación en el cual se desarrolla la Tercera Edición del Curso Internacional en Salud Sexual y Reproductiva para Adolescentes, con énfasis en la Prevención del Embarazo”, dirigido a diez países de América Latina para compartir la experiencia mexicana en esta materia

Como resultado de este proyecto de colaboración en cada uno de los países participantes se establecerá un programa de acción en materia de salud sexual y reproductiva que atienda las necesidades particulares de su población de 10 a 19 años.

De manera particular el programa de Salud Sexual y Reproductiva para Adolescentes tiene como objetivos:

  • Favorecer el acceso universal a información, educación y orientación en salud sexual y reproductiva para adolescentes;

  • Reducir embarazos no planeados e infecciones de transmisión sexual (ITS) en adolescentes, mediante el acceso efectivo a servicios de calidad específicos para esta población, e Incidir en los determinantes que impiden el ejercicio pleno de la sexualidad y salud reproductiva de la población adolescente.

Categoria: 
Noticias Locales

Evaluation of health resource utilization efficiency in community health centers of Jiangsu Province, China

Abstract Background

While the demand for health services keep escalating at the grass roots or rural areas of China, a substantial portion of healthcare resources remain stagnant in the more developed cities and this has entrenched health inequity in many parts of China. At its conception, China’s Deepen Medical Reform started in 2012 was intended to flush out possible disparities and promote a more equitable and efficient distribution of healthcare resources. Nearly half a decade of this reform, there are uncertainties as to whether the attainment of the objectives of the reform is in sight.

Methods

Using a hybrid of panel data analysis and an augmented data envelopment analysis (DEA), we model human resources, material, finance to determine their technical and scale efficiency to comprehensively evaluate the transverse and longitudinal allocation efficiency of community health resources in Jiangsu Province.

Results

We observed that the Deepen Medical Reform in China has led to an increase concern to ensure efficient allocation of community health resources by health policy makers in the province. This has led to greater efficiency in health resource allocation in Jiangsu in general but serious regional or municipal disparities still exist. Using the DEA model, we note that the output from the Community Health Centers does not commensurate with the substantial resources (human resources, materials, and financial) invested in them. We further observe that the case is worst in less-developed Northern parts of Jiangsu Province.

Conclusions

The government of Jiangsu Province could improve the efficiency of health resource allocation by improving the community health service system, rationalizing the allocation of health personnel, optimizing the allocation of material resources, and enhancing the level of health of financial resource allocation.

Categorías: Investigaciones

Barriers to and strategies for addressing the availability, accessibility, acceptability and quality of the sexual, reproductive, maternal, newborn and adolescent health workforce: addressing the post-2015 agenda

Abstract Background

In a post-2015 development agenda, achieving Universal Health Coverage (UHC) for women and newborns will require a fit-for-purpose and fit-to-practice sexual, reproductive, maternal, adolescent and newborn health (SRMNAH) workforce. The aim of this paper is to explore barriers, challenges and solutions to the availability, accessibility, acceptability and quality (AAAQ) of SRMNAH services and workforce.

Methods

The State of the World’s Midwifery report 2014 used a broad definition of midwifery (“the health services and health workforce needed to support and care for women and newborns”) and provided information about a wide range of SRMNAH workers, including doctors, midwives, nurses and auxiliaries. As part of the data collection, 36 out of the 73 participating low- and middle-income countries conducted a one-day workshop, involving a range of different stakeholders. Participants were asked to discuss barriers to the AAAQ of SRMNAH workers, and to suggest strategies for overcoming the identified barriers. The workshop was facilitated using a discussion guide, and a rapporteur took detailed notes. A content analysis was undertaken using N-Vivo software and the AAAQ model as a framework.

Results

Across the 36 countries, about 800 participants attended a workshop. The identified barriers to AAAQ of SRMNAH workers included: insufficient size of the workforce and inequity in its distribution, lack of transportation, user fees and out of pocket payments. In some countries, respondents felt that women mistrusted the workforce, and particularly midwives, due to cultural differences, or disrespectful behaviour towards service users. Quality of care was undermined by a lack of supplies/equipment and inadequate regulation. Against these, countries identified a set of solutions including adequate workforce planning supported by a fast and equitable deployment system, aligned with the principles of UHC. Acceptability and quality could be improved with the provision of respectful care as well as strategies to improve education and regulation.

Conclusions

The number and scale of the barriers still needing to be addressed in these 36 countries was significant. Adequate planning and policies to support the development of the SRMNAH workforce and its equitable distribution are a priority. Enabling strategies need to be put in place to improve the status and recognition of midwives, whose role is often undervalued.

Categorías: Investigaciones

The shaded side of the UHC cube: a systematic review of human resources for health management and administration in social health protection schemes

Abstract

Managers and administrators in charge of social protection and health financing, service purchasing and provision play a crucial role in harnessing the potential advantage of prudent organization, management and purchasing of health services, thereby supporting the attainment of Universal Health Coverage. However, very little is known about the needed quantity and quality of such staff, in particular when it comes to those institutions managing mandatory health insurance schemes and purchasing services. As many health care systems in low- and middle-income countries move towards independent institutions (both purchasers and providers) there is a clear need to have good data on staff and administrative cost in different social health protection schemes as a basis for investing in the development of a cadre of health managers and administrators for such schemes. We report on a systematic literature review of human resources in health management and administration in social protection schemes and suggest some aspects in moving research, practical applications and the policy debate forward.

Categorías: Investigaciones

Cost-effectiveness of the treatment of uncomplicated severe acute malnutrition by community health workers compared to treatment provided at an outpatient facility in rural Mali

Abstract Background

The Malian Nutrition Division of the Ministry of Health and Action Against Hunger tested the feasibility of integrating treatment of severe acute malnutrition (SAM) into the existing Integrated Community Case Management package delivered by community health workers (CHWs). This study assessed costs and cost-effectiveness of CHW-delivered care compared to outpatient facility-based care.

Methods

Activity-based costing methods were used, and a societal perspective employed to include all relevant costs incurred by institutions, beneficiaries and communities. The intervention and control arm enrolled different numbers of children so a modelled scenario sensitivity analysis was conducted to assess the cost-effectiveness of the two arms, assuming equal numbers of children enrolled.

Results

In the base case, with unequal numbers of children in each arm, for CHW-delivered care, the cost per child treated was 244 USD and cost per child recovered was 259 USD. Outpatient facility-based care was less cost-effective at 442 USD per child and 501 USD per child recovered. The conclusions of the analysis changed in the modelled scenario sensitivity analysis, with outpatient facility-based care being marginally more cost-effective (cost per child treated is 188 USD, cost per child recovered is 214 USD), compared to CHW-delivered care. This suggests that achieving good coverage is a key factor influencing cost-effectiveness of CHWs delivering treatment for SAM in this setting. Per week of treatment, households receiving CHW-delivered care spent half of the time receiving treatment and three times less money compared with those receiving treatment from the outpatient facility.

Conclusions

This study supports existing evidence that the delivery of treatment by CHWs is a cost-effective intervention, provided that good coverage is achieved. A major benefit of this strategy was the lower cost incurred by the beneficiary household when treatment is available in the community. Further research is needed on the implementation costs that would be incurred by the government to increase the operability of these results.

Categorías: Investigaciones

A model for developing postgraduate trauma and emergency nursing capacity in a resource-constrained setting

Publication date: Available online 17 February 2018
Source:International Emergency Nursing









Categorías: Investigaciones

Task sharing interventions for cardiovascular risk reduction and lipid outcomes in low-middle income countries. A systematic review and meta-analysis

Publication date: Available online 16 February 2018
Source:Journal of Clinical Lipidology

Author(s): T.N. Anand, Linju M. Joseph, A.V. Geetha, Joyita Chowdhury, Dorairaj Prabhakaran, Panniyammakal Jeemon

Background One of the potential strategies to improve health care delivery in understaffed low-middle income countries (LMIC) is task sharing, where specific tasks are transferred from more qualified healthcare cadre to a lesser trained cadre. Dyslipidaemia is a major risk factors for cardiovascular disease but often it is not managed appropriately. Objective We conducted a systematic review with the objective to identify, and evaluate the effect of task sharing interventions on dyslipidaemia in LMIC. Methods Published studies (RCTs and observational studies) were identified via electronic databases such as PubMed, EMBASE, Cochrane Library, PsycINFO, and CINAHL. We searched the databases from inception to September 2016 and updated till 30 June 2017, using search terms related to task shifting, and cardiovascular disease prevention in LMIC. All eligible studies were summarised narratively, and potential studies were grouped for meta-analysis. Results Although our search yielded 2938 records initially and another 1628 in the updated search, only 15 studies met the eligible criteria. Most of the studies targeted lifestyle modification, and care-coordination by involving nurses or allied health workers. Eight RCTs were included in the meta-analysis. Task sharing intervention were effective in lowering LDL- c (-6.90 mg/dl; 95% CI -11·81- -1·99) and total cholesterol (-9.44 mg/dl; 95% CI -17·94- -0.93) levels with modest effect size. However, there were no major differences in HDL-c (-0·29 mg/dl; 95% CI -0·88- 1·47) and triglycerides (-14·31 mg/dl; 95% CI -33.32- 4·69). The overall quality of evidence based on GRADE was either ‘low’ or ‘very low’. Conclusion Available data are not adequate to make recommendations on the role of task sharing strategies for the management of dyslipidaemia in LMIC. However, the studies conducted in LMIC demonstrate the potential use of this strategy especially in terms of reduction in LDL-cholesterol and total cholesterol levels. Our review calls for the need of well-designed, and large-scale studies to demonstrate the effect of task sharing strategy on lipid management in LMIC.





Categorías: Investigaciones

Assessing retention in care after 12 months of the Pediatric Development Clinic implementation in rural Rwanda: a retrospective cohort study

Abstract Background

In Africa, a high proportion of children are at risk for developmental delay. Early interventions are known to improve outcomes, but they are not routinely available. The Rwandan Ministry of Health with Partners In Health/Inshuti Mu Buzima created the Pediatric Development Clinic (PDC) model for providing interdisciplinary developmental care for high-risk infants in rural settings. As retention for chronic care has proven challenging in many settings, this study assesses factors related to retention to care after 12 months of clinic enrollment.

Methods

This study describes a retrospective cohort of children enrolled for 12 months in the PDC program in Southern Kayonza district between April 2014–March 2015. We reviewed routinely collected data from electronic medical records and patient charts. We described patient characteristics and the proportion of patients retained, died, transferred out or lost to follow up (LTFU) at 12 months. We used Fisher’s exact test and multivariable logistic regression to identify factors associated with retention in care.

Results

228 children enrolled in PDC from 1 April 2014–31 March 2015, with prematurity/low birth weight (62.2%) and hypoxic ischemic encephalopathy (34.5%) as the most frequent referral diagnoses. 64.5% of children were retained in care and 32.5% were LTFU after 12 months. In the unadjusted analysis, we found male sex (p = 0.189), having more children at home (p = 0.027), health facility of first visit (p = 0.006), having a PDC in the nearest health facility (p = 0.136), referral in second six months of PDC operation (p = 0.006), and social support to be associated (100%, p < 0.001) with retention after 12 months. In adjusted analysis, referral in second six months of PDC operation (Odds Ratio (OR) 2.56, 95% CI 1.36, 4.80) was associated with increased retention, and being diagnosed with more complex conditions (trisomy 21, cleft lip/palate, hydrocephalus, other developmental delay) was associated with LTFU (OR 0.34, 95% CI 0.15, 0.76). As 100% of those receiving social support were retained in care, this was not able to be assessed in adjusted analysis.

Conclusions

PDC retention in care is encouraging. Provision of social assistance and decentralization of the program are major components of the delivery of services related to retention in care.

Categorías: Investigaciones

Opportunities, challenges and strategies when building a midwifery profession. Findings from a qualitative study in Bangladesh and Nepal

Publication date: Available online 12 February 2018
Source:Sexual &amp; Reproductive Healthcare

Author(s): Malin Bogren, Kerstin Erlandsson

Objective The aim of this paper was to identify opportunities and challenges when building a midwifery profession in Bangladesh and Nepal. Methods Data were collected through 33 semi-structured interviews with government officials, policy-makers, donors, and individuals from academia and non-government organizations with an influence in building a midwifery profession in their respective countries. Data were analyzed using content analysis. Findings The opportunities and challenges found in Bangladesh and Nepal when building a midwifery profession emerged the theme “A comprehensive collaborative approach, with a political desire, can build a midwifery profession while competing views, interest, priorities and unawareness hamper the process”. Several factors were found to facilitate the establishment of a midwifery profession in both countries. For example, global and national standards brought together midwifery professionals and stakeholders, and helped in the establishment of midwifery associations. The challenges for both countries were national commitments without a full set of supporting policy documents, lack of professional recognition, and competing views, interests and priorities. Conclusion and clinical application This study demonstrated that building a midwifery profession requires a political comprehensive collaborative approach supported by a political commitment. Through bringing professionals together in a professional association will bring a professional status. Global standards and guidelines need to be contextualized into national policies and plans where midwives are included as part of the national health workforce. This is a key for creating recognized midwives with a protected title to autonomously practice midwifery, to upholding the sexual and reproductive health and rights for women and girls.





Categorías: Investigaciones

Supportive supervision and constructive relationships with healthcare workers support CHW performance: Use of a qualitative framework to evaluate CHW programming in Uganda

Abstract Background

While evidence supports community health worker (CHW) capacity to improve maternal and newborn health in less-resourced countries, key implementation gaps remain. Tools for assessing CHW performance and evidence on what programmatic components affect performance are lacking. This study developed and tested a qualitative evaluative framework and tool to assess CHW team performance in a district program in rural Uganda.

Methods

A new assessment framework was developed to collect and analyze qualitative evidence based on CHW perspectives on seven program components associated with effectiveness (selection; training; community embeddedness; peer support; supportive supervision; relationship with other healthcare workers; retention and incentive structures). Focus groups were conducted with four high/medium-performing CHW teams and four low-performing CHW teams selected through random, stratified sampling. Content analysis involved organizing focus group transcripts according to the seven program effectiveness components, and assigning scores to each component per focus group.

Results

Four components, ‘supportive supervision’, ‘good relationships with other healthcare workers’, ‘peer support’, and ‘retention and incentive structures’ received the lowest overall scores. Variances in scores between ‘high’/‘medium’- and ‘low’-performing CHW teams were largest for ‘supportive supervision’ and ‘good relationships with other healthcare workers.’ Our analysis suggests that in the Bushenyi intervention context, CHW team performance is highly correlated with the quality of supervision and relationships with other healthcare workers. CHWs identified key performance-related issues of absentee supervisors, referral system challenges, and lack of engagement/respect by health workers. Other less-correlated program components warrant further study and may have been impacted by relatively consistent program implementation within our limited study area.

Conclusions

Applying process-oriented measurement tools are needed to better understand CHW performance-related factors and build a supportive environment for CHW program effectiveness and sustainability. Findings from a qualitative, multi-component tool developed and applied in this study suggest that factors related to (1) supportive supervision and (2) relationships with other healthcare workers may be strongly associated with variances in performance outcomes within a program. Careful consideration of supervisory structure and health worker orientation during program implementation are among strategies proposed to increase CHW performance.

Categorías: Investigaciones

Health insurance is important in improving maternal health service utilization in Tanzania—analysis of the 2011/2012 Tanzania HIV/AIDS and malaria indicator survey

Abstract Background

Maternal mortality rates vary significantly from region to region. Interventions such as early and planned antenatal care attendance and facility delivery with skilled health workers can potentially reduce maternal mortality rates. Several factors can be attributed to antenatal care attendance, or lack thereof, including the cost of health care services. The aim of this study was to examine the role of health insurance coverage in utilization of maternal health services in Tanzania.

Methods

Secondary data analysis was conducted on the nationally representative sample of men and women aged 15–49 years using the 2011/12 Tanzania HIV and Malaria Indicator Survey. It included 4513 women who had one or more live births within three years before the survey. The independent variable was health insurance coverage. Outcome variables included proper timing of the first antenatal care visit, completing the recommended number of antenatal care (ANC) visits, and giving birth under skilled worker. Data were analyzed both descriptively and using regression analyses to examine independent association of health insurance and maternal health services.

Results

Of 4513 women, only 281 (6.2%) had health insurance. Among all participants, only 16.9%, 7.1%, and 56.5%, respectively, made their first ANC visit as per recommendation, completed the recommended number of ANC visits, and had skilled birth assistance at delivery. A higher proportion of women with health insurance had a proper timing of 1st ANC attendance compared to their counterparts (27.0% vs. 16.0%, p < 0.001). Similar trend was for skilled birth attendance (77.6% vs. 55.1%, p < 0.001). After adjusting for other confounders and covariates, having health insurance was associated with proper timing of 1st ANC attendance (AOR = 1.89, p < 0.001) and skilled birth attendance (AOR = 2.01, p < 0.01).

Conclusions

Health insurance coverage and maternal health services were low in this nationally representative sample in Tanzania. Women covered by health insurance were more likely to have proper timing of the first antenatal visit and receive skilled birth assistance at delivery. To improve maternal health, health insurance alone is however not enough. It is important to improve other pillars of health system to attain and sustain better maternal health in Tanzania and areas with similar contexts.

Categorías: Investigaciones

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